ORIGINAL ARTICLE Indications for thoracoscopic repair of congenital diaphragmatic hernia in neonates Tadaharu Okazaki • Kinya Nishimura • Toshiaki Takahashi • Hiromichi Shoji • Toshiaki Shimizu • Toshitaka Tanaka • Satoru Takeda • Eiichi Inada • Geoffrey J. Lane • Atsuyuki Yamataka Published online: 18 September 2010 Ó Springer-Verlag 2010 Abstract Purpose We reviewed 26 consecutive cases of congenital diaphragmatic hernia (CDH) prospectively to establish selection criteria for successful thoracoscopic CDH repair (TR). Methods Five preoperative deaths were excluded, leaving 21 subjects. TR was only considered once pulmonary hypertension (PH) improved on echocardiography, and if cardiopulmonary status was stable in the decubitus position in the neonatal intensive care unit (NICU) under conven- tional mechanical or high-frequency oscillatory ventilation (HFOV) with/without nitric oxide (NO) for at least 10 min as a marker for tolerating surgery and manual ventilation was possible for transfer to the operating room. All other patients had open repair (OR). Results 8/21 had TR and 13/21 had OR. There were significant differences between TR and OR for prenatal diagnosis (37.5 vs. 84.6%, p \ 0.05) and earlier surgery (1.4 ± 0.8 vs. 2.5 ±1.1 days after birth, p \ 0.05), respectively. Intraoperative HFOV was required in all OR and 3 TR (p \ 0.01). NO was required in 1 TR and 10 OR (p \ 0.01). Organ herniation was significantly less in TR (50 vs. 100%, p \ 0.01 for stomach; 0 vs. 54%, p \ 0.05 for liver). Three TR required conversion to OR because of technical difficulties. One OR died from deteriorating PH. Conclusions Our selection criteria for TR would appear to be safe and reasonable. Keywords Congenital diaphragmatic hernia Á Operation Á Thoracoscopy Á Pulmonary hypertension Á Nitric oxide Introduction Minimally invasive surgery (MIS) for infants and chil- dren continues to grow. MIS was first introduced for the treatment of congenital diaphragmatic hernia (CDH) in 1995; Silen et al. [1] used thoracoscopy, while van der Zee and Bax [2] used laparoscopy. However, most pediatric surgeons have hesitated to apply MIS to CDH because of the associated fragile respiratory status and pulmonary hypertension (PH). Nevertheless, thoraco- scopic repair under high-frequency oscillatory ventilation (HFOV) [3] or after extracorporeal membrane oxygena- tion (ECMO) therapy [4] have been reported recently, and MIS appears to be gaining added acceptance for CDH repair without any fixed selection criteria being established [4–7]. We introduced thoracoscopic CDH repair (TR) for CDH in 2007 and reviewed our patients to define safe indications for TR use because to date there are no established indications. T. Okazaki (&) Á T. Takahashi Á G. J. Lane Á A. Yamataka Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-Ku, Tokyo 113-8421, Japan e-mail: okazakit@juntendo.ac.jp K. Nishimura Á E. Inada Department of Anesthesiology, Juntendo University School of Medicine, Tokyo, Japan H. Shoji Á T. Shimizu Department of Pediatrics, Juntendo University School of Medicine, Tokyo, Japan T. Tanaka Á S. Takeda Department of Obstetrics and Gynecology, Juntendo University School of Medicine, Tokyo, Japan 123 Pediatr Surg Int (2011) 27:35–38 DOI 10.1007/s00383-010-2724-0