Risk factors for recurrence after thoracoscopic repair of congenital diaphragmatic hernia (CDH)

Purpose To identify technical modifications concerning factors that may lower the risk of recurrence following thoracoscopic repair of congenital diaphragmatic hernia (CDH). Methods All CDH patients who underwent thoracoscopic repair from April 2003 to September 2017 were retrospectively reviewed. Some of the more recently treated patients underwent technically modified repairs with underlay and overlay buttresses. Results Sixty-eight patients underwent thoracoscopic repair of a diaphragmatic hernia that presented either neonatally (n = 52) or beyond the neonatal period (> 1 month) (n = 16). At our institution, the minimally invasive surgical approach is considered for clinically stable CDH patients, who are likely to have type A or B defects. 21 patients had a sac-type defect. Forty-seven patients with type A defect had primary closure, buttressed in 6 cases. In 21 patients, the type B defect was repaired with a patch, buttressed in 11 patients. Median follow-up was 36 months (IQR 9–45). Recurrence occurred in 13 patients (overall 19% recurrence rate); all had a neonatally presented defect (25% vs. 0%, p = 0.03). Patients with a sac-type defect had a lower recurrence rate than patients with no hernia sac (5% vs. 26%, p = 0.05). Recurrence complicated 7 of 47 (15%) patients after primary closure and 6 of 21 (29%) patients with patch repair; none of the 17 cases with buttressed repairs had a recurrence. Conclusions Due to a higher rate of recurrence following thoracoscopic CDH repair compared to the standard open approach, we suggest a sandwich-type buttress repair with underlay and overlay components for both primary and patch repairs. Level of Evidence Level III cohort study.