title: Thoracoscopic repair of congenital diaphragmatic hernia with countermeasures against reported complications for safe outcomes comparable to laparotomy.
abstract: BACKGROUND
  Thoracoscopic repair is the preferred treatment for congenital diaphragmatic hernia (CDH); however, several complications, including visceral injury, hypercapnia, and a high incidence of recurrence, have been reported. The purpose of this study was to evaluate the efficacy of countermeasures against these complications at ensuring safe thoracoscopic repair.
  
  
  METHODS
  Between January 2000 and December 2014, 40 patients with Bochdalek-type CDH were treated. Of these, 24 patients met the defined criteria for this study, 8 of whom underwent thoracoscopic repair beginning in January 2010 (TS group) and 16 underwent laparotomy before December 2009 (LT group). Perioperative variables and postoperative complications were compared between the groups. Countermeasures against adverse events in the TS group included an endoscopic surgical spacer to prevent visceral injury, intrapulmonary percussive ventilation to avoid hypercapnia, pausing CO2 insufflation to reduce tension during the repair, and prioritizing patch repair in cases of strong tension at the defect.
  
  
  RESULTS
  Primary closure was performed in 4 of 8 cases in the TS and 11 of 16 cases in the LT group. There was no visceral injury or conversion to laparotomy in the TS group. The mean operative duration was significantly longer (212 vs. 115 min, respectively, p = 0.0001), and the mean blood loss was significantly less in the TS than in the LT group (1.0 vs. 10.1 mL, respectively, p = 0.01). The intraoperative minimum arterial pH and maximum pCO2 were similar between the groups. All patients survived, and none experienced recurrence.
  
  
  CONCLUSIONS
  Our countermeasures to complications of thoracoscopic repair may contribute to safe outcomes equivalent to those of laparotomy in patients meeting our criteria.
authors.affiliation: Department of Gastrointestinal and Pediatric Surgery, Mie University Graduate School of Medicine, Edobashi 2-174, Tsu, Mie, 514-8507, Japan. mikihiro@clin.medic.mie-u.ac.jp.
authors.forename: Mikihiro
authors.initials: M
authors.lastname: Inoue
authors.affiliation: Department of Gastrointestinal and Pediatric Surgery, Mie University Graduate School of Medicine, Edobashi 2-174, Tsu, Mie, 514-8507, Japan.
authors.forename: Keiichi
authors.initials: K
authors.lastname: Uchida
authors.affiliation: Department of Gastrointestinal and Pediatric Surgery, Mie University Graduate School of Medicine, Edobashi 2-174, Tsu, Mie, 514-8507, Japan.
authors.forename: Kohei
authors.initials: K
authors.lastname: Otake
authors.affiliation: Department of Gastrointestinal and Pediatric Surgery, Mie University Graduate School of Medicine, Edobashi 2-174, Tsu, Mie, 514-8507, Japan.
authors.forename: Yuka
authors.initials: Y
authors.lastname: Nagano
authors.affiliation: Department of Gastrointestinal and Pediatric Surgery, Mie University Graduate School of Medicine, Edobashi 2-174, Tsu, Mie, 514-8507, Japan.
authors.forename: Koichiro
authors.initials: K
authors.lastname: Mori
authors.affiliation: Department of Gastrointestinal and Pediatric Surgery, Mie University Graduate School of Medicine, Edobashi 2-174, Tsu, Mie, 514-8507, Japan.
authors.forename: Kiyoshi
authors.initials: K
authors.lastname: Hashimoto
authors.affiliation: Department of Gastrointestinal and Pediatric Surgery, Mie University Graduate School of Medicine, Edobashi 2-174, Tsu, Mie, 514-8507, Japan.
authors.forename: Kohei
authors.initials: K
authors.lastname: Matsushita
authors.affiliation: Department of Gastrointestinal and Pediatric Surgery, Mie University Graduate School of Medicine, Edobashi 2-174, Tsu, Mie, 514-8507, Japan.
authors.forename: Yuhki
authors.initials: Y
authors.lastname: Koike
authors.affiliation: Department of Clinical Anesthesiology, University of Mie, Tsu, Mie, Japan.
authors.forename: Aki
authors.initials: A
authors.lastname: Uemura
authors.affiliation: Department of Gastrointestinal and Pediatric Surgery, Mie University Graduate School of Medicine, Edobashi 2-174, Tsu, Mie, 514-8507, Japan.
authors.forename: Masato
authors.initials: M
authors.lastname: Kusunoki
mesh_terms: D005260:Female; D005500:Follow-Up Studies; D065630:Hernias, Diaphragmatic, Congenital / Q000601:surgery*; D059685:Herniorrhaphy / Q000379:methods*; D006801:Humans; D007231:Infant, Newborn; D007813:Laparotomy; D008297:Male; D011183:Postoperative Complications / Q000209:etiology / Q000517:prevention & control*; D012008:Recurrence; D012189:Retrospective Studies; D013906:Thoracoscopy / Q000379:methods*; D016896:Treatment Outcome
keywords: Complication; Congenital diaphragmatic hernia; Conversion; Recurrence; Small bowel obstruction; Thoracoscopic repair