CDH is a congenital disease that causes a defect in the diaphragm due to abnormal embryonic development, causing abdominal organs to herniate into the thoracic cavity and causing a series of pathophysiological changes. Generally, CDH occurs more often on the left side than the right side with the incidence ratio on the left and right sides being approximately 6:1, and CDH is rare on both sides with an incidence rate of approximately 2% . In this study, the number of children with CDH on the left side (81.65%) was far greater than that of children with CDH on the right side (18.35%), which was consistent with literature reports.The incidence of CDH combined with other malformations is 30%-70%, including cardiovascular formations (27.5%), genitourinary system malformations (17.7%), skeletal muscle system malformations (15.7%) and central nervous system malformations (9.8%) . In this group, congenital pulmonary dysplasia (53, 48.62%) and congenital heart disease (45, 41.28%) were the main malformations in this study. Other combined malformations included cryptorchidism, pectus excavatum, right shifted heart and congenital intestinal malrotation, which was consistent with literature reports.
The traditional treatment for CDH is transthoracic or transabdominal diaphragmatic hernia repair. In the open group, 56 patients underwent transabdominal diaphragmatic hernia repair, and 6 patients underwent transthoracic diaphragmatic hernia repair. We believe that transabdominal surgery has the following advantages: easy to reset abdominal organs; easy to suture the edge of the diaphragm; and easy to deal with abdominal deformities, such as intestinal rotation malrotation. Therefore, transabdominal surgery is recommended for left-side diaphragmatic hernias. Transthoracic surgery is used for right-side diaphragmatic hernia due to liver obstruction because the diaphragm is clearly exposed during transthoracic surgery. Additionally, transthoracic surgery addresses thoracic adhesions and other combined chest deformities. However, in the open group, 5 children with right CDH without thoracic malformations were treated with transabdominal diaphragmatic hernia repair, which also achieved satisfactory clinical results. Therefore, we believe that the choice of approach is mainly based on the characteristics of the patient’s CDH lesions and which approach the surgeon is more familiar with. In this study, 47 patients underwent thoracoscopic diaphragmatic hernia repair.A purse-string suture with a needled suture was used to repair the diaphragmatic defect, close the diaphragmatic hernia, restabilize and suture the edge of the defect with barbed sutures. We believe that compared with ordinary absorbable sutures, continuous suturing of the diaphragm with barbed sutures has the following advantages: less bleeding, absorbability, no knot response, tight sutures and no knots during the suture process, which greatly shortens the operation time. Moreover, re-strengthening the diaphragm reduces recurrence.
With the development of MIS, thoracoscopy has gradually been used in the treatment of CDH. We compared the effects of open surgery and thoracoscopy in the treatment of CDH in children. The operation time, postoperative mechanical ventilation time, postoperative hospital stay and postoperative CCU admission time in the thoracoscopy group were shorter than those in the open group. Therefore, thoracoscopic treatment of CDH has the advantages of less bleeding and faster recovery than traditional open surgery. However, the results of this analysis may be affected by selection bias. In general, we give priority to thoracoscopic surgery, and if the operation is difficult, we will switch to open surgery.When the patient's condition is severe and the diaphragm defect is large, surgeons are more inclined to use open surgery to repair the defect.
This study compared the incidence of complications of thoracoscopy and open surgery. The literature reports that the most common complications of diaphragm hernia repair include intestinal obstruction, pneumothorax, pleural effusion and atelectasis. Other studies have reported scoliosis and pectus excavatum after open surgery . In this study, the overall incidence of postoperative complications in the open group (45.16%) was higher than that in the thoracoscopy group (36.17%), which was equivalent to the incidence reported in the literature . In this study, the main complications of the open group were lung infection, pleural effusion and respiratory failure. The main complications of the thoracoscopy group were respiratory failure and pneumothorax. The incidence of complications in the open group was higher than that in the thoracoscopy group, but there was no significant difference between the two groups (P > 0.05).There were 6 cases of pleural effusion and 7 cases of pneumonia in the open group. Open surgery has a larger traumatic area than thoracoscopic surgery and more exudation, which is likely to cause pleural effusion. Moreover, children are young and have poor resistance to lung infections. Two children in the open group died of respiratory failure after surgery. The possible causes were that the children had severe pulmonary dysplasia, poor cardiopulmonary function after surgery and could not tolerate open surgery.
This study compared the postoperative recurrence rate of the thoracoscopy and open groups. The recurrence rate of the thoracoscopy group (8.51%) was higher than that of the open group (3.23%), but the difference was not statistically significant. Some scholars have compared open surgery and thoracoscopic surgery, suggesting that the recurrence rate after thoracoscopic surgery for CDH is higher [12, 13] and that intraoperative hypercapnia and acidosis are more serious. The recurrence rate of thoracoscopic diaphragmatic hernia repair is reported to be between 0% and 25%. Most authors have reported that the recurrence rate is higher than 15% [14, 15]. The recurrence rate in this study was lower than that reported in the literature, which may be attributed to the thoracoscopic diaphragmatic hernia repair being only performed in patients with a small diaphragm defect (defect A/B/C). If a large defect was found under thoracoscopy, it was converted to open repair. In the open group, there were 2 cases of recurrence, which may have been due to poor development of the diaphragm, suture not reaching the edge of the normal diaphragm and a long-term increase in intra-abdominal pressure. The 2 cases of recurrence may have also been related to the large defect of the diaphragm, high tension of the diaphragm suture and loose suture. There were 4 cases of recurrence in the thoracoscopy group. We found that all recurrences occurred in the early stage of the use of thoracoscopy. The postoperative recurrence may have been related to several factors. (1) The surgical operation was performed under thoracoscopy, and the surgical field was enlarged. In addition, the surgeon could not accurately estimate the suture distance. As a result, the suture distance of each stitch was large, and the defect could not be closed well. (2) The diaphragm muscle tension was too large when sutured, and the sutured diaphragm muscle tissue was not thick enough, causing the diaphragm to tear. (3) The use of continuous sutures led to loose knots. In the later period, a purse-string suture with needled suture was used to repair the diaphragmatic defect, close the diaphragmatic hernia, restabilize and suture the edge of the defect with barbed sutures to achieve better clinical results. Scholars at home and abroad have also proposed the use of special equipment to assist in knotting and have achieved good results .One of the major limitations of this study was the retrospective nature, which may be biased when collecting data. The second limitation in this study was that it was not a randomized study, and selection bias may have existed.