Patch repair versus flap repair for congenital diaphragmatic hernia: A systematic review and meta-analysis

Background: Congenital diaphragmatic hernia (CDH) often requires non-primary repair of large defects using either a prosthetic patch or an autologous muscle flap. However, their comparative effectiveness remains uncertain. We systematically reviewed the existing literature to synthesize outcomes relevant to durability and perioperative safety of patch versus flap repair in neonates. Methods: PubMed, Embase, and Scopus were systematically searched from inception to May 2025 for pediatric studies directly comparing patch versus flap repair for CDH in neonates. Meta-analyses were performed using random-effects models on RevMan v5.4.1. Risk of bias was assessed using the ROBINS-I tool. Results: Ten single-center retrospective cohorts comprising a total of 450 patients (Patch Repair: 220, Flap Repair: 230) who underwent CDH repair were included in our synthesis. Patch repair was associated with an increased risk of hernia recurrence (RR: 3.57 [95 % CI: 1.47–8.69]), postoperative bleeding complications (RR: 2.15 [95 % CI: 1.09–4.24]), and in-hospital mortality (RR: 1.66 [95 % CI: 1.13–2.43]). No statistically significant differences were detected in the rates of chest wall deformities, scoliosis, bowel obstruction, ventral incisional hernia, operative time, or hospital length of stay. However, the overall certainty of evidence was very low across most outcomes, reflecting the retrospective designs, small sample sizes, and inconsistent follow-up/definitions. Conclusions: Within low-certainty evidence, patch repair was associated with higher observed hernia recurrence. Data on postoperative bleeding and mortality, including among on-ECMO repairs, were limited and insufficient to support causal inference. Definitive guidance will require prospective multicenter studies using standardized techniques, adjudicated bleeding endpoints, and long-term surveillance.