Thoracoscopic Repair of Congenital Diaphragmatic Hernia After Extracorporeal Membrane Oxygenation: Feasibility and Outcomes

Abstract

Introduction: Thoracoscopic repair of congenital diaphragmatic hernia (CDH) has been associated with faster recovery, earlier extubation, and decreased morbidity. Nevertheless, thoracoscopic repair is rarely attempted in the post-extracorporeal membrane oxygenation (ECMO) patient. Commonly cited reasons for not attempting thoracoscopy include concerns that the patients' respiratory status is too tenuous to tolerate insufflation pressures or that presumed defect size is so large that it precludes thoracoscopic repair. Our purpose is to review our experience with post-ECMO thoracoscopic CDH repair and evaluate the success of this approach.

Methods: We performed retrospective analysis of attempted thoracoscopic CDH repairs after ECMO decannulation at our institution from 2001 to 2015. Primary outcome was rate of conversion. Secondary outcomes were intraoperative end-tidal CO₂, time to extubation, and rate of recurrence.

Results: We identified 21 post-ECMO patients in whom thoracoscopic CDH repair was attempted. Thoracoscopic repair was successfully completed in 28%. No patients had reported intolerance to insufflation at 3-7 mmHg. Average end-tidal CO₂ at 15 operative minutes was 36.9 mmHg in the thoracoscopic group versus 50.7 mmHg in the open group and at 60 minutes was 34.25 mmHg versus 45.6 mmHg, respectively. One patient in the thoracoscopic group died and 1 experienced a large pneumothorax. In the converted group there was one clinically significant pneumothorax and three pleural effusions. Survivors after thoracoscopy were extubated an average of 5.6 ± 2.6 days after surgery versus 19.4 ± 10 days in the converted group (P < .05). Recurrence rates at last follow-up were equal between the two groups at 20%.

Conclusions: Thoracoscopic CDH repair is both safe and feasible after ECMO with no increase in operative morbidity or mortality. Insufflation pressures of 3-7 mmHg are well tolerated without undue increase in end-tidal CO_2. When compared to conversion cases, thoracoscopic repair is associated with significantly decreased time to extubation with no difference in recurrence.

Keywords: congenital diaphragmatic hernia; extracorporeal membrane oxygenation; thoracoscopy.