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J Chest Surg 2023; 56(3): 177-178

Published online May 5, 2023 https://doi.org/10.5090/jcs.23.019

Copyright © Journal of Chest Surgery.

Commentary: Is the Data Strong Enough to Prorocolize the Approach in Diaphragmatic Hernia Repair? Aspects of Technique and the Sample Size of a Longitudinal Single-Center Study

Hyo Yeong Ahn , M.D., Hoseok I , M.D.

Department of Thoracic and Cardiovascular Surgery, Pusan National University Hospital, Medical Research Institution, Pusan National University School of Medicine, Busan, Korea

Correspondence to:Hyo Yeong Ahn
Tel 82-51-240-7267
Fax 82-51-243-9389
E-mail doctorahn02@hanmail.net
ORCID
https://orcid.org/0000-0003-3198-8237

Received: January 26, 2023; Accepted: January 27, 2023

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Linked Article: J Chest Surg. 2023;56(3):171-176 https://doi.org/10.5090/jcs.22.129

Figure 1.Fig. 1
Figure 2.Fig. 2

In this issue of the Journal of Chest Surgery, Oh et al. [1] at Samsung Medical Center present a retrospective cohort study that investigated the clinicopathologic characteristics of patients with diaphragmatic hernia (DH) who underwent different surgical treatment approaches. To date, there are no established criteria for the proper indications and patient selection for the different surgical approaches to DH repair [2]. The article clearly summarized the recommended surgical approaches to use in a variety of cases, especially considering the duration of DH and the location of the herniated organs.

Since the variety in size, location, and severity contributes to different surgical outcomes and prognoses, the number of patients in this study was too small to protocolize the approach and derive any definitive conclusions. Spe­cifically, with regard to the transthoracic approach, there is a lack of evidence to prove the value of video-assisted thoracoscopic surgery (VATS) in the management of DH based on merely 5 cases.

As mentioned in the article, in cases with longer duration, “tension-free” repair using mesh is recommended. To prevent injury to the lung and to protect the abdominal organs, the thoracic approach allowed better visualization of the surgical field than the abdominal approach, ensuring safe dissection in cases with a longer hernia duration [3]. Open surgery is safe and facilitates the effective use of various instruments, allowing the diaphragm to lie at the lowest level. Especially, using VATS, flattening the diaphragm is not as easy to achieve as it is through open surgery. In this study, there is no discussion of methods to flatten the diaphragm at the lowest level during VATS. We recommend pneumatic compression with carbon dioxide (CO2) gas during VATS. This is an effective and safe option to maintain the dissection plane and to easily flatten the diaphragm. However, during pneumatic compression, CO2 could move into the abdominal space, resulting in inadequate compression of the diaphragm in some cases. This can be overcome by approximation of the mesh using tagging sutures just after dissecting the plane under the diaphragm.

This paper summarized the surgical approaches to the management of DH. Due to the variety of conditions affecting these patients, surgeons are faced with making the best decision in the moment. This study is subject to the main weaknesses of single-center studies, including a small sample size. Since it is necessary to outline the selection criteria and proper indications in DH patients depending on their clinicopathologic characteristics, more evidence is needed to protocolize the approach and derive any definitive conclusions.

Author contributions

All the work was done by Hyo Yeong Ahn and Hoseok I.

Conflict of interest

Hoseok I is an editorial board member of the journal. No other potential conflict of interest relevant to this article was reported.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

  1. Oh S, Lim SK, Cho JH, et al. Surgery for diaphragmatic hernia repair: a longitudinal single-institutional experience. J Chest Surg 2023 Jan 30. [Epub]. https://doi.org/10.5090/jcs.22.129.
    Pubmed CrossRef
  2. Li H, Zhao S, Wu C, Pan Z, Wang G, Dai J. Surgical treatment of congenital diaphragmatic hernia in a single institution. J Cardiothorac Surg 2022;17:344. https://doi.org/10.1186/s13019-022-02098-w.
    Pubmed KoreaMed CrossRef
  3. Jones EK, Andrade R, Bhargava A, Diaz-Gutierrez I, Rao M. Surgical management of delayed-presentation diaphragm hernia: a single-institution experience. JTCVS Tech 2022;13:263-9. https://doi.org/10.1016/j.xjtc.2022.04.012.
    Pubmed KoreaMed CrossRef

Article

Commentary

J Chest Surg 2023; 56(3): 177-178

Published online May 5, 2023 https://doi.org/10.5090/jcs.23.019

Copyright © Journal of Chest Surgery.

