JOURNAL OF LAPAROENDOSCOPIC & ADVANCED SURGICAL TECHNIQUES

Volume 26, Number 11, 2016 2016 IPEG Papers

ª Mary Ann Liebert, Inc.
DOI: 10.1089/lap.2016.0247

Approach to Recurrent Congenital Diaphragmatic Hernia:

Results of an International Survey

Nicholas E. Bruns, MD,1 Ian C. Glenn, MD,1 Neil L. McNinch, MS, RN,2 Kelly Arps, BS,3
Todd A. Ponsky, MD,1 and Avraham Schlager, MD1

Abstract

Purpose: Although recurrence remains one of the most feared complications following congenital diaphrag-
matic hernia (CDH) repair, there are minimal data on the optimal surgical approach to these complex situations.
The purpose of this study was to survey the international pediatric surgery community to ascertain practice
patterns for both minimally invasive (MIS) and open approaches for recurrent CDH.
Materials and Methods: A survey was e-mailed to members of an online community of pediatric surgeons. The
questionnaire elicited surgeons’ clinical experience, the continent in which they practice, and their surgical
approach (laparotomy, thoracotomy, laparoscopy, or thoracoscopy) to five clinical cases, including initial and
recurrent Bochdalek hernias. Fisher’s exact test and chi-square test were used for statistical analysis.
Results: Two-hundred eighty pediatric surgeons responded to the survey. In total, 52.1% of surgeons chose an MIS
approach for an initial repair of left CDH with the younger surgeons more likely to use an MIS approach. For the
recurrence scenarios, 42.5%–55.5% of these surgeons would attempt an MIS repair after a recurrence. Specifically,
thoracoscopy was favored over laparoscopy following both prior laparotomy (30.0% versus 7.5%) and prior right
thoracoscopy (26.4% versus 10.0%), less favored following thoracotomy (9.3% versus 18.9%), and relatively similar
proportions following prior left thoracoscopy (17.5% versus 16.4%). Laparotomy was the preferred open approach
both for initial presentation and all recurrence scenarios. Among surgeons who would treat initial CDH with an open
procedure, between 10.4% and 17.9% would switch to an MIS approach, most commonly after prior failed laparotomy.
Conclusions: Approximately half surgeons who approach initial left CDH in an MIS manner would attempt an
MIS approach for recurrence. The tendency to approach CDH recurrence from the opposite body cavity as the
initial repair clearly impacted the surgical approach. This was particularly pronounced for MIS repairs, whereas
for open approach, laparotomy remained, by far, the most popular in all scenarios.

Keywords: congenital diaphragmatic hernia, congenital diaphragmatic repair; minimally invasive surgery,
thoracoscopy, laparoscopy

Introduction ternational pediatric surgery community to ascertain practice

R ecurrence remains one of the most feared compli-
cations after congenital diaphragmatic hernia (CDH)
repair. Despite this prevalent concern, there is a paucity of
data in the medical literature on the optimal approach to CDH
recurrence. Minimally invasive (MIS) approaches to CDH
repair have been gaining popularity over the past 10 years
with both thoracoscopic and laparoscopic approaches de-
scribed. Nevertheless, data on treatment for recurrences are
limited due to its low incidence,1 especially within a single
institution. The purpose of this study was to survey the in-
patterns for MIS and open approaches for recurrent CDH.
Materials and Methods
A survey was e-mailed to members of an online commu-
nity of pediatric surgeons affiliated with GlobalCastMD
(Shaker Heights, OH). The questionnaire was created using
Google Forms (Mountain View, CA) and consisted of 10
questions. It began by asking surgeons to identify their
clinical experience as a pediatric surgeon by selecting how
many years they have been in practice (0–10, 11–20, or >20)

1
Division of Pediatric Surgery, Akron Children’s Hospital, Akron, Ohio.
2
Rebecca D. Considine Research Institute, Akron Children’s Hospital, Akron, Ohio.
3
Emory University School of Medicine, Atlanta, Georgia.

1
2 BRUNS ET AL.

