Bladder pressure-guided delayed abdominal closure in a neonate treated with ECMO for congenital diaphragmatic hernia repair: a case report.

Background: Delayed abdominal closure (DAC) after congenital diaphragmatic hernia (CDH) repair is often guided by subjective assessment. This is particularly critical in neonates receiving extracorporeal membrane oxygenation (ECMO), where inappropriate closure can precipitate abdominal compartment syndrome (ACS), yet objective guidance is lacking. Here, we describe a case where intraoperative bladder pressure (BP) monitoring provided an objective guide for DAC. Case introduction: A term male neonate with severe left-sided CDH and pulmonary hypertension required veno-arterial ECMO. On ECMO day 4, he underwent repair of the diaphragmatic defect. Following visceral reduction, abdominal wall tension increased, and BP was measured at 20mmHg. Based on this objective evidence of intra-abdominal hypertension, DAC was performed with placement of a temporary silastic silo. Following decompression, the BP decreased to 8 mmHg. The patient was successfully weaned from ECMO on postoperative day 1. Definitive abdominal wall closure was performed on day 7. The infant recovered and was discharged on day 38 of life. Conclusion: Intraoperative BP monitoring is a simple, reproducible, and objective tool that can effectively guide the decision for DAC in neonates undergoing ECMO-assisted CDH repair, potentially preventing ACS and improving outcomes.