In group 2, sutured diaphragm failure and severe deformation of the left
half of the chest wall were observed, the overall mortality was 33.3%. Made
conclusion of the rationality of the proposed operational benefits in patients
false with congenital diaphragmatic hernia with severe hypoplasia of the diaphragm.
Congenital diaphragmatic hernia is a severe pain, which
3% of cases the cause of neonatal death. Population frequency of congenital
diaphragmatic hernia is 1 case per 2,300 births, and this disease
in 40% of cases combined with malformations of other organs, most often with defects
CNS and pulmonary sequestration ekstralobarnymi and often part of the chromosome
and genetic syndromes. Most frequently (60 - 80% of all hernias diaphragm) found
left-sided false hernia proper aperture 4, 8. Defect size range
from the slit to aplasia dome of the diaphragm, and on the affected side always
marked hypoplasia or aplasia of the lungs. Congenital diaphragmatic hernia false
almost always accompanied by phenomena asfiksicheskogo infringement, which requires
urgent surgical treatment. The aim of our study was to optimize
surgical treatment of congenital diaphragmatic hernia false in children
with severe hypoplasia of the diaphragm.
were studied and compared the results of treatment of 12 newborns who were
hospitalized in the regional children's hospital in Donetsk in 1994
to 1999 on the false left-sided congenital diaphragmatic hernia
hernial large sizes. In all patients, a defect of the left dome of the diaphragm
accounted formorethan half of the area, there were no lumbar part gipoplazirovannoy
diaphragm and lumbocostal muscle spindle, and the lower edge of her was presented
tense "chord." Boys were 8 (66,7%), girls 4 (33,3%).
During the first 3 hours after birth was delivered 1 (8,3%) children, 3-6
h - 2 (16,7%), 6-12 hours - 2 (16,7%), 12-24 - 5 (41,6%) after 24
h later and 2 (16,7%) newborns. All patients had asfiksicheskoe infringement
and hypoplasia of the left lung, expressed to a greater or lesser degree. Co
malformations and deformities were found in 7 - (58,3%) patients.
General characteristics of associated malformations is presented in Table. 1.
Patients were divided into 2 comparable groups. Elections were compiled by
continuous selection: In Group 1 included 6 children who were at the hospital
treatment from 1994 to 1996. All these patients had surgery after 1-3 h after
admission to the hospital.
Table 1
General characteristics of associated malformations in patients with congenital
false diaphragmatic hernia
| Nosology | Co-whipping of a patients with congenital diaphragmatic hernia false | |
| % | abs. | |
| Congenital heart disease | 3 | 25 |
| hypoplasia of the thoracic aorta | 1 | 8,3 |
| Hypoplasia of the right lung | 2 | 16,7 |
| Hydrocephalus | 1 | 8,3 |
| Hydronephrosis | 1 | 8,3 |
| Megaureter | 1 | 8,3 |
| Polydactyly | 2 | 16,7 |
| Total | 11 | 91,7 |
Example Remark and e. The table below shows the absolute number of malformations
and deformities, some patients were observed ublirovanie or multiple forms
vices.
Preoperative preparation included decompression of the stomach,
short-term infusion therapy, and warm, humidified insufflation and enriched
oxygen. Proper surgical treatment consisted of plastic left
dome of the diaphragm with local tissues (3 children), the plastic of the left dome of the diaphragm
local tissues with podshivaniem edges of the diaphragm to the periosteum of 7.8 ribs (2 children)
autoplasty musculo-aponeurotic flap in the leg (1 child). In the postoperative
period was carried out ventilation, posindromnuyu infusion,
antibacterial, fermentoterapiyu.
