Thoracoscopic and laparoscopic plication of the hemidiaphragm is effective in the management of diaphragmatic eventration

Laparoscopic approach in the management of diaphragmatic eventration in adults: gastrointestinal surgical perspective

The current literature is poor with studies handling the role of laparoscopy in managing diaphragmatic eventration (DE). Herein, we describe our experience regarding the role of laparoscopy in managing DE patients presenting mainly with gastrointestinal symptoms. We retrospectively reviewed the data of 20 patients who underwent laparoscopic diaphragmatic plication between January 2010 and December 2018. Postoperative outcomes and quality of life were assessed. Most DEs were left sided (95%). Laparoscopic diaphragmatic plication was possible in all patients, along with correcting all associated gastrointestinal and diaphragmatic problems. The former included gastric volvulus (60%), reflux esophagitis (25%), cholelithiasis (5%), and pyloric obstruction (5%), while the latter included diaphragmatic and hiatus hernia (10% and 15%, respectively).The average operative time was 142 min. All patients had a regular (reviewer #1) postoperative course except for one who developed hydro-pneumothorax. At a median follow-up of 48 months, midterm outcomes were satisfactory, with an improvement (reviewer #1) in gastrointestinal symptoms. Three patients (reviewer #1) developed radiological recurrence without significant clinical symptoms. Patient's quality of life, including all parameters, significantly improved after the laparoscopic procedure compared to the preoperative values. Laparoscopic approach is safe and effective for managing adult diaphragmatic eventration (reviewer #1).

Effects of Muscle Energy Technique and Joint Manipulation on Pulmonary Functions, Mobility, Disease Exacerbations, and Health-Related Quality of Life in Chronic Obstructive Pulmonary Disease Patients: A Quasiexperimental Study

Chronic obstructive pulmonary disease (COPD) is primarily a disease of the lungs; however, extrapulmonary comorbidities like rib cage stiffness, decreased thoracic spine mobility, postural changes, and skeletal muscle dysfunctions also coexist. Muscle energy technique (MET) and joint manipulation (JM) may help alleviate these musculoskeletal problems. This study was aimed at evaluating the effectiveness of MET and JM on pulmonary functions, dyspnea, chest wall mobility, disease exacerbations, and health-related quality of life in COPD patients. A total of 16 patients (7 women and 9 men) suffering from COPD between the ages of 35 and 65 years participated in the study. Pretest-posttest quasiexperimental design was used. MET was applied to the sternocleidomastoid, anterior scalene, pectoralis major muscles, and at the C4-C6 level of the cervical spine. Maitland JM was performed in the thoracic region at the intervertebral, costovertebral, and costotransverse joints. The treatment intervention lasted for 3 weeks. FEV1/FVC, maximum inspiratory pressure (MIP), SpO2, modified Borg dyspnea scale (MBDS), COPD assessment test (CAT), mMRC dyspnea scale, BODE index, right and left hemidiaphragm excursion, and chest wall expansion at T4 and T10 levels were the outcome measures. Significant improvement ( $p<0.05$ ) was observed in FEV1/FVC, MIP, SpO2, MBDS, CAT, mMRC dyspnea scale, BODE index, and chest expansion at T4 and T10 levels. Only for the hemidiaphragm excursion, no significant ( $p>0.05$ ) improvement was observed. Combined application of MET to accessory respiratory muscles and cervical spine and JM to thoracic spine improved pulmonary functions, chest wall mobility, and health-related quality of life and reduced dyspnea and disease exacerbations in patients with mild to moderate COPD.

Phrenic nerve paralysis and phrenic nerve reconstruction surgery

Phrenic nerve injury results in paralysis of the diaphragm muscle, the primary generator of an inspiratory effort, as well as a stabilizing muscle involved in postural control and spinal alignment. Unilateral deficits often result in exertional dyspnea, orthopnea, and sleep-disordered breathing, whereas oxygen or ventilator dependency can occur with bilateral paralysis. Common etiologies of phrenic injuries include cervical trauma, iatrogenic injury in the neck or chest, and neuralgic amyotrophy. Many patients have no identifiable etiology and are considered to have idiopathic paralysis. Diagnostic evaluation requires radiographic and pulmonary function testing, as well as electrodiagnostic assessment to quantitate the nerve deficit and determine the extent of denervation atrophy. Treatment for symptomatic diaphragm paralysis has traditionally been limited. Medical therapies and nocturnal positive airway pressure may provide some benefit. Surgical repair of the nerve injury to restore functional diaphragmatic activity, termed phrenic nerve reconstruction, is a safe and effective alternative to static repositioning of the diaphragm (diaphragm plication), in properly selected patients. Phrenic nerve reconstruction has increasingly become a standard surgical treatment for diaphragm paralysis due to phrenic nerve injury. A multidisciplinary approach at specialty referral centers combining diagnostic evaluation, surgical treatment, and rehabilitation is required to achieve optimal long-term outcomes.

