Abstract
Abstract
Purpose:
Although recurrence remains one of the most feared complications following congenital diaphragmatic hernia (CDH) repair, there are minimal data on the optimal surgical approach to these complex situations. The purpose of this study was to survey the international pediatric surgery community to ascertain practice patterns for both minimally invasive (MIS) and open approaches for recurrent CDH.
Materials and Methods:
A survey was e-mailed to members of an online community of pediatric surgeons. The questionnaire elicited surgeons' clinical experience, the continent in which they practice, and their surgical approach (laparotomy, thoracotomy, laparoscopy, or thoracoscopy) to five clinical cases, including initial and recurrent Bochdalek hernias. Fisher's exact test and chi-square test were used for statistical analysis.
Results:
Two-hundred eighty pediatric surgeons responded to the survey. In total, 52.1% of surgeons chose an MIS approach for an initial repair of left CDH with the younger surgeons more likely to use an MIS approach. For the recurrence scenarios, 42.5%–55.5% of these surgeons would attempt an MIS repair after a recurrence. Specifically, thoracoscopy was favored over laparoscopy following both prior laparotomy (30.0% versus 7.5%) and prior right thoracoscopy (26.4% versus 10.0%), less favored following thoracotomy (9.3% versus 18.9%), and relatively similar proportions following prior left thoracoscopy (17.5% versus 16.4%). Laparotomy was the preferred open approach both for initial presentation and all recurrence scenarios. Among surgeons who would treat initial CDH with an open procedure, between 10.4% and 17.9% would switch to an MIS approach, most commonly after prior failed laparotomy.
Conclusions:
Approximately half surgeons who approach initial left CDH in an MIS manner would attempt an MIS approach for recurrence. The tendency to approach CDH recurrence from the opposite body cavity as the initial repair clearly impacted the surgical approach. This was particularly pronounced for MIS repairs, whereas for open approach, laparotomy remained, by far, the most popular in all scenarios.
Introduction
R
Materials and Methods
A survey was e-mailed to members of an online community of pediatric surgeons affiliated with GlobalCastMD (Shaker Heights, OH). The questionnaire was created using Google Forms (Mountain View, CA) and consisted of 10 questions. It began by asking surgeons to identify their clinical experience as a pediatric surgeon by selecting how many years they have been in practice (0–10, 11–20, or >20) or if they are not a pediatric surgeon (trainee or none of the above). Participants that identified themselves as trainees or not pediatric surgeons were excluded from the study.
Next, participants identified the continent in which they practice (Asia, Europe, North America, South America, or other).
Participants were then presented several clinical cases of a hemodynamically stable infant with a CDH (both initial and recurrent). Respondents were prompted to select their preferred approach (laparotomy, thoracotomy, laparoscopy, or thoracoscopy) for cases of both initial and recurrent Bochdalek CDH. Refer to Appendix A for the complete survey.
Fisher's exact test and chi-square test were used for examination of associations among variables of interest, which are outlined below. All testing were completed utilizing SAS v 9.4/13.2 software (Cary, NC) and evaluated at the type I error rate of alpha = 0.05 level for statistical significance.
Results
The survey received 287 responses. Seven respondents did not identify themselves as pediatric surgeons and were excluded from analysis. Of the remaining 280 pediatric surgeons, 28.6% had been in practice for 0–10 years, 29.6% for 11–20 years, and 41.8% for 20 years or more. The locations of the respondents were diverse: 39.3% were in North America; 27.5% Europe; 16.8% Asia; 7.1% South America; and 9.3% other.
Younger surgeons were significantly more likely to select an MIS approach compared to surgeons who had been in practice for longer (Table 1; P < .01). There was no statistically significant association between location of practice and preference for MIS (P = .25).
MIS, minimally invasive surgery.
Initial CDH repair
52.1% of all responding surgeons chose an MIS approach for the initial repair of a left Bochdalek CDH (Table 2). Hereto forward, the 52.1% of surgeons that chose an MIS approach will be referred to as “MIS surgeons” and the 47.9% surgeons that selected an open approach will be referred to as “open surgeons,” reflecting their preferred treatment for routine initial CDH. Of the MIS surgeons, 88.4% chose thoracoscopy and 11.6% chose laparoscopy (Table 3). Among the open surgeons, 97.8% chose laparotomy and 2.2% chose thoracotomy (Table 4).
CDH, congenital diaphragmatic hernia.
CDH, congenital diaphragmatic hernia.
CDH, congenital diaphragmatic hernia.
CDH recurrence
MIS surgeons would attempt an MIS repair after a recurrence 42.5%–55.5% of the time (Table 5). Among this group, thoracoscopy was the most common approach to both recurrent left CDH after laparotomy (47.8%) and right CDH after thoracoscopy (36.3%), although laparotomy was almost as common for right CDH recurrence (34.2%). However, even in this MIS group, laparotomy was the most selected approach for a recurrent left CDH after thoracoscopy and thoracotomy with 43.2% and 49.3%, respectively. Nevertheless, MIS surgeons were overall more likely to select an MIS approach for all recurrence types compared to surgeons who prefer an open repair for initial CDH (P < .01 for all cases).
CDH, congenital diaphragmatic hernia; MIS, minimally invasive surgery.
