Monday, July 10, 2017

Pediatric Surgery Congenital diaphragmatic hernia

Congenital Diaphragmatic Hernia
Mostly a left sided hernia, through a defect in the dome of the diaphragm, pushing the abdominal viscera into the chest.
Problems
   Respiratory distress due to lung compression
   Associated ipsilateral lung hypoplasia
   Poorly developed abdominal cavity.
Objectives
   Reduce the hernial contents to abdomen
   Repair the defect in the diaphragm
   Allow slow expansion of the hypoplastic lung
   Increase the space in the abdominal cavity.
Position
Supine with a folded towel under the lower chest.
Anesthesia
   General with endotracheal intubation
   Face-mask inhalation of gases-contraindicated.
Procedure
   1.  Subcostal incision 5-7 cm long and 1 cm below the costal margin.
   2.  Divide subcutaneous tissue and muscles with cautery.
   3.  Open the peritoneum.
   4.  Reduce the contents (stomach, intestine, colon, spleen) from the chest.
   5.  Retract left lobe of the liver medially.
   6.  Retract the stomach, intestine and spleen inferiorly.
   7.  Identify the defect in the diaphragm.
   8.  Mobilize the edges of the defect.
   9.  Drain the left chest under water seal.
10.  Suture the defect in 2 layers (double breasting) with 4/0 silk.
11.  Stretch the abdominal muscles, if required.
12.  Avoid undue resistance to breathing.
Options
1. Gastrostomy for abdominal decompression.
2. Marlex mesh to repair the large defects of the diaphragm.
3. Creation of a ventral hernia to prevent respiratory distress.
4. Elective postoperative ventilation to assist in respiration.
Instruments
General pediatric set.
Special
   Red rubber catheter (#8)                 1
   Under-water seal bottle, tubes and         1
connector
   Marlex or prolene mesh.
Sutures
   4/0 Catgut 1
   4/0 Silk                   2

   4/0 Nylon    1

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