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The Surgical Repair: Timing, Options, and Patches

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CDH surgery is carefully timed until a baby's heart and lungs are stable. Surgeons repair the diaphragm hole using either the baby's own tissue (primary closure) or a synthetic patch, depending on the hole's size. The procedure can be done via open surgery or a minimally invasive approach.

Key Takeaways

  • • CDH surgery is delayed until a baby's pulmonary pressure and heart function are stable enough to safely handle the procedure.
  • • Small diaphragm defects are typically repaired with primary closure, which uses the baby's own tissue to sew the hole shut.
  • • Larger defects require a patch repair using synthetic materials like Gore-Tex, which carry a higher risk of future hernia recurrence since the patch does not grow.
  • • Surgical access can be achieved through an open incision or a minimally invasive thoracoscopic approach, each with specific benefits and risks.

Once your baby has stabilized in the NICU, the next major step in their journey is the surgical repair of the diaphragm. This surgery is not a race; the goal is to wait until your baby’s heart and lungs are strong enough to handle the procedure safely [1][2].

Determining the “Perfect Timing”

Surgeons and neonatologists look for specific signs that a baby is “stable” enough for surgery. While every hospital has its own protocols, common markers include:

  • Pulmonary Pressure: Doctors often wait until the blood pressure in the lungs (pulmonary hypertension) has decreased to a certain level—typically less than 80% of the blood pressure in the rest of the body [3][1].
  • Heart Function: An echocardiogram (an ultrasound of the heart) is used to ensure the heart is pumping effectively and isn’t being overly stressed by the lungs [1].
  • ECMO Considerations: For babies on ECMO, the timing is even more complex. Some teams prefer to repair the hole while the baby is still on the machine, while others wait until the baby has successfully transitioned off. Both approaches have unique risks, such as a higher risk of bleeding while on ECMO [4][5].

Types of Repair: Closing the Gap

The way the surgeon closes the hole depends entirely on the size of the defect and the strength of the remaining diaphragm tissue.

Primary Closure

If the hole is small and there is enough healthy muscle, the surgeon can simply sew the edges of the diaphragm together. This is called a primary closure [6]. It is generally the preferred method because it uses the baby’s own tissue, which will grow as they grow.

Patch Repair

If the hole is too large to be sewn shut without causing tension, a patch is used to bridge the gap [6].

  • Materials: Patches are often made of synthetic materials like Gore-Tex. In some specialized centers, a muscle flap (using a piece of the baby’s own abdominal muscle) may be used instead.
  • Considerations: While patches are lifesaving for large defects, they do not grow with the baby. This means there is a higher chance that the hernia could return (called a recurrence) as the child gets older, sometimes requiring further surgery [7][8].

Surgical Approaches: Open vs. Minimally Invasive

There are two main ways a surgeon can access the diaphragm:

  1. Open Repair: The surgeon makes an incision (usually just below the ribs). This “traditional” approach is often preferred for larger defects or for babies who are less stable, as it allows for a very secure and direct repair [9][10].
  2. Thoracoscopic (Minimally Invasive) Repair: The surgeon uses small cameras and instruments through tiny incisions in the chest [11].
    • Benefits: Smaller scars and potentially shorter hospital stays [12].
    • Risks: There is evidence that minimally invasive surgery may have a higher risk of the hernia coming back compared to open surgery [12][13]. It can also cause temporary changes in CO2 levels during the procedure [14].

Your surgical team will recommend the approach that offers your baby the most secure repair with the lowest risk of future complications [9]. Although the surgery is a huge milestone, it is just one part of the long-term care your baby will receive to support their growing lungs.

Frequently Asked Questions

When is the right time for my baby's CDH surgery?
Doctors wait until your baby is stable enough for surgery, which means their pulmonary hypertension has decreased and their heart is pumping effectively. This ensures the heart and lungs can safely handle the stress of the procedure.
What is the difference between a primary closure and a patch repair?
A primary closure uses stitches to sew the hole shut using the baby's own tissue, which is preferred because it grows with the baby. A patch repair is used for larger holes and utilizes synthetic materials like Gore-Tex to bridge the gap.
Will a CDH patch grow with my baby?
No, synthetic patches used in CDH repair do not grow as your baby grows. Because of this, there is a chance the hernia could return later in life as your child grows, potentially requiring another surgery.
Is minimally invasive surgery better for CDH repair?
Minimally invasive surgery offers smaller scars and potentially shorter hospital stays, but it may carry a slightly higher risk of the hernia returning compared to traditional open surgery. Your surgeon will recommend the safest approach based on your baby's specific defect and stability.
Can CDH surgery be done while a baby is on ECMO?
Yes, some babies undergo CDH repair while still on ECMO, though it carries specific risks such as increased bleeding. Other medical teams prefer to wait until the baby has successfully transitioned off the ECMO machine before operating.

Questions for Your Doctor

  • • Based on my baby's echocardiogram, is their pulmonary hypertension stable enough for surgery?
  • • Do you expect to perform a primary closure or will a patch likely be needed?
  • • If a patch is used, what material do you prefer, and why?
  • • What are the benefits and risks of an open surgery versus a minimally invasive (thoracoscopic) approach for my baby?
  • • If my baby is on ECMO, what are the specific risks of performing the surgery now versus waiting until they are off the machine?
  • • What is your personal or hospital's recurrence rate for the type of repair you are recommending?