The feasibility and safety of same-day surgery for diaphragmatic eventration by minithoracotomy in children

PURPOSE

The diaphragmatic plication procedure by thoracoscopy has gradually become standard treatment for diaphragmatic eventration (DE). However, thoracoscopic diaphragmatic plication is difficult to manipulate and the surgical learning curve is long. This study aimed to demonstrate the feasibility and safety of same-day surgery for DE by minithoracotomy in children.

METHODS

From December 2017 to December 2019, we included 22 patients who underwent diaphragmatic plication of DE in the Department of Pediatric Thoracic Surgery at the Guangzhou Women and Children's Medical Center. A total of 10 patients underwent diaphragmatic plication by minithoracotomy and 12 patients underwent thoracoscopic plication. The perioperative condition and postoperative follow-up were evaluated, respectively.

RESULTS

The age, sex, and weight were no different in the minithoracotomy group versus the thoracoscopy group (P > 0.05). The intraoperative time, blood loss volume, and postoperative hospital stay of the minithoracotomy group were significantly less than that of the thoracoscopy group (31.10 ± 4.70 min vs. 72.08 ± 22.8 min; 1.20 ± 0.42 ml vs. 2.58 ± 1.67 ml; and 1.00 ± 0.00 days vs. 6.00 ± 2.95 days, respectively, all P < 0.05). The eventration levels in these two groups were significantly different in the perioperative and postoperative periods as detected by chest X-ray. No chest tubes were inserted and no recurrence of DE occurred in the thoracoscopy group through the postoperative follow-up of at least 6 months.

CONCLUSION

Same-day surgery by minithoracotomy as a treatment for DE was feasible and safe with less operative time, less blood loss, and low recurrence. Same-day surgery for DE was attributed to a quick recovery. More prospective studies are necessary to further explore the consequences of same-day surgery for DE by minithoracotomy.

Is the pleating technique superior to the invaginating technique for plication of diaphragmatic eventration in infants?

BACKGROUNDS

The pleating technique is widely used in plication but is difficult to perform with thoracoscopy because of its complex procedure and the limited surgical space. Thus, the invaginating technique was introduced to facilitate thoracoscopic surgery and is now widely used in video-assisted thoracoscopic surgery (VATS) plication. However, the usefulness of the invaginating technique in children has not been established because of the lack of data on long-term outcomes after surgery using the technique.

METHODS

From March 2007 to December 2017, 21 patients who were surgically treated for congenital diaphragmatic eventration and phrenic nerve palsy after congenital cardiac surgery were divided into 2 groups according to the surgical method used (pleating technique: 10 patients, invaginating technique: 11 patients). We evaluated the patients for postoperative outcomes and recurrence of diaphragmatic eventration over 5 years. Postoperative recurrence of diaphragmatic eventration was confirmed by calculating the ratio of the eventration level between the eventrated and normal diaphragms.

RESULTS

In the 21 patients who underwent diaphragmatic plication, the pleating and invaginating techniques were used in 10 and 11 patients, respectively. The mean follow-up duration was 63.4 ± 48.4 months (pleating group [P] vs invaginating group [I]: 89.1 ± 52.4 vs 40.1 ± 30.8 months, p = 0.022). The mean eventration rates in the 21 patients was 26.7% ± 9.1% (P vs I: 26.6% ± 6.1% vs 26.9% ± 11.3%, p = 0.945) before operation and -2.1% ± 7.3% (-2.8% ± 7.5% vs -1.5% ± 7.4%, p = 0.695) in the immediate postoperative period. From the first to the fifth postoperative year, no recurrence of diaphragmatic eventration was found in any of the groups during the follow-up.

CONCLUSIONS

The invaginating technique was easier to perform but showed a similar long-term result as compared with the pleating technique in terms of the growth and development of the chest cavity in the pediatric patients in this study. Thus, we recommend that the invaginating technique be applied in VATS plication for children as an alternative to the pleating technique.

