Minimally Invasive Approaches to Congenital Diaphragmatic Hernias



Fig. 12.1.
Two variations on standard positioning for thoracoscopic repair of L CDH: option 1 (a) and option 2 (b).




  1. (a)


    Horizontally at the foot of the bed with the surgeon at the patient’s head facing the screen and the assistant at the foot of the bed on the patient’s left side

     

  2. (b)


    Longitudinally at the head of the bed with all extraneous pieces of the bed broken down with the surgeon at the patient’s head and the assistant on the left

     




 

  • 2.


    Position the patient in the lateral decubitus position with the affected side up and slightly angled toward supine.


    1. (a)


      Coordinate carefully with anesthesia to ensure that the patient’s head and the joints of the ET tube connection remain at or slightly below the level of the patient’s body so that they will not interfere with or become dislodged during thoracoscopic instrumentation.

       

    2. (b)


      A bronchial blocker is not necessary as the remaining lung on the affected side is hypoplastic and will be further compressed with thoracoscopic insufflation.

       

     

  • 3.


    Place a “jelly roll” to support the posterior aspect of the patient and a cushion between the patient’s arms. Use other appropriate cushioning as needed.


    1. (a)


      Place the shoulder roll in a readily accessible fashion so that it can be removed and allow sterile repositioning of the patient to a supine position if conversion to subcostal laparotomy is necessary.

       

    2. (b)


      Beanbags are often too large for patients of this size and are generally more cumbersome than helpful.

       

     

  • 4.


    Position the arms in a neutral position with respect to abduction/adduction and reaching superiorly at approximately 120° to avoid interference with the ipsilateral port.

     

  • 5.


    Tape the hips and ipsilateral shoulder to the bed to further support the patient’s position.

     

  • 6.


    Prep the left thorax and abdomen from the patient’s spine to the anterior midline, superiorly beyond the tip of the scapula and inferiorly to the pelvis. This will allow sterile repositioning without re-prepping if conversion to laparotomy becomes necessary.

     

  • 7.


    Drape the patient to expose the left hemithorax in a manner that allows visualization of important landmarks: the ipsilateral nipple, the spine, and the tip of the scapula.


    1. (a)


      Place a removable sterile towel over the abdomen during thoracoscopy.

       

     






      Trocar/Port Placement





      1. 1.


        Access the thorax using the Veress technique. Hold respirations temporarily and place the Veress needle just posteriorly to the tip of the scapula at approximately the fourth intercostal space.

         

      2. 2.


        Insufflate to a pressure of 3 mmHg at a flow of 1 L/min.


        1. (a)


          Warn the anesthesia team to expect a temporary increase in the patient’s end-tidal CO2 that will usually resolve without intervention. Communication with the anesthesia team is essential at this point to ensure that the patient is tolerating the insufflation pressure.

           

         

      3. 3.


        If the patient tolerates initial insufflation, raise the pressure to 5 mmHg.

         

      4. 4.


        Replace the Veress needle with a 4-mm trocar and laparoscope.

         

      5. 5.


        Place two additional 3.5-mm ports approximately 3 cm on either side of the first port and one to two rib spaces below it (Fig. 12.2).

        A336954_1_En_12_Fig2_HTML.jpg


        Fig. 12.2.
        Standard trocar placement for thoracoscopic repair of L CDH.



        1. (a)


          Reduce instrument torque with the overlying rib by angling the trocars at a 45° angle or even tunneling a rib space caudad.

           

        2. (b)


          Place the ports as cephalad as possible to facilitate this angling, enable easier reduction of the abdominal viscera, and allow room for thoracoscopic dissection and repair in an already restricted workspace.

           

        3. (c)


          Take care not to place the ports too far medially and laterally as this causes collisions with the patient’s arms and increases torque on the instruments when trying to operate in the superior aspect of the surgical field.

           

         


      Reduction of Abdominal Viscera





      1. 1.


        Use an adjustable grasper and a bowel grasper to gently reduce the abdominal viscera from the chest in the following order: the small bowel, colon, stomach, and spleen (Fig. 12.3a).

        A336954_1_En_12_Fig3_HTML.jpg


        Fig. 12.3.
        (a) Abdominal contents are gently reduced into the abdominal cavity. (b) A splenic cap prevents migration of the abdominal contents back into the thoracic cavity during repair.



