Surgical Timing in Left Mild-to-Moderate Congenital Diaphragmatic Hernia

Background: The optimal timing of surgery for left-sided mild-to-moderate congenital diaphragmatic hernia (CDH) remains unknown. Objectives: To determine the optimal timing of surgery for left-sided mild-to-moderate CDH. Methods: Thirty newborns were randomly divided into emergency (EAR) and delayed (DEL) surgery groups. Thoracoscopic repair of CDH was performed within 48 hours after birth in the EAR group and then in the DEL group. Next, the baseline data, primary and secondary endpoints, and adverse reactions were assessed. Results: Differences between the two groups were not significant in terms of the measured lung-to-head ratio (LHR), preoperative pulmonary artery hypertension (PAH)-free/mild PAH ratio, surgery duration, duration of postoperative mechanical ventilation, incidence of postoperative moderate-to-severe PAH, postoperative mortality, and recurrence rate in the follow-up (P > 0.05 for all). Meanwhile, age at surgery (P = 0.001), duration of fasting (P = 0.001), and hospital stay (P = 0.032) were significantly different between the two groups. Conclusions: Timing of thoracoscopy, performed within 85 hours of birth for left-sided CDH repair, does not affect the therapeutic outcomes of children with left-sided mild-to-moderate CDH.

Feasible techniques in robotic thoracoscopic repair of congenital esophageal atresia: case report and literature review

Background Robotic repair for esophageal atresia (EA) using da Vinci system is challenging. Specific surgical techniques need to be explored to overcome the current hurdles. Case presentation Two cases with EA (type I and type III by Gross classification, respectively) were repaired using da Vinci robotic system. Step trocar insertion and asymmetric ports distribution techniques were used. The mean weight was 3.2 kg. Operative times were 95 min totally, with the anastomotic time of 27.5 min. Follow-up duration was 12 months. Esophageal fistula reoccurred in one case. None was confirmed anastomotic stricture. Conclusion Step trocar insertion procedure and asymmetric ports distribution technique are effective in robotic esophageal atresia.

Thoracoscopic oesophageal atresia/tracheo-oesophageal fistula (OA/TOF) repair is associated with a higher stricture rate: a single institution’s experience

Purpose Thoracoscopic OA/TOF repair was first described in 1999. Currently, less than 10% of surgeons routinely employ minimally access surgery. Our primary aim was to review our immediate-, early- and long-term outcomes with this technique compared with the open approach. Methods A retrospective review of all patients undergoing primary OA/TOF (Type C) repair at our institution from 2009 was conducted. Outcome measures included length of surgery, conversion rate from thoracoscopy, early complications such as anastomotic leak and post-operative complications such as anastomotic strictures needing dilatations. Fisher’s exact and Kruskal–Wallis tests were used for statistical analysis. Results 95 patients in total underwent OA/TOF repair during the study period of which 61 (64%) were completed via an open approach. 34 were attempted thoracoscopically of which 11 (33%) were converted. There was only one clinically significant anastomotic leak in our series that took place in the thoracoscopic group. We identified a significantly higher stricture rate in our thoracoscopic cohort (72%) versus open surgery (43%, P < 0.05). However, the median number of dilations (3) performed was not significantly different between the groups. There was one recurrent fistula in the thoracoscopic converted to open group. Our median follow-up was 60 months across the groups. Conclusion In our experience, the clinically significant leak rate for both open and thoracoscopic repair as well as recurrent fistula is much lower than has been reported in the literature. We do not routinely perform contrast studies and are, thus, reporting clinically significant leaks only. The use of post-operative neck flexion, ventilation and paralysis is likely to be protective towards a leak. Thoracoscopic OA/TOF repair is associated with a higher stricture rate compared with open surgery; however, these strictures respond to a similar number of dilatations and are no more refractory. Larger, multicentre studies may be useful to investigate these finding further.