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Gritsiuta AI, Gordon M, Bakhos CT, Abbas AE, Petrov RV. Minimally Invasive Diaphragm Plication for Acquired Unilateral Diaphragm Paralysis: A Systematic Review. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2022; 17:180-190. [PMID: 35549933 DOI: 10.1177/15569845221097761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective: Diaphragm paralysis is a relatively uncommon entity that can be both congenital and acquired in nature. While commonly asymptomatic, it can also cause a significant decrease in pulmonary function and reserve, particularly in patients with underlying pulmonary diseases. Our aim was to summarize the current literature regarding the minimally invasive techniques used in the surgical correction of acquired diaphragm paralysis via traditional and robotic minimally invasive approaches. Methods: We conducted a systematic review of available literature using the Cochrane methodology and reported findings according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) standards. Results: A total of 6,561 citations were identified through initial database and reference searches, of which 90 articles met the inclusion criteria for review. After further assessment, 33 appropriate full-text studies were selected for the review. Of the selected publications, the majority represented case reports and single-center retrospective studies with level of evidence 4. Only 1 level 2b study (individual cohort study) was identified, comparing minimally invasive and open approaches. Conclusions: Each of the minimally invasive approaches has its unique benefits and disadvantages, which are summarized and delineated in this article. Ultimately, no preferred method of diaphragm plication for diaphragm paralysis can be recommended at this time based on clinical data. The choice of procedure and surgical approach continues to be selected based on the surgeon's experience and preference.
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Affiliation(s)
- Andrei I Gritsiuta
- Department of Surgical Services, 6595University of Pittsburgh Medical Center, PA, USA
| | - Matthew Gordon
- Department of Thoracic Medicine and Surgery, Division of Thoracic Surgery, 12314Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Charles T Bakhos
- Department of Thoracic Medicine and Surgery, Division of Thoracic Surgery, 12314Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Abbas E Abbas
- Department of Thoracic Oncology, 12321Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Roman V Petrov
- Department of Thoracic Medicine and Surgery, Division of Thoracic Surgery, 12314Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
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Parlak A, Gurpınar AN, Dogruyol H. Double purse-string suturing: An easy plication technique in thoracoscopic repair of diaphragmatic eventration. J Pediatr Surg 2020; 55:967-971. [PMID: 31761455 DOI: 10.1016/j.jpedsurg.2019.10.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Revised: 09/15/2019] [Accepted: 10/03/2019] [Indexed: 10/25/2022]
Abstract
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.
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Affiliation(s)
- Ayse Parlak
- Department of Pediatric Surgery, Uludag University Medical Faculty, Bursa, Turkey.
| | - Arif Nuri Gurpınar
- Department of Pediatric Surgery, Uludag University Medical Faculty, Bursa, Turkey
| | - Hasan Dogruyol
- Department of Pediatric Surgery, Uludag University Medical Faculty, Bursa, Turkey
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Abstract
AIM To develop examination algorithm and to determine the indications for various options for surgical treatment. MATERIAL AND METHODS It is presented analysis of surgical treatment of 25 patients with unilateral diaphragm relaxation for the period from 1963 to 2016. There were 15 men and 10 women aged from 39 to 65 years. Diagnosis included predominantly radiological methods. All patients were operated openly through thoracotomy. Procedure consisted of creation of new diaphragmatic cupola at the usual level with two flaps of diaphragm and prosthesis between them. In 12 (48%) patients who were operated before 1990 xenopericardial patch was used. Further, synthetic materials (Teflon, polypropylene) were preferred. RESULTS Postoperative morbidity and mortality was 20% (n=6) and 4% (n=1) respectively. Long-term results were followed-up within terms from 8 months to 12 years. Recurrent relaxation was absent. Most of patients had improved dyspnea, increased vital capacity and FEV1 in long-term period. Certain and general values of SF-36 life quality questionnaire were high in long-term postoperative period and similar to those in general population.
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Affiliation(s)
- V D Parshin
- Sechenov First Moscow State Medical University of Healthcare Ministry of the Russian Federation, Burdenko Clinic of Faculty Surgery, Moscow, Russia
| | - M A Khetagurov
- Sechenov First Moscow State Medical University of Healthcare Ministry of the Russian Federation, Burdenko Clinic of Faculty Surgery, Moscow, Russia
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Demos DS, Berry MF, Backhus LM, Shrager JB. Video-assisted thoracoscopic diaphragm plication using a running suture technique is durable and effective. J Thorac Cardiovasc Surg 2017; 153:1182-1188. [DOI: 10.1016/j.jtcvs.2016.11.062] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Revised: 11/15/2016] [Accepted: 11/24/2016] [Indexed: 11/27/2022]
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Podgaetz E, Garza-Castillon R, Andrade RS. Best Approach and Benefit of Plication for Paralyzed Diaphragm. Thorac Surg Clin 2017; 26:333-46. [PMID: 27427528 DOI: 10.1016/j.thorsurg.2016.04.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Diaphragmatic eventration and diaphragmatic paralysis are 2 entities with different etiology and pathology, and are often clinically indistinguishable. When symptomatic, their treatment is the same, with the objective to reduce the dysfunctional cephalad excursion of the diaphragm during inspiration. This can be achieved with diaphragmatic plication through the thorax or the abdomen with either open or minimally invasive techniques. We prefer the laparoscopic approach, due to its easy access to the diaphragm and to avoid pain associated with intercostal incisions and instrument use. Short-term and long-term results are excellent with this technique.
