Persistent nonhealing skin fistulous tract after congenital diaphragmatic hernia repair.

A newborn boy had surgical repair of a CDH through a right subcostal incision. Surgeons closed the diaphragmatic defect with interrupted nonabsorbable sutures. A wound abscess developed and was drained on postoperative day 10. For the next 11 years, seropurulent fluid drained from a skin fistula with its opening in the right subcostal scar. The patient received intermittent courses of antibiotics that stopped the drainage for days or weeks, only to resume thereafter. He was otherwise asymptomatic. There was no erythema or tenderness to palpation, and test results for fungus, atypical bacteria (Nocardia and Actinomyces species) and tuberculosis were negative. A computed tomography (CT) scan of the chest and abdomen (Fig. 1) revealed a contained, small herniation of the colon through the right diaphragm and a chronic posterior right subdiaphragmatic abscess (5 × 3 × 2 cm) with a fistulous tract going through the chest and upper abdominal wall toward a pinpoint opening in the scar (Fig. 2). A fistulogram confirmed that the origin of the skin fistula was the subdiaphragmatic abscess. The patient underwent surgery. We injected methylene blue into the skin opening and followed it with a metallic probe. We then completely unroofed and excised the fistula tract through an incision extending from the old scar