LEVEL OF EVIDENCE

Level III.

A Rare Case of Contralateral Diaphragm Paralysis following Birth Injury with Brachial Plexus Palsy: A Case Report and Review of the Literature

Clinical History. A 4.4 kg male was born to a 25-year-old, G2P1, nondiabetic woman at 39 and 5/7 weeks. Delivery was complicated by shoulder dystocia requiring forceps-assisted vaginal delivery, resulting in left arm Erb's palsy secondary to left brachial plexus injury. He was born with low muscle tone and bradycardia and subsequently required intubation for poor respiratory effort. He was extubated on day one of life but continued to be tachypneic and have borderline oxygen saturation, requiring intensive care. Chest radiographs demonstrated a progressive clearing of his lung fields, consistent with presumptively diagnosed meconium aspiration. However, a persistent elevation of the right hemidiaphragm was noted, and his tachypnea and increased work of breathing continued. Focused ultrasound of the diaphragm was performed, confirming decreased motion of the right hemidiaphragm. Following a multidisciplinary discussion, thoracoscopic right diaphragm plication was performed on the 33rd day of life. He was extubated postoperatively and subsequently weaned to room air with a notable decrease in tachypnea over 48 hours. He was discharged on postoperative day 12 and continues to thrive at 6 months of age without respiratory embarrassment. Purpose. Ipsilateral phrenic nerve injury with diaphragm paralysis from shoulder dystocia during vaginal delivery is a recognized phenomenon. Herein, we present a case of contralateral diaphragm paralysis in order to draw attention to the clinician that this discordance is possible. Key Points. According to Raimbault et al., clinical management of newborns who experience birth injury is a multidisciplinary effort. According to Fitting and Grassino, though most cases of phrenic nerve injuries are ipsilateral to shoulder dystocia brachial plexus palsy, contralateral occurrence is possible and should be considered. According to Waters, diaphragm plication is a safe and effective operation.

Surgical treatment of 125 cases of congenital diaphragmatic eventration in a single institution

BACKGROUND

This study sought to investigate the clinical characteristics of congenital diaphragmatic eventration (CDE) and to compare the efficacies of thoracoscopy and traditional open surgery in infants with CDE.

METHODS

We retrospectively analyzed the clinical data of 125 children with CDE (90 boys, 35 girls; median age: 12.2 months, range: 1 h-7 years; body weight: 1.99-28.5 kg, median body weight: 7.87 ± 4.40 kg) admitted to our hospital in the previous 10 years, and we statistically analyzed their clinical manifestations and surgical methods.

RESULTS

A total of 108 children in this group underwent surgery, of whom 67 underwent open surgery and 41 underwent thoracoscopic diaphragmatic plication. A total of 107 patients recovered well postoperatively, except for 1 patient who died due to respiratory distress after surgery. After 1-9.5 years of follow-up, 107 patients had significantly improved preoperative symptoms. During follow-up, the location of the diaphragm was normal, and no paradoxical movement was observed. Eleven of the 17 children who did not undergo surgical treatment did not have a decrease in diaphragm position after 1-6 years of follow-up. The index data on the operation time, intraoperative blood loss, chest drainage time, postoperative mechanical ventilation time, postoperative hospital stay and postoperative CCU admission time were better in the thoracoscopy group than in the open group. The difference between the two groups was statistically significant (P < 0.05).

CONCLUSIONS

The clinical symptoms of congenital diaphragmatic eventration vary in severity. Patients with severe symptoms should undergo surgery. Both thoracoscopic diaphragmatic plication and traditional open surgery can effectively treat congenital diaphragmatic eventration, but compared with open surgery, thoracoscopic diaphragmatic plication has the advantages of a short operation time, less trauma, and a rapid recovery. Thus, thoracoscopic diaphragmatic plication should be the first choice for children with congenital diaphragmatic eventration.

Thoracoscopic repair of diaphragmatic eventration in children: a comparison of two repair techniques

BACKGROUND

Thoracoscopic plication has gained popularity in the management of diaphragmatic eventration, and several suturing techniques have been described. However, the superiority of one technique over the other has not been demonstrated. The purpose of this study is to report our experience with diaphragmatic plication and to compare the thoracoscopic interrupted and pleated suture techniques in pediatric patients with diaphragmatic eventration.

METHODS

This is a retrospective cohort study (level of evidence: 3) performed on 14 patients with diaphragmatic eventration. All patients were symptomatic and had diaphragmatic plication via thoracoscopy. The patients were further divided into two groups according to the repair technique; interrupted repair (n = 9) and pleated repair (n = 5). Preoperative, operative and postoperative data were compared between the two groups.

