CDH Surgical Treatment

Determining CDH Treatment

Babies with a congenital diaphragmatic hernia (CDH) can have different treatment plans depending on the severity of the case. Most times, a baby is diagnosed with CDH in utero, and during the pregnancy, a treatment plan is developed prior to giving birth. Learn more about diagnosing CDH.

In addition to CDH surgical repair, postnatal treatment options can include a ventilator, the NICU and/or ECMO. Your baby might not need all these treatments, but it’s vital that they have immediate access to them if necessary. That is why it’s important you deliver your baby in a hospital that can provide this type of postnatal care.

Learn more about CDH treatment at CHOC.

CDH Treatment After Birth

NICU

A diaphragmatic hernia can be life-threatening and requires care in a neonatal intensive care unit (NICU). After your baby is born, they will be transported to the NICU to gain stability before their repair surgery. The NICU provides babies with CDH specialty round-the-clock care from neonatologists and surgical teams.

Babies with CDH are often unable to breathe on their own at first due to underdeveloped lungs, and will need to be placed on a mechanical ventilator, a machine to assist their breathing. Ventilation levels are determined by your baby’s response to assisted breathing. Some babies will require high-frequency oscillatory ventilation that offers different breaths and pressure than the typical ventilator.

Often, babies will also have a tube placed in the nose or mouth and leading directly to their stomach. This tube will work to keep their stomach decompressed and allow the lungs room to expand while breathing. Other intravenous lines may be inserted into your baby’s hands and feet to allow blood level monitoring and administer any needed medications/fluids.

Most importantly, the NICU offers a safe space for your baby away from environmental disturbances. Due to the associated pulmonary hypertension, babies with CDH are in a very sensitive and reactive state. It’s vital that their surroundings are kept stable through low and minimized lighting, noise and handling.

Learn more about CHOC’s Level 4 NICU.

ECMO

If your baby does not respond to the initial effort to stabilize them or they have severe complications, they may be placed on extracorporeal membrane oxygenation (ECMO), a temporary heart and lung bypass machine. ECMO allows your baby’s heart and lungs to rest while the machine functions as their heart and lungs. It provides oxygen in the bloodstream while removing carbon dioxide and pumps blood to the body. It can be used while a baby is trying to stabilize and improve. Most of the babies who require ECMO treatment do so the day they are born.

While a specific set of guidelines determine the use of ECMO in CDH cases, the most common indicators include:

• Pulmonary hypertension
• Heart failure
• Respiratory support that could damage their lungs

Typical ECMO treatment lasts for an average of two weeks but varies depending on each CDH case. The timeline for stopping ECMO treatment is determined by a baby’s stability, lung appearance, tolerance to care, blood work and the continued presence of the above factors. When weaning a baby off of ECMO, ventilation support is often increased as ECMO is decreased, allowing your baby’s organs to take over more and more. Learn about CHOC’s center of excellence for ECMO.

CDH Repair Surgery

Surgery for CDH depends on your baby’s progress in the days following birth. When your baby’s condition has improved, the hole in the diaphragm caused by CDH will be surgically repaired. As babies with CDH are sensitive to movement, surgery may be done in the NICU to limit the stress of being transported to an operating room.

During open surgery, an incision will be made below the rib cage. Through this incision, any abdominal organs that have herniated into the chest cavity will be moved back into the abdomen. The hole in the diaphragm (hernia) is then sewn together. For babies with larger defects, the hole is closed using a muscle flap or a soft tissue patch, GORE-TEX®. This patch’s condition will continue to be monitored as the child develops.

Select patients may be candidates for thoracoscopic, or minimally invasive, surgery. If this is the case, three or more tiny incisions will be made in the chest and the repair will be completed using a special scope and small surgical instruments.

After surgery, most babies will need to remain in the NICU for continued care and monitoring. Although the abdominal organs are now in the right place, the lungs remain underdeveloped. Babies usually need to have breathing support for a period after the operation as the lungs continue to develop. Depending on your baby’s condition, after removing the ventilator, they may still need oxygen and medication to help with breathing for weeks, months or years.

Next Steps

CHOC has the only Surgical NICU on the West Coast and a gold-level Extracorporeal Life Support Organization Award of Excellence for our ECMO program, which allows us to provide highly specialized care for babies who need surgery for conditions like CDH. Learn more about specialized CDH care at CHOC.