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.