Thoracoscopic versus open congenital diaphragmatic hernia repair: a systematic review and meta-analysis by the Pediatric Surgery Meta-Analysis Study Group (PESMA).

PURPOSE: To compare outcomes of thoracoscopic repair (TR) versus conventional open repair (COR) for congenital diaphragmatic hernia (CDH) through a systematic review and meta-analysis. METHODS: PubMed, EMBASE, SCOPUS, and Web of Science were searched up to August 2025 for comparative neonatal CDH studies. Randomized, prospective, and retrospective designs reporting at least one clinical outcome were included. Risk ratios (RR) with 95% confidence intervals (CI) were pooled using a random-effects model. The review followed PRISMA guidelines and was registered in PROSPERO (CRD420251128490). RESULTS: Nineteen studies involving 434 TR and 631 COR cases were included. Total recurrence was higher after TR (12.9% vs. 4.1%; RR 2.40; p = 0.0003). Primary repair recurrence showed the largest difference (12% vs. 0%; RR 4.39; p = 0.001), and patch repair recurrence remained higher in TR (21% vs. 11.5%; RR 1.98; p = 0.04). Bowel obstruction was lower after TR (6% vs. 14.6%; RR 0.52; p = 0.02). No significant differences were found for chylothorax, pneumothorax, pleural effusion, or bowel injury. Mortality was lower in TR (0.9% vs. 5.9%; RR 0.31; p < 0.0001), likely reflecting patient selection. CONCLUSION: TR is feasible in selected neonates and is associated with lower bowel obstruction and mortality but higher recurrence. Standardized criteria for selecting TR versus COR remain essential.