Minimally invasive diaphragm plication in an infant

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.

Robot-assisted thoracoscopic plication for diaphragmatic eventration

BACKGROUND

Though conventional thoracoscopic plication is a favorable option of diaphragmatic eventration (DE), ribs limited the movement of trocars, making it difficult to suturing, knot-tying and time-consuming. The purpose of this study was to evaluate delicate surgical maneuvers and suturing time for the management of DE in robot-assisted thoracoscopic plication (RATP).

METHODS

From January 2015 to November 2019, 20 patients (14 males; mean age: 10.5 ± 5.2 months; mean weight: 8.6 ± 4.5 kg) who underwent diaphragmatic plication for DE were reviewed at our institution. There were 13 patients with congenital diaphragmatic eventration and 7 patients with acquired diaphragm eventration after congenital heart surgery. RATP was performed on 9 patients (3 on the left and 6 on the right), and conventional thoracoscopic plication (CTP) was applied to 11 patients (5 on the left and 6 on the right). Demographics, the suturing time and complications were respectively evaluated.

RESULTS

There was no difference between 2 groups with respect to gender, age at surgery and weight (p > 0.05). No conversion to thoracotomy was needed. The suturing time in RATP group was shorter than CTP group (27.7 ± 3.4 min vs 48.1 ± 4.2 min, p < 0.001). One patient (9.09%) experienced recurrence in CTP group and none was found in RATP group.

CONCLUSIONS

Diaphragmatic plication with robot-assisted thoracoscopy or conventional thoracoscopy in DE has minimally invasive and good effect on children. RATP overcome the intercostal limitations to complete delicate suturing and free knot-tying, and has better ergonomics.

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.

Neurofibromas of the Phrenic Nerve: A Case Report and Review of the Literature

BACKGROUND

Phrenic neurofibromas are a rare pathologic entity, with 9 cases described in the English literature. They may occur in conjunction with or independently of neurofibromatosis type 1. Phrenic neurofibromas pose distinct therapeutic challenges compared with the more common phrenic schwannoma. We describe here a 12-year-old boy with neurofibroma of the left phrenic nerve presenting as dextroposition of the heart after paralysis of the left hemidiaphragm allowed herniation of abdominal contents into the left hemithorax and displaced the heart.

METHOD

Surgical resection of the tumor followed by diaphragmatic plication was performed to assess its degree of malignancy, reduce abdominal herniation, and improve lung capacity.

RESULTS

The operation markedly improved his hemidiaphragmatic elevation.

CONCLUSIONS

The spectrum of management options ranges from conservative surveillance to open thoracic surgery. Functional preservation of the phrenic nerve is technically challenging, and although phrenic neurofibromas often present with absent function that cannot be recovered, surgical intervention can be fruitful in restoring lung capacity through diaphragmatic reconstruction.

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.

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.

Functional and Physiologic Results of Video-Assisted Thoracoscopic Diaphragm Plication in Adult Patients With Unilateral Diaphragm Paralysis

BACKGROUND

Plication of the hemidiaphragm for unilateral diaphragm paralysis is infrequently performed in adults. Barriers to diaphragm plication have included the perceived need for thoracotomy and uncertainty of the potential benefits. The purpose of this investigation was to assess the effects of video-assisted thoracoscopic diaphragm plication in symptomatic adult patients with unilateral diaphragm paralysis.

METHODS

Patients with unilateral diaphragm paralysis underwent an evaluation that included a chest radiograph, fluoroscopic sniff test, pulmonary spirometry, and the Medical Research Council (MRC) dyspnea score. Patients with symptomatic unilateral diaphragm paralysis present for at least 6 months were offered video-assisted thoracoscopic diaphragm plication. Patients who underwent diaphragm plication as well as those who declined surgery were reassessed at 6 months with a chest radiograph, spirometry, and the MRC dyspnea score.