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Affiliation(s)
- Eitan Podgaetz
- Section of Thoracic and Foregut Surgery, Division of Cardiothoracic Surgery, University of Minnesota, 420 Delaware Street Southeast, MMC 207, Minneapolis, MN 55455, USA.
| | - Rafael Garza-Castillon
- Section of Thoracic and Foregut Surgery, Division of Cardiothoracic Surgery, University of Minnesota, 420 Delaware Street Southeast, MMC 207, Minneapolis, MN 55455, USA
| | - Rafael S Andrade
- Section of Thoracic and Foregut Surgery, Division of Cardiothoracic Surgery, University of Minnesota, 420 Delaware Street Southeast, MMC 207, Minneapolis, MN 55455, USA
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Ahn HY, Kim YD, Hoseok I, Cho JS, Lee J, Son J. Surgical Outcomes of Pneumatic Compression Using Carbon Dioxide Gas in Thoracoscopic Diaphragmatic Plication. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2016; 49:456-460. [PMID: 27965923 PMCID: PMC5147471 DOI: 10.5090/kjtcs.2016.49.6.456] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Revised: 03/29/2016] [Accepted: 03/29/2016] [Indexed: 01/20/2023]
Abstract
Background Surgical correction needs to be considered when diaphragm eventration leads to impaired ventilation and respiratory muscle fatigue. Plication to sufficiently tense the diaphragm by VATS is not as easy to achieve as plication by open surgery. We used pneumatic compression with carbon dioxide (CO2) gas in thoracoscopic diaphragmatic plication and evaluated feasibility and efficacy. Methods Eleven patients underwent thoracoscopic diaphragmatic plication between January 2008 and December 2013 in Pusan National University Hospital. Medical records were retrospectively reviewed, and compared between the group using CO2 gas and group without using CO2 gas, for operative time, plication technique, duration of hospital stay, postoperative chest tube drainage, pulmonary spirometry, dyspnea score pre- and postoperation, and postoperative recurrence. Results The improvement of forced expiratory volume at 1 second in the group using CO2 gas and the group not using CO2 gas was 22.46±11.27 and 21.08±5.39 (p=0.84). The improvement of forced vital capacity 3 months after surgery was 16.74±10.18 (with CO2) and 15.6±0.89 (without CO2) (p=0.03). During follow-up (17±17 months), there was no dehiscence in plication site and relapse. No complications or hospital mortalities occurred. Conclusion Thoracoscopic plication under single lung ventilation using CO2 insufflation could be an effective, safe option to flatten the diaphragm.
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Affiliation(s)
- Hyo Yeong Ahn
- Department of Thoracic and Cardiovascular Surgery, Pusan National University Hospital, Medical Research Institution
| | - Yeong Dae Kim
- Department of Thoracic and Cardiovascular Surgery, Pusan National University Hospital, Medical Research Institution
| | - I Hoseok
- Department of Thoracic and Cardiovascular Surgery, Pusan National University Hospital, Medical Research Institution
| | - Jeong Su Cho
- Department of Thoracic and Cardiovascular Surgery, Pusan National University Hospital, Medical Research Institution
| | - Jonggeun Lee
- Department of Thoracic and Cardiovascular Surgery, Pusan National University Hospital, Medical Research Institution
| | - Joohyung Son
- Department of Thoracic and Cardiovascular Surgery, Pusan National University Hospital, Medical Research Institution
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Video-assisted minimally invasive diaphragmatic plication: feasibility of a recognized procedure through an uncharacteristic hybrid approach. Surg Endosc 2016; 31:1772-1777. [PMID: 27519592 DOI: 10.1007/s00464-016-5171-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Accepted: 08/06/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Diaphragmatic plication is an approved surgical procedure for treatment of symptomatic diaphragmatic paralysis and eventration. We aim to define our minimally invasive technique of plication and objectively assess our surgical outcomes of the largest series reported in the literature so far, using pulmonary function tests. METHODS Symptomatic patients whom were planned to undergo plication using video-assisted mini-thoracotomy between December 2009 and December 2015 were the cohort of this retrospective study. Single camera port and a utility incision (3-4 cm) were used for access. Data of patient demographics with preoperative and postoperative spirometric results were collected for statistical comparison. RESULTS Procedure (30 left, 7 right) was completed in 37 (27 male, 10 female) patients. One patient was excluded because of insufficient objective postoperative comparison criteria due to previous permanent tracheostomy. Mean length of surgery was 48.8 ± 19.7 (range: 30-70) min. Postoperative overall morbidity was 8.3 %, with no mortality. The mean length of hospital stay was 3.1 ± 1.7 days. All patients except one (97.3 %) were asymptomatic on discharge and on follow-ups. Significant improvement in measurements of forced expiratory volume in 1st second was observed on postoperative measurements (P < 0.001), with a mean overall increase of 13 % in whole cohort. No recurrence was detected throughout a mean follow-up of 19 months. CONCLUSIONS Diaphragmatic plication via video-assisted mini-thoracotomy is an effective and curative surgical procedure which can be performed successfully with low morbidity rates. As it combines the rapidity and economical benefits of open thoracotomy with the advantages of video thoracoscopic procedures such as fast recovery and short postoperative hospital stay, it can be preferred as a safe and effective alternative hybrid method compared to standard open or closed techniques, for symptomatic patients with non-functional hemidiaphragm.
