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Recurrent congenital diaphragmatic hernia: A novel repair
Recurrent Congenital Diaphragmatic Hernia: A Novel Repair By Daniel A. Saltzman, Jared S. Ennis, John R. Mehall, Richard J. Jackson, Samuel D. Smith, and Charles W. Wagner Minneapolis, Minnesota and Little Rock, Arkansas
Background/Purpose: Repair of recurrent diaphragmatic hernia continues to be a difficult problem. An innovative method using a nonabsorbable polypropylene prosthetic mesh plug placed via the thoracic approach using minimal dissection is presented. Methods: A retrospective analysis showed 39 children with congenital diaphragmatic hernia (CDH) who underwent repair between January 1997 and March 2000. Five children suffered a recurrence and underwent repair via the thoracic approach using the Bard Marlex Mesh Perfix Plug (C.R. Bard Inc, Billerica, MA). Follow-up was available in all children and ranged from 1 to 33 months (average, 13.8 months).
repair and recurrence was 8.2 months (range, 2 to 16 months). There were no recurrences after the transthoracic mesh plug diaphragmatic hernioplasty. One child died of multiple congenital anomalies 6 months after repair.
Conclusion: The transthoracic repair of recurrent diaphragmatic hernias using a nonabsorbable polypropylene prosthetic mesh plug represents an innovative approach to a difficult problem in which 5 repairs have been accomplished without recurrence in nearly 14 months of follow-up. J Pediatr Surg 36:1768-1769. Copyright © 2001 by W.B. Saunders Company.
Results: Age at recurrence ranged from 2 to 48 months (average, 14.8 months), and the average time between initial
INDEX WORDS: Recurrent diaphragmatic hernia, mesh plug hernioplasty, transthoracic repair.
R
ECURRENCE of congenital diaphragmatic hernia (CDH) after primary repair has continued to plague the pediatric surgeon. Although very little has been written on this subject, most agree that a thoracic approach is preferred. We present 5 cases of recurrent diaphragmatic hernias in which a nonabsorbable polypropylene prosthetic mesh plug was used successfully without further recurrence.
noted to have little or no posterior rim. Recurrences were consistently located postero-medially. Recurrent repairs were approached with an anterolateral thorocotomy, and the herniated viscera subsequently was reduced, and no sac was excised. In all cases, a Marlex mesh plug was used to fill the diaphragmatic defect, and the edges of the flange were secured to the surrounding tissues with nonabsorbable suture. (Figs 1 and 2) A flat piece of the polypropylene mesh occasionally was fashioned over the plug and secured with nonabsorbable sutures. A tube thoracostomy then was performed, and the thoracic cavity closed in the conventional manner.
MATERIALS AND METHODS
RESULTS
A retrospective analysis was conducted over a 3-year period, between January 1997 and March 2000, which found 39 patients with CDH who were evaluated and treated at the Arkansas Children’s Hospital. Five of these children had a recurrence of their CDH, which was corrected using a Bard Marlex Mesh Perfix Plug (C.R. Bard Inc, Billerica, MA). Although all patients had their diaphragmatic hernias initially repaired transabdominally, recurrent repairs were approached transthoracically. All initial repairs were performed transabdominally with interrupted nonabsorbable sutures. The diaphragmatic defects were
Five children had recurrent diaphragmatic hernias that were repaired transthoracically using the mesh plug. At the initial repair of the CDH, 3 children required a prosthetic patch (Gor-Tex, W.L. Gore and Associates, Flagstaff, AZ), and 2 children required extracorporeal membrane oxygenation. Age at the time of recurrence ranged from 2 to 48 months with an average of 14.8 months. The average time from initial transabdominal repair of the CDH to transthoracic repair of the recurrence was 8.2 months (range, 2 to 16 months). In 4 children the recurrence occurred after a single transabdominal approach, the remaining child had undergone 2 transabdominal approches before the definitive repair. Follow-up data were available in all children. There were no recurrences after the transthoracic mesh plug hernioplasty. Average follow-up time was 13.8 months (range, 1 to 33 months). One child with multiple congenital anomalies, including agenesis of the corpus collosum, died 6 months postoperatively of causes unrelated to her recurrent diaphragmatic hernia repair.