For all CDH recurrence scenarios, laparotomy was the most popular choice among open surgeons, ranging between 59.7% and 79.1%. Open surgeons attempted MIS 10.4%–17.9% of the time in the recurrence scenarios. The two most common recurrence situations for an open surgeon to select an MIS approach were recurrent left CDH after laparotomy (14.9% thoracoscopy, 3.0% laparoscopy) and right recurrence after thoracoscopy (15.7% thoracoscopy, 2.2% laparoscopy).
Discussion
MIS for initial CDH
There are a number of factors that influence approach to a left Bochdalek CDH. The potential benefits of MIS repair of CDH include decreased pain, improved cosmetic result, faster recovery times, and, most importantly, avoidance of morbidity of laparotomy (adhesive disease) and thoracotomy (scoliosis).2–4 Even within MIS techniques, there are a variety of factors that can influence which approach to utilize in various scenarios. Advantages of thoracoscopy over laparoscopy for initial CDH repair include the greater working space in a thorax with an underdeveloped lung compared to a scaphoid abdomen and the relative ease of thoracoscopically visualizing and accessing the posterolateral aspect of the defect which often extends overlying the retroperitoneum compared to the laparoscopic approach. Finally, it is often easier to reduce the herniated viscera by pushing it through the defect with the aid of thoracic insufflation compared to pulling it laparoscopically. Laparoscopic repair for initial left CDH is much less commonly encountered. For recurrences, on the other hand, a laparoscopic approach allows dissection in a “virgin” workspace (as most primary repairs are performed thoracoscopically) and may allow easier evaluation of the herniated viscera, as well as certainty that abdominal viscera have not been incorporated into the repair. For right CDH, thoracoscopy may be preferred due to the liver making laparoscopy more difficult.
Open repair for initial CDH
Open surgeons generally prefer open repair over MIS due to greater comfort operating through laparotomy or thoracotomy or due to the lower recurrence profile suggested by a number of articles.3–8 In this study, 48% of surgeons selected an open procedure for initial CDH. Laparotomy was vastly more popular with 46% of all surgeons and 98% of open surgeons choosing it. When comparing the laparotomy to thoracotomy, laparotomy may be preferred due to better overall view and avoidance of potential chest wall defects and scoliosis associated with thoracotomy.2,9 Similar to MIS, in the case of right CDH, the liver can be the main obstacle of the repair. While this may lead some surgeons to use a thoracotomy, laparotomy can visualize the space superior to the liver as well.
MIS for recurrent CDH
MIS surgeons would frequently use MIS for a CDH recurrence as 42.5%–55.5% of MIS surgeons selected an MIS approach in recurrence scenarios. Thoracoscopy was the MIS procedure of choice in all cases except for a left-sided recurrence after a thoracotomy in which laparoscopy was favored 18.9% versus 9.3% for all surgeons and 27.4% versus 15.1% for MIS surgeons, respectively. This may illustrate the concept of a “virgin plane” in which the opposite body cavity as the initial repair is preferred due to surgical adhesions. This concept has been described in other types of hernia such as inguinal hernia recurrences. For right-sided recurrence, the liver most likely played a larger factor in shifting MIS surgeons toward thoracoscopy.
Among open surgeons, between 10% and 17% selected an MIS approach for recurrences: majority of these were thoracoscopy. This was highest after laparotomy, lending support to the virgin plane theory.
Open repair for recurrent CDH
Among all surgeons polled, laparotomy was most popular approach for all cases of recurrent CDH, suggesting that it is the open procedure of choice. Thoracotomy appears to have fallen out of favor in general with less than 10% selection rates for all left-sided CDH cases. Even for a recurrence after laparotomy, laparotomy remained more popular than thoracotomy by a large margin (53.6% versus 30.0%, respectively), indicating that the desire to operate in a virgin field is likely not enough to compel a second open incision.
For right-sided recurrent CDH, there was more of a preference for thoracotomy, although it was never a majority. This is illustrated by the fact that thoracotomy was utilized 17% for the recurrent right-sided CDH after a thoracoscopic attempt versus 6% for a recurrent left-sided CDH after a thoracoscopic attempt. Perhaps this is because the liver obstructs an abdominal approach, rendering it more difficult.
Limitations
The population of pediatric surgeons came from an e-mail list from GlobalCastMD. GlobalCastMD is an online virtual platform for medical education. It is possible that this group of surgeons would be more technologically oriented than the rest of the pediatric surgery population and could potentially be more likely to use MIS.
Surgeon preferences on treating initial right CDH were not ascertained in this survey. Without this information, it is difficult to draw conclusions as to how approach changes when faced with a right recurrence.
Further study is needed to elicit what the advantages and disadvantages are of the available technical options for repair of CDH.
Conclusion
Among MIS approaches, thoracoscopy is preferred to laparoscopy for initial CDH and all recurrences except after thoracotomy. Surgeons who approach an initial left CDH in an MIS manner would frequently attempt an MIS repair for a recurrence. There is a tendency to approach a CDH recurrence from the opposite body cavity as the initial repair. Among open approaches, laparotomy is favored over thoracotomy for initial and recurrent CDH. These findings may inform surgeons when confronted with a CDH recurrence.
Footnotes
Disclosure Statement
Dr. Bruns, Dr. Glenn, Mr. McNinch, Ms. Arps, and Dr. Schlager have no disclosures. Dr. Ponsky is the co-owner and chief medical officer of GlobalCastMD.
Appendix A. Congenital Diaphragmatic Hernia Survey
If so, to what do you attribute the infection?
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