2.9 - Case progression
Based on his respiratory insufficiency and risk of long-term complications secondary to persistent atelectasis and aspiration, the team decided for surgical repair of his diaphragmatic eventration. He was intubated pre-operatively and underwent bilateral plication via laparotomy and abdominal wall closure with mesh insertion at 39+6 weeks corrected gestation age. A chevron incision was made to access the abdominal cavity, revealing a left hemidiaphragm with a muscular anterior two-thirds and a thin membranous posterior third, along with the left kidney and large bowel occupying the thoraco-abdominal area underneath the intact diaphragm. The diaphragm was flattened by a series of U-stitches to plicate it, and the kidney was repositioned down further in the abdomen. The right side revealed a similar issue with the right kidney and liver in the thoraco-abdomen below intact diaphragm; both were reduced to the proper abdominal cavity. Both sides of the diaphragm were successfully plicated, resulting in a stable, flat position. Loss of abdominal domain was noted after repositioning the liver, kidneys, and bowel. A Gore-Tex DualMesh was used for abdominal wall reconstruction to prevent abdominal compartment syndrome. The infant tolerated the procedure well and was sent back to the NICU intubated with minimal blood loss. His postoperative course was complicated by suspected Necrotizing enterocolitis (NEC) on Post-operative Day (POD) 6, which presented as abdominal distention and suspected pneumatosis on X-ray. During that time, he received parenteral nutrition and treated with antibiotics for 7 days. His abdominal distention improved and he successfully transitioned to full enteral feeds without difficulty following treatment.
He was extubated to non-invasive respiratory support on POD 10 and gradually weaned to room air by POD 18. He was discharged from the NICU on room air and tolerating full oral feeds at 73 days of age. Since being discharged he presented once to an emergency department for bloody stools, suspected to be a cow’s milk protein allergy (CMPA) after his breastfeeding mother introduced milk products into her diet. This issue was resolved by switching to a hydrolyzed formula. He continues to grow well and meet his developmental milestones.