medical

1. RE OPERATIVE IN
DIAPHRAGMATIC
HERNIA
Dr/Medhat M. Ibrahim
Consultant of pedia-surgery

2.  “Good judgment comes from experience, and
often experience comes from poor judgment.”

3. OVERVIEW
 The complexity of patients born with CDH
creates a challenge to every surgeon who
must bring these infants to the operating
theater for the initial repair.
 In this instance, the operation is relatively
straight forward,
 but the physiology is treacherous.

4. Cont,
 Conversely, when situations arise requiring a
subsequent procedure, the physiology is often,
but not always, more settled, but the
procedure is usually much more difficult.
 With increased survival has come increased
morbidity and, not surprisingly, subsequent
operations have become fairly common.

5. Cont,
 In one report, 42% of CDH survivors required
at least one additional operation. The need for
reoperation is often predictable, as are the
common indications.
 First and foremost is a recurrence of the
hernia.
 Second feeding problem(gastro esophageal
reflux (GER),
 Then variable other causes as un descended
testes, inguinal hernia, other.

6. Incidence of Reherniation
 Re herniation after a CDH repair has varied from
2–22%.
 But has been reported to be as high as 80% in a
select group:
 large defect,
 absent posterior portion of the diaphragm,
 Sever lung hypo- plasia that require ECMO ,long
mechanical ventilation.
 Patch graft repair,
 Neuorogenic defect associated with CDH as
phrenic nerve affection.

7. CONT,
 Also the method of initial reconstruction.
 Most important is the length of follow-up:
 Van Meurs et al., 40% of CDH survivors with a
patch repair eventually had a recurrence.
 Moss et al; reported that within 3 years of initial
repair, nearly 50% of patients who underwent a
patch repair had developed a re-herniation.
 Moss also noted that the majority of re-herniations
were owing to the patch pulling away from the
posterior thoracic wall

8. Presentation
 The majority present within the first 24 months
of life.
 Moss and colleagues found a bimodal peak
incidence of recurrence.
 The first being between 1 and 3 months of age
and the second between 10 and 36 months.
 Saltzman et al. reported that the age at time of
recurrence ranged from 2 to 48 months, with
the average being approximately 14 months

9. CONT,
 In fact, reherniation is often only discovered on
routine chest radiographs.
 For this recommend regular surveillance chest
radiographs is important as:
 Monthly for the first 6 months.
 3months until the age of 24 months.
 Then at 30 and 36 months.
 Every 2–3 years until age 10.

10. Cont,
 in may experience the incidence of recurrence
drops precipitously after 6 months, so I do not
obtain annual chest x-rays (CXR) for
surveillance purposes alone unless there is
clinical need after that time.

11. symptoms related to a
reherniation
 Generally fall into two categories:
1. pulmonary symptoms.
2. gastrointestinal symptoms.

12. pulmonary symptoms
I. Pulmonary symptoms are rare beyond the
neonatal period.
II. Tachypnea,
III. Persistent cough,
IV. Development of aspiration pneumonia,
and/or recurrent
V. Wheezing requiring increased use of
bronchodilators

13. Cont,
 Respiratory distress in an older child is an
ominous sign as tachypnea is usually a
physiologic response to metabolic acidosis
rather than pulmonary compromise.
 Development of any of these symptoms should
trigger a search for an occult reoccurrence.

14. The gastrointestinal symptoms
 Progressive oral aversion.
 New or increased feeding intolerance.
 Increased vomiting or worsening GER.
 Abdominal distension, or abdominal pain.
 Although these symptoms are not unique to
reherniation,so I have differentiate between
rehernation, adhesive intestinal obstruction,
GER.

15. Diagnostic Tools
 The diagnosis of recurrent CDH should be
suspected based on history and physical exam,
and can often be confirmed with a single chest
radiograph.
 Adjunctive radiological studies will be necessary
to help better understand the anatomy as
regards the location of reherniation and the
amount of abdominal contents involved.

