A male baby was born to a 30-year-old second gravida by normal vaginal delivery, in a private hospital. The baby had birth asphyxia and resuscitated with bag and mask ventilation. APGAR scores were 6 and 7 at 3 and 5 minutes, respectively. Patient was kept in the intensive care unit under oxygen hood and feeds were started.
He was referred to our hospital on day 6 with persistent respiratory distress. On admission his respiratory rate was 70/min, SpO2 was 87% with oxygen hood. The abdomen was soft and not distended. Air entry on both sides was reduced, more so on the right side. Liver dullness was noted abnormally high in the chest. A chest radiograph suggested right sided diaphragmatic eventration. Patient was intubated and ventilation started. A repeat radiograph showed elevated right hemi-diaphragm and shift of mediastinum to the left (Fig. 1A). Echocardiography revealed no cardiac abnormality.
Figure 1: Preoperative chest radiograph.
After preoperative stabilization the baby was operat-ed through a right sub-costal incision. The liver was very large and difficult to manipulate, hence the incision was extended in a roof top fashion. Falciform ligament was divided to mobilize the liver. It was discovered that a large part of right lobe of liver was inside the right hemithorax. The intrathoracic portion of right liver was reduced into the abdomen by gentle manipulation. This revealed a well defined defect in the diaphragm with well formed anterior and posterior lips of the muscle of the diaphragm. The lung was visible through a transparent sac (Fig. 2A). Manipulation of the left lobe of liver revealed a diaphragmatic hernia on the left side as well. The content of left hernia was part of left lobe of liver, spleen and a small part of splenic flexure of colon. There was a sac covering the contents.
Figure 2: (A) Bilateral CDH with sac. (B) After excision of sac fairly well developed lung seen.
Figure 3: Postoperative chest radiograph.
The contents were reduced, sac excised and the defect closed with polypropylene sutures on both sides. Intercostal tubes were placed on both sides. After reducing liver and other contents, primary closure of the abdominal wall was not possible. Hence a silo was created using a polypropylene mesh sandwiched between two layers of Ioban TM (3M, Minnesota, USA). Postoperatively the baby was electively ventilated at rates of 50 per minute and FiO2 of 80%. The silo was further reduced by 1.5 cm after 24 hours. The patient, however, deteriorated and developed severe pulmonary hypertension. Although the lung showed reasonable expansion on a post operative chest radiograph (Fig. 1B), the child went into refractory shock and died 30 hours after surgery.