Commentary: Is the Data Strong Enough to Prorocolize the Approach in Diaphragmatic Hernia Repair? Aspects of Technique and the Sample Size of a Longitudinal Single-Center Study

Hyo Yeong Ahn , M.D., Hoseok I , M.D.

Department of Thoracic and Cardiovascular Surgery, Pusan National University Hospital, Medical Research Institution, Pusan National University School of Medicine, Busan, Korea

Correspondence to:Hyo Yeong Ahn
Tel 82-51-240-7267
Fax 82-51-243-9389
E-mail doctorahn02@hanmail.net
ORCID
https://orcid.org/0000-0003-3198-8237

Received: January 26, 2023; Accepted: January 27, 2023

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Linked Article: J Chest Surg. 2023;56(3):171-176 https://doi.org/10.5090/jcs.22.129

Body

Figure 1. Fig. 1
Figure 2. Fig. 2

In this issue of the Journal of Chest Surgery, Oh et al. [1] at Samsung Medical Center present a retrospective cohort study that investigated the clinicopathologic characteristics of patients with diaphragmatic hernia (DH) who underwent different surgical treatment approaches. To date, there are no established criteria for the proper indications and patient selection for the different surgical approaches to DH repair [2]. The article clearly summarized the recommended surgical approaches to use in a variety of cases, especially considering the duration of DH and the location of the herniated organs.

Since the variety in size, location, and severity contributes to different surgical outcomes and prognoses, the number of patients in this study was too small to protocolize the approach and derive any definitive conclusions. Spe­cifically, with regard to the transthoracic approach, there is a lack of evidence to prove the value of video-assisted thoracoscopic surgery (VATS) in the management of DH based on merely 5 cases.

As mentioned in the article, in cases with longer duration, “tension-free” repair using mesh is recommended. To prevent injury to the lung and to protect the abdominal organs, the thoracic approach allowed better visualization of the surgical field than the abdominal approach, ensuring safe dissection in cases with a longer hernia duration [3]. Open surgery is safe and facilitates the effective use of various instruments, allowing the diaphragm to lie at the lowest level. Especially, using VATS, flattening the diaphragm is not as easy to achieve as it is through open surgery. In this study, there is no discussion of methods to flatten the diaphragm at the lowest level during VATS. We recommend pneumatic compression with carbon dioxide (CO2) gas during VATS. This is an effective and safe option to maintain the dissection plane and to easily flatten the diaphragm. However, during pneumatic compression, CO2 could move into the abdominal space, resulting in inadequate compression of the diaphragm in some cases. This can be overcome by approximation of the mesh using tagging sutures just after dissecting the plane under the diaphragm.

This paper summarized the surgical approaches to the management of DH. Due to the variety of conditions affecting these patients, surgeons are faced with making the best decision in the moment. This study is subject to the main weaknesses of single-center studies, including a small sample size. Since it is necessary to outline the selection criteria and proper indications in DH patients depending on their clinicopathologic characteristics, more evidence is needed to protocolize the approach and derive any definitive conclusions.

Article information

Author contributions

All the work was done by Hyo Yeong Ahn and Hoseok I.

Conflict of interest

Hoseok I is an editorial board member of the journal. No other potential conflict of interest relevant to this article was reported.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Fig 1.

Figure 1.Fig. 1
Journal of Chest Surgery 2023; 56: 177-178https://doi.org/10.5090/jcs.23.019

Fig 2.

Figure 2.Fig. 2
Journal of Chest Surgery 2023; 56: 177-178https://doi.org/10.5090/jcs.23.019

There is no Table.

References

  1. Oh S, Lim SK, Cho JH, et al. Surgery for diaphragmatic hernia repair: a longitudinal single-institutional experience. J Chest Surg 2023 Jan 30. [Epub]. https://doi.org/10.5090/jcs.22.129.
    Pubmed CrossRef
  2. Li H, Zhao S, Wu C, Pan Z, Wang G, Dai J. Surgical treatment of congenital diaphragmatic hernia in a single institution. J Cardiothorac Surg 2022;17:344. https://doi.org/10.1186/s13019-022-02098-w.
    Pubmed KoreaMed CrossRef
  3. Jones EK, Andrade R, Bhargava A, Diaz-Gutierrez I, Rao M. Surgical management of delayed-presentation diaphragm hernia: a single-institution experience. JTCVS Tech 2022;13:263-9. https://doi.org/10.1016/j.xjtc.2022.04.012.
    Pubmed KoreaMed CrossRef

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