Page 21 - 65 thorax41-48_opt

296 Congenital Diaphragmatic Hernia and Diaphragmatic Eventration
Surgery
For left-sided lesions, the approach can be either abdominal or tho-
racic. For lesions on the right side, a thoracic approach is preferential.
The thoracic approach is through a posterolateral 7th to 9th rib space.
The abdominal approach is usually subcostal. Bilateral cases can be
approached through a transverse upper abdominal incision. A thoraco-
scopic approach may be used if skills and resources are available.
The key features of the operation are:
• Confirmation of the diagnosis (versus CDH).
• Plication of the diaphragm by using several rows of pledgeted non-
absorbable sutures to obtain a relatively flat diaphragm.
• Bites of the diaphragm are taken at suitable intervals (~1 cm) in a
radial fashion (usually, three or four rows of sutures are needed).
• These sutures can be placed individually without tying, and tied
sequentially at the end.
• Identification and avoidance of the branches of the phrenic nerve,
if possible.
Figure 45.7: Right-sided eventration of the diaphragm.
• A chest drain may be left after a thoracic approach, although this is
not mandatory.
A postoperative chest x-ray is suggested to check the position of the
diaphragm (Figure 45.9).
Postoperative Complications
19
There are relatively few postoperative complications with this surgery.
Trauma to the intestines and liver during a thoracic approach is avoided
by careful placement of sutures into the diaphragm. Postoperative pneu-
mothorax is also uncommon, and usually resolves with chest drainage.
Adhesive intestinal obstruction is possible after an abdominal approach.
Recurrence is possible, but is much less common than in CDH.
Prognosis and Outcomes
The prognosis is very good in the absence of other anomalies.
Respiratory mechanics are improved by plication, with increased tidal
volume and vital capacity and improvement of symptoms. In a follow-
up study 1 to 5 years postplication, there was no recurrence of symp-
toms, with only one of nine patients having an elevated diaphragm. In
19
the rest, the diaphragm was flat but immobile.
Prevention
Avoidance of the phrenic nerve during surgery and procedures that put
it at risk is preventive in cases due to phrenic nerve injury.
Figure 45.8: Left-sided eventration of the diaphragm. Evidence-Based Research
Table 45.1 presents a meta-analysis that evaluates the use of ECMO in
infants with CDH.

Figure 45.9: Postoperative chest x-ray after right-sided eventration repair for the
same patient as in Figure 45.7.