Interested in what is being used across the world: synthetic, biological, native tissue etc.
This is a complicated question. There is some data in the literature - biologics such as Surgisis and others tend to resorb and reherniate around 6 months. Same with absorbable meshes like Vicryl, etc. Use of muscle and fascial flaps is more reliable but has a cost in terms of difficult to repair flank and ventral hernias, and adhesions. Use of Gortex is common - Gortex is a Teflon product, so tissue ingrowth is less than perfect, and there is a very high rate of re-herniation. But Gortex is available in sheets. Polyester and Dacron gets excellent tissue ingrowth, but is less commonly used - Sheets are hard to find large enough for CDH repair, and the other option of cutting up a vascular conduit is expensive. It would appear there is room for improvement in the is area. Rusty
I guess everyone is using Gore-tex or Dacron meshes. I think it is difficult to continuously renew the mesh as child grows. I don’t know, which of the best range, or when at the earliest changing the mesh.
If you use a permanent patch to repair the diaphragm, and it does not pull out, you do not need to replace it. The surrounding diaphragm grows as the child grows, and the patch remains the same size. If you re-operate on a teenager for some reason who had a diaphragm repair as an infant with a permanent patch, the patch is a little 3 cm patch on the back of a large nearly normal diaphragm.
I am very thankful to Dr Jennings for contributions. Frankly I have no experience of living babies with large diaphragmatic defect and used nonabsorbable synthetic
mesh.
There is no doubt that the defect needs to be closed with own tissues. By larger defects the posterior rim is hidden by the pleuro-peritoneal membrane and I always incise the membrane in order to mobilize enough the rim. After placing interrupted mattress sutures the primary repair is accomplished. If hard to carry out, the Gore-tex patch is preferred - if not disposable I use nonresorbable prosthetic patches. But, the main problem for me is the cases, when the medial rim is absent thus making the anchoring of the patch difficult.
There are a large variety of types of diaphragmatic hernias - and right and left are different. Large posterior left diaphragmatic hernias can be very challenging to repair - there may be almost no posterior or lateral rim - in that case I place sutures around the transverse process and the ribs, avoiding the intercostal arteries. One can also sew to the spinal ligaments. Almost always there is a small rim of diaphragm over the esophagus - use this. One trick to minimize recurrences is to place the spleen over the patch so it forms a type of biological patch in addition to the primary patch.
Our last case that was repaired diaphragmatic hernia with used synthetic mesh in whom persistent chylothorax fluid accumulates in the pleural cavity. Would you like to suggest to us how deal with.challenging this problem.
The first issue is to confirm a chylous leak. Transudation of fluid from the peritoneum can occur, but it is not chylous. That will resolve as the patch becomes ingrown, hopefully. A true chylous collection has several etiologies, from injury to a small peripheral duct during dissection, to division of the thoracic duct or cisterna chyli at the diaphragm by the aorta, to congenital lymphatic leaks from the pleural or lung. My initial strategy would be similar for most of them - TPN, chest tube drainage, NPO. Once controlled for a week or more, transistion to a medium triglyceride based formula. If this does not seal after 6 weeks, it may be time for more surgery. That may be a different discussion.
Thank you very much for your interest. You gave us power and also support. We are very grateful for sharing the experiences of Boston Children's Hospital. We thought that just like you, we’re now following the patient with a chest tube, 25-30 cc fluid that transudes draining daily. We also think that this fluid drainage will be stopped in time. Yours truly..
Just checking in - how are things working out? What has happened? Rusty
Dear Rusty, Thank you for your interest. Two months after diaphragmatic operation, chylous fluid over time gradually decreased from the chest tube and then tube was removed. But we were unable to save the patient from the ventilator and intubation. While good and active patient was following, we performed tracheostomy to avoid tracheal injury. Unfortunately after tracheostomy same night we lost the patient post-op due to the tension pneumothorax.
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