Table 1. Preference for Treating Initial Left
Congenital Diaphragmatic Hernia
by Clinical Experience (N = 280)
Years of experience n % MIS
0–10 80 66.3
11–20 83 56.6
>20 117 39.3
MIS, minimally invasive surgery.
or if they are not a pediatric surgeon (trainee or none of the
above). Participants that identified themselves as trainees or
not pediatric surgeons were excluded from the study.
Next, participants identified the continent in which they
practice (Asia, Europe, North America, South America,
or other).
Participants were then presented several clinical cases of
a hemodynamically stable infant with a CDH (both initial
and recurrent). Respondents were prompted to select their
preferred approach (laparotomy, thoracotomy, laparoscopy,
or thoracoscopy) for cases of both initial and recurrent
Bochdalek CDH. Refer to Appendix A for the complete
survey.
Fisher’s exact test and chi-square test were used for ex-
amination of associations among variables of interest, which
are outlined below. All testing were completed utilizing SAS
v 9.4/13.2 software (Cary, NC) and evaluated at the type I
error rate of alpha = 0.05 level for statistical significance.
Results
The survey received 287 responses. Seven respondents did
not identify themselves as pediatric surgeons and were excluded
from analysis. Of the remaining 280 pediatric surgeons, 28.6%
had been in practice for 0–10 years, 29.6% for 11–20 years, and
41.8% for 20 years or more. The locations of the respondents
were diverse: 39.3% were in North America; 27.5% Europe;
16.8% Asia; 7.1% South America; and 9.3% other.
Younger surgeons were significantly more likely to select
an MIS approach compared to surgeons who had been in
practice for longer (Table 1; P < .01). There was no statisti-
cally significant association between location of practice and
preference for MIS (P = .25).
Initial CDH repair
52.1% of all responding surgeons chose an MIS approach
for the initial repair of a left Bochdalek CDH (Table 2).
Hereto forward, the 52.1% of surgeons that chose an MIS
approach will be referred to as ‘‘MIS surgeons’’ and the
47.9% surgeons that selected an open approach will be re-
ferred to as ‘‘open surgeons,’’ reflecting their preferred
treatment for routine initial CDH. Of the MIS surgeons,
88.4% chose thoracoscopy and 11.6% chose laparoscopy
(Table 3). Among the open surgeons, 97.8% chose laparo-
tomy and 2.2% chose thoracotomy (Table 4).
CDH recurrence
MIS surgeons would attempt an MIS repair after a recurrence
42.5%–55.5% of the time (Table 5). Among this group, thor-
acoscopy was the most common approach to both recurrent left
CDH after laparotomy (47.8%) and right CDH after thoraco-
scopy (36.3%), although laparotomy was almost as common for
right CDH recurrence (34.2%). However, even in this MIS
group, laparotomy was the most selected approach for a re-
current left CDH after thoracoscopy and thoracotomy with
43.2% and 49.3%, respectively. Nevertheless, MIS surgeons
were overall more likely to select an MIS approach for all re-
currence types compared to surgeons who prefer an open repair
for initial CDH (P < .01 for all cases).
For all CDH recurrence scenarios, laparotomy was the most
popular choice among open surgeons, ranging between 59.7%
and 79.1%. Open surgeons attempted MIS 10.4%–17.9% of
the time in the recurrence scenarios. The two most common

Table 2. All Pediatric Surgeons’ Preference for Treating Left and Right Bochdalek
Congenital Diaphragmatic Hernia (N = 280)
CDH type Laparoscopy, n (%) Thoracoscopy, n (%) Laparotomy, n (%) Thoracotomy, n (%)
Initial left 17 (6.1) 129 (46.1) 131 (46.8) 3 (1.1)
Left recurrence after thoracoscopy 46 (16.4) 49 (17.5) 168 (60.0) 17 (6.1)
Left recurrence after laparotomy 21 (7.5) 84 (30.0) 150 (53.6) 25 (8.9)
Left recurrence after thoracotomy 53 (18.9) 26 (9.3) 178 (63.6) 23 (8.2)
Right recurrence after thoracoscopy 28 (10.0) 74 (26.4) 130 (46.4) 48 (17.1)
CDH, congenital diaphragmatic hernia.

