Can CDH Surgery Be Done While on ECMO?

Yes, congenital diaphragmatic hernia (CDH) repair surgery can be performed while a baby is still on Extracorporeal Membrane Oxygenation (ECMO)—a life-support machine that temporarily takes over the work of the heart and lungs. However, doctors generally prefer to wait until the baby can be weaned off ECMO before performing the surgery, if possible ^[1]. Operating while on ECMO carries significantly higher risks, particularly for severe bleeding, because the ECMO machine requires the use of strong blood thinners to prevent clots ^[2][3].

Why Surgery Might Be Done on ECMO

Sometimes, a baby’s lungs and heart are so compressed by the abdominal organs in the chest that their condition cannot improve enough to come off ECMO without the repair ^[4][5]. In these situations, the surgery must be done while the baby is still on life support. Doing the surgery allows the abdominal organs to be moved back into place, giving the lungs room to expand and function.

Understanding the Risks: Bleeding and Blood Thinners

The most significant risk of operating while on ECMO is hemorrhage (severe bleeding) ^[2]. Because the baby’s blood must continuously flow through the ECMO tubing without clotting, continuous systemic blood thinners (anticoagulants) are mandatory.

To help manage and minimize this bleeding risk, the surgical and intensive care teams take several precautions:

• Careful Medication Management: Doctors closely monitor and adjust blood thinner medications. Depending on the hospital’s protocols, they may use different types of blood thinners—such as heparin or a newer medication called bivalirudin ^[6]—and carefully tailor the dosage to balance the needs of the ECMO machine with the goal of minimizing bleeding risks for your baby.
• Surgical Technique: The surgeon may choose specific techniques to repair the hole in the diaphragm. For instance, instead of using a synthetic patch, they might use a muscle flap from the baby’s own body (typically using nearby muscle tissue from the abdomen or chest wall). Some studies suggest this approach may help reduce the risk of bleeding at the surgical site ^[7].

What the Research Says About Timing

The decision of when to operate is a delicate balance. Research shows that babies who are stable enough to be weaned off ECMO before their CDH repair generally experience lower rates of postoperative bleeding and have better overall survival rates ^[1]. Their time spent on ECMO also tends to be shorter ^[1].

However, when a baby cannot be weaned off ECMO because the unrepaired hernia is too severe, early repair on ECMO may be the only path forward ^[4][5]. Because every baby’s anatomy and resilience are different, survival statistics can vary widely. Your medical team will constantly evaluate your baby’s lung function, heart stability, and overall strength to determine the safest possible timing for the operation. You should always discuss your baby’s specific outlook with your surgeon to understand what to expect.