Recurrent congenital diaphragmatic hernia; which factors are involved?

The medical records of 66 surviving children born with congenital posterolateral diaphragmatic hernia (CDH) were reviewed to determine which factors are involved in the development of a recurrent hernia. Fifty-seven patients had a left-sided defect and 9 patients had a right sided defect. In 54 patients the defect was closed primarily and 12 patients required a prosthetic patch. Nine of the 66 patients (14%)--5 patients (9%) with a left-sided defect and 4 patients (44%) with a right-sided defect--developed a recurrent hernia on the average of 4.0 months (range 0.2-6.9) after the initial repair. Except for one, all patients with a recurrence presented with dyspnoea (n = 5) and/or feeding problems (n = 6). Of these 9 recurrences 4 patients (7%) had primary closure of the defect and in 5 patients (42%) a prosthetic patch was required. Four of the 11 patients (36%) who needed extracorporeal membrane oxygenation (ECMO) had a recurrence versus 5 patients (9%) who were conventionally treated. A hernial sac was found in 4 patients during the repair of the recurrent hernia. In 3 of them the initial defect was closed primarily. In conclusion, large-patch repaired defects and right-sided defects are risk factors for the development of a recurrent hernia. Furthermore the lack of a biological union between the sutured patch and the diaphragm tissue remnants is likely to be the cause of a reherniation. Meticulous inspection for a hernial sac during the initial operation could reduce the incidence of a reherniation.