From the Departments of Pediatric Surgery, University of Minnesota Hospital and Clinics, Minneapolis, MN, and Arkansas Children’ Hospital, University of Arkansas for Medical Sciences, Little Rock, AR. No commercial or external sources of funding were sought or aided in the preparation of this study. Address reprint requests to Daniel A. Saltzman, MD, PhD, Department of Surgery, Division of Pediatric Surgery, University of Minnesota Hospital and Clinics, 420 Delaware St SE, Box 195 UMHC, Minneapolis, MN 55455. Copyright © 2001 by W.B. Saunders Company 0022-3468/01/3612-0008$35.00/0 doi:10.1053/jpsu.2001.28818 1768
Journal of Pediatric Surgery, Vol 36, No 12 (December), 2001: pp 1768-1769
RECURRENT CDH
1769
Fig 1. The placing of a Bard Marlex Mesh Perfix Plug (C.R. Bard Inc, Billerica, MA) into the diaphragmatic defect.
Fig 2. Securing the Marlex Mesh plug into place with nonabsorbable suture.
DISCUSSION
1992 who described rolling a prosthetic mesh to place in the inguinal canal. Robbins and Rutkow5 reported his successful use of the mesh plug hernioplasty in 3,268 patients with a recurrence rate of less than 1%. The use of the mesh plug for recurrent diaphragmatic hernia uses the same principles of repair as that of the inguinal mesh plug hernioplasty. Minimal dissection is required, and the umbrella-shaped configuration of the mesh plug handles easily and forms a total occlusion of the defect. The characteristics of the mesh plug are such that the interstices of the mesh become infiltrated with fibroblast and over time insure a tension-free diaphragmatic hernia repair. As with any implanted foreign material, concerns regarding the long-term sequela of the implanted mesh and side effects must be acknowledged; however, polypropylene mesh has been successful in clinical use for over 4 decades. In most circumstances, a hernia sac or pseudoperitoneum is present, thus, direct apposition of the mesh material and intestine is avoided in repair. Most recently, an additional recurrent diaphragmatic hernia was repaired in a similar fashion; however, no hernia sac or pseudoperitoneum was present; thus, we used a porcine-based collagen material as a buffer between the mesh and intestine. This technique represents a novel alternate approach to this very difficult problem. To date, we have performed 5 such repairs with no evidence of a recurrence in a follow-up time of nearly 14 months.
Most recurrent diaphragmatic hernias are diagnosed by chest radiographs or contrast radiographic studies prompted by respiratory or gastrointestinal symptoms including wheezing, cough, or reflux symptoms.1 Although recurrence rates have been reported to range from 2% to 22%, the use of extracorporeal membrane oxygenation (ECMO) or a prosthetic patch can increase the recurrence rate to as high as 80%.2 There are several approaches that have been described to repair the recurrent diaphragmatic hernia.3 The most popular is the thoracic approach; however, there is no consensus on how the repair should be done. Several reports describe the use of prosthetic material or cadaveric dura.4 Others have recommended the use of flaps of endothoracic fascia, renal fascia, sliding muscle flaps from the transversus abdominus, the latissimus dorsi, or a pedicle flap of abdominal muscle.3 Repositioning the diaphragm as well as thoracoplasty and using the liver or diaphragmatic surface of the lung to occlude the defect all have been described.3 Since the mid 1980s, the use of prosthetic mesh for inguinal hernia repair has increased greatly, and it has been estimated that by 1998, 750,000 inguinal hernia repairs were done using prosthetic mesh.5 Although the use of a plug for inguinal hernia repair was described initially in the in the mid 1830s using a wooden plug placed externally in the inguinal canal, it was Gilbert6 in
REFERENCES 1. Arensman RM, Bambini DA: Congenital diaphragmatic hernia and eventration, in Ashcraft KW, Murphy JP, Sharp RJ, et al (eds): Pediatric Surgery (ed 3). Philadelphia, PA, Saunders, 2000, pp 300-317 2. Reickert CA, Hirschl RB: Congenital diaphragmatic hernia, in Stringer MD, Oldham KT, Mouriquand PDE, et al (eds): Pediatric Surgery and Urology: Long Term Outcomes. London, England Saunders, 1998, pp 131-137 3. Cohen D, Reid IS: Recurrent diaphragmatic hernia. J Pediatr Surg 16:42-44, 1981
4. Koot VC, Bergmeijer JH, Molenaar JC: Lyophylized dura patch repair of congenital diaphragmatic hernia: Occonce of relapses. J Pediatr Surg 28:667-668, 1993 5. Robbins AW, Rutkow IM: Mesh plug repair and groin hernia surgery. Surg Clin North Am 78:1007-1023, 1998 6. Gilbert Al: Inguinal hernia repair: Biomaterials and sutureless repair. Perspectives in General Surgery 2:113, 1991
Background/Purpose: Repair of recurrent diaphragmatic hernia continues to be a difficult problem. An innovative method using a nonabsorbable polypropylene prosthetic mesh plug placed via the thoracic approach using minimal dissection is presented. Methods: A retrospective analysis showed 39 children with congenital diaphragmatic hernia (CDH) who underwent repair between January 1997 and March 2000. Five children suffered a recurrence and underwent repair via the thoracic approach using the Bard Marlex Mesh Perfix Plug (C.R. Bard Inc, Billerica, MA). Follow-up was available in all children and ranged from 1 to 33 months (average, 13.8 months).