        1. (a)


          The smaller dimensions of the adjustable grasper facilitate reduction and dissection in the restricted surgical field.

           

        2. (b)


          If necessary, divide diaphragmatic attachments to the colon and other viscera with the hook electrocautery to enable complete reduction of the viscera and unfurling of the diaphragmatic edge.

           

        3. (c)


          Use two blunt/atraumatic graspers to reduce the viscera toward the anteromedial or right upper aspect of the field.

           

        4. (d)


          Cover the viscera with the splenic cap to prevent the return of the viscera to the chest (Fig. 12.3b).

           

         


      Diaphragm Repair





      1. 1.


        Place a Surgisis SIS underlay (Cook Medical, Bloomington, IN). It is our practice to do so whether or not a prosthetic patch is required, although at this time evidence is limited regarding its success in reducing recurrence rates. We do not cauterize the edge of the diaphragm peritoneum prior to repair, as there is no well-known evidence that this impacts outcomes.


        1. (a)


          Cut the SIS to size, leaving at least 1 cm excess in all directions, and roll it gently.

           

        2. (b)


          Remove one of the two lateral trocars and pass the contralateral grasper transthoracically through the vacant port site.

           

        3. (c)


          Use the grasper to drag the rolled mesh into the thorax (Fig. 12.4).

          A336954_1_En_12_Fig4_HTML.jpg


          Fig. 12.4.
          SIS mesh is pulled into the thorax through a vacant port site.

           

        4. (d)


          Unfurl the SIS on the abdominal side of the diaphragm.

           

        5. (e)


          Fasten the SIS to the diaphragm by including it in every second or third stitch of the diaphragmatic closure.

           

         

      2. 2.


        Close the diaphragm defect by passing stitches every 8–10 mm. Pass stitches via trocar or transthoracically.


        1. (a)


          If placing via trocar, it is our practice to use a 2-0 silk on a ski needle, which can be passed through a 3.5-mm port. The lack of memory in the silk facilitates easier intracorporeal knot tying.

           

        2. (b)


          If placing stitches transthoracically, a standard RB needle may be used rather than a ski needle.

           

         

      3. 3.


        Begin primary repair of the diaphragm from the medial to lateral aspect to evaluate whether a patch is required.


        1. (a)


          We prefer to begin medially out of concern that although the lateral stitch may successfully approximate the edges of the diaphragm, it may cause undue tension on the repair that only increases upon approximation of the remainder of the diaphragm. By working toward the lateral side, we evaluate whether the lateral edges can be brought together without tension after the rest of the defect is approximated.

           

        2. (b)


          Alternatively, the benefit of beginning laterally is that areas of redundancy in the medial diaphragm, if present, can be incorporated into the lateral stitch to re-approximate the lateral defect. This potentially alleviates the need for a prosthetic patch in a subset of patients.

           

        3. (c)


          If necessary, ask the assistant to perform external compression of the chest wall when placing lateral stitches, as this is the most challenging part of the repair.

           

        4. (d)


          If no patch is necessary, proceed to step 7.

           

         

      4. 4.


        If a patch is necessary, begin by placing a pericostal or “rib stitch” to approximate the lateral portion of the defect (Fig. 12.5a). It is easiest to place these first, as they will hang the patch in position while leaving adequate mobility to place the remainder of the stitches. The “rib stitch” may be placed using a variety of techniques:

        A336954_1_En_12_Fig5a_HTML.gifA336954_1_En_12_Fig5b_HTML.gif


        Fig. 12.5.
        Extracorporeal-assisted rib stitches . (a) Location of the rib stitch. (b) 2-mm nick overlying the anticipated rib. (c) A transthoracic rib stitch is performed by passing the needle from the outside of the body to the thoracic cavity, through the diaphragmatic edge, and (d) back outside the thoracic cavity, followed by (e) a backhand technique to pass the needle driver into the initial 2-mm nick. (f) Alternatively, the free end of the rib stitch is passed back out of the thoracic cavity through an angiocatheter. (g) A loop of Prolene or nylon is used to lasso the free end.



        1. (a)


          Extracorporeal-assisted rib stitches . Begin with a 2-mm nick in the skin overlying the anticipated rib (Fig. 12.5b). Place the stitch using one of two devices:
    1. Oct 25, 2017 | Posted by in PEDIATRICS | Comments Off on Minimally Invasive Approaches to Congenital Diaphragmatic Hernias
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