Table 3. MIS Surgeons’ Preference for Treating Left and Right Bochdalek Congenital
Diaphragmatic Hernia (N = 146)
CDH type Laparoscopy, n (%) Thoracoscopy, n (%) Laparotomy, n (%) Thoracotomy, n (%)
Initial left 17 (11.6) 129 (88.4) — —
Left recurrence after thoracoscopy 39 (26.7) 42 (28.8) 63 (43.2) 2 (1.4)
Left recurrence after laparotomy 17 (11.6) 64 (47.8) 56 (38.4) 9 (6.2)
Left recurrence after thoracotomy 40 (27.4) 22 (15.1) 72 (49.3) 12 (8.2)
Right recurrence after thoracoscopy 25 (17.1) 53 (36.3) 50 (34.2) 18 (12.3)
CDH, congenital diaphragmatic hernia.
APPROACH TO RECURRENT DIAPHRAGMATIC HERNIA 3

Table 4. Open Surgeons’ Preference for Treating Recurrent Left and Right Bochdalek
Congenital Diaphragmatic Hernia (N = 134)
CDH type Laparoscopy, n (%) Thoracoscopy, n (%) Laparotomy, n (%) Thoracotomy, n (%)
Initial left — — 131 (97.8) 3 (2.2)
Left recurrence after thoracoscopy 7 (5.2) 7 (5.2) 105 (78.4) 15 (11.2)
Left recurrence after laparotomy 4 (3.0) 20 (14.9) 94 (70.1) 16 (11.9)
Left recurrence after thoracotomy 13 (9.7) 4 (3.0) 106 (79.1) 11 (8.2)
Right recurrence after thoracoscopy 3 (2.2) 21 (15.7) 80 (59.7) 30 (22.4)
CDH, congenital diaphragmatic hernia.

