Thoracoscopic diaphragmatic eventration repair in children: about 10 cases

Congenital unilateral diaphragmatic eventration in adults – a case series with a brief literature review

 Objective: The aim of this article was to present the results of thoracotomy performed in three symptomatic adult patients with congenital diaphragm eventration in the light of current literature data. Methods: Along with representation of the surgical management of each case, a brief review of literature was performed. Results and Conclusion:  Diaphragmatic eventration is a rare clinical entity that may be congenital or acquired. Surgery, which may be open or endoscopic, is the primary treatment modality for symptomatic patients.

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.

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.

A Simple Technique for Thoracoscopic Treatment of Diaphragmatic Eventration

True diaphragmatic eventration is a rare congenital defect that is most commonly asymptomatic, but can result in dyspnea and recurrent respiratory infections. Advancements in endoscopic technology and technique have resulted in minimally invasive methods for repair of this defect with pronounced benefit when compared to the open thoracotomy. We report a case in which a two year old male who suffered from recurrent respiratory infections was found to have unilateral right diaphragmatic eventration that underwent plication utilizing thoracoscopy and cutting endostaplers with Peri-strips. This procedure was followed by a remarkably fast recovery and discharge, improved radiological findings, and a reprieve from respiratory infection.

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.

Anesthetic management of staged thoracoscopic repair of bilateral eventration of diaphragm in a neonate

Congenital eventration of the diaphragm is a rare disorder, the perioperative management of which is challenging. The introduction of thoracoscopic repair of these defects has considerably reduced the perioperative morbidity and mortality in these patients. In spite of the advantages of thoracoscopy which include smaller chest incisions, reduced postoperative pain, and more rapid postoperative recovery compared with thoracotomy, it is still inherent with complications unique to it. A clear understanding of the pathophysiologic changes, potential complications and institution of appropriate monitoring and good planning is essential for the safe conduct of thoracoscopic procedures in neonates. We describe the anesthetic management of staged thoracoscopic repair of bilateral congenital eventration of the diaphragm in a neonate.

Diaphragmatic eventration in children: laparoscopy versus thoracoscopic plication

AIM

To determine the best way to perform diaphragmatic plication for diaphragmatic eventration (DE) using minimally invasive surgery.

MATERIALS AND METHODS

We conducted a retrospective review of pediatric cases of DE treated between 2007 and 2012. Thoracoscopic plication (TP) is performed using single-lung ventilation with three 5-mm ports; laparoscopic plication (LP) is performed using three or four 5-mm ports. The choice of technique was determined preferentially by the treating surgeon.

RESULTS

There were 20 subjects (13 treated by LP and 7 treated by TP). Etiology of DE was phrenic nerve injury (LP, n=11; TP, n=1) and muscular deficiency (LP, n=2; TP, n=6). Mean age (LP, 18 months; TP, 25 months) and weight (LP, 8.0 kg; TP, 9.7 kg) at surgery were not significantly different. Mean operating time was 155.6 minutes in LP and 167.0 minutes in TP (P=not significant). Mean intraoperative end-tidal CO2 was 41.9 mm Hg (range, 35-52 mm Hg) in LP and 36.9 mm Hg (range, 33-41 mm Hg) in TP (P=.01). Mean duration of postoperative ventilation was 1.2 days in LP and 1.3 days in TP (P=not significant). Mean time taken to recommence feeding postoperatively was 1.6 days in both groups (P=not significant). Complications were one conversion to thoracotomy in TP, 1 case of atelectasis in each group (P=not significant), and 6 cases of recurrence in LP versus none in TP (P=.04).

CONCLUSIONS

Both TP and LP are beneficial for treating small children with DE. However, there is a higher incidence of recurrence after LP, and the role of TP in cardiac patients requiring subsequent surgery is debatable.

