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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