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Asian J Endosc Surg ISSN 1758-5902
C A S E R E P O RT
Thoracoscopic repair of a large neonatal congenital diaphragmatic hernia using Gerota’s fascia Hiroaki Fukuzawa, Akihiko Tamaki, Jyunkichi Takemoto, Keiichi Morita, Kosuke Endo, Tamaki Iwade, Okata Yuichi, Yuko Bitoh, Akiko Yokoi & Kosaku Maeda Department of Pediatric Surgery, Kobe Children’s Hospital, Kobe, Japan
Keywords Congenital diaphragmatic hernia; Gerota’s fascia; thoracoscopic repair Correspondence Hiroaki Fukuzawa, Takakuradai 1-1-1, Suma-ku, Kobe 654-0081, Japan. Tel: +81 78 732 6961 Fax: +81 78 735 0910 Email: [email protected] Received 11 November 2014; revised 13 December 2014; accepted 30 December 2014
Abstract A large congenital diaphragmatic hernia needing patch repair has a high risk of recurrence. Thus, managing these large congenital diaphragmatic hernias under thoracoscopy has become a problem. Here, a large congenital diaphragmatic hernia that was repaired using Gerota’s fascia under thoracoscopy is reported. In the present case, it was impossible to close the hernia directly under thoracoscopy because the hernia was too large. Gerota’s fascia was raised up by the left kidney and used for the repair. The left colon adhering to Gerota’s fascia was mobilized, and a large space was made under thoracoscopy. Gerota’s fascia was fixed to the diaphragmatic defect. The patient’s postoperative course was good, and there was no recurrence. This technique could be one option for repairing a large hernia under thoracoscopy.
DOI:10.1111/ases.12172
Introduction
Procedure
The use of thoracoscopic repair for congenital diaphragmatic hernia (CDH) has increased since the late 1990s. However, it has been reported that the rate of recurrence is higher with thoracoscopic repair than with open procedure (1). In cases of large CDH, a Gore-Tex patch has been used to close the defect under thoracoscopy, but the recurrence rate in such cases is high (2). Thus, managing large CDH under thoracoscopy has become a problem. Here, we report a case of a large CDH that could not be closed directly but was closed using Gerota’s fascia under thoracoscopy.
The operation was performed with the patient under general anesthesia, with induced muscular relaxation, while in the right side-lying position. First, a 5-mm port was inserted at the left side of the left nipple. CO2 was insufflated, and the pressure inside the thoracic cavity was kept at 4–8 mmHg. The entire small intestine, colon, stomach, and spleen were in the thoracic cavity. Two more 5-mm ports were inserted in appropriate positions. The organs were gently reduced into the abdominal cavity through the diaphragmatic hernia. The diaphragm rim was seen around the mediastinum side, but the hernia of the lateral side was large. Direct closure was attempted with 3-0 non-absorbable sutures from the mediastinum side to the lateral side. It was possible to close the mediastinum side but not the lateral side, because the hernia was too large. It was then decided to use Gerota’s fascia to close the diaphragmatic hernia. Gerota’s fascia was raised up by the left kidney and seen though the hernia (Figure 2). The left colon adhering to Gerota’s fascia was mobilized, and a large space was made in Gerota’s fascia with an electrocautery scissors (Figures 3,4). Gerota’s fascia was attached to the
Case Presentation A left-sided CDH was detected at 27 weeks’ gestational age by ultrasonography. The 2932-g baby was born by planned cesarean delivery at 38 weeks’ gestational age. After birth, tracheal intubation was performed as soon as possible, and intensive care was started. Persistent pulmonary hypertension was not severe; therefore, nitrous oxide gas was not used (Figure 1). The day after birth, repair of the CDH was performed under thoracoscopy.
Asian J Endosc Surg 8 (2015) 219–222 © 2015 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd.
219
Thoracoscopic repair of large CDH
H Fukuzawa et al.