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Kozlov Y, Novozhilov V. Thoracoscopic Plication of the Diaphragm in Infants in the First 3 Months of Life. J Laparoendosc Adv Surg Tech A 2015; 25:342-7. [DOI: 10.1089/lap.2014.0205] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Yury Kozlov
- Department of Neonatal Surgery, Municipal Pediatric Hospital, Irkutsk, Russia
- Department of Pediatric Surgery, Irkutsk State Medical Academy of Continuing Education, Irkutsk, Russia
- Department of Pediatric Surgery, Irkutsk State Medical University, Irkutsk, Russia
| | - Vladimir Novozhilov
- Department of Neonatal Surgery, Municipal Pediatric Hospital, Irkutsk, Russia
- Department of Pediatric Surgery, Irkutsk State Medical Academy of Continuing Education, Irkutsk, Russia
- Department of Pediatric Surgery, Irkutsk State Medical University, Irkutsk, Russia
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9
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Eventration of diaphragm presenting as recurrent respiratory tract infections – A case report. EGYPTIAN JOURNAL OF CHEST DISEASES AND TUBERCULOSIS 2015. [DOI: 10.1016/j.ejcdt.2014.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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10
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Rombolá CA, Genovés Crespo M, Tárraga López PJ, García Jiménez MD, Honguero Martínez AF, León Atance P, Rodríguez Ortega CR, Triviño Ramírez A, Rodríguez Montes JA. Is video-assisted thoracoscopic diaphragmatic plication a widespread technique for diaphragmatic hernia in adults? Review of the literature and results of a national survey. Cir Esp 2014; 92:453-62. [PMID: 24602484 DOI: 10.1016/j.ciresp.2013.12.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2013] [Revised: 12/04/2013] [Accepted: 12/05/2013] [Indexed: 02/01/2023]
Abstract
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.
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Affiliation(s)
- Carlos A Rombolá
- Servicio de Cirugía Torácica, Complejo Hospitalario Universitario de Albacete, Albacete, España.
| | - Marta Genovés Crespo
- Servicio de Cirugía Torácica, Complejo Hospitalario Universitario de Albacete, Albacete, España
| | | | | | | | - Pablo León Atance
- Servicio de Cirugía Torácica, Complejo Hospitalario Universitario de Albacete, Albacete, España
| | | | - Ana Triviño Ramírez
- Servicio de Cirugía Torácica, Complejo Hospitalario Universitario de Albacete, Albacete, España
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Le Pimpec-Barthes F, Pricopi C, Mordant P, Arame A, Badia A, Grand B, Bagan P, Hernigou A, Riquet M. [Diaphragmatic palsy and dysfunction: from physiology to surgery]. REVUE DE PNEUMOLOGIE CLINIQUE 2014; 70:95-107. [PMID: 24566026 DOI: 10.1016/j.pneumo.2013.11.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2013] [Revised: 11/07/2013] [Accepted: 11/07/2013] [Indexed: 06/03/2023]
Abstract
The clinical presentations of diaphragm dysfunctions vary according to etiologies and unilateral or bilateral diseases. Elevation of the hemidiaphragm from peripheral origins, the most frequent situation, requires a surgical treatment only in case of major functional impact. Complete morphological and functional analyses of the neuromuscular chain and respiratory tests allow the best selection of patients to be operated. The surgical procedure may be proposed only when the diaphragm dysfunction is permanent and irreversible. Diaphragm plication for eventration through a short lateral thoracotomy, or sometimes by videothoracoscopy, is the only procedure for retensioning the hemidiaphragm. This leads to a decompression of intrathoracic organs and a repositioning of abdominal organs without effect on the hemidiaphragm active contraction. Morbidity and mortality rates after diaphragm plication are very low, more due to the patient's general condition than to surgery itself. Functional improvements after retensioning for most patients with excellent long-term results validate this procedure for symptomatic patients. In case of bilateral diseases, very few bilateral diaphragm plications have been reported. Some patients with diaphragm paralyses from central origins become permanently dependent on mechanical ventilation whereas their lungs, muscles and nerves are intact. In patients selected by rigorