Minimally Invasive vs Open Congenital Diaphragmatic Hernia Repair: Is There a Superior Approach?
BACKGROUND
The minimally invasive surgery (MIS) approach for congenital diaphragmatic hernia (CDH) repair remains controversial. Our objective was to compare outcomes and complications of the MIS and open approaches, with risk-stratification of patients based on defect size and key patient characteristics.


METHODS
The multinational CDH Study Group (CDHSG) registry was queried for the period from 2007 to 2015. Patient demographics and operative details, including the CDHSG Staging System defect size (A to D), were reviewed. Open cases consisted of laparotomy and thoracotomy; MIS repairs included laparoscopy and thoracoscopy. Outcomes included length of stay (LOS) for patients surviving to discharge, hernia recurrence, and adhesive small bowel obstruction (SBO) requiring surgery. Regression analyses were performed. Odds ratios (ORs) with 95% CIs were derived.


RESULTS
A total of 3,067 CDH patients underwent open (n = 2,579; 84%) or MIS (n = 488; 16%) repair. Patients undergoing open repair were more likely to be diagnosed prenatally, be premature, have lower 5-minute Apgar scores, and have major cardiac anomalies (all p < 0.001). Among MIS repairs, 79% were low risk (size A and B) defects vs 50% among open repairs (p < 0.001). Patients undergoing MIS repair experienced shorter overall median LOS, higher recurrence rates, and fewer SBO. With multivariable regression adjusting for defect size and key patient characteristics, an MIS approach was significantly associated with decreased LOS (mean -13.4 days; 95% CI -18 to -8.8 days), increased recurrences (OR 3.10; 95% CI 1.91 to 5.04), and decreased SBO (OR 0.19; 95% CI 0.06 to 0.60).


CONCLUSIONS
After risk-stratification of CDH patients, an MIS approach was independently associated with decreased LOS and SBO, but higher recurrence rates.
Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, TX; Center for Surgical Trials and Evidence-based Practice (CSTEP), University of Texas Medical School at Houston, Houston, TX.
Luke R
LR
Putnam
Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, TX; Center for Surgical Trials and Evidence-based Practice (CSTEP), University of Texas Medical School at Houston, Houston, TX.
Kuojen
K
Tsao
Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, TX; Center for Surgical Trials and Evidence-based Practice (CSTEP), University of Texas Medical School at Houston, Houston, TX.
Kevin P
KP
Lally
Department of Pediatric Surgery, Vanderbilt University School of Medicine, Nashville, TN.
Martin L
ML
Blakely
Department of Pediatric Surgery, University of Tennessee Health Science Center, Memphis, TN.
Tim
T
Jancelewicz
Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, TX; Center for Surgical Trials and Evidence-based Practice (CSTEP), University of Texas Medical School at Houston, Houston, TX.
Pamela A
PA
Lally
Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, TX; Center for Surgical Trials and Evidence-based Practice (CSTEP), University of Texas Medical School at Houston, Houston, TX. Electronic address: matthew.t.harting@uth.tmc.edu.
Matthew T
MT
Harting
D065630:Hernias, Diaphragmatic, Congenital / Q000601:surgery*; D059685:Herniorrhaphy / Q000379:methods*; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D010535:Laparoscopy; D007902:Length of Stay; D016014:Linear Models; D016015:Logistic Models; D015999:Multivariate Analysis; D016017:Odds Ratio; D011183:Postoperative Complications / Q000453:epidemiology; D012008:Recurrence; D012042:Registries; D013906:Thoracoscopy; D016896:Treatment Outcome