Figure 3 The left colon adhering to Gerota’s fascia was mobilized, and a large space was made in Gerota’s fascia with electrocautery scissors.
Figure 1 Preoperative X-ray. The stomach and intestines can be seen in the left thoracic cavity.
Figure 4 A large space was made in Gerota’s fascia for the repair.
course was good, and at postoperative day 4, enteral feeding was started through a nasogastric tube. Extubation of the tracheal tube was done on postoperative day 5. Eight months later, a chest X-ray showed that the portion of Gerota’s fascia attached to the left diaphragm was slightly elevated, but there was no recurrence (Figure 7). Figure 2 Gerota’s fascia was raised by the left kidney. It could easily be seen thorough the diaphragmatic hernia.
Discussion diaphragmatic defect from the abdominal side and fixed by 3-0 non-absorbable sutures (Figures 5,6). A drainage tube was not used. Results Total operation time was 144 min. There were no intraoperative difficulties. The patient’s postoperative
220
The survival rate for CDH has improved in recent years (3,4). Traditionally, surgery for CDH used the conventional open approach (either laparotomy or thoracotomy), but minimally invasive surgery has had good results. Silen et al. reported the first case of minimally invasive repair of a Bochdalek-type CDH in 1995 (5). However, this was undertaken in an adolescent patient. The first report of thoracoscopic repair for
Asian J Endosc Surg 8 (2015) 219–222 © 2015 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd.
Thoracoscopic repair of large CDH
H Fukuzawa et al.
neonatal CDH was in 2003 (6). Since then, thoracoscopic repair for CDH, especially neonatal cases, has been performed by many pediatric surgeons. As more procedures have been performed, the problems of thoracoscopic repair for neonatal CDH have gradually become emerged. In 2010, Lansdale et al. reported a systematic review and meta-analysis of thoracoscopic repair for neonatal CDH (1). This report indicated that the recurrence rate and operative time were significantly higher and longer with endosurgical repair than with the open procedure, even though the survival rate did not differ between open and endoscopic surgery. In 2014, Chan et al. also reported a meta-analysis comparing minimally invasive surgery and open surgery. That report said that the recurrence rate was higher after minimally invasive surgery than after open repair only when a patch was used. For primary repair without a patch, there was no difference between minimally invasive surgery and open repair (2). One must consider the cause for these findings. First, it is more difficult to fix a patch under thoracoscopy than under open surgery. Second, in open surgery, a patch is usually attached to the diaphragm from the abdominal side. However, under thoracoscopic repair, a patch is attached to the diaphragm from the thoracic side. This explains the difference: the thoracic-side patch is
easily torn off by abdominal pressure. Reducing the high recurrence rate for a large hernia needing patch repair under thoracoscopy remains a problem. In the present report, a thoracoscopic technique for CDH repair using Gerota’s fascia was described. A similar technique (using Gerota’s fascia flap for a large CDH defect) under laparotomy was reported by Okazaki et al. (7), who described the durability of Gerota’s fascia as a material for repairing CHD and also suggested that it could reduce dependence on synthetic patch repair. In the present case, it was possible to fix Gerota’s fascia directly from the abdominal side easily. In cases of large diaphragmatic hernia, the left kidney sometimes gets out of position under Gerota’s fascia close to the diaphragm, as in the present case. The left kidney also sometimes raises Gerota’s fascia to a position suitable for repair. Thus, in this situation, it is easy to attach this fascia without creating a flap. This is the first case report involving the successful treatment of CDH with thoracoscopic repair using Gerota’s fascia. It appears that Gerota’s fascia cannot cover all sizes of CDH. However, if it is possible to use Gerota’s fascia as a
Figure 5 Gerota’s fascia was attached to the diaphragmatic hernia from the abdominal side and fixed by 3-0 non-absorbable sutures.
Figure 7 Gerota’s fascia used to fix the diaphragmatic hernia is slightly elevated, but recurrence has not been observed.
