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Live Event Content
Controversies in Congenital Diaphragmatic Hernia: Update Course 2018
hosted by Dr. Todd Ponsky
Chapter 1 of 7 · Case-Based Learning
Repair timing
Introduction and Case 1: Timing of Repair in Stable CDH
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Host summaries · secondary, not cited in answers
Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
For stable CDH patients not on ECMO, waiting 24-48 hours allows transitional circulation to stabilize and provides ventilator reserve before repair
Bowel distention in unreduced CDH compromises pulmonary and cardiac function over time, favoring earlier repair
Echocardiography to assess pulmonary hypertension guides timing of CDH repair
Recurrence rates improve with surgical experience and technique refinement in thoracoscopic CDH repair
Surgeons may unconsciously avoid placing adequate sutures in MIS repair if knot-tying is time-consuming, contributing to recurrence
Cauterizing the edge of the CDH defect promotes inflammation and healing, similar to unfolding the posterior leaflet in open repair
Excessive tension during thoracoscopic CDH closure can create an overly flat diaphragm, though Avi Schleger's work suggests post-op bowing may not significantly affect outcomes
Liberal use of absorbable mesh as underlay beneath primary repair reduces CDH recurrence
MIS approach to CDH repair greatly reduces small bowel obstruction compared to laparotomy
In the speaker's series, MIS and open CDH repairs showed similar recurrence rates, with patch use being a major factor
For CDH with agenesis or near-agenesis (type C or D defects), open repair is preferred due to complexity and proximity to esophagus
Severe CDH patients (O-to-E ratios 25% or below) often have small left ventricles causing hemodynamic problems in addition to pulmonary issues
VV ECMO may not work well in CDH patients with small left ventricles; VA ECMO is preferred in those cases
Inhaled nitric oxide (iNO) should not be trialed before ECMO in severe CDH; data show it does not work pre-ECMO
After birth, severe CDH patients may initially have high CO2 that falls over the first couple hours; this response guides ECMO cannulation timing
When repairing CDH on ECMO, leaving the abdomen open or using a silo prevents compromised pulmonary compliance from increased intra-abdominal pressure
Transversalis muscle flap repair for CDH shows very low recurrence rates but results in abdominal wall bulge
Overall mortality for any CDH patient requiring ECMO is approximately 50%
Midgut volvulus after CDH repair is surprisingly low in incidence; routine Ladd's procedure is not performed
Indications for the FETO trial (fetal tracheal occlusion) are liver herniation and lung-to-head ratio (LHR) greater than 0.9
A Columbia paper showed high recurrence rates with MIS CDH repair, creating resistance to the approach
Charlie Stoller showed approximately 30% recurrence rate with thoracoscopic CDH repair
Using buttress material reduces recurrence rates in CDH repair, per data from Rusty and Craig's institution
A recent Pediatric Surgery International paper showed low rates of return to ECMO and death following CDH repair, not justifying routine repair on ECMO
Timing of CDH repair has no real influence on ultimate survival
David Kays in Saint Petersburg achieves 100% survival in CDH (last 75 patients, all comers including preemies and heart disease), with 80% requiring ECMO and all repaired immediately on ECMO
David Kays switched to using bivalirudin for ECMO anticoagulation and reports decreased bleeding rates with immediate CDH repair on ECMO