Minimally Invasive Surgery For Congenital Diaphragmatic Hernia In Children

OBJECTIVE:To retrospectively analyze the clinical data of children with congenital diaphragmatic hernia(CDH)who were admitted to our hospital,compare the preoperative,intraoperative and postoperative indexes of open surgery and minimally invasive surgery(MIS),to discuss the clinical efficacy of MIS on threating CDH in children,the effects of the learning curve of MIS on the intraoperative and postoperative indexes,as well as the indications,safety and efficacy of MIS in neonates.It aims to provide a reference for the clinical application of MIS in children.METHODS:This study retrospectively analyzed the data of 137 children with CDH admitted to the Department of Pediatric Surgery in our hospital from January 2006 to December 2016.According to the research objective,the children were divided into several groups,such as:the neonatal group(?28 days),the non-neonatal(>28 day)group,the minimally invasive group,the open surgery group,the former group(from 2006 to2014),and the recent group(from 2015 to 2016),etc.,Statistical analysis of preoperative,intraoperative and postoperative data between the groups was performed,to objectively evaluate the indications and advantages of MIS for infants and neonates,and the impacts of learning curve on surgery and surgery effect.RESULT:1.A total of 33 cases of non-neonatal(>28 days)CDHs were admitted to our hospital.Five of the nine patients who underwent open surgery was the recurrent hernia.Of the 24 children who underwent MIS,1 patient with right CDH was treated with thoracoscopic repair at first but converted to open surgery.The mean duration of operation in the MIS group was108.70±33.61 min,and 106.33±35.85 min in open group.There was no statistical difference between the two groups.Intraoperative blood gas:PH value and Pa CO₂ have no significantly statistical difference.The average postoperative feeding time and average postoperative length of stay in the MIS group were significantly shorter than those in the open group(P=0.022,0.043).There was no significant difference in postoperative blood gas,postoperative rate of ventilator usage and postoperative extubation time between the two groups.All patients had no recurrence and complications after surgery.2.Of the 46 children who underwent MIS operated by the same sugeon,4have relapsed(10.81%).The average length of surgery in the former group(from 2006 to 2014)was 105.58±33.03 min,and the average length of surgery in the recent group(from 2015 to 2016)was 79.56±39.18 min(P=0.004).The birth weight and the gestational age of the newborn group in the recent years was smaller than that of the former group(P=0.009,0.046).The gestational age,Apgar score,first blood gas after birth,preoperative blood gas,pulmonary hypertension ratio,and the proportion of the preoperative using of the high frequency ventilation were not statistically significant.In recent group,the length of the application of ventilator postopative in neonates was longer than that in former years(P=0.004).There were no significant differences in postoperative blood gas,postoperative feeding time,and postoperative length of hospitalisation.3.Among the 104 neonatal CDHs(?28 days),22 cases(21.15%)died or were discharged from the hospital after abandoning the treatment.21 cases(20.19%)needed patch.In the 21 cases that needed patch,13 cases(61.90%)died.45 cases were treated with thoracoscopy.Among them,3cases conversed to open surgery(6.67%).5 patients relapsed(4.81%),4 of them occurred in the thoracoscopic group,and 1 patient occurred in the open group.The mortality rate of the open group was 32.20%,which was much higher than 7.14%of the thoracoscopic group(P=0.003).After we classified the newborns according to the severity,there was no significant difference between the open group and the thoracoscopic group in intraoperative and postoperative data.CONCLUSION:1.MIS for non-neonatal children has the advantages of small trauma,small surgical scar,and quick recovery.There was no significant correlation between the resection of the hernia sac and the recurrence rate.The high recurrence rate after MIS may be related to the surgeon's operating technique.The right-sided CDH and the recurrent CDH who firstly treated by MIS may also be operated by MIS.2.The rich experience of the MIS can greatly reduce the length of the operation,and achieve the same effect as open surgery.Compared with the early reports,the indications for MIS of neonatal CDH were less.The learning curve can be shortened under the guidance of an experienced MIS surgery doctor.3.The influence factors for the survival rate of neonatal CDH are pre-natal diagnosis of gestational weeks,Apgar score,birth weight,pulmonary hypertension etc.,and has little relation with surgical methods.With the maturity of MIS techniques,some of the early contraindications for MIS in neonates are worth reconsidering.For the prognosis of thoracoscopic surgery and open surgery,it is necessary to evaluate after eliminating the severity of the disease itself.