Fetal surgery for congenital diaphragmatic hernia

Abstract

Fetal surgery for congenital diaphragmatic hernia (CDH) is controversial. The rationale for fetal intervention remains as compelling today as it was a decade ago. There continue to be newborns delivered with CDH who have severe enough pulmonary hypoplasia to result in significant morbidity or mortality. During the past decade ECMO, high-frequency ventilation, nitric oxide, surfactant therapy, and other advances in neonatal care have been applied to newborns with severe CDH. Although some would disagree, there is little convincing evidence that these therapies have had a major impact on the morbidity rate and mortality rate of patients with severe CDH. On the other hand, fetal surgery has not yet fulfilled its early promise. Although tremendous strides have been made in operative techniques, fetal monitoring, maternal-fetal anesthesia, and tocolysis, fetal repair of CDH has proved to be a formidable challenge and has not improved on the natural history of the disease. Recent application of tracheal ligation as a relatively simple method to accelerate lung growth in utero has been promising but requires further experience. The purpose of this article is to critically assess whether there is a role for fetal surgery in the treatment of CDH, and, if so, under what selected circumstances.