RESULTS

Twenty-five patients underwent left (19) or right (6) diaphragm plication through video-assisted thoracoscopic diaphragm plication (22) or thoracotomy (3). There were no operative deaths. Mean hospital length of stay for diaphragm plication was 3.7 days for video-assisted thoracoscopic diaphragm plication and 5.4 days for thoracotomy. After diaphragm plication, mean forced vital capacity, forced expiratory volume at 1 second, functional residual capacity, and total lung capacity improved by 17%, 21.4%, 20.3%, and 16.1%, respectively (p < 005) at 6 months. Mean MRC dyspnea scores also significantly improved in the operative cohort (p < 0001). Seventeen patients in the surgical cohort had returned to work at 6 months. Seven patients treated without surgery displayed a trend toward more frequent hospitalizations and deteriorating pulmonary spirometry and MRC dyspnea scores during the follow-up period.

CONCLUSIONS

Plication of the hemidiaphragm using minimally invasive techniques produced significant improvements in patients' functional status, pulmonary spirometry, and MRC dyspnea scores. Video-assisted thoracoscopic diaphragm plication should be considered appropriate therapy in symptomatic adult patients with unilateral diaphragm paralysis.

Thoracoscopic diaphragmatic eventration repair in children: about 10 cases

BACKGROUND AND AIM

Recent reports in literature have emphasized the clinical perception of reduced pain, postoperative morbidity, and dysfunction associated with thoracoscopic approach compared with standard thoracotomy. The authors describe a thoracoscopic approach and technical details for diaphragmatic eventration repair in children.

PATIENTS AND METHODS

Ten patients, 4 girls and 6 boys, 1 teenager (14 years old) and 9 children (age range, 6-41 months; average, 17 months), were operated for a diaphragmatic eventration in 3 different pediatric surgery teams, according to the same technique. Symptoms were recurrent infection (7 cases), dyspnea on exertion (2 cases), and a rib deformity (1 case). An elective thoracoscopy was performed, patient in a lateral decubitus. A low carbon dioxide insufflation allowed a lung collapse. Reduction of the eventration was made progressively when folding and plicating the diaphragm. Plication of the diaphragm was done with an interrupted suture (6 cases) or a running suture (4 cases). The procedure finished either with an exsufflation (4 cases) or a drain (6 cases).

RESULTS

A conversion was necessary in 2 cases: 1 insufflation was not tolerated and 1 diaphragm, higher than the fifth space, reduced too much the operative field. Patients recovered between 2 and 4 days. Dyspnea disappeared immediately. Mean follow-up of 16 months could assess the clinical improvement in every patient.

DISCUSSION

Thoracoscopic conditions are quite different between a diaphragmatic hernia repair previously reported and an eventration. Concerning diaphragmatic hernias, reduction is easy, giving a large operative space for suturing the diaphragm. Concerning diaphragmatic eventrations, the lack of space remains important at the beginning of the procedure despite the insufflation into the pleural cavity. The operative ports must be high enough in the chest to allow a good mobility of the instruments. Chest drainage seems to be unnecessary.

CONCLUSION

Diaphragmatic eventration repair by thoracoscopy is feasible, safe, and efficient in children. Above all, it avoids a thoracotomy. It improves the immediate postoperative results with a good respiratory function.

Surgical treatment of diaphragmatic eventration using video-assisted thoracic surgery: a prospective study

BACKGROUND

This study seeks to evaluate results regarding the repair of diaphragmatic eventration using video-assisted thoracic surgery (VATS).

METHODS

We performed a prospective observational study including patients referred to us for surgical treatment of diaphragmatic eventration during a 12-year period. Clinical, radiologic, and functional data were prospectively recorded. VATS was performed with two thoracoports and a 4-cm mini-thoracotomy. Diaphragmatic plication was performed using two nonresorbable running sutures from periphery to the cardio-phrenic angle. Follow-up data (clinical examination, chest roentgenogram, lung function tests at 3, 6, 12 months, and annually thereafter) were also prospectively recorded.