recurrence situations for an open surgeon to select an MIS
approach were recurrent left CDH after laparotomy (14.9%
thoracoscopy, 3.0% laparoscopy) and right recurrence after
thoracoscopy (15.7% thoracoscopy, 2.2% laparoscopy).
Discussion
MIS for initial CDH
There are a number of factors that influence approach to a
left Bochdalek CDH. The potential benefits of MIS repair of
CDH include decreased pain, improved cosmetic result,
faster recovery times, and, most importantly, avoidance of
morbidity of laparotomy (adhesive disease) and thoracotomy
(scoliosis).2–4 Even within MIS techniques, there are a vari-
ety of factors that can influence which approach to utilize in
various scenarios. Advantages of thoracoscopy over lapa-
roscopy for initial CDH repair include the greater working
space in a thorax with an underdeveloped lung compared to a
scaphoid abdomen and the relative ease of thoracoscopically
visualizing and accessing the posterolateral aspect of the
defect which often extends overlying the retroperitoneum
compared to the laparoscopic approach. Finally, it is often
easier to reduce the herniated viscera by pushing it through
the defect with the aid of thoracic insufflation compared to
pulling it laparoscopically. Laparoscopic repair for initial left
CDH is much less commonly encountered. For recurrences,
on the other hand, a laparoscopic approach allows dissection
in a ‘‘virgin’’ workspace (as most primary repairs are per-
formed thoracoscopically) and may allow easier evaluation
of the herniated viscera, as well as certainty that abdominal
viscera have not been incorporated into the repair. For right
Table 5. Proportion of MIS and Open Surgeons
Who Select an MIS Approach for Congenital
Diaphragmatic Hernia Recurrences
MIS surgeons Open surgeons
CDH type (n = 146), n (%) (n = 134), n (%)
Left recurrence after 55.5 10.4
thoracoscopy
Left recurrence after 55.5 17.9
laparotomy
Left recurrence after 42.5 12.7
thoracotomy
Right recurrence after 53.4 17.9
thoracoscopy
CDH, congenital diaphragmatic hernia; MIS, minimally invasive
surgery.
CDH, thoracoscopy may be preferred due to the liver making
laparoscopy more difficult.
Open repair for initial CDH
Open surgeons generally prefer open repair over MIS due to
greater comfort operating through laparotomy or thoracotomy
or due to the lower recurrence profile suggested by a number of
articles.3–8 In this study, 48% of surgeons selected an open
procedure for initial CDH. Laparotomy was vastly more
popular with 46% of all surgeons and 98% of open surgeons
choosing it. When comparing the laparotomy to thoracotomy,
laparotomy may be preferred due to better overall view and
avoidance of potential chest wall defects and scoliosis asso-
ciated with thoracotomy.2,9 Similar to MIS, in the case of right
CDH, the liver can be the main obstacle of the repair. While
this may lead some surgeons to use a thoracotomy, laparotomy
can visualize the space superior to the liver as well.
MIS for recurrent CDH
MIS surgeons would frequently use MIS for a CDH re-
currence as 42.5%–55.5% of MIS surgeons selected an MIS
approach in recurrence scenarios. Thoracoscopy was the MIS
procedure of choice in all cases except for a left-sided re-
currence after a thoracotomy in which laparoscopy was fa-
vored 18.9% versus 9.3% for all surgeons and 27.4% versus
15.1% for MIS surgeons, respectively. This may illustrate the
concept of a ‘‘virgin plane’’ in which the opposite body
cavity as the initial repair is preferred due to surgical adhe-
sions. This concept has been described in other types of
hernia such as inguinal hernia recurrences. For right-sided
recurrence, the liver most likely played a larger factor in
shifting MIS surgeons toward thoracoscopy.
Among open surgeons, between 10% and 17% selected an
MIS approach for recurrences: majority of these were thor-
acoscopy. This was highest after laparotomy, lending support
to the virgin plane theory.
Open repair for recurrent CDH
Among all surgeons polled, laparotomy was most popular
approach for all cases of recurrent CDH, suggesting that it is
the open procedure of choice. Thoracotomy appears to have
fallen out of favor in general with less than 10% selection
rates for all left-sided CDH cases. Even for a recurrence after
laparotomy, laparotomy remained more popular than thora-
cotomy by a large margin (53.6% versus 30.0%, respective-
ly), indicating that the desire to operate in a virgin field is
likely not enough to compel a second open incision.
4 BRUNS ET AL.
For right-sided recurrent CDH, there was more of a pref-
erence for thoracotomy, although it was never a majority.
This is illustrated by the fact that thoracotomy was utilized
17% for the recurrent right-sided CDH after a thoracoscopic
attempt versus 6% for a recurrent left-sided CDH after a
thoracoscopic attempt. Perhaps this is because the liver ob-
structs an abdominal approach, rendering it more difficult.
Limitations
The population of pediatric surgeons came from an e-mail
list from GlobalCastMD. GlobalCastMD is an online virtual
platform for medical education. It is possible that this group
of surgeons would be more technologically oriented than the
rest of the pediatric surgery population and could potentially
be more likely to use MIS.
Surgeon preferences on treating initial right CDH were not
ascertained in this survey. Without this information, it is
difficult to draw conclusions as to how approach changes
when faced with a right recurrence.
Further study is needed to elicit what the advantages and
disadvantages are of the available technical options for repair
of CDH.
Conclusion
Among MIS approaches, thoracoscopy is preferred to
laparoscopy for initial CDH and all recurrences except after
thoracotomy. Surgeons who approach an initial left CDH in
an MIS manner would frequently attempt an MIS repair for a
recurrence. There is a tendency to approach a CDH recur-
rence from the opposite body cavity as the initial repair.
Among open approaches, laparotomy is favored over thora-
cotomy for initial and recurrent CDH. These findings may
inform surgeons when confronted with a CDH recurrence.
Disclosure Statement
Dr. Bruns, Dr. Glenn, Mr. McNinch, Ms. Arps, and Dr.
Schlager have no disclosures. Dr. Ponsky is the co-owner and
chief medical officer of GlobalCastMD.
References
1. Torfs CP, Curry CJ, Bateson TF, Honoré LH. A population-
based study of congenital diaphragmatic hernia. Teratology
1992;46:555–565.
Appendix A. Congenital Diaphragmatic Hernia Survey
1. How long have you been practicing pediatric surgery?
a. 0–10 years
b. 11–20 years
c. 20+ years
d. I am a trainee (resident or fellow)
e. I am not a pediatric surgeon
2. Where do you practice?
a. Asia
b. Europe
c. North America
d. South America
e. Other
2. Westfelt JN, Nordwall A. Thoracotomy and scoliosis. Spine
1991;16:1124–1125.
3. Gourlay DM, Cassidy LD, Sato TT, Lal DR, Arca MJ. Be-
yond feasibility: A comparison of newborns undergoing
thoracoscopic and open repair of congenital diaphragmatic
hernias. J Pediatr Surg 2009;44:1702–1707.
4. Lao OB, Crouthamel MR, Goldin AB, Sawin RS, Wald-
hausen JHT, Kim SS. Thoracoscopic repair of congenital
diaphragmatic hernia in infancy. J Laparoendosc Adv Surg
Tech 2010;20:271–276.
5. Gander JW, Fisher JC, Gross ER, Reichstein AR, Cowles
RA, Aspelund G, Stolar CJH, Kuenzler KA. Early recur-
rence of congenital diaphragmatic hernia is higher after
thoracoscopic than open repair: A single institutional study. J
Pediatr Surg 2011;46:1303–1308.
6. Shah SR, Wishnew J, Barsness K, Gaines BA, Potoka
DA, Gittes GK, Kane TD. Minimally invasive congen-
ital diaphragmatic hernia repair: A 7-year review of one
institution’s experience. Surg Endosc 2009;23:1265–
1271.
7. Kim AC, Bryner BS, Akay B, Geiger JD, Hirschl RB, My-
chaliska GB. Thoracoscopic repair of congenital diaphrag-
matic hernia in neonates: Lessons learned. J Laparoendosc
Adv Surg Tech 2009;19:575–580.
8. McHoney M, Giacomello L, Nah SA, De Coppi P, Kiely
EM, Curry JI, Drake DP, Eaton S, Pierro A. Thoracoscopic
repair of congenital diaphragmatic hernia: Intraoperative
ventilation and recurrence. J Pediatr Surg 2010;45:355–
359.
9. Frola C, Serrano J, Cantoni S, Casiglia M, Turtulici I,
Loria F. CT findings of atrophy of chest wall muscle
after thoracotomy: Relationship between muscles in-
volved and type of surgery. AJR Am J Reoentgen 1995;
164:599–601.
Address correspondence to:
Nicholas E. Bruns, MD
Division of Pediatric Surgery
Akron Children’s Hospital
One Perkins Square
Suite 8400
Akron, OH 44308
E-mail: nickebruns@gmail.com
APPROACH TO RECURRENT DIAPHRAGMATIC HERNIA 5