RESULTS

The median age was 9.5 months (25th- 75th percentiles: 6 to 15 months), and 8 (57%) were males. Twelve patients (85.71%) had right side eventration, and nine patients (64.29%) had congenital diaphragmatic eventration. One case was converted to open thoracotomy because of adhesions. There was no difference in the preoperative characteristics between both groups. Median operative time was 117 min (25th- 75th percentiles: 101-129 min) and 77 min (25th- 75th percentiles: 73-83 min) in the interrupted and pleated groups, respectively (p = 0.004). One patient had a postoperative elevation of the diaphragm (incomplete repair) in the pleated group (p = 0.357). No recurrence was reported during the follow-up.

CONCLUSION

Thoracoscopic plication is an effective technique for management of diaphragmatic eventration in children. Pleating technique is easy, fast, and associated with a marked reduction in operative time.

TYPE OF THE STUDY

Retrospective cohort study.

LEVELS OF EVIDENCE

Level of evidence: 3.

Double purse-string suturing: An easy plication technique in thoracoscopic repair of diaphragmatic eventration

OBJECTIVE

The aim of this study was to describe a new double purse-string suturing plication method that was developed to minimize difficulties experienced in thoracoscopic plication in pediatric patients.

METHODS

We retrospectively analyzed the data of patients that underwent diaphragmatic eventration repair with new technique developed in our clinic. In this technique, we perform diaphragm plication with continuous double layer purse-string suturing. A third suturing may be necessary in case of wide eventrations. Thoracic drainage catheter is inserted into the thorax on a routine basis.

RESULTS

Thoracoscopic plication was performed using the double purse-string suturing technique on 16 cases that presented with diaphragmatic eventration between April 2012 and December 2018. The patients' mean age was 2.2 years (6 months-17 years). The main causes of admission were recurrent respiratory system infections (n: 14), respiratory distress with effort (n: 4), ventilator dependence (n: 1), and gastrointestinal complaints such as nutritional problems (n: 1). Diaphragmatic eventration was incidentally detected in 1 patient. No complications were observed during the postoperative period, except for 1 patient that developed pneumothorax. The mean duration of hospital stay was 4.9 days (2-7 days), except for 1 patient who had ventilator dependence and congenital myopathy. The mean descending distance of the diaphragm was 2.3 intercostal spaces at postoperative first month. The clinical outcomes were satisfactory and all patients experienced symptom improvements.

CONCLUSIONS

Diaphragm plication with double purse-string suturing method enables symmetrical stretching of the diaphragmatic muscles. Therefore, the diaphragmatic surface and costophrenic sinium are protected and remain functional. The advantages of this new double purse-string suturing method are easy application and durability. We believe that this method can become a preferred thoracoscopic plication technique for treatment of diaphragmatic eventration.

Thoracic versus abdominal approach to correct diaphragmatic eventration in children

BACKGROUND

Plication of diaphragm (DP) for eventration (DE) can be done using thoracic or abdominal approaches. The purpose of our study was to compare outcomes between these approaches based on our experience and on systematic literature review.

METHODS

Retrospective records of children <16 years who underwent DP (single-center, 2004-2018) were recorded and analyzed. Systematic review and meta-analysis of related studies was undertaken. Data are reported as median (range).

RESULTS

Eighty-nine cases were identified in thoracic (Congenital = 5, Acquired = 84) and 13 (Congenital = 10, Acquired = 3) in abdominal group aged 5.88 (0.36-184.44) and 10.0 (0.12-181.8) months. Improvement in diaphragm level post-DP was significantly higher in abdominal [2(0-4)] than chest [1.5(0-5)] group (p = 0.04). On Cox regression analysis, there was a non-significant trend to a longer time to extubation in the chest group (Hazard ratio (HR) = 0.539[0.208-1.395], p = 0.203). Patients operated transthoracically left intensive care unit after a significantly longer time (HR = 0.339[0.119-0.966], p = 0.043). Patients operated transabdominally tended to be fed later, although this was not significant (HR = 1.801[0.762-4.253], p = 0.043). On Kaplan-Meier analysis, there was a non-significant trend to a lower rate of recurrence in the abdominal group (HR = 0.3196[0.061-1.675], p = 0.1876). In the meta-analysis including three published studies as well as our data (total n = 181, Thoracic = 139, Abdominal = 42), no difference was found in the incidence of recurrence amongst the 2 groups (RD = -0.04, 95%CI = -0.25, 0.18, p = 0.74).