Questions for You

  • • Do I understand the difference between 'primary repair' and 'patch repair' and why one might be chosen over the other?
  • • Have I discussed the pros and cons of the surgical approach (open vs. minimally invasive) with the surgeon?
  • • How am I feeling about the timing of the surgery? Do I feel informed about why we are waiting or moving forward now?
  • • What is my plan for recovering myself (physically and emotionally) while my baby is in the operating room?

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References

  1. 1

    Evaluation and Monitoring of Pulmonary Hypertension in Neonates With Congenital Diaphragmatic Hernia.

    Sanchez Mejia AA, Rodgers NJ

    Current treatment options in cardiovascular medicine 2019; (21(2)):11 doi:10.1007/s11936-019-0711-x.

    PMID: 30767157
  2. 2

    Congenital Diaphragmatic Hernia: Considerations for the Adult General Surgeon.

    Han XY, Selesner LT, Butler MW

    The Surgical clinics of North America 2022; (102(5)):739-757 doi:10.1016/j.suc.2022.07.007.

    PMID: 36209743
  3. 3

    Impact of Objective Echocardiographic Criteria for Timing of Congenital Diaphragmatic Hernia Repair.

    Deeney S, Howley LW, Hodges M, et al.

    The Journal of pediatrics 2018; (192()):99-104.e4 doi:10.1016/j.jpeds.2017.09.004.

    PMID: 29106923
  4. 4

    Hemorrhage after on-ECMO repair of CDH is equivalent for muscle flap and prosthetic patch.

    Nolan H, Aydin E, Frischer JS, et al.

    Journal of pediatric surgery 2019; (54(10)):2044-2047 doi:10.1016/j.jpedsurg.2019.04.025.

    PMID: 31103273
  5. 5

    The Timing of Surgery for Congenital Diaphragmatic Hernia in Infants, on or after Weaning from Extracorporeal Membrane Oxygenation: A Meta-Analysis.

    Lin M, Liao J, Li L

    European journal of pediatric surgery : official journal of Austrian Association of Pediatric Surgery ... [et al] = Zeitschrift fur Kinderchirurgie 2024; (34(5)):435-443 doi:10.1055/a-2228-6969.

    PMID: 38092047
  6. 6

    Congenital heart disease and arrhythmia disorders in newborns with congenital diaphragmatic hernia: a 23-year experience at a UK university pediatric surgical centre.

    Lee WT, Kwok CS, Losty PD

    Pediatric surgery international 2024; (41(1)):32 doi:10.1007/s00383-024-05927-2.

    PMID: 39694918
  7. 7

    NeoAPACHE II. Relationship Between Radiographic Pulmonary Area and Pulmonary Hypertension, Mortality, and Hernia Recurrence in Newborns With CDH.

    Amodeo I, Pesenti N, Raffaeli G, et al.

    Frontiers in pediatrics 2021; (9()):692210 doi:10.3389/fped.2021.692210.

    PMID: 34322463
  8. 8

    Does creating a dome reduce recurrence in congenital diaphragmatic hernia following patch repair?

    Verla MA, Style CC, Lee TC, et al.

    Journal of pediatric surgery 2022; (57(4)):637-642 doi:10.1016/j.jpedsurg.2021.10.014.

    PMID: 34836640
  9. 9

    Recurrence in congenital diaphragmatic hernia: A multicenter, postdischarge pilot study.

    Gupta VS, Holden KI, Chiu PP, et al.

    Surgery 2025; (181()):109209 doi:10.1016/j.surg.2025.109209.

    PMID: 39978174
  10. 10

    Thoracoscopic Guided Pericostal Sutures as a Solid Fixation for Primary Closure of Congenital Diaphragmatic Hernias.

    Michel AJ, Metzger U, Rice SA, Metzger R

    Children (Basel, Switzerland) 2022; (9(8)) doi:10.3390/children9081116.

    PMID: 35892619
  11. 11

    A Multi-Institutional Review of Thoracoscopic Congenital Diaphragmatic Hernia Repair.

    Weaver KL, Baerg JE, Okawada M, et al.

    Journal of laparoendoscopic & advanced surgical techniques. Part A 2016; (26(10)):825-830 doi:10.1089/lap.2016.0358.

    PMID: 27603706
  12. 12

    Comparison of the Efficacy and Safety of Thoracoscopic Surgery and Conventional Open Surgery for Congenital Diaphragmatic Hernia in Neonates: A Meta-analysis.

    Srivastav S, Singh S, Khan TR

    Journal of Indian Association of Pediatric Surgeons 2024; (29(5)):511-516 doi:10.4103/jiaps.jiaps_24_24.

    PMID: 39479429
  13. 13

    Recurrent diaphragmatic hernia: Modifiable and non-modifiable risk factors.

    Al-Iede MM, Karpelowsky J, Fitzgerald DA

    Pediatric pulmonology 2016; (51(4)):394-401 doi:10.1002/ppul.23305.

    PMID: 26346806
  14. 14

    Intraoperative acidosis and hypercapnia during thoracoscopic repair of congenital diaphragmatic hernia and esophageal atresia/tracheoesophageal fistula.

    Zani A, Lamas-Pinheiro R, Paraboschi I, et al.

    Paediatric anaesthesia 2017; (27(8)):841-848 doi:10.1111/pan.13178.

    PMID: 28631351

This page is for educational purposes only and does not replace professional medical advice. Always discuss your baby's specific surgical plan, timing, and risks with their pediatric surgeon and neonatologist.

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