the 2-nd group consisted of 6 children. who were hospitalized at the clinic
from 1997 to 1999 Surgical treatment of patients in this group included a modified
plastic diaphragm with local tissues (the application for invention No 99l16318, decision
Examination of the State Enterprise of Ukraine Institute of Industrial
ownership "of registration from 11.22.1999). Plastic diaphragm in children with
false congenital diaphragmatic hernia and severe hypoplasia of the diaphragm was carried out
follows. Following a median laparotomy and evacuation of
abdominal cavity from the pleural cavity was performed dissection gipoplazirovannoy
aperture in the middle in the sagittal direction to the sternum-rib muscle
roll with the formation of two triangular flaps (Fig. 1). The base of each
formed from the triangular flaps were fixed to 7 or 8 ribs 2 separate
synthetic sutures (Fig. 2). After this defect were sutured with double diaphragm
U-shaped seams, and two rear seams picked up a transverse fascia
and retroperitoneal fat (Fig. 3). In the early postoperative period was performed
regulation of thermoregulatory provide decompression of the stomach and intestines
by setting the permanent nasogastric tube. Throughout the period,
As long as the diversion of stagnant separated by nasogastric tube,
conducting adequate parenteral nutrition.
During 1-x postoperative days was carried out forced ventilation
(OPV) in the mode of IMV (intermittent forced ventilation) with the establishment of
parameters of artificial ventilation (RIR, PEEP, i: E, the rate of gas
flux corresponded to 2 l / min kg). The vast majority of patients through
day APW was replaced with a permanent positive breath (PEEP) via the tracheal
tube with expiratory pressure 4 - 6 cm of water. Art. with the concentration of O 2 (FiO 2) 40
- 50%. If within 12 - 24 h state is not adversely affected, the children were transferred
by breathing through a nasal cannula (P 5 cm of water. Art.). In the future gradually
reduced pressure in the airways. 2 cm of water. Art. every 8 - 12 pm and
transferred to moist oxygenation of 30 - 40% O 2 through a mask. In order to prevent
septic complications, all patients received 1 - 2 courses of antibiotic therapy
(Imipenem, cephalosporins, aminoglycosides).
image001U patients in Group 1 complications in the postoperative
period were mainly cardiorespiratory in nature. Nature of such complications
was due, on one hand: the left lung hypoplasia (1 patient was
hypoplasia of both lungs), and with another - vistseroabdominalnoy imbalance that
led to the development of a syndrome of increased intra-abdominal and intrathoracic pressure
in the early postoperative period.
Results of surgical treatment of children with congenital diaphragmatic false
hernia
| Group 1 | Group 2 | |||||||||||
| Survivors | deaths | Insolvency sutured diaphragm | Survivors | deaths | Insolvency sutured diaphragm | |||||||
| abs. | % | abs. | % | abs. | % | abs. | % | abs. | % | abs. | % | |
| 1 | 16,7 | 5 | 83,3 | 2 | 33,3 | 4 | 66,7 | 2 | 33,3 | 0 | - | |
image002Iz 3 children who had undergone plastic gipoplazirovannoy
Aperture local tissues, in 2 (66.7%) developed failure of sutured diaphragm
and recurrence of false diaphragmatic hernia, which resulted in death. Neonates
underwent plasty of the left diaphragm cupola with local tissues podshivaniem edges
diaphragm to the rib periosteum of 8.7, in the postoperative period was marked by severe
deformity of the left half of the chest wall, which made it difficult to trip the chest
cells and is a cosmetic defect. Autoplasty musculo-aponeurotic
graft on the leg (1 case) was accompanied by a large and traumatic blood loss,
which eventually led to the death of the patient. Overall mortality among patients in this
group was 83.3%, recovery was only one girl who has undergone
plastic diaphragm local tissues from the edges of the diaphragm podshivaniem to the periosteum
8 ribs (Table 2).
image003Kardiorespiratornaya insufficiency, severe
to a greater or lesser extent, also observed in all patients in group 2.
In this group of insolvency sutured diaphragm and deformation of the left marked
half of the chest wall were noted. In 1 patient in the early postoperative
period of intense left-sided pneumothorax developed, requiring drainage
the left pleural cavity of Byullau with subsequent recovery. Children with
favorable course of disease depending on the severity of vistseroabdominalnoy
imbalances enteroplegia resolved to a 4-day 7 post-operative period.
