Commentary: Is the Data Strong Enough to Prorocolize the Approach in Diaphragmatic Hernia Repair? Aspects of Technique and the Sample Size of a Longitudinal Single-Center Study

Abstract

See Article page 171.

In this issue of the Journal of Chest Surgery, Oh et al. [1] at Samsung Medical Center present a retrospective cohort study that investigated the clinicopathologic characteristics of patients with diaphragmatic hernia (DH) who underwent different surgical treatment approaches. To date, there are no established criteria for the proper indications and patient selection for the different surgical approaches to DH repair [2]. The article clearly summarized the recommended surgical approaches to use in a variety of cases, especially considering the duration of DH and the location of the herniated organs.

Since the variety in size, location, and severity contributes to different surgical outcomes and prognoses, the number of patients in this study was too small to protocolize the approach and derive any definitive conclusions. Spe­cifically, with regard to the transthoracic approach, there is a lack of evidence to prove the value of video-assisted thoracoscopic surgery (VATS) in the management of DH based on merely 5 cases.

As mentioned in the article, in cases with longer duration, “tension-free” repair using mesh is recommended. To prevent injury to the lung and to protect the abdominal organs, the thoracic approach allowed better visualization of the surgical field than the abdominal approach, ensuring safe dissection in cases with a longer hernia duration [3]. Open surgery is safe and facilitates the effective use of various instruments, allowing the diaphragm to lie at the lowest level. Especially, using VATS, flattening the diaphragm is not as easy to achieve as it is through open surgery. In this study, there is no discussion of methods to flatten the diaphragm at the lowest level during VATS. We recommend pneumatic compression with carbon dioxide (CO₂) gas during VATS. This is an effective and safe option to maintain the dissection plane and to easily flatten the diaphragm. However, during pneumatic compression, CO₂ could move into the abdominal space, resulting in inadequate compression of the diaphragm in some cases. This can be overcome by approximation of the mesh using tagging sutures just after dissecting the plane under the diaphragm.

This paper summarized the surgical approaches to the management of DH. Due to the variety of conditions affecting these patients, surgeons are faced with making the best decision in the moment. This study is subject to the main weaknesses of single-center studies, including a small sample size. Since it is necessary to outline the selection criteria and proper indications in DH patients depending on their clinicopathologic characteristics, more evidence is needed to protocolize the approach and derive any definitive conclusions.

Funding Statement

Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.