16. The studies of value
 upper gastrointestinal (UGI) with small bowel
follow through.
 contrast enema.
 With the advent of faster CT scans which have
eliminated the need for sedation, CT has
become our preferred diagnostic tool.
 In cases where reherniation is suspected on
clinical grounds, but the chest film is equivocal

17. Upper gastrointestinal (UGI) with small bowel
follow through.

18. Recurrent left CDH with bowel in
chest. Note the pH probe.

19. Coronal CT reconstruction right
CDH recurrence

20. The Surgical Approach
 patients can be divided into symptomatic and
asymptomatic groups.
 Symptomatic-------- urgent repair.
 Asymptomatic------- treated expectantly for
several months, or in some cases years, as
long as they are carefully monitored.
 I believe that all recurrences will eventually
necessitate repair.

21. The justification for delaying repair
in asymptomatic patients
 includes allowing time for improvement in:
 Pulmonary
 nutritional parameters
 Tissue to be viable and tolerate repair
 Avoid bleeding and subsequent non required morbid
procedures.
 From a practical standpoint, repairing or replacing
a patch simply resets the clock until the next
recurrence. So allowing the asymptomatic child to
grow might allow for a more secure repair later
and fewer repairs in total.

22. The choice of approach
 Theoretically, the repair can be performed
either via open or minimally invasive
technique, but as a practical matter, the latter
is probably only appropriate for the most
minimal of defects.
 The choice of approach may be influenced by
other circumstances such as:
Fundoplication
Gastrostomy tube will also be performed at the time of
the repair,
An incisional hernia is present

23. The trans thoracic approach
 Favored by some
 It is more likely to provide a virgin operative field
in patients who initially underwent a trans
abdominal repair.
 Well not be reasonable in :
 child has evidence of pulmonary hypertension
 inadequate lung reserve
 Practically you cant repair the postero medial herniation
through it, also the retro peritoneal weakness cant be
managed through.
 If the patient need for other procedure as gastrostomy
,fundoplication, adhesolysis,

24. Trans abdominal approach
 which is often a bit more challenging and time
consuming.
 Allows us better visualization of the defect itself,
and the organs and structures that must be
preserved.
 It also provides ready access to perform a
fundoplication and/or gastrostomy tube should
one be needed.

25. The thoraco-scope
 It can be diagnostic
 Repair small postero lateral defect.
 Large rehernation is associated with adhesion
exposing the procedure to failure or end with
morbidity.
 So theoretically it is helpful ,practically it is too
risk.

26. Repair Techniques
 plan the most appropriate repair technique.
 the mode of failure of the initial repair must be
ascertained.
 The location of failure is important, as it will dictate
subtle but important differences in timing and
technique.
 there are four primary modes of failure:
 failure of a primary repair
 failure of the medial aspect of the repair
 recurrence at the posterior-lateral margin
 Development of a paraesophageal hernia
which is not recurrence in all most the
literature.

27. Anterior and lateral
 failures are rare
 probably because the anterior lip of diaphragm
seems to be the thickest muscle.
 The liver act as a support foe the repair.
 The heart also from above.
 There is no real negative force at this site as
the maximum force loud come at the center of
the diaphragm and posterolateral.

28. the cause of recurrence
 In the case of a failed primary repair, the cause of
recurrence is often a high-tension initial repair in
which the sutures simply could not hold the tissue
together.
 In these cases, another primary repair is usually
impossible and a new prosthetic patch should be
placed.
 A novel dome technique was described by Loff
and coworkers in 2005.
 A variety of novel approaches to repairing a
recurrent hernia both with prosthetic patches and
with muscle flaps have been described.

29. Holy Grail
 The “Holy Grail” of CDH repair is a patch that can
grow and remodel with the child. Recent large
animal data suggest that CDH repair with
autologous, engineered tendon patches is
possible.
 These grafts can be made available at birth, as
they can be engineered in parallel to gestation,
from cells normally present in, and harvested
from, the amniotic fluid.
 A proposed protocol for the first clinical trial of this
novel therapeutic concept is currently under
review by the Food and Drug Administration
(FDA)

30. What we do?
 However, until pre-engineered bio prosthetic
patches
become a clinical reality, we will continue to
rely on the synthetic devices currently
available.