Open vs Thoracoscopic Repair in Congenital Diaphragmatic Hernia: A Comparative Study

Congenital diaphragmatic hernia (CDH) is a developmental defect of the diaphragm characterized by herniation of abdominal viscera into the thoracic cavity, resulting in pulmonary hypoplasia and persistent pulmonary hypertension of the newborn. It remains a significant cause of neonatal morbidity and mortality, with an estimated incidence of approximately 1 in 2500–4000 live births [1,2].

 The pathophysiology of CDH is complex and involves impaired lung development, abnormal pulmonary vasculature, and varying degrees of cardiorespiratory compromise at birth. Despite advances in neonatal intensive care, including gentle ventilation strategies and extracorporeal membrane oxygenation (ECMO), the overall survival remains variable depending on the severity of pulmonary hypoplasia and associated anomalies [3,4].

 Surgical repair is a definitive component of CDH management and is typically performed after preoperative stabilization. Traditionally, CDH repair has been carried out through an open abdominal or thoracic approach, which allows direct visualization and secure closure of the diaphragmatic defect. Open repair remains widely practiced due to its reliability, especially in large defects and hemodynamically unstable patients [5,6].

 Over the past two decades, minimally invasive surgery (MIS), particularly thoracoscopic repair, has gained increasing acceptance in pediatric surgical practice. Thoracoscopy offers several advantages, including smaller incisions, reduced postoperative pain, shorter duration of mechanical ventilation, improved cosmetic outcomes, and faster recovery [7,8]. Additionally, enhanced magnification during thoracoscopy may facilitate precise dissection and repair.

 However, concerns persist regarding the technical difficulty of thoracoscopic repair, especially in neonates with limited physiological reserve. Several studies have reported longer operative times and a steeper learning curve associated with thoracoscopic procedures [9]. More importantly, higher recurrence rates have been observed in some series, possibly due to tension at the repair site, intracorporeal suturing challenges, and selection bias toward less severe cases [10,11].

 Given these considerations, the choice between thoracoscopic and open repair remains a subject of ongoing debate. While thoracoscopic repair may offer short-term advantages, its long-term outcomes, particularly recurrence rates, require further evaluation.

Therefore, the present prospective comparative study was undertaken to evaluate and compare the clinical outcomes of thoracoscopic versus open repair in patients with congenital diaphragmatic hernia at a tertiary care pediatric surgery center.

Ethical Considerations

The study was conducted after obtaining approval from the Institutional Ethics Committee. Written informed consent was obtained from parents or legal guardians prior to inclusion. Patient confidentiality was strictly maintained throughout the study.

Study Design

This was a prospective comparative study. The data were collected from different patient’s records. The study was carried out over a period of five years.

Study Population

All consecutive patients diagnosed with congenital diaphragmatic hernia (CDH) and admitted during the study period were prospectively enrolled.

A total of 68 patients were included. They were divided into two groups; Group I (thoracoscopic repair group) including 26 patients. Group II (open repair group) including 42 patients.

Inclusion Criteria

Included in the study were; neonates and infants diagnosed with congenital diaphragmatic hernia.

 The study also included those patients who underwent surgical repair (thoracoscopic or open)  All hemodynamically stable patients deemed fit for surgery were as well considered.  

Exclusion Criteria

Excluded from the study were patients with major congenital anomalies incompatible with survival,

those who expired before surgical intervention and patients with recurrent CDH cases previously operated elsewhere  plus  those who had incomplete clinical data or loss to follow-up.

Preoperative Management

All patients underwent standardized preoperative stabilization, including; mechanical ventilation using lung-protective strategies, correction of acidosis and electrolyte imbalance, hemodynamic stabilization with inotropic support when required. All patients underwent echocardiographic evaluation for pulmonary hypertension.

Surgical intervention

Surgical techniques  were only performed after achieving clinical and hemodynamic stabilization.

Group Allocation

Patients were allocated into the  two groups; I and II based on; their hemodynamic stability, size of diaphragmatic defect (assessed radiologically/intraoperatively) as well as the surgeon expertise and preference. However, thoracoscopic repair was preferred in stable patients with smaller defects, while open repair was performed in patients with larger defects or borderline stability

Surgical Technique

-         Thoracoscopic Repair

Thoracoscopic repair was performed under general anesthesia with single-lung ventilation where feasible. Patients were placed in the lateral decubitus position. Three ports were inserted, and CO₂ insufflation was used to facilitate visualization. Herniated abdominal contents were reduced into the peritoneal cavity, and the diaphragmatic defect was closed using interrupted non-absorbable sutures. Patch repair was used when primary closure was not feasible.