CONCLUSION

This is one of the largest reports on outcomes of children undergoing DP for DE. There is no significant difference in recurrence rate, even though all recurrences in our series (15.7%) were in the acquired cases operated using a thoracic approach.

TYPE OF STUDY

Treatment Retrospective Comparative Study.

LEVEL OF EVIDENCE

Level III.

Congenital diaphragmatic eventration and hernia sac compared to CDH with true defects: a retrospective cohort study

Congenital diaphragmatic eventration (CDE) and congenital diaphragmatic hernia (CDH) with or without hernia sac are three different types of congenital diaphragmatic malformations, which this study evaluates. All surgically treated patients with CDE or Bochdalek type CDH between 2000 and 2016 were included in this retrospective analysis. Demographics, CDH-characteristics, treatment, and clinical outcome were evaluated. In total, 200 patients were included. Patients with an eventration or hernia sac had no significant differences and were compared as patients without a true defect to patients with a true defect. The 1-year survival of patients with a true defect was significantly lower than patients with no true defect (76% versus 97%, p = 0.001). CDH with no true defect had significantly better short-term outcomes than CDH with true defect requiring patch repair. However, at 30 days, they more often required oxygen supplementation (46% versus 26%, p = 0.03) and had a higher recurrence rate (8% versus 0%, p = 0.006) (three eventration and two hernia sac patients). Conclusion: Patients without a true defect seem to have a more similar clinical outcome than CDH patients with a true defect, with a better survival. However, the recurrence rate and duration of oxygen supplementation at 30 days are higher than CDH patients with a true defect.What is Known:• Congenital diaphragmatic hernia with or without hernia sac and congenital diaphragmatic eventration (incomplete muscularization) are often treated similarly.• Patients with hernia sac and eventration are thought to have a relatively good outcome, but exact numbers are not described.What is New:• Congenital diaphragmatic eventration and patients with hernia sac seem to have a more similar clinical outcome than Bochdalek type CDH with a true defect.• Patients without a true defect (eventration or hernia sac) have a high recurrence rate.

Comparison of clinical outcomes between open and thoracoscopic repair for esophageal atresia with tracheoesophageal fistula: a systematic review and meta-analysis

OBJECTIVE

A meta-analysis was performed for a comparison of outcomes between open repair (OR) and thoracoscopic repair (TR) for esophageal atresia with tracheoesophageal fistula (EA with TEF).

METHODS

Electronic databases, including PubMed, Cochrane Library, and Medline, were searched systematically for the literatures aimed mainly at comparing the therapeutic effects for EA with TEF administrated by OR and TR. Corresponding data sets were extracted and two reviewers independently assessed the methodological quality. Meta-analysis was performed with Stata 12.0.

RESULTS

Ten studies meeting the inclusion criteria were included, involving 447 subjects in total. It was observed that OR entailed a shorter operative time with significant statistical differences (SMD 0.604; 95% CI 0.344-0.864, P = 0). While TR was superior in two aspects: shorter length of hospital stay (SMD 0.584; 95% CI 0.214-0.953; P = 0.002) and shorter first oral feeding time (SMD 0.652; 95% CI 0.27-1.035; P = 0.001). However, meta-analyses of occurrence rate of leaks (OR, 1.747; 95% CI 0.817-3.737; P = 0.15), strictures (OR, 0.937; 95% CI 0.5-1.757; P = 0.839), pulmonary complications (OR, 1.08; 95% CI 0.21-5.44; P = 0.897), fundoplication rate of Gastroesophageal Reflux Disease (GERD) (OR, 1.642; 95% CI 0.855-3.153; P = 0.601), and blood loss (SMD 0.048; 95% CI -1.292 to 1.388; P = 0.944) showed no significant differences between OR and TR. Meta-analysis of ventilation time showed similar outcome between OR and TR (SMD 0.474; 95% CI 0.02-0.968; P = 0.06), but the result remained controversial due to estimated result changing after sensitivity analysis (SMD 0.61; 95% CI 0.16-1.07; P = 0).

CONCLUSIONS

Compared with OR, a longer operative time was associated within TR group, although the TR procedure could possibly reduce the length of hospital stay and first oral feeding time. Meanwhile, the occurrence rate for leaks, strictures, pulmonary complications, and the fundoplication rate of GERD, and blood loss were similar between the OR and TR groups. Estimated result of ventilation time between the two groups remained ambiguous.