Figure 6 The schema of the operation.
Asian J Endosc Surg 8 (2015) 219–222 © 2015 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd.
221
Thoracoscopic repair of large CDH
H Fukuzawa et al.
patch, it could be one option for repairing a large hernia under thoracoscopy, and it may reduce the recurrence rate.
Acknowledgment The authors have no conflicts of interest associated with this manuscript to declare. The subject gave informed consent and patient anonymity was preserved.
References 1. Lansdale N, Alam S, Losty PD et al. Neonatal endosurgical congenital diaphragmatic hernia repair: A systematic review and meta-analysis. Ann Surg 2010; 252: 20–26. 2. Chan E, Wayne C, Nasr A. Minimally invasive versus open repair of Bochdalek hernia: A meta-analysis. J Pediatr Surg 2014; 49: 694–699.
222
3. Okazaki T, Kohno S, Hasegawa S et al. Congenital diaphragmatic hernia: Efficacy of ultrasound examination in its management. Pediatr Surg Int 2003; 19: 176–179. 4. Okuyama H, Kubota A, Oue T et al. Inhaled nitric oxide with early surgery improved the outcome of antenatally diagnosed congenital diaphragmatic hernia. J Pediatr Surg 2002; 37: 1188–1190. 5. Silen ML, Canvasser DA, Kurkchubasche AG et al. Videoassisted thoracic surgery repair of a foramen of Bochdalek hernia. Ann Thorac Surg 1995; 60: 448–450. 6. Liem NT. Thoracoscopic surgery for congenital diaphragmatic hernia: A report of nine cases. Asian J Surg 2003; 26: 210–212. 7. Okazaki T, Hasegawa S, Urushihara N et al. Toldt’s fascia flap: A new technique for repairing large diaphragmatic hernia. Pediatr Surg Int 2005; 21: 64–67.
Asian J Endosc Surg 8 (2015) 219–222 © 2015 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd.
Asian J Endosc Surg ISSN 1758-5902
C A S E R E P O RT
Thoracoscopic repair of a large neonatal congenital diaphragmatic hernia using Gerota’s fascia Hiroaki Fukuzawa, Akihiko Tamaki, Jyunkichi Takemoto, Keiichi Morita, Kosuke Endo, Tamaki Iwade, Okata Yuichi, Yuko Bitoh, Akiko Yokoi & Kosaku Maeda Department of Pediatric Surgery, Kobe Children’s Hospital, Kobe, Japan
Keywords Congenital diaphragmatic hernia; Gerota’s fascia; thoracoscopic repair Correspondence Hiroaki Fukuzawa, Takakuradai 1-1-1, Suma-ku, Kobe 654-0081, Japan. Tel: +81 78 732 6961 Fax: +81 78 735 0910 Email: [email protected] Received 11 November 2014; revised 13 December 2014; accepted 30 December 2014
Abstract A large congenital diaphragmatic hernia needing patch repair has a high risk of recurrence. Thus, managing these large congenital diaphragmatic hernias under thoracoscopy has become a problem. Here, a large congenital diaphragmatic hernia that was repaired using Gerota’s fascia under thoracoscopy is reported. In the present case, it was impossible to close the hernia directly under thoracoscopy because the hernia was too large. Gerota’s fascia was raised up by the left kidney and used for the repair. The left colon adhering to Gerota’s fascia was mobilized, and a large space was made under thoracoscopy. Gerota’s fascia was fixed to the diaphragmatic defect. The patient’s postoperative course was good, and there was no recurrence. This technique could be one option for repairing a large hernia under thoracoscopy.