Autopsy features in a newborn baby affected by a central congenital diaphragmatic hernia

Congenital diaphragmatic hernia is a congenital malformation of the diaphragm, resulting in the herniation of the abdominal organs into the thoracic cavity. The most common types of congenital diaphragmatic hernia are Bochdalek hernia (postero-lateral hernia), Morgagni hernia (anterior defect), and diaphragm eventration (abnormal displacement of part or all of an otherwise intact diaphragm into the chest cavity). Congenital diaphragmatic hernia is a life-threatening pathology in infants, and a major cause of death due to pulmonary hypoplasia and pulmonary hypertension. We present a fatal case of congenital diaphragmatic hernia in a newborn. At the autopsy, a central defect of the diaphragm was found, 8 × 5 cm in size, that led to a herniation of the small intestine, the right lobe of the liver, and the right adrenal gland into the thorax. An esophageal atresia was associated with the congenital diaphragmatic hernia. The lungs showed severe hypoplasia and atelectasia. Physicians should pay attention to a prenatal diagnosis of congenital diaphragmatic hernia in order to prevent newborn fatalities.

Thoracoscopic plication for diaphragmatic eventration after surgery for congenital heart disease in children

OBJECTIVE

The aim of this study was to clarify the role of thoracoscopic plication for diaphragmatic eventration after surgery for congenital heart disease (CHD) in children.

PATIENTS AND METHODS

We retrospectively reviewed the medical charts of pediatric patients who had undergone thoracoscopic plication of diaphragmatic eventration after surgery for CHD between 2008 and 2013 at our department.

RESULTS

Five patients were identified during the study period. The median age and body weight of the patients were 7.6 months and 6.6 kg, respectively. The associated CHDs were pulmonary artery atresia in 3 patients, truncus arteriosus in 1 patient, and double-outlet right ventricle in 1 patient. Four patients needed preoperative mechanical respiratory support. At operation, all the patients received CO2 insufflation (4 mm Hg), and single-lung ventilation was attempted in 3 patients using a bronchial blocker. A sufficient operative field was maintained by CO2 insufflation in all the patients regardless of single-lung ventilation. The procedure was not converted to open operation in any patient. Postoperative extubation was performed in the operating room in 1 patient, on the day of operation in 2 patients, and on postoperative Days 1 and 2 in 2 patients. Air embolism was not observed in any of the patients. Diaphragmatic eventration did not recur in any of the patients after thoracoscopic plication.

CONCLUSIONS

Thoracoscopic plication is a safe and effective procedure for pediatric diaphragmatic eventration after surgery for CHD. Considering the sufficient operative field maintained by CO2 insufflation, single-lung ventilation using a bronchial blocker would be unnecessary for this procedure. With its safety and good outcome, early thoracoscopic plication is a good treatment option for pediatric patients with symptomatic diaphragmatic eventration after surgery for CHD.

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.

Is video-assisted thoracoscopic diaphragmatic plication a widespread technique for diaphragmatic hernia in adults? Review of the literature and results of a national survey

Diaphragmatic plication is the most accepted treatment for symptomatic diaphragmatic hernia in adults. The fact that this pathology is infrequent and this procedure not been widespread means that this is an exceptional technique in our field. To estimate its use in the literature, we carried out a review in English and Spanish, to which we added our series. We found only six series that contribute 59 video-assisted mini-thoractomy for diaphragmatic plications in adults, and none in Spanish. Our series will be the second largest with 18 cases. Finally, we conducted a survey in all the Spanish Thoracic Surgery units in Spain: none reported more than 10 cases operated by thoracoscopy in the last 8 years (except our series) and most continue employing thoracotomy as the main approach. We believe that many patients with symptomatic diaphragmatic hernia could benefit from the use of such techniques.

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

PURPOSE

Diaphragmatic plication by minimally invasive surgery is thought to allow for a quick recovery and has been performed on small children. Here, we report our experience with different plication procedures to discuss how to choose among these different plication procedures in endoscopic surgery for pediatric patients with diaphragmatic eventration.

PATIENTS AND METHODS

We retrospectively analyzed clinical data of 27 pediatric patients (21 boys, 6 girls; median age: 12.7 months, range 2 months-3 years) admitted to our hospital between November 2008 and July 2013. Three different plication procedures were used: the "reefing the mainsail" technique (8 patients), "invaginating the diaphragmatic dome" technique (10 patients), and "pleating" technique (9 patients). Indications included ventilator dependency (7.41 %), respiratory distress (22.22 %), chronic lung lobe collapse (11.11 %), persistent atelectasis with recurrent pneumonias (18.52 %), and asymptomatic severe eventration (40.74 %).

