Surgical correction of false congenital diaphragmatic hernias in children by means of anatropic osteotomy

Abstract

Introduction: Congenital diaphragmatic hernias (CDH) belong to the group of vitally dangerous defects of development of respiratory system accompanied by heavy derangements of respiratory, cardiovascular, nervous systems and the organs of gastrointestinal path. According to scientific works in this field the frequency of this anomaly is very high - 1 case on 2000-4000 newborns, including mortinatus. The lethality at the pathology has been quite high, it averages 18-33,4%. Despite significant achievements in the treatment of CDH, surgical treatment still is the most effective method, consisting in clearing pleural cavity of hernial contents with the further liquidation of the diaphragmatic defect. However, even among the children operated in due time the lethality is 40-60 %. Timeliness, the choice of surgical interfere, method and techniques of a plasticity of the diaphragm, the liquidation of visceroabdominal disproportion and of the respiratory distress, the prevention of postoperative complications still are controversial points. All this requires the search of the new surgical approaches, the development of which is impossible without an adequate experimental model of the diaphragmatic hernia. Objective: The purpose of the work is to develop an experimental model of a false diaphragmatic hernia on dogs with the possibility of the further surgical correction with the application of anatropic osteotomy. Materials and methods: Surgical interfere was carried out upon 12 mongrels aged from 1 to 2 months. After the survey X-radiography of the organs of thoracic and abdominal cavities, animals received the combined intravenous narcosis supplemented with endotracheal intubation. Further on the edge of the left costal arch laparotomy was carried out. Having provided access to the left dome of a diaphragm, the superposition of ligature for fixing was carried out, between which a big rag in the form of a triangle was cut. Through the formed defect the loops of the small intestine were introduced into the pleural cavity and fixed at the level of gate of the created diaphragmatic hernia by the sero-muscular sutures. The pleural cavity was draining. The wound of the anterior abdominal wall was layer by layer stitched up in separate nodal tight sutures. In 2 hours after the end of surgery investigation a control survey X-radiography was carried out. Considering the fact that the created model of the diaphragmatic hernia has to resemble the natural one as much as possible, the second stage of surgery investigation was carried out a month later. Under the combined intravenous narcosis in the projection of the 6th rib of the animals thoracotomy was carried out. Having removed fixation sutures, small intestine loops were displaced to the pleural cavity. Having found the 6th rib, the soft fabrics were dissected layer by layer to a rib with dissection periosteum, its mobilization and performance triangular osteotomy, with the further renewal of integrity periosteum. Then the edges of gate diaphragmatic hernia was stitched with U-shaped suture and the defect in the diaphragm was consistently sewn up, its edges pulled together without tension. An operational wound was sewn up layer by layer and tightly. Then the extubation of the animals was conducted and in 2 hours time after the end of the surgery investigation a control survey X-radiography was carried out. Results: Starting with the first days after the surgery, the dogs had general delicacy, disturbia, refusing to take water and nutrition. The objective changes signified the development of the syndrome of intrathoracic strain: frequent shallow breathing, a tachycardia, the sunk down gaste, asymmetry, deformation, blasting and backlog in the certificate of breath of the wounded half of the thorax. Percussion in the low parts of the thorax on the side of a probable hernia helped to determined tympany. At auscultation in this field the sharp indulgence of breath and periodic peristaltic noise was heard. In 2 hours after the operation on the plain film in two projections the regions of a ring-shaped clarification and the level of the lungs collapse were positioned. Within a month, despite the improvement of the state, the animals still had the signs of the intrathoracic strain. After conducting thoracotomy and returning the loops of a small intestine into the abdominal cavity, the defect of the diaphragm of significant dimensions and high position of bottom edge of the left lung were preserved. After osteotomy the rib lost rigidity of an arch and sag in pleural cavity under the traction of the surrounding intercostal muscles, letting to occlude the defect of the diaphragm reliably and without additional tension. Conclusion: Thus a simple and reliable way of modeling of a false diaphragmatic hernia is offered, resembling the congenital one as much as possible, and a new method of surgical correction of the pathology with the application of osteotomy in a projection of the diaphragmatic defect is developed.