RESULTS

Twelve patients (4 male adults, mean age 57.7 +/- 14.8 years) were operated on between 1992 and 2003. The left side was involved in 8 patients and the mean height of diaphragm elevation was 7.5 +/- 1.8 cm. All patients experienced symptoms related to the disease; in 2 patients the operation was carried out to achieve weaning from mechanical ventilation. The etiologic mechanism could be identified in 11 out of 12 patients (trauma, n = 9; Charcot-Marie disease, n = 1; calcified para-aortic nodes, n = 1). Mean operative time, drainage output, and hospital stay were 77 +/- 15 minutes, 0.8 +/- 04 L, and 3.4 +/- 0.7 days, respectively. No mortality was observed; 1 patient experienced postoperative pneumonia, which was treated using antibiotics. All patients experienced amelioration of symptoms and long-term lung function tests revealed a marked improvement of both the forced volume capacity and the forced expiratory volume at 1 second. No relapses were observed at follow-up chest roentgenogram.

CONCLUSIONS

Treatment using VATS is a safe and effective alternative to conventional surgery. Functional improvement persists at long-term follow-up.

Thoracoscopic diaphragm plication in children and indications for conversion to open thoracotomy

Thoracoscopic plication of the diaphragm has been recently described as an alternative treatment for eventration. It is considered to be much less traumatic than the conventional method. We attempted thoracoscopic diaphragm plication on three patients. Two patients were treated successfully by the minimally invasive technique and were discharged from hospital on the second postoperative day. In the third case, the presence of a mobile intrathoracic kidney due to previous diaphragmatic hernia repair necessitated conversion to open thoracotomy. This patient was discharged on postoperative day six following an uneventful recovery. All patients are well and asymptomatic on followup. We advocate thoracoscopic diaphragm plication in children as a safe procedure with less morbidity and excellent cosmetic results.

Laparoscopic diaphragmatic plication: long-term results of a novel surgical technique for postoperative phrenic nerve palsy

BACKGROUND

Paralysis of the diaphragm is a severe complication of cardiothoracic surgery carrying significant morbidity and mortality. This study demonstrates a novel minimally invasive technique for treatment of phrenic nerve injuries presenting with symptomatic eventration of the diaphragm. It also presents long-term results of three patients treated with this operation.

METHODS

Chest x-ray proved eventration of the left diaphragm in all patients. Two patients required treatment due to prolonged respirator therapy/assisted ventilation for 4 weeks after cardiac surgery. One patient suffered from progressive dyspnea caused by increasing left-sided diaphragmatic elevation and underwent surgery 2 years after cardiac surgery. In all cases, a minimally invasive abdominal approach was chosen. During surgery the dome of the diaphragm was pulled down via three percutaneously inserted retention stitches. This resulted in two or three folds of the diaphragm located within the abdomen. These diaphragmatic folds were subsequently tightened using 12 to 15 unresorbable sutures with extracorporally prepared knots. Surgical as well as long-term follow-up results are presented of all patients and a review of the current literature is provided.

RESULTS

Mean operating time was 203 min; mean intraoperative blood loss was 130 ml. No major complications occurred during surgery or the postoperative period. At a median follow-up of 72 months no recurrence was observed.

CONCLUSIONS

Laparoscopic diaphragmatic plication provides excellent relief of symptoms caused by diaphragmatic paralysis. There is no perioperative morbidity, and hospital stay is short. The laparoscopic approach, therefore, is an attractive surgical alternative for the treatment of phrenic nerve palsy and should be considered in all suitable patients.

Video-assisted diaphragm plication in children

BACKGROUND

Diaphragm paralysis after cardiac surgery may be secondary to phrenic nerve injury by ice, electrocautery, or dissection. Although most are asymptomatic, some patients, particularly children, have significant respiratory compromise. Video-assisted plication may offer more rapid improvement and recovery than thoracotomy in pediatric patients.