RESULTS

Descending distance of diaphragm after surgery ranged from 1 to 4.5 intercostal spaces (mean distance: 2.65 intercostal spaces). All patients recovered well postoperatively, except for one patient with a pneumothorax. Two patients who required respiratory support before the operation no longer required it within 7 d after surgery. Follow-up ranged from 1 to 35 months. Clinical results were satisfactory with obvious improvement in symptoms and a slight re-elevation within a distance of one intercostal space.

CONCLUSION

For pediatric patients with diaphragmatic eventration, different endoscopic surgeries and plication procedures all yielded satisfactory results. We believe that the choice of one procedure over the other depends only on the surgeon's experience.

Laparoscopic transperitoneal repair of pediatric diaphragm eventration using an endostapler device

BACKGROUND

Minimally invasive repairs of pediatric diaphragm eventration have been well described via a thoracoscopic approach, oftentimes requiring single-lung ventilation and tube thoracostomy, with the disadvantage of not being able to clearly visualize what lies beneath the diaphragm. We describe a novel pediatric diaphragm eventration repair using a laparoscopic transperitoneal approach and an endostapler device. We also describe our initial experience with this technique.

PATIENTS AND METHODS

Four pediatric diaphragmatic eventration patients underwent laparoscopic transperitoneal repair using an endostapler device. Repairs were performed in both male and female patients with right-sided eventrations. We approach the repair in a transperitoneal fashion using inverting sutures at the apex of the diaphragm to create tension toward the pelvis. Subsequently, an endostapler is used to remove the redundant portion of diaphragm, leaving a repaired, taut diaphragm.

RESULTS

The median age at operation was 10.5 months. The median operative time was 70 minutes. There was no mortality, surgical complications, or recurrence at a median follow-up of 17 months.

CONCLUSIONS

This laparoscopic approach allows for clear visualization of the intraabdominal organs and, at least in our early experience, a very simple, straightforward operation. Additionally, with the use of the endostapler, the redundant, often weakened diaphragm is removed, leaving the native, healthy diaphragm behind, resulting in a reliable and reproducible repair. This repair should be considered as a feasible alternative approach to the more traditional open and thoracoscopic repairs.

Respiratory distress in a one-month-old child suffering brachial plexus palsy

This paper describes a one-month-old girl presenting with respiratory and growth failure due to diaphragmatic paralysis associated with left brachial plexus palsy after forceps delivery. Despite continuous positive pressure ventilation and nasogastric feeding, the situation did not improve and a laparoscopic diaphragmatic plication had to be performed. When dealing with a child born with brachial plexus palsy, one must think of this possible association and if necessary proceed to the complementary radiological examinations. The treatment must avoid complications like feeding difficulties and failure to thrive, respiratory infections or atelectasis. It includes intensive support and a good evaluation of the prognosis of the lesion to decide the best moment for a surgical therapy.

Thoracoscopic plication for diaphragmatic eventration in a neonate

BACKGROUND

Currently, thoracoscopic surgery is replacing thoracotomy for an ever increasing number of indications, even in pediatric surgery. However, there are few reports describing thoracoscopic plication (TP) for diaphragmatic eventration in children, particularly in neonates. We report a case of TP under single-lung ventilation in a neonate with diaphragmatic eventration.

CASE REPORT

A 10-day-old boy was referred for surgical management of right diaphragmatic eventration. Birth was at term, following an uncomplicated pregnancy and delivery. Shortness of breath, labored respiration and chest retraction presented soon after birth, necessitating mechanical ventilation. Chest radiography and computed tomography revealed an elevated right hemidiaphragm. Attempted weaning off mechanical ventilation failed with persistence of respiratory symptoms, requiring nasal directional positive airway pressure. However, because there was no resolution of symptoms, TP was performed using a 3 port technique under single-lung ventilation on day 17 of life. The postoperative course was excellent with complete resolution of respiratory symptoms with no recurrence for 9 months.

