Introduction
Congenital diaphragmatic hernia repair is a surgical procedure that aims to close an opening or space in a baby's diaphragm, which is called a hernia. This type of birth defect is rare and referred to as a congenital condition, meaning it is present at birth. The left side is the most common location for CDH to occur, where there is a hole in the diaphragm that allows abdominal contents, such as the stomach, intestine, liver, spleen, or kidney, to herniate into the fetal chest. This herniation occupies space in the chest, which can hinder the normal growth of the lungs, leading to pulmonary hypoplasia, where both lungs may be affected. While in the uterus, a fetus does not require its lungs for breathing, as the placenta performs this function. However, if the lungs are underdeveloped at birth, the newborn won't be able to obtain sufficient oxygen to survive.
What Is Diaphragmatic Hernia Repair?
Before and after the surgery, nearly all infants with CDH require a breathing machine to enhance their oxygen levels. Extracorporeal membrane oxygenation (ECMO) may also be necessary for many babies with CDH. This method uses a pump to circulate blood through an artificial lung and then return it to the baby's bloodstream.
The surgery is performed under general anesthesia while the child is asleep and can't feel any pain. The surgeon typically makes an incision in the upper abdomen below the ribs to access the organs in the area. The surgeon then gently guides these organs into their correct position, passing them through the diaphragm opening and into the abdominal cavity.
For less severe cases, the surgery may be conducted using smaller incisions in the chest. A thoracoscope, a tiny video camera, is placed through one of the incisions to enable the surgeon to observe the chest's interior. The other incision is made to put the instruments through it to repair the hole in the diaphragm.
Regardless of the type of operation performed, the surgeon repairs the diaphragm hole. If the hole is small, stitches may be sufficient for repair. Or, to cover the hole, an artificial patch is used.
Why and When Is Diaphragmatic Hernia Repair Required?
Diaphragmatic hernia repair is a surgical procedure that is performed to treat a diaphragmatic hernia. It is a condition where there is a hole or a defect in the diaphragm muscle that separates the chest from the abdomen. During the surgery, the diaphragm is repaired by closing the hole or defect using various techniques, such as sutures or the use of a prosthesis. The goal of the surgery is to restore the normal function of the diaphragm, which helps in breathing and also prevents abdominal organs from moving into the chest cavity. The repair may be done through traditional open surgery or using minimally invasive techniques, depending on the size and location of the hernia and the surgeon's preference. Although there is no perfect time for repairing a congenital diaphragmatic hernia (CDH), experts recommend that the best chance for success is within the first 24 to 48 hours of life, when it is possible to achieve normal lung function and oxygen levels with minimal ventilation. However, if CDH is accompanied by other life-threatening abnormalities, repairing the hernia may not be advisable.
What Is the Procedure of Diaphragmatic Hernia Repair Surgery?
Before the Surgery:
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Babies born with diaphragmatic hernia require admission to a neonatal intensive care unit (NICU), where they can receive critical medical care. Due to the life-threatening nature of the condition and the risks associated with transporting a very ill newborn, it is recommended that babies known to have CDH are delivered in a medical center that has both pediatric surgeons and neonatologists.
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Before surgery, the child may require a breathing machine, also known as a mechanical ventilator, in the NICU to help breathing. In some cases, a heart-lung bypass machine, such as an extracorporeal membrane oxygenator (ECMO), may be needed to perform the work of the heart and lungs for the baby.
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Before the surgery, the baby will undergo x-rays and regular blood tests to assess lung function. A pulse oximeter will also be attached to the baby's skin to monitor blood oxygen levels. To control blood pressure and ensure comfort, the baby may be given medication.
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To prevent air from entering the stomach, a tube will be inserted through the mouth or nose to the stomach. Additionally, an artery tube will be placed to monitor blood pressure, and a vein tube will be placed to deliver nutrients and medication.
After the Surgery:
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After the diaphragmatic hernia repair surgery, the baby will need to stay in the hospital for several weeks and will require a breathing machine during this time. However, not every child requires breathing machine or a ventilator after surgery. The severity of pulmonary hypertension (an important predictor) or pulmonary hypoplasia determines the artificial ventilation duration. Even after being taken off the machine, oxygen, and medication may still be necessary for a period.
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Once the baby's bowels are functioning, feeding can commence. Typically, soft feeding tubes are used to provide nutrition through the mouth or nose into the stomach or small intestine until your baby is ready to consume milk by mouth.
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Infants with diaphragmatic hernia frequently experience reflux during feedings, where food or stomach acid moves up into the esophagus. This condition can cause discomfort and vomiting, which can make feeding challenging. Reflux also increases the risk of pneumonia if milk is inhaled into the lungs. Feeding specialists and nurses will teach you how to feed and hold the baby to minimize reflux. Some babies may require feeding tubes for an extended period to ensure sufficient calorie intake for growth.
Conclusion
Diaphragmatic hernia repair is a surgical procedure performed to close an opening in the diaphragm of a baby born with a congenital diaphragmatic hernia (CDH). This rare birth defect can cause the abdominal organs to move into the chest cavity, preventing the lungs from developing normally. During the surgery, the surgeon makes an incision in the baby's belly under the upper ribs to reach the organs and pull them down through the opening in the diaphragm. In less severe cases, the surgery can be performed with smaller incisions. Repair can be done either laparoscopically or thoracoscopically or by open approach .Babies with CDH also experience reflux when they eat, and the nurses and feeding specialists can teach parents techniques to prevent this. With proper care and treatment, most babies with CDH can recover and grow normally.