Thoracoscopic Diaphragmatic Plication for Eventration in Pregnant Woman: A Case Report

Diaphragmatic eventration is an uncommon malady, underdiagnosed and often treated only in emergent situations. Eventration of the diaphragm is best treated by plication of diaphragm with or without meshplasty. Various studies have shown that thoracoscopic plication is as efficient as laparotomy or laparoscopic plication. We present here the report of thoracoscopic diaphragmatic plication for eventration performed in the third trimester of pregnancy in a 28-year-old woman who presented with acute respiratory distress. To our knowledge, we believe this to be the first published case in medical literature.

Laparoscopic Diaphragmatic Hemiplication in Children with Acquired Diaphragmatic Eventration After Congenital Heart Surgery

PURPOSE

To report our technique and experiences in the laparoscopic diaphragmatic hemiplication (LDHP) in children with acquired diaphragmatic eventration after congenital heart surgery.

SUBJECTS AND METHODS

Between October 2007 to December 2013, 3498 children with congenital heart disease underwent cardiac surgery in our hospital, and 40 (1.14%) of them had unilateral diaphragmatic elevation on postoperative chest X-ray (mean elevation, 2.5 ± 0.26 intercostal spaces [ICS]) and were diagnosed as having diaphragmatic eventration due to diaphragmatic hemiparesis as a result of phrenic nerve injury. These 40 patients were followed up, and 22 of them recovered after conservative treatment; the other 18 needed surgical intervention. We conducted a retrospective study relating to surgical indications, surgical technique, complications, and outcomes.

RESULTS

There were 24 boys and 16 girls with a mean age of 10.0 ± 4.5 months old (range, 2 months-4 years). Twenty-two patients did not require surgical intervention. Eighteen patients underwent LDHP (12 cases left-sided and 6 cases right-sided); 2 of them had emergency LDHP with a history of ventilator dependency after cardiac surgery, and 16 of them had planned LDHP with a history of recurrent pneumonia and dyspnea. The operative time was 60 ± 7.9 minutes (range, 45-105 minutes), with minimal blood loss (3 ± 1.5 mL [range, 1-9 mL]), no intra- or postoperative complications, and postoperative hospital stay of 7 ± 1.3 days (range, 5-10 days). The diaphragmatic drop was 2.4 ± 0.2 (range, 2-4 ICS) without recurrence, and the follow-up time for all 40 patients was 14.8 ± 1.6 months (range, 11-36 months).

CONCLUSIONS

Our study further shows that LDHP is feasible and effective in selected patients after congenital heart surgery. Our technique is convenient and provides excellent clinical and radiological results.

Spontaneous rupture of a congenital diaphragmatic eventration in an infant

Rupture of the diaphragm may be traumatic or spontaneous. A spontaneous rupture occurring in a congenital eventration of the diaphragm is extremely rare. Only one such case has been reported previously. We report a case of a 5-month-old male infant who presented with acute life-threatening respiratory distress secondary to spontaneous rupture of a congenital diaphragmatic eventration.

A simple thoracoscopic plication technique for diaphragmatic eventration in neonates and infants: technical details and initial results

PURPOSE

Existing minimal-access surgical approaches for correction of symptomatic diaphragmatic eventration may be technically difficult in neonates and infants. We report technical details and initial outcomes of a novel, simple thoracoscopic repair technique.

METHODS

The technique uses one 3-mm camera port, a 3-mm instrument incision without a port, and an 18-gauge spinal needle, which is passed through the chest wall into the pleural space. The excess diaphragm is first plicated over the needle, after which a non-absorbable suture is passed through the needle and tied extracorporeally. The needle is passed repeatedly until the desired degree of tension is achieved. A retrospective review was performed for all patients undergoing repair by this technique.

RESULTS

Nine patients have undergone thoracoscopic plication at a median age of 3 months (range 0.2-13.2 mos.) and a median weight of 4.5 kg (range 2.3-8.2 kg). No organ injuries or conversions to thoracotomy occurred. Median operative time was 60 min. Patients repaired beyond the neonatal period were extubated in the operating room. There were two post-operative pneumothoraces. No recurrences have been seen at a mean follow-up of 17 months.

CONCLUSION

This technique of thoracoscopic diaphragm plication is safe, effective, and technically straightforward in neonates and infants.