Philippine Journal of Surgical Specialties Vol. 74, No. 2, July-December, 2019, pp 58-61
Use of Low-Pressure Pneumothorax During Thoracoscopic Repair of a Pediatric Congenital Diaphragmatic Hernia: A Case Report
Author(s): Johann Paulo S. Guzman, MD, Angelie Paz Azurin, MD and Ryan Ed Comuelo, MD, FPCS, FPSGS
Abstract:
Reported here is the case of a 6-year-old male child with a left Congenital Diaphragmatic Hernia who underwent thoracoscopic repair. The use of continuous low-pressure CO2 insufflation pneumothorax during the procedure not only made manipulation during the reduction of bowel contents back into the abdomen easier, but also facilitated repair of the defect as it maintained bowel reduction during suturing. Although prolonged CO2 has been hypothesized to be hazardous leading to hypercapnea and aggravating pulmonary hypertension in Congenital Diaphragmatic Hernia patients. The authors found it to be a safe modification of the technique as long as pre-operative planning, patient selection and intra-operative maneuvers were properly performed.
According to a large European register-based study, the reported incidence of Congenital Diaphragmatic Hernia (CDH) is 2.3 cases per 10,000 live births. Whereas, a similar American study reported an incidence of 1.93 cases per 10,000 live births. CDH is a rare congenital abnormality associated with a defect in the diaphragm closely associated with pulmonary hypoplasia and pulmonary hypertension. Most common is the posterolateral defect (Bochdaleck). It can be unilateral or bilateral, isolated or syndromic and is associated with high mortality rates.3Thoracoscopic repair has been proven to be a safe approach in the treatment of CDH, using 3 trocars in the chest using Carbon Dioxide (CO2) insufflations of 4-6mm Hg popularized by Liem. Single or double lung ventilation can be used during the repair and insufflation of the chest helps in the easier reduction of bowels back into the abdomen. Once the bowel has been reduced, insufflation can be stopped and the diaphragm can be repaired with interrupted non-absorbable sutures tied either intra or extracorporeal.
In this case report, the authors highlight a variation of the technique where they used continuous chest insufflation while closing the diaphragm.
Key words: Hernias, diaphragmatic, congenital; Pneumothorax; child