C. N. Criss1, M. A. Coughlin2, N. Matsuko3, S. K. Gadepalli1 1C.S. Mott Children’s Hospital,Pediatric Surgery,Ann Arbor, MI, USA 2Henry Ford Health System,General Surgery,Detroid, MI, USA 3University Of Michigan Health System,General Surgery,Ann Arbor, MI, USA
Introduction: Despite its popularity, the thoracoscopic approach to congenital diaphragmatic hernia (CDH) repairs continues to be heavily debated and criticized. The variability in defect size, disease severity and patient characteristics pose a challenge when determining the ideal technique. Few studies use a patient and disease-matched comparison of techniques. We aimed to compare the clinical outcomes of open versus thoracoscopic repairs of small to moderate sized hernia defects in a low risk population.
Methods: All neonates receiving CDH repair of small (type A) and moderate (type B) size defects (as defined by the CDH study group) at an academic children’s hospital between 2006 and 2015 were retrospectively reviewed and analyzed. Patients less than 36 weeks EGA, weighing less than 1500 kg at birth, and requiring ECMO were excluded. Demographics, including CDH severity index, and hernia characteristics were recorded. Primary outcome parameter was recurrence. Secondary outcomes included length of hospital stay, length of mechanical ventilation, time to goal feeds, time to recurrence and mortality.
Results: The 49 patients receiving thoracoscopic (34) and open (15) repairs were similar in patient and hernia characteristics, with median 27 month follow-up (range 1-102) for both groups. A patch was utilized in 2 (13.3%) open repairs and 9 (26.5%) thoracoscopic repairs (p=0.3).Patients with thoracoscopic repair had shorter hospital stay (16 vs. 23 days, p=0.03), days on ventilator (5 vs. 12, p=0.02), days to start of enteral feeds (5 vs 10, p<0.001), and days to goal feeds (11 vs. 20, p=0.006). Higher recurrence rates in the thoracoscopic groups (14.7% vs. 6.7%) were not statistically significant (p=0.45). Average time to recurrence was 88 days for the open repair and 648 days (range 104-1837) for the thoracoscopic group. A single mortality was noted in the thoracoscopic group (3%).
Conclusion: In low risk patients presenting with small to moderate size defects, a thoracoscopic approach demonstrated decreased hospital length of stay, shorter mechanical ventilation days, and a shorter time to feeding. Despite these favorable outcomes, the long-term effectiveness of a thoracoscopic repair versus open repair remains debatable.