repair and recurrence was 8.2 months (range, 2 to 16 months). There were no recurrences after the transthoracic mesh plug diaphragmatic hernioplasty. One child died of multiple congenital anomalies 6 months after repair.
Conclusion: The transthoracic repair of recurrent diaphragmatic hernias using a nonabsorbable polypropylene prosthetic mesh plug represents an innovative approach to a difficult problem in which 5 repairs have been accomplished without recurrence in nearly 14 months of follow-up. J Pediatr Surg 36:1768-1769. Copyright © 2001 by W.B. Saunders Company.
Results: Age at recurrence ranged from 2 to 48 months (average, 14.8 months), and the average time between initial
INDEX WORDS: Recurrent diaphragmatic hernia, mesh plug hernioplasty, transthoracic repair.
R
ECURRENCE of congenital diaphragmatic hernia (CDH) after primary repair has continued to plague the pediatric surgeon. Although very little has been written on this subject, most agree that a thoracic approach is preferred. We present 5 cases of recurrent diaphragmatic hernias in which a nonabsorbable polypropylene prosthetic mesh plug was used successfully without further recurrence.
noted to have little or no posterior rim. Recurrences were consistently located postero-medially. Recurrent repairs were approached with an anterolateral thorocotomy, and the herniated viscera subsequently was reduced, and no sac was excised. In all cases, a Marlex mesh plug was used to fill the diaphragmatic defect, and the edges of the flange were secured to the surrounding tissues with nonabsorbable suture. (Figs 1 and 2) A flat piece of the polypropylene mesh occasionally was fashioned over the plug and secured with nonabsorbable sutures. A tube thoracostomy then was performed, and the thoracic cavity closed in the conventional manner.
MATERIALS AND METHODS
RESULTS
A retrospective analysis was conducted over a 3-year period, between January 1997 and March 2000, which found 39 patients with CDH who were evaluated and treated at the Arkansas Children’s Hospital. Five of these children had a recurrence of their CDH, which was corrected using a Bard Marlex Mesh Perfix Plug (C.R. Bard Inc, Billerica, MA). Although all patients had their diaphragmatic hernias initially repaired transabdominally, recurrent repairs were approached transthoracically. All initial repairs were performed transabdominally with interrupted nonabsorbable sutures. The diaphragmatic defects were
Five children had recurrent diaphragmatic hernias that were repaired transthoracically using the mesh plug. At the initial repair of the CDH, 3 children required a prosthetic patch (Gor-Tex, W.L. Gore and Associates, Flagstaff, AZ), and 2 children required extracorporeal membrane oxygenation. Age at the time of recurrence ranged from 2 to 48 months with an average of 14.8 months. The average time from initial transabdominal repair of the CDH to transthoracic repair of the recurrence was 8.2 months (range, 2 to 16 months). In 4 children the recurrence occurred after a single transabdominal approach, the remaining child had undergone 2 transabdominal approches before the definitive repair. Follow-up data were available in all children. There were no recurrences after the transthoracic mesh plug hernioplasty. Average follow-up time was 13.8 months (range, 1 to 33 months). One child with multiple congenital anomalies, including agenesis of the corpus collosum, died 6 months postoperatively of causes unrelated to her recurrent diaphragmatic hernia repair.
