Evolution of minimally invasive surgery for congenital diaphragmatic hernia: a nationwide multicenter retrospective cohort analysis in Japan.

BACKGROUND

Minimally invasive surgery (MIS) for congenital diaphragmatic hernia (CDH) has previously been associated with higher recurrence rates and uncertain indications compared with open surgery. Since 2017, the Japanese Congenital Diaphragmatic Hernia Study Group (JCDHSG) has implemented a standardized national protocol, potentially improving perioperative management and surgical outcomes.

METHODS

This multicenter retrospective study analyzed 1,081 infants who underwent definitive CDH surgery at 15 tertiary centers in Japan between 2007 and 2023. Patients were categorized by surgical approach and period: early-period MIS (≤ 2016, n = 62), late-period MIS (≥ 2017, n = 109), early-period open (≤ 2016, n = 536), and late-period open (≥ 2017, n = 374). In-hospital mortality was assessed for the "Intended-MIS" group (including conversions), while surgical outcomes and recurrence were evaluated for the "Complete-MIS" group (successfully completed procedures without conversion).

RESULTS

In the Intended-MIS group, the conversion rate dropped significantly from 29% in the early period to 10% in the late period (p < 0.01). Compared with the early period, the late-period MIS group had lower severity indices (oxygenation index < 8: 76.6% vs. 93.3%, p = 0.012; Terui category 3: 11.4% vs. 1.1%, p = 0.007). In the Complete-MIS group, early postoperative recovery improved, with a higher rate of ventilator weaning within 7 days (20% vs. 58.3%, p < 0.001). The recurrence rate at discharge in the Complete-MIS group decreased significantly (8.2% vs. 1.0%, p = 0.044), while remaining unchanged in the open surgery group. In-hospital mortality in the Intended-MIS group was eliminated in the late period (3.2% vs. 0%, p = 0.252).

CONCLUSIONS

Following nationwide protocol implementation, MIS for CDH has evolved into a safe and effective alternative to open surgery in carefully selected neonates. Improved patient selection based on physiologic severity, stabilization of technical proficiency, and advances in perioperative management have led to earlier respiratory recovery and a significant reduction in recurrence.