Rare surgery saves 44-day-old boy
Doctors who operated on the boy said the infant’s abdominal organs had entered the chest cavity through the hole in the diaphragm, pushing the heart and lungs to the right
Mumbai Two days ago, 44-day-old Shivansh Singh was declared free of health complications and that he can lead a normal life following his first follow-up examination at the paediatric surgery department at Nanavati Max Hospital, Vile Parle.
Born with a rare large congenital diaphragmatic hernia (CHD) – a hole in the thin skeletal muscle that sits on the base of the chest and separates the abdomen from the chest – Singh was not even a day old when a team of eight doctors at the hospital performed a three-and-half-hour long minimal invasive surgery to realign all his abdominal organs such as intestine, bladder, spleen and part of the liver to their correct position.
Doctors who operated on the child said the infant’s abdominal organs had entered the chest cavity through the hole in the diaphragm, pushing the heart and lungs to the right. The condition was detected via sonography at a primary nursing home in December 2021, when his mother was in the 24th week of pregnancy.
“Considering the foetal complications and need for advanced obstetric and neonatal care, we were advised abortion or immediate transfer to a tertiary care medical facility. From that very moment, we were certain that abortion wasn’t an option,” said Krishna Singh, the father and a small-time businessman. The Santacruz-based family has spent ₹6 lakh on the surgery.
Being a rare condition, CHD is associated with a high mortality rate with an incidence rate of 2.6 per 10,000 births. Due to a lack of awareness about antenatal testing and tertiary care neonatal care facilities, almost 50% of babies born with CDH succumb within a week of birth due to underdeveloped lungs and heart muscles.
Dr Suruchi Desai, senior consultant, gynaecology and obstetrics who treated the mother and child said, “A case like Shivansh is even rare in CHD- 1 in 60,000 births. CDH often affects lung development and functions of the heart, liver and intestine. Moreover, we had an obstetric challenge as the mother had undergone two caesarean section surgeries in the past.”
Dr Desai, along with Dr Tejal Shetty, consultant neonatologist and paediatrician and Dr Kant Shah, consultant paediatric surgeon monitored the foetal growth for two months to ensure safe delivery. On February 28, Dr Desai’s team successfully delivered the baby boy, weighing 3.1kg through a caesarean section in the 38th week of gestation.
Within 24-hours of his birth, Shivansh was taken up for the surgery that had 8 doctors- paediatric surgeons, neonatologists, gynaecologists, and anaesthetists.
“He is our youngest surgical patient. The surgical challenge started right from anaesthesia management, which is administered based on the weight, size and maturity of paediatric cases. Administering a combination of 8 to 10 anaesthetic drugs to counterbalance the effects, in a baby weighing merely 3.1kg, was a test of the anaesthesiologist’s skill and experience,” said Dr Shah.
Shivansh was kept on a ventilator soon after the birth. “Due to underdeveloped lungs, he required ventilation even during the surgery. The intensive care team exercised special, gentle ventilation—known as Gentilation, to ensure the brittle lungs of the baby are oxygenated at the same time they don’t rupture,” explained Dr Shah.
He added that the most challenging part of the surgery was to realign fragile internal organs while restructuring the diaphragm as a permanent clinical solution.
“Usually, in CDH, the hole in the diaphragm is located posteriorly. Since this hernia or gap was anterolateral and there was no other side to suture the hole together, we had to stretch it around and stitch it to the ribs. In most cases, the suturing or stitching occurs away from critical organs but in this case, the proximity of suturing needles to the heart and liver was unsettling. Moreover, due to being in contact for a long time, both the heart and liver had virtually merged. We had to separate them and keep them apart while we manoeuvred the diaphragm and stitched it around the ribs. Performing the task through keyholes measuring merely 3mm was a true challenge,” explained Dr Shah.
Doctors said that while the minimally invasive approach wasn’t the only surgical modality available, open surgeries in such young patients come with a possibility of future health risks. “Opening the chest at such young age may have long-term effects on the spinal and rib structure and the child has a probability of developing scoliosis (spine becomes rotated and curved sideways). However, despite the challenges, we were in complete control and at no time we thought the patient’s life was at risk,” said Dr Shetty.
Post-surgery, the baby returned on ventilator support and his vitals were closely observed for possible signs of complication. However, doctors said, a day after the surgery, the baby developed respiratory distress and his oxygen saturation dropped.
“We immediately performed an X-Ray and detected Pneumothorax—a serious lung condition that forces the lung to collapse. Pneumothoraxes are more likely to occur in neonates with CDH associated with a large defect of the diaphragm due to the excessive pressure on the lungs by other abdominal organs. We successfully managed the condition and the baby was weaned off the ventilator in five days and was put on Continuous Positive Airway Pressure (CPAP) machine,” said Dr Shetty.
Shivansh was discharged on the 24th day of being born. “We never lost hope, even when we were informed about the condition of our child the first time,” said Singh.