From the Departments of Pediatric Surgery, University of Minnesota Hospital and Clinics, Minneapolis, MN, and Arkansas Children’ Hospital, University of Arkansas for Medical Sciences, Little Rock, AR. No commercial or external sources of funding were sought or aided in the preparation of this study. Address reprint requests to Daniel A. Saltzman, MD, PhD, Department of Surgery, Division of Pediatric Surgery, University of Minnesota Hospital and Clinics, 420 Delaware St SE, Box 195 UMHC, Minneapolis, MN 55455. Copyright © 2001 by W.B. Saunders Company 0022-3468/01/3612-0008$35.00/0 doi:10.1053/jpsu.2001.28818 1768
Journal of Pediatric Surgery, Vol 36, No 12 (December), 2001: pp 1768-1769
RECURRENT CDH
1769
Fig 1. The placing of a Bard Marlex Mesh Perfix Plug (C.R. Bard Inc, Billerica, MA) into the diaphragmatic defect.
Fig 2. Securing the Marlex Mesh plug into place with nonabsorbable suture.
DISCUSSION
1992 who described rolling a prosthetic mesh to place in the inguinal canal. Robbins and Rutkow5 reported his successful use of the mesh plug hernioplasty in 3,268 patients with a recurrence rate of less than 1%. The use of the mesh plug for recurrent diaphragmatic hernia uses the same principles of repair as that of the inguinal mesh plug hernioplasty. Minimal dissection is required, and the umbrella-shaped configuration of the mesh plug handles easily and forms a total occlusion of the defect. The characteristics of the mesh plug are such that the interstices of the mesh become infiltrated with fibroblast and over time insure a tension-free diaphragmatic hernia repair. As with any implanted foreign material, concerns regarding the long-term sequela of the implanted mesh and side effects must be acknowledged; however, polypropylene mesh has been successful in clinical use for over 4 decades. In most circumstances, a hernia sac or pseudoperitoneum is present, thus, direct apposition of the mesh material and intestine is avoided in repair. Most recently, an additional recurrent diaphragmatic hernia was repaired in a similar fashion; however, no hernia sac or pseudoperitoneum was present; thus, we used a porcine-based collagen material as a buffer between the mesh and intestine. This technique represents a novel alternate approach to this very difficult problem. To date, we have performed 5 such repairs with no evidence of a recurrence in a follow-up time of nearly 14 months.
Most recurrent diaphragmatic hernias are diagnosed by chest radiographs or contrast radiographic studies prompted by respiratory or gastrointestinal symptoms including wheezing, cough, or reflux symptoms.1 Although recurrence rates have been reported to range from 2% to 22%, the use of extracorporeal membrane oxygenation (ECMO) or a prosthetic patch can increase the recurrence rate to as high as 80%.2 There are several approaches that have been described to repair the recurrent diaphragmatic hernia.3 The most popular is the thoracic approach; however, there is no consensus on how the repair should be done. Several reports describe the use of prosthetic material or cadaveric dura.4 Others have recommended the use of flaps of endothoracic fascia, renal fascia, sliding muscle flaps from the transversus abdominus, the latissimus dorsi, or a pedicle flap of abdominal muscle.3 Repositioning the diaphragm as well as thoracoplasty and using the liver or diaphragmatic surface of the lung to occlude the defect all have been described.3 Since the mid 1980s, the use of prosthetic mesh for inguinal hernia repair has increased greatly, and it has been estimated that by 1998, 750,000 inguinal hernia repairs were done using prosthetic mesh.5 Although the use of a plug for inguinal hernia repair was described initially in the in the mid 1830s using a wooden plug placed externally in the inguinal canal, it was Gilbert6 in
REFERENCES 1. Arensman RM, Bambini DA: Congenital diaphragmatic hernia and eventration, in Ashcraft KW, Murphy JP, Sharp RJ, et al (eds): Pediatric Surgery (ed 3). Philadelphia, PA, Saunders, 2000, pp 300-317 2. Reickert CA, Hirschl RB: Congenital diaphragmatic hernia, in Stringer MD, Oldham KT, Mouriquand PDE, et al (eds): Pediatric Surgery and Urology: Long Term Outcomes. London, England Saunders, 1998, pp 131-137 3. Cohen D, Reid IS: Recurrent diaphragmatic hernia. J Pediatr Surg 16:42-44, 1981
4. Koot VC, Bergmeijer JH, Molenaar JC: Lyophylized dura patch repair of congenital diaphragmatic hernia: Occonce of relapses. J Pediatr Surg 28:667-668, 1993 5. Robbins AW, Rutkow IM: Mesh plug repair and groin hernia surgery. Surg Clin North Am 78:1007-1023, 1998 6. Gilbert Al: Inguinal hernia repair: Biomaterials and sutureless repair. Perspectives in General Surgery 2:113, 1991