3. Suppose you are evaluating an infant in the neonatal intensive care unit (NICU) with a LEFT-SIDED Bochdalek
CDH. The infant is hemodynamically stable and has been cleared for surgery. Would you attempt a minimally
invasive (MIS) repair?
a. Yes, I would use a laparoscopic approach
b. Yes, I would use a thoracoscopic approach
c. No, I would perform a laparotomy
d. No, I would perform a thoracotomy
4. Would you attempt an MIS approach for a RECURRENT LEFT-SIDED Bochdalek CDH after a THORACO-
SCOPIC repair?
a. Yes, I would use a laparoscopic approach
b. Yes, I would use a thoracoscopic approach
c. No, I would perform a laparotomy
d. No, I would perform a thoracotomy
5. How often do you predict that an MIS repair will be successfully completed without conversion to open in the patient
with a prior THORACOSCOPIC repair?
a. <25% of cases
b. 25%–50% of cases
c. 50%–75% of cases
d. >75% of cases
6. Would you attempt an MIS approach for a RECURRENT LEFT-SIDED Bochdalek CDH after a prior THOR-
ACOTOMY?
a. Yes, I would use a laparoscopic approach
b. Yes, I would use a thoracoscopic approach
c. No, I would perform a laparotomy
d. No, I would perform a thoracotomy
7. Would you attempt an MIS approach for a RECURRENT LEFT-SIDED Bochdalek CDH after a prior LAPAROTOMY?
a. Yes, I would use a laparoscopic approach
b. Yes, I would use a thoracoscopic approach
c. No, I would perform a laparotomy
d. No, I would perform a thoracotomy
8. How often would you predict that an MIS technique will be successfully completed without conversion to open
following a prior OPEN repair?
a. <25% of cases
b. 25%–50% of cases
c. 50%–75% of cases
d. >75% of cases
9. Would you attempt an MIS approach for a RECURRENT RIGHT-SIDED Bochdalek CDH after a THORACO-
SCOPIC repair?
a. Yes, I would use a laparoscopic approach
b. Yes, I would use a thoracoscopic approach
c. No, I would perform a laparotomy
d. No, I would perform a thoracotomy
10. Have you ever witnessed or experienced a patch infection following a CDH repair with a prosthetic patch?
a. Yes
b. No
If so, to what do you attribute the infection?
_______________