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The Symptoms

Dr. Zareen explains, “We received

a baby from the labor room and as

the baby had respiratory distress,

we treated this baby boy as a case

of congenital pneumonia. After

the apparent chest infection was

not settling down, we then needed

to see other problems associated

with this baby. We repeated a

chest x-ray on day three which

did not look good. It indicated

the intestines and part of the liver

were in the right side of the chest.

This is not common at all. Usually

we see this pathology on the left

side. More importantly, we have

ante-natal diagnosis in which we

do ultra sound on mothers during

pregnancy, but in this case the

scans did not show any evidence

of right sided CDH. More so, the

first chest x-ray and ultrasound

done on day one did not show

diaphragmatic hernia.”

The Diagnosis

After that, the baby underwent a

CT scan of the chest and abdomen

which confirmed the findings.

Dr. Zareen then consulted with

Dr. Lalit Parida and the decision

was taken to operate and was in

fact the first neo-natal surgery

case ever done at GMC Hospital.

According to Dr. Zareen, typically

when pneumonia is expected,

the baby is placed on antibiotics

and normally the baby shows a

response. That’s clinical recovery.

She adds, “However, in this case

we weren’t seeing clinical recovery

at all from antibiotics. Otherwise

the baby was a good weight and

healthy otherwise.”

The Surgery

On March 14, Dr. Lalit met with Dr. Zareen to examine the baby’s CT

scan of the chest which showed presence of the liver on the right side.

Dr. Lalit continues,

“In this case, 75 to 80 percent of the liver was in

the baby’s chest cavity along with the small intestine and the large

intestinal loops. It was mechanically pressing the right lung and

heart all squishing up to the left side. The heart is supposed to be

more in the center but in this case was completely shifted to the left

side. In this case, the baby was breathing using a single lung.”

It was

for this reason Dr. Zareen had put the baby on a mechanical breathing

machine to ease the baby. Secondly in this case, the team had to

examine if there were any defects in the heart using heart ultrasound or

echocardiogram. It was done and revealed as normal.

After this, Dr. Lalit counselled the parents who were surprised by

the diagnosis. He explained the diaphragm is a thick muscle which

separates the chest cavity from the abdominal cavity that is important

in terms of breathing. In this particular case, it was a huge defect as

almost half of the diaphragm had split apart. From this right defect, Dr.

Lalit explains that the liver had gone into the chest as well as the large

and small intestinal. “In terms of surgery, I took very high risk consent

because whenever the liver goes up certain veins of the liver (hepatic

veins) are twisted at its connection to the main vein of the body,” he

says, so when pushing the liver back these could potentially separate

and cause bleeding. This can cause a baby to lose blood very quickly

during surgery and can potentially result in death during surgery.

So as far as the surgery preparations were concerned,

Dr. Lalit points out that sometimes these defects

are so huge that they cannot be joined by simple

stitches. “Sometimes it may require a plastic surgical

mesh and that was procured on an urgent basis by

the purchasing department in addition to other

specialized surgical tools required,” he says. However,

a mesh was not required during this surgery.

May/June 2015