CONCLUSION

To the best of our knowledge, this is the youngest case of TP for diaphragmatic eventration performed under single-lung ventilation. TP is safe, effective and minimally invasive and should be considered actively for the treatment of symptomatic diaphragmatic eventration even in neonates.

A helping clamp for thoracoscopic plication of eventration of the diaphragm

Background and Aim:

It is difficult to suture an extremely thin and billowed up congenital eventration of the diaphragm thoracoscopically, without insufflation.

Materials and Methods:

The authors describe their technique using an intestinal clamp to control the redundant tissue and a feeding tube as a flexible knot pusher, to perform the thoracoscopic plication without risking hypercapnia.

Results:

A satisfactory result was obtained in all the four children.

Conclusion:

This is a useful adjunctive for thoracoscopic plication of diaphragmatic eventration.

Robotic repair of congenital diaphragmatic anomalies

PURPOSE

Congenital diaphragm anomalies, including eventration, Morgagni diaphragmatic hernias (M-CDH), and Bochdalek diaphragmatic hernias (B-CDH), have been successfully repaired by using minimally invasive surgery (MIS). However, some reports have shown a high recurrence rate for some defects, potentially due to difficulty associated with the rigid instruments. Robotic surgery may help close diaphragmatic anomalies more effectively. In this paper, we present a series of 8 consecutive patients with diaphragmatic anomalies who underwent robotic repair.

METHODS

We retrospectively reviewed patients with diaphragmatic anomalies. There were 2 patients with eventration, 5 with B-CDH, and 1 with M-CDH. All procedures were performed by using the Standard Da Vinci surgical robot (Intuitive Surgical, Sunnyvale, CA) with one camera arm (5-mm two-dimensional scope) and two instrument arms (5 mm).

RESULTS

Average age was 3.9 months (4 days to 12 months). Average weight was 3.6 kg (range, 2.2-10.5). Four B-CDH patients were approached through the chest and 1 from the abdomen. The patient with M-CDH had an abdominal repair, and both eventrations were performed from the chest. One B-CDH and 1 eventration were converted to thoracoscopic procedures. Average operative time was 1 hour and 20 minutes. One recurrence developed in a relatively large B-CDH repair that was closed primarily. Average follow-up was 20 months.

CONCLUSIONS

Robotic surgery is safe and effective for repairing diaphragm anomalies in small children. Although we prefer the thoracic approach for repairing the B-CDH, occasionally smaller newborns-perhaps those less than 2.5 kg-may do better with the abdominal approach, since the articulating instruments requiring a significant length in order to maneuver.

Thoracoscopic repair of neonatal diaphragmatic hernia

INTRODUCTION

The use of minimally invasive surgery (MIS) in the neonatal population is increasing. Thoracoscopic intervention for congenital diaphragmatic hernia (CDH) is no exception. In this report, we describe our initial experience with thoracoscopic repair of left-sided diaphragmatic defects in neonates.

MATERIALS AND METHODS

We performed retrospective chart reviews on all neonates who underwent thoracoscopic repair of CDH between November 2004 and January 2008. Neonates that underwent thoracoscopic repair were physiologically stable with resolved pulmonary hypertension and minimal to moderate ventilatory support. They had no associated cardiac anomalies.

RESULTS

We identified 15 neonates with CDH who underwent thoracoscopic repair during the study period. Ten neonates underwent primary repair of the diaphragmatic defect. Five neonates with large defects required closure with a synthetic patch, which was placed thoracoscopically. The average operating room time was 134 minutes. There were no instances of intraoperative respiratory or cardiac instability. Three patients had a recurrence. One recurrence was seen after thoracoscopic patch repair. Two recurrences occurred following primary repair of left diaphragmatic hernias. There were no deaths. Follow-up has been 4-40 months.

CONCLUSIONS

Neonatal MIS for CDH should be limited to stable patients. The ideal candidate is the newborn without associated anomalies, not requiring extracorporeal membrane oxygenation, on minimal ventilatory support, and without evidence of pulmonary hypertension. It is technically possible to perform thoracoscopic repair with a patch.