DOI:10.1111/ases.12172
Introduction
Procedure
The use of thoracoscopic repair for congenital diaphragmatic hernia (CDH) has increased since the late 1990s. However, it has been reported that the rate of recurrence is higher with thoracoscopic repair than with open procedure (1). In cases of large CDH, a Gore-Tex patch has been used to close the defect under thoracoscopy, but the recurrence rate in such cases is high (2). Thus, managing large CDH under thoracoscopy has become a problem. Here, we report a case of a large CDH that could not be closed directly but was closed using Gerota’s fascia under thoracoscopy.
The operation was performed with the patient under general anesthesia, with induced muscular relaxation, while in the right side-lying position. First, a 5-mm port was inserted at the left side of the left nipple. CO2 was insufflated, and the pressure inside the thoracic cavity was kept at 4–8 mmHg. The entire small intestine, colon, stomach, and spleen were in the thoracic cavity. Two more 5-mm ports were inserted in appropriate positions. The organs were gently reduced into the abdominal cavity through the diaphragmatic hernia. The diaphragm rim was seen around the mediastinum side, but the hernia of the lateral side was large. Direct closure was attempted with 3-0 non-absorbable sutures from the mediastinum side to the lateral side. It was possible to close the mediastinum side but not the lateral side, because the hernia was too large. It was then decided to use Gerota’s fascia to close the diaphragmatic hernia. Gerota’s fascia was raised up by the left kidney and seen though the hernia (Figure 2). The left colon adhering to Gerota’s fascia was mobilized, and a large space was made in Gerota’s fascia with an electrocautery scissors (Figures 3,4). Gerota’s fascia was attached to the
Case Presentation A left-sided CDH was detected at 27 weeks’ gestational age by ultrasonography. The 2932-g baby was born by planned cesarean delivery at 38 weeks’ gestational age. After birth, tracheal intubation was performed as soon as possible, and intensive care was started. Persistent pulmonary hypertension was not severe; therefore, nitrous oxide gas was not used (Figure 1). The day after birth, repair of the CDH was performed under thoracoscopy.
Asian J Endosc Surg 8 (2015) 219–222 © 2015 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd.
219
Thoracoscopic repair of large CDH
H Fukuzawa et al.
Figure 3 The left colon adhering to Gerota’s fascia was mobilized, and a large space was made in Gerota’s fascia with electrocautery scissors.
Figure 1 Preoperative X-ray. The stomach and intestines can be seen in the left thoracic cavity.
Figure 4 A large space was made in Gerota’s fascia for the repair.
course was good, and at postoperative day 4, enteral feeding was started through a nasogastric tube. Extubation of the tracheal tube was done on postoperative day 5. Eight months later, a chest X-ray showed that the portion of Gerota’s fascia attached to the left diaphragm was slightly elevated, but there was no recurrence (Figure 7). Figure 2 Gerota’s fascia was raised by the left kidney. It could easily be seen thorough the diaphragmatic hernia.
Discussion diaphragmatic defect from the abdominal side and fixed by 3-0 non-absorbable sutures (Figures 5,6). A drainage tube was not used. Results Total operation time was 144 min. There were no intraoperative difficulties. The patient’s postoperative
220
The survival rate for CDH has improved in recent years (3,4). Traditionally, surgery for CDH used the conventional open approach (either laparotomy or thoracotomy), but minimally invasive surgery has had good results. Silen et al. reported the first case of minimally invasive repair of a Bochdalek-type CDH in 1995 (5). However, this was undertaken in an adolescent patient. The first report of thoracoscopic repair for
Asian J Endosc Surg 8 (2015) 219–222 © 2015 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd.
