Bedside Neonatal Intensive Care Unit Correction of Congenital Diaphragmatic Hernia: Is Repair without Compromise?

Abstract

Objectives This study aims to evaluate the feasibility, safety, limitations, and outcomes of performing different surgical approaches and techniques for the bedside repair of congenital diaphragmatic hernia (CDH) in critically ill patients who cannot be transferred to the operating room.

Study Design Between December 1997 and July 2013, medical charts of all neonates operated on at the bedside for CDH while on high-frequency oscillatory ventilation (HFOV) and nitric oxide were reviewed. Demographic data; contributing antenatal, perinatal, and postnatal factors; clinical presentation; associated anomalies; respiratory and hemodynamic status; operative details; complications, and outcome were analyzed.

Results A total of 101 cases of CDH were operated on, of which 11 were in very critical condition and operated on at the bedside in the neonatal intensive care unit (NICU). The mean gestational age was 38.09 weeks, birth weight, 2.91 kg, and age at surgery, 10 days. All were on HFOV and inotropic support and had pulmonary hypertension. Nine of them were on nitric oxide. Mean preoperative parameters were as follows: O₂, 52%; mean airway pressure, 15; pH, 7.40; Po ₂, 88.5 mm Hg; and Pco ₂, 47 mm Hg. Nine patients underwent laparotomy and two underwent thoracoscopy. All procedures were completed uneventfully.

Conclusions Bedside repair of CDH in the NICU while on HFOV is feasible and safe. It is not associated with any compromise in the surgical approach or technique.

Keywords

congenital diaphragmatic hernia - bedside repair - neonatal intensive care unit - surgery - critically ill

• References

• 1 McKee M. Operating on critically ill neonates: the OR or the NICU. Semin Perinatol 2004; 28 (3) 234-239
• 2 Besag FM, Singh MP, Whitelaw AG. Surgery of the ill, extremely low birthweight infant: should transfer to the operating theatre be avoided?. Acta Paediatr Scand 1984; 73 (5) 594-595
• 3 Finer NN, Woo BC, Hayashi A, Hayes B. Neonatal surgery: intensive care unit versus operating room. J Pediatr Surg 1993; 28 (5) 645-649
• 4 Gavilanes AW, Heineman E, Herpers MJ, Blanco CE. Use of neonatal intensive care unit as a safe place for neonatal surgery. Arch Dis Child Fetal Neonatal Ed 1997; 76 (1) F51-F53
• 5 Fanning NF, Casey W, Corbally MT. In-situ emergency paediatric surgery in the intensive care unit. Pediatr Surg Int 1998; 13 (8) 587-589
• 6 Frawley G, Bayley G, Chondros P. Laparotomy for necrotizing enterocolitis: intensive care nursery compared with operating theatre. J Paediatr Child Health 1999; 35 (3) 291-295
• 7 Boloker J, Bateman DA, Wung JT, Stolar CJ. Congenital diaphragmatic hernia in 120 infants treated consecutively with permissive hypercapnea/spontaneous respiration/elective repair. J Pediatr Surg 2002; 37 (3) 357-366
• 8 Beres AL, Puligandla PS, Brindle ME ; CAPSNet. Stability prior to surgery in Congenital Diaphragmatic Hernia: is it necessary?. J Pediatr Surg 2013; 48 (5) 919-923
• 9 Rozmiarek AJ, Qureshi FG, Cassidy L, Ford HR, Hackam DJ. Factors influencing survival in newborns with congenital diaphragmatic hernia: the relative role of timing of surgery. J Pediatr Surg 2004; 39 (6) 821-824 , discussion 821–824
• 10 Lally KP, Paranka MS, Roden J , et al. Congenital diaphragmatic hernia. Stabilization and repair on ECMO. Ann Surg 1992; 216 (5) 569-573
• 11 Fallon SC, Cass DL, Olutoye OO , et al. Repair of congenital diaphragmatic hernias on Extracorporeal Membrane Oxygenation (ECMO): does early repair improve patient survival?. J Pediatr Surg 2013; 48 (6) 1172-1176
• 12 Mallick MS, Jado AM, Al-Bassam AR. Surgical procedures performed in the neonatal intensive care unit on critically ill neonates: feasibility and safety. . Ann Saudi Med 2008; 28 (2) 105-108
• 13 Clark RH, Hardin Jr WD, Hirschl RB , et al. Current surgical management of congenital diaphragmatic hernia: a report from the Congenital Diaphragmatic Hernia Study Group. J Pediatr Surg 1998; 33 (7) 1004-1009
• 14 Truog RD, Schena JA, Hershenson MB, Koka BV, Lillehei CW. Repair of congenital diaphragmatic hernia during extracorporeal membrane oxygenation. Anesthesiology 1990; 72 (4) 750-753
• 15 Liem NT, Dien TM, Ung NQ. Thoracoscopic repair in the neonatal intensive care unit for congenital diaphragmatic hernia during high-frequency oscillatory ventilation. J Laparoendosc Adv Surg Tech A 2010; 20 (1) 111-114
• 16 Lago P, Meneghini L, Chiandetti L, Tormena F, Metrangolo S, Gamba P. Congenital diaphragmatic hernia: intensive care unit or operating room?. Am J Perinatol 2005; 22 (4) 189-197