Thoracoscopic repair of congenital diaphragmatic hernia: review of the results.

Congenital diaphragmatic hernia (CDH) remains one of the major challenges in neonatal surgery. Survival rate has increased in the last decades mainly due to perinatal care and surgical technique improvements. Classically, a laparotomy has been performed after cardiovascular and respiratory stabilization. Introduction of thoracoscopy in the repair of CDH brought the known advantages of reduced postoperative pain and better cosmesis. However, its safety and effectiveness have been questioned in the last few years. Although there is lack of high evidence data, it seems consensual that thoracoscopy is associated with: 1) longer operative time on account of the learning curve; 2) increased acidosis during surgery whose effects have not been clarified but there is evidence suggesting that neurodevelopment is not affected; 3) reduced morbidity, namely postoperative ileum and adhesions, pain and scar formation; 4) similar mortality rate; 5) higher number of recurrences. While the majority of outcomes are comparable between open and thoracoscopic repair, reduced postoperative morbidity and better cosmesis are advantages to be considered. Technique improvements are still required to reduce recurrence rate. Division of the pleura from the peritoneum is a major step of the procedure; suture type and quality must simulate those in the open repair. The authors believe that careful and meticulous execution of the principles of open surgery will improve outcomes regarding recurrence.