Thoracoscopic repair of large CDH
H Fukuzawa et al.
neonatal CDH was in 2003 (6). Since then, thoracoscopic repair for CDH, especially neonatal cases, has been performed by many pediatric surgeons. As more procedures have been performed, the problems of thoracoscopic repair for neonatal CDH have gradually become emerged. In 2010, Lansdale et al. reported a systematic review and meta-analysis of thoracoscopic repair for neonatal CDH (1). This report indicated that the recurrence rate and operative time were significantly higher and longer with endosurgical repair than with the open procedure, even though the survival rate did not differ between open and endoscopic surgery. In 2014, Chan et al. also reported a meta-analysis comparing minimally invasive surgery and open surgery. That report said that the recurrence rate was higher after minimally invasive surgery than after open repair only when a patch was used. For primary repair without a patch, there was no difference between minimally invasive surgery and open repair (2). One must consider the cause for these findings. First, it is more difficult to fix a patch under thoracoscopy than under open surgery. Second, in open surgery, a patch is usually attached to the diaphragm from the abdominal side. However, under thoracoscopic repair, a patch is attached to the diaphragm from the thoracic side. This explains the difference: the thoracic-side patch is
easily torn off by abdominal pressure. Reducing the high recurrence rate for a large hernia needing patch repair under thoracoscopy remains a problem. In the present report, a thoracoscopic technique for CDH repair using Gerota’s fascia was described. A similar technique (using Gerota’s fascia flap for a large CDH defect) under laparotomy was reported by Okazaki et al. (7), who described the durability of Gerota’s fascia as a material for repairing CHD and also suggested that it could reduce dependence on synthetic patch repair. In the present case, it was possible to fix Gerota’s fascia directly from the abdominal side easily. In cases of large diaphragmatic hernia, the left kidney sometimes gets out of position under Gerota’s fascia close to the diaphragm, as in the present case. The left kidney also sometimes raises Gerota’s fascia to a position suitable for repair. Thus, in this situation, it is easy to attach this fascia without creating a flap. This is the first case report involving the successful treatment of CDH with thoracoscopic repair using Gerota’s fascia. It appears that Gerota’s fascia cannot cover all sizes of CDH. However, if it is possible to use Gerota’s fascia as a
Figure 5 Gerota’s fascia was attached to the diaphragmatic hernia from the abdominal side and fixed by 3-0 non-absorbable sutures.
Figure 7 Gerota’s fascia used to fix the diaphragmatic hernia is slightly elevated, but recurrence has not been observed.
Figure 6 The schema of the operation.
Asian J Endosc Surg 8 (2015) 219–222 © 2015 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd.
221
Thoracoscopic repair of large CDH
H Fukuzawa et al.
patch, it could be one option for repairing a large hernia under thoracoscopy, and it may reduce the recurrence rate.
Acknowledgment The authors have no conflicts of interest associated with this manuscript to declare. The subject gave informed consent and patient anonymity was preserved.
References 1. Lansdale N, Alam S, Losty PD et al. Neonatal endosurgical congenital diaphragmatic hernia repair: A systematic review and meta-analysis. Ann Surg 2010; 252: 20–26. 2. Chan E, Wayne C, Nasr A. Minimally invasive versus open repair of Bochdalek hernia: A meta-analysis. J Pediatr Surg 2014; 49: 694–699.
222
3. Okazaki T, Kohno S, Hasegawa S et al. Congenital diaphragmatic hernia: Efficacy of ultrasound examination in its management. Pediatr Surg Int 2003; 19: 176–179. 4. Okuyama H, Kubota A, Oue T et al. Inhaled nitric oxide with early surgery improved the outcome of antenatally diagnosed congenital diaphragmatic hernia. J Pediatr Surg 2002; 37: 1188–1190. 5. Silen ML, Canvasser DA, Kurkchubasche AG et al. Videoassisted thoracic surgery repair of a foramen of Bochdalek hernia. Ann Thorac Surg 1995; 60: 448–450. 6. Liem NT. Thoracoscopic surgery for congenital diaphragmatic hernia: A report of nine cases. Asian J Surg 2003; 26: 210–212. 7. Okazaki T, Hasegawa S, Urushihara N et al. Toldt’s fascia flap: A new technique for repairing large diaphragmatic hernia. Pediatr Surg Int 2005; 21: 64–67.
Asian J Endosc Surg 8 (2015) 219–222 © 2015 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd.
