title: Implantation of a cone-shaped double-fixed patch increases abdominal space and prevents recurrence of large defects in congenital diaphragmatic hernia.
abstract: BACKGROUND
  Large defects in patients with congenital diaphragmatic hernia (CDH) are frequently closed with a polytetrafluoroethylene patch (PTFE). Intraoperative problems include lack of abdominal domain for the reduction of organs and closure of the abdominal wall. Main surgical postoperative complication is the recurrence of the hernia. We suggest a new and easy method of patch implantation, improving these problems, and report first follow-up results.
  
  
  METHODS
  In our clinic, 103 children with CDH were treated, and 87 children underwent reconstruction of the diaphragm in the 5 years between 1998 and 2002. In 52 patients, a patch implantation had to be performed. We have been optimizing our complete pediatric and surgical procedure and present a new standardized technique of preparation and implantation of a PTFE patch. The flat patch is folded to a 90 degrees cone. The cone is fixed in its form with few single stitches. It is implanted with an overlapping border of 1 cm circumferentially. The border is separately fixed with absorbable single stitches to keep from rolling up. The rough side of the patch points toward the rim of the diaphragm to enable ingrowth of the connective tissue. In a 1-year follow-up study, the recurrences in the 3 following groups of PTFE patches were studied: conventional implantation (simple patch without overlapping border), patch with separately fixed overlapping border, and cone-shaped patch with overlapping separately fixed border.
  
  
  RESULTS
  Thirty-three patients were included in the study. After conventional PTFE-patch implantation, 6 (46%) of 13 patients developed reherniation. After PTFE-patch implantation with separately fixed overlapping border, 1 (11%) of 9 patients had a recurrent hernia. In the group with the PTFE-cone implantation, 1 (9%) of 11 patients developed a recurrence. Meanwhile, another 20 CDH patients received implantation of a cone-shaped patch, and no further recurrence occurred up to now. With the additional space (20 mL) provided by the cone-shaped patch, the closure of the abdomen was easier, and the fundus had intraoperatively a physiological position.
  
  
  CONCLUSIONS
  This optimized patch implantation technique in large diaphragmatic defects offers considerable advantages especially regarding recurrence of the hernia and closure of the abdomen, which are currently the most challenging surgical problems. 1. The cone-shaped 3-dimensional patch increases abdominal capacity. 2. Redundant chest capacity is reduced, and the reconstructed diaphragm shows a physiological shape. 3. The dome of the patch allows a physiological position of the gastric fundus and a normal Hiss angle, thus preventing gastroesophageal reflux. 4. Additional safety of the implantation is achieved by separate fixation of the overlapping border of the cone, preventing recurrence.
authors.affiliation: University Clinic of Pediatric Surgery, Klinikum Mannheim, University of Heidelberg, Mannheim 68167, Germany. steffan.loff@kch.ma.uni-heidelberg.de
authors.forename: Steffan
authors.initials: S
authors.lastname: Loff
authors.forename: Hartmut
authors.initials: H
authors.lastname: Wirth
authors.forename: Iwgo
authors.initials: I
authors.lastname: Jester
authors.forename: Stuart
authors.initials: S
authors.lastname: Hosie
authors.forename: Carmen
authors.initials: C
authors.lastname: Wollmann
authors.forename: Thomas
authors.initials: T
authors.lastname: Schaible
authors.forename: Ozge
authors.initials: O
authors.lastname: Ataman
authors.forename: Karl-Ludwig
authors.initials: KL
authors.lastname: Waag
mesh_terms: D000005:Abdomen / Q000033:anatomy & histology; D002648:Child; D005500:Follow-Up Studies; D006548:Hernia, Diaphragmatic / Q000601:surgery*; D065630:Hernias, Diaphragmatic, Congenital; D006801:Humans; D011138:Polytetrafluoroethylene; D011474:Prosthesis Design; D019919:Prosthesis Implantation; D012008:Recurrence; D013526:Surgical Mesh; D013536:Suture Techniques; D016896:Treatment Outcome
chemical_list: D011138:Polytetrafluoroethylene