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>> HISTORICALLY, WHEN A BABY WAS BORN WITH A DIAPHRAGMATIC
HERNIA, THE IMPORTANT THING WAS TO GET THEM TO THE OR
AND GET THEM REPAIRED.
>> SINCE THAT TIME WE'VE LEARNED THAT THAT'S NO LONGER REQUIRED.
YOU STABILIZE THE BABY FIRST.
YOU DECOMPRESS THE GASTROINTESTINAL TRACT
WITH NASOGASTRIC TUBE.
YOU BILI LIGHT THE BABY.
YOU TAKE CARE OF THE VARIOUS CIRCULATORY PROBLEMS
AND TRY AND GET A STABLE BABY THAT YOU CAN OPERATE,
ALMOST IN AN ELECTIVE CIRCUMSTANCE.
THE DECISION ON WHEN TO DO THE OPERATION TO FIX
THE DIAPHRAGMATIC HERNIA DEPENDS, IN LARGE PART,
TO HOW THE BABY RESPONDS TO THERAPY.
>> IN THE BEST CARE SCENARIO THINGS ARE PRETTY SETTLED DOWN,
AND THE BABY ACTUALLY DOESN'T HAVE MUCH TROUBLE.
WE'RE ABLE TO WEAN THE VENTILATOR.
WE'RE ABLE TO WEAN DRUGS, AND THE BABY IS VERY STABLE.
IN THAT SITUATION THEN WE COULD UNDERTAKE THE REPAIR
OF THE DIAPHRAGMATIC HERNIA AS EARLY AS THREE DAYS OF LIFE.
>> SOMETIMES BABIES WITH DIAPHRAGMATIC HERNIA WHO ARE
SEVERELY AFFECTED ARE ACTUALLY ALREADY ON THE ECMO MACHINE,
AND THEN WE HAVE TO DECIDE, BASED ON HOW THE BABY'S DOING,
ON THE TIMING OF WHEN THE OPERATION IS DONE,
EITHER DURING THE ECMO RUN, WHICH MAY BE TWO WEEKS OR
MORE, OR AFTER THE BABY HAS BEEN WEANED OFF THE ECMO CIRCUIT.
>> WHEN THE SURGERY IS PERFORMED, WE ACTUALLY BRING THE WHOLE
TEAM DOWN TO THE NEONATAL INTENSIVE CARE UNIT.
WE ACTUALLY TURN IT INTO AN OPERATING ROOM.
>> THE ANESTHESIOLOGISTS, THE SURGEONS, THE NURSES,
ALL THE STAFF BASICALLY-- IT'S LIKE A--ALMOST LIKE
A MASH UNIT THAT COMES TO THE BABY.
>> WE DO THAT BECAUSE WE THINK IT'S VERY IMPORTANT NOT
TO CHANGE THINGS.
THE BABY'S STABLE AND JUST A TRANSPORT COULD MAKE
THINGS DIFFERENT.
>> IT JUST SHOWS THAT THEY'RE VERY, VERY CAREFUL,
AND THEY ELIMINATE AS MUCH RISK AS THEY CAN.
>> THEY CLOSED OFF THE ENTIRE NICU TO EVEN OTHER DOCTORS
AND NURSES THAT WEREN'T TAKING CARE OF OTHER BABIES BECAUSE
THEY DO IT RIGHT THERE.
THEY STERILIZE THE WHOLE ENVIRONMENT,
AND THE DOCTORS DO THEIR SURGERY RIGHT ON THE SAME BED
THAT SHE'S LAYING ON ALL THE TIME.
>> THE SURGERY INVOLVES AN INCISION, USUALLY JUST BELOW
THE RIB CAGE.
THE GOALS OF THE SURGERY ARE TO TAKE ALL THE STUFF THAT'S UP IN
THE CHEST AND BRING IT DOWN INTO THE BELLY AND THEN TO CLOSE THAT
HOLE THAT'S IN THE DIAPHRAGM.
>> IF THERE'S A SMALL HOLE WITH A RIM OF MUSCLE ALL THE WAY
AROUND, ONE CAN JUST SIMPLY CLOSE THE HOLE BY SEWING THE RIM
OF MUSCLE TOGETHER.
THOSE ARE USUALLY MUCH MORE FAVORABLE CASES.
FOR THOSE BABIES WITH LARGE DEFECTS,
OR WHO HAVE COMPLETE LACK OF A DIAPHRAGM ON THAT SIDE,
THOSE ARE EVEN MORE TRICKY, SURGICALLY, BECAUSE ONE NEEDS
TO PLACE A PATCH, USUALLY A GORE-TEX PATCH.
A GORE-TEX PATCH USED FOR REPAIR OF A LARGE DIAPHRAGMATIC
DEFECT IS SEWN TO WHATEVER TISSUE IS THERE.
THERE MAY BE A RIM OF MUSCLE, PARTIALLY.
IT MAY NEED TO BE SEWN TO THE RIB.
ONE THING WE NEED TO WATCH LONG TERM IS,
OF COURSE, THE BABY'S GOING TO GROW.
THE PATCH IS NOT GOING TO GROW SO IT'S VERY IMPORTANT THAT
THESE BABIES BE FOLLOWED LONG TERM SO THAT WE CAN SEE
WHETHER OR NOT THE PATCH WILL TEAR AWAY FROM THE BODY WALL
ON THE INSIDE AND LEAD TO A RECURRENT HERNIA PROBLEM.
>> THE ONE THING THAT WE FOUND IS MOST IMPORTANT, THOUGH, IS TO
BE SURE THEY'RE REALLY STABLE ENOUGH TO UNDERGO THE SURGERY
BECAUSE THERE'S REALLY NO RUSH TO GET IN THERE IF THEY'RE
NOT PERFECTLY STABLE, BECAUSE YOU CAN ACTUALLY
PUT THEM INTO ONE OF THOSE CRISES THAT WE TALKED ABOUT.