The indication for removal of nasogastric tube and early enteral nutrition was considered
decrease in the volume evacuated per night stagnant intestinal contents
up to 20 cm Overall mortality in this group was 33.3% (see Table 2.).
know a significant number of ways plastic diaphragm used in patients
with 36 false congenital diaphragmatic hernia. Essentially the existing methods
plastic diaphragm can be divided into 5 groups: 1) simple autoplastic methods;
2) autoplasty muscular or musculo-aponeurotic flap in the leg, and 3) tamponade
neighboring organs, 4) free auto-and gomoplastika, 5) plastic, synthetic
materials 3, 5, 8. Autoplasty muscular or musculo-aponeurotic flap
on the leg, as well as free fascia and autokozhey now almost do not apply.
The reason for this complexity, most traumatic and unreliability of these methods. Then
The same applies to tamponade the defect dome of the diaphragm overlying the abdominal organs
and thoracic cavity 2. The most widely used synthetic materials,
however, their use has revealed significant negative moments. First
all these materials are irritating to the pleura and lead to development of exudative pleurisy.
Another objection to the use of nonabsorbable synthetic materials
is that their use in children prevents further normal growth
and development of the diaphragm. These observations, though to a lesser extent, are also
and allo - and ksenoplastike Dura 5, 7.
currently the leading role played by simple autoplastic methods 5, 6.
However, there are times when simple methods of plastic or entirely inapplicable
or extremely unreliable. Basically, it refers to cases of large defect in the zone
Bogdaleka gap on the left and respectively marked hypoplasia of the diaphragm. In such
cases there is no lumbar part, the bottom edge gipoplazirovannoy
diaphragm before tense "chord." In this situation, closure of
hernial gate leads to a pronounced tension seam lines, which in turn
bodily easption sutures in the postoperative period and recurrence of false diaphragmatic
hernia. Proposed by Lai Ping-yao a local plastic diaphragm fabrics with podshivaniem
edges of the diaphragm to the rib periosteum 7.8 to a greater extent prevents line joints
from the easption in the early postoperative period, but is always accompanied by
severe deformity of the left half of the chest wall, which makes it difficult to trip
thorax and is resistant cosmetic defect.
We proposed a way to plastic diaphragm has several advantages over those described.
After dissection in the sagittal direction gipoplazirovannogo dome of the diaphragm
together with the bottom edge (hard "chord"), formed twomoremobile
triangular flap, thus reducing tension through the joints between them and
probability of insolvency. Besides fixing the edges of the diaphragm to 7 or
8 ribs can give a "rigidity" of the grounds formed triangular
flaps, and it promotes amoreintimate diligence edges of the diaphragm to the transverse
fascia, and retroperitoneal fat, and prevents the easption of the joints between them. Imposition
double U-shaped joints promotes a better adaptation of the edges of the diaphragm and reduces the
load on the line cutter. Application of the technique enabled us to avoid relapse
disease and reduce the overall mortality rate at 50.0% in patients with congenital false
diaphragmatic hernia with severe hypoplasia of the diaphragm.
Conclusions
1. Results of treatment of children with congenital diaphragmatic hernia false depend
the size of the defect and the severity of hypoplasia of the diaphragm, the presence of associated defects
Development and malformations, as well as operational tactics.
2. Children with congenital diaphragmatic hernia false with severe hypoplasia of the diaphragm
operative treatment rationally spend on our proposed method.
3. Optimization of the surgical treatment of congenital diaphragmatic hernia patients with a false
sizes newborn possible to avoid recurrence of the disease andreduce the total
mortality at 50.0%.
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4. "Human Teratology", Ed. GI Lazjuk. M., 1991.
5. Taskin KD, Zhebrovsky VV "Hernia of the abdominal wall." M., 1990.
6. Tosovsky B. "acute process in abdominal cavity in children: Trans. with
Czech. Prague, 1987.
7. Stolf N. A., Zerbini E., J / / Rev. Paul. Med. 1974. Vol. 83, N 1. P. 34
36.
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