METHODS

We performed five procedures. The diaphragm was elevated, clamped, oversewn, and tacked down into the pleural gutter. The procedure was performed on 2 infants after repair of total anomalous pulmonary venous connection, on 1 child after the Fontan procedure, on 1 child after repair of tetralogy of Fallot, and on 1 child with congenital eventration. Indications included ventilator dependency, post-Fontan protein losing enteropathy with elevated venous pressures and chronic right lower lobe collapse, persistent atelectasis with recurrent pneumonias, and asymptomatic severe eventration.

RESULTS

Ventilator-dependent patients were extubated after 2 and 3 days. The remaining patients were immediately extubated. One patient was discharged the day of surgery and 2 were discharged at 1 and 3 days postoperatively. The remaining 2 were discharged on postoperative day 30 and 45 after continued issues with feeding and prematurity. The child with the eventration had rapid expansion and growth of the left lung over the next few weeks with a normal chest radiograph 3 weeks later. The child with recurrent pneumonia reexpanded her left lower lobe and remains free of infection. There were no wound infections, lung or vascular injuries, or complications from the procedure. All the patients had successful flattening of the hemidiaphragm as documented by chest radiograph, with successful lung reexpansion.

CONCLUSIONS

Video-assisted plication of paralyzed diaphragms is effective and safe, involves less morbidity, and has quicker recovery times than traditional open techniques.

A simple technique for the thoracoscopic plication of the diaphragm

We describe a simple technique for video-assisted thoracoscopic plication in patients with diaphragmatic eventration. During the plication, which is performed with a continuous running suture, a surgical assistant maintains the continuous suture traction using a homemade hook through the port. The technique can be performed easily, without any kind of thoracotomy.

Reducing the trauma of congenital heart surgery

While describing the circulatory system in De Moto Cordis, in 1628, William Harvey developed precepts for investigation, which could be modified slightly to guide the adoption of new technology and technique in the twenty-first century. Harvey might suggest (1) careful and accurate observation and description of a new technique, (2) a tentative explanation of how the technique improves on existing techniques, (3) a controlled testing of the hypothesis, and (4) conclusions based on the results of the experiments. Also, he might admonish surgery today, with its massively enhanced capabilities for information management, to rigorously test the validity of these conclusions with quantitative reasoning. In the future, precise measurement of the "trauma" of surgery, or even an individual surgeon, may be possible, and the long-term impact of a chest wall incision on a patient's self-esteem may be predictable. Absent such objective measures, justifications for "minimally invasive" deviations from conventional technique in surgery for CHD lack substance. Morbidity, mortality, and physiological endpoints will continue to form the foundation for therapeutic plans; however, the potential for emerging technology to reduce the trauma of these plans remains tantalizing.

Thoracoscopic plication of diaphragmatic eventration using endostaplers

Unilateral diaphragmatic eventration and paralysis require plication in cases of progressive dyspnea on exertion and recurrent respiratory infection. The patient, a 40-year-old woman, who had complained of worsening dyspnea on exertion and elevation of the left diaphragm on chest radiographs for 4 years, underwent plication by thoracoscopy with knifeless endostaplers. Improvements in pulmonary functions and dyspnea on exertion have been maintained for 14 months.

Use of the laryngeal mask for placement of a bronchial blocker in children

For one-lind ventilation in children, a bronchial blocker (e.g. Fogarty catheter) is often used, but its insertion may not be easy. We report a new method of placement of a bronchial blocker in an infant, using the laryngeal mask.

Minimally invasive pediatric cardiac surgery

Minimally invasive cardiac surgery has evolved in response to the intrinsic irony facing cardiac surgeons: that we must injure our patients to treat them. In recent years, advances in fiberoptic imaging technology, applied to other surgical specialties, suggested the possibility that cardiac surgery might also be performed endoscopically. The anatomic and spatial constraints of pediatric cardiac surgery, and its dependence on extreme levels of speed, precision, and three-dimensional perception, made the application of remote, two-dimensional operating systems seem impossible, or at least imprudent in this special group of patients. Despite these limitations, however, applications of video-assisted endoscopic surgical techniques have been demonstrated to allow the safe and effective performance of an expanding range of operative procedures in congenital heart surgery. The guided development of new technology will accelerate this process in the coming years.