Toldt?s fascia flap: a new technique for repairing large diaphragmatic hernias

Abstract

The most popular techniques for repairing large diaphragmatic defects involve the use of synthetic patches. We present an alternative approach using living tissue. We reviewed our cases of congenital diaphragmatic hernia (CDH) diagnosed within the first 24 h of life from 1991 to 2003. Toldt's fascia (TF) flap was used to repair defects that were too large to repair primarily even though the anterior rim of the diaphragm was present. After confirming that a small medial muscle remnant of the diaphragm was present, its mesothelial covering was incised, and the incision was extended to the TF far enough to create a flap sufficiently large to repair the defect. The TF flap, consisting of the small medial muscle remnant, TF, peritoneum, and retroperitoneal connective tissue, was mobilized carefully from the ipsilateral kidney and adrenal gland, and the repair completed with interrupted sutures using nonabsorbable material. We used this TF flap approach in seven of 43 patients with CDH. Two had right-sided CDH. Six survived. The mean size of the diaphragmatic defects in the seven TF flap cases was 5.43+/-0.53 x 3.86+/-1.07 cm, which was significantly larger than the defects in direct primary repair cases (3.40+/-0.77 x 2.03+/-0.59 cm) (p<0.01). The six survivors had good outcomes, and none of them have had recurrence of herniation or required any additional surgical intervention (mean follow-up period: 4.7 years). To the best of our knowledge, this is the first report of TF being used to repair large diaphragmatic hernias. Our technique is simple and has proven to be reliable for durable restoration of the diaphragm, suggesting that it could reduce the dependence on synthetic patch repair, which is associated with certain long-term complications.

Prosthetic patches for congenital diaphragmatic hernia repair: Surgisis vs Gore-Tex

“…Our institution has also used a reversed latissimus dorsi muscle flap for repair of selected recurrent hernia cases [23]. Okazaki has described use of a Toldt's fascial flap, demonstrating no recurrence in a small series of patients [24]. These more extensive procedures may require longer operating times and are not advisable for repairs in sick newborns.…”

Congenital diaphragmatic hernia: onset of respiratory distress and size of the defect

“…Despite of reported complications, primary reconstruction of large diaphragmatic defect with GT patch is generally used in most centers [1,7,13]. More complex techniques such as the muscle flap or repair with Toldt's fascia flap are rarely performed primarily, and experiences are limited to small series of patients [14,15]. From our point of view, reconstruction with GT patch in a critically ill infant remains a suitable solution.…”

Free fascia lata repair for a second recurrent congenital diaphragmatic hernia

“…Synthetic patches are a good early solution, but they may present some long-term problems. The most common is patch failure [4]. Although CDH recurrence rates have been reported to range from 2% to 22%, the use of a synthetic patch can increase the rate of recurrence to as high as 40% [3].…”

“…The most popular techniques for repairing large diaphragmatic defects that cannot be closed primarily involve the use of patches [4]. According to data from a CDH study group, synthetic patches were used in 51% of the patients [2].…”