A term infant is born with a left sided congenital diaphragmatic hernia (CDH). At exploration a large defect is encountered, which the surgeon determines is not amenable to primary repair. The repair technique for large CDH defects that is associated with the lowest recurrence risk is:

 

A Surgisis™ (porcine small intestinal submucosa)

 

B Gore-tex™

 

C Marlex™(monofilament polypropylene)

 

D Muscle flap​

B

C

Correct answer

D muscle flap

 

Decision-making in the repair of large diaphragmatic defects often reflects surgeon or institutional bias. Historically, patches made of non-absorbable prosthetic such as polytetrafluoroethylene (PTFE), and polypropylene have been used. However, their inert nature, lack of expansibility and high recurrence rates have encouraged consideration of biologic materials manufactured from a variety of sources, including porcine small intestinal submucosa (Surgisis™), cadaveric (Alloderm™), or porcine (Permacol™) acellular dermal matrix.

 

Gore-tex™ is by the most commonly used prosthetic patch with a recurrence rate that averages about 25%, although recent studies report lower rates. Most recurrences tend to occur within the first 12 months. The most commonly used biologic mesh has been Surgisis™ which is associated with a high recurrence rate that should limit its use as the sole replacement material. The experience with other biologic meshes, namely Alloderm™ and Permacol™ is limited but promising.

 

Completely autologous diaphragmatic replacement using a split abdominal wall muscle flap was first reported 50 years ago but has not received the same attention as artificial patches until recently. This repair requires placement of the left subcostal incision at least 2 cm below the costal margin, with separation of the transversus abdominis and internal oblique from the external oblique in the superior abdominal flap which is turned inward and becomes the neo diaphragm. A combined experience with muscle flaps in 120 patients from 3 institutions yielded a recurrence rate of 5%. Concerns regarding an increased predisposition to ventral hernia are not supported by current reports.

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