Open Repair

Open repair was performed via a subcostal abdominal incision. Herniated viscera were reduced, and the diaphragmatic defect was repaired using non-absorbable sutures, with or without patch placement depending on defect size.

Data Collection

Data were collected prospectively using a standardized structured proforma, including:

demographic details (age, sex), clinical presentation and side of hernia, operative details (type of surgery, operative time), postoperative  course parameters plus complications and outcomes.

Outcome Measures

 They included;  primary outcomes such as;  the duration of mechanical ventilation pre and post-surgery, length of hospital stay and also recorded was the recurrence rate.  Also reported was the secondary Outcomes including , mean operative time, postoperative complications (wound infection, respiratory complications)  plus the overall mortality rate.

Follow-Up

All patients were followed up for a minimum period of 6–12 months postoperatively. Follow-up evaluation involved;  clinical examination, chest radiography when indicated  plus assessment for recurrence and respiratory function

Statistical Analysis

Data were entered and analyzed using statistical software package  (SPSS version 20).

Continuous variables were expressed as mean ± standard deviation (SD).

complete excision of the pedunculated subcutaneous soft-tissue mass arising from the right lower back.

Congenital diaphragmatic hernia (CDH) continues to be a major neonatal surgical challenge due to its association with pulmonary hypoplasia and pulmonary hypertension, which significantly influence outcomes [15]. With advances in minimally invasive surgery, thoracoscopic repair has emerged as an alternative to open repair; however, its safety, feasibility, and long-term outcomes remain topics of ongoing debate [1,2].

In the present prospective study, baseline demographic and clinical characteristics were comparable between the thoracoscopic and open

repair groups, allowing a reliable comparison of surgical outcomes. Similar comparability has been emphasized in previous studies evaluating CDH repair techniques [3,4].

A key finding of our study was the significantly longer operative time in the thoracoscopic group compared to open repair. This observation is consistent with earlier studies, which attribute prolonged operative duration to the technical complexity of thoracoscopic suturing, limited working space in neonates, and the steep learning curve associated with minimally invasive procedures [2,4,13]. However, with increasing experience and refinement of techniques, operative times have been shown to decrease over time [5].

Despite longer operative time, thoracoscopic repair demonstrated clear advantages in postoperative recovery. In our study, patients undergoing thoracoscopic repair had significantly shorter duration of mechanical ventilation, ICU stay, and overall hospital stay. These findings are supported by several studies and meta-analyses, which report improved postoperative recovery and reduced morbidity with minimally invasive approaches due to decreased surgical trauma and better preservation of respiratory mechanics [7,9,10,12].

Postoperative respiratory outcomes in our study also favored the thoracoscopic approach, with reduced oxygen dependency and shorter ICU stay. This is particularly relevant in CDH patients, where minimizing ventilatory support is crucial in preventing further lung injury and improving outcomes [11].

With regard to recurrence, our study demonstrated a higher rate in the thoracoscopic group compared to open repair, although the difference was not statistically significant. This trend has been consistently reported in the literature, with multiple studies and meta-analyses indicating higher recurrence rates following thoracoscopic repair [6,9,10]. The increased recurrence is often attributed to technical challenges such as intracorporeal suturing, tension at the repair site, and difficulties in managing larger defects thoracoscopically [6,13]. Careful patient selection and use of patch repair when indicated may help mitigate this risk [8].

In contrast, wound-related complications were more common in the open repair group in our study. This finding aligns with existing literature, where minimally invasive approaches are associated with lower rates of wound infection, reduced postoperative pain, and superior cosmetic outcomes [7,14]. These advantages are particularly important in pediatric populations.

Importantly, the mortality rates were comparable between the two groups in our study, suggesting that the surgical approach does not significantly influence survival. Mortality in CDH is largely determined by the severity of pulmonary hypoplasia, pulmonary hypertension, and associated anomalies rather than the operative technique itself [11,15].

Recent systematic reviews and meta-analyses have further reinforced these findings, concluding that thoracoscopic repair offers improved short-term recovery outcomes but carries a higher risk of recurrence, while open repair remains more reliable for larger defects and unstable patients [9,10,12]. Similarly, single-center experiences have demonstrated that thoracoscopic repair can be safely performed in selected hemodynamically stable patients with favorable anatomy [16].

It may be concluded that; thoracoscopic repair of congenital diaphragmatic hernia is a feasible, safe and effective alternative to open repair in carefully selected patients, offering the advantages of shorter ventilation duration and reduced hospital stay. However, it is associated with a relatively higher risk of recurrence and longer operative time. Open repair remains a reliable approach, particularly in complex cases. Optimal outcomes depend on appropriate patient selection and surgical expertise. Extra cohort studies with major numbers may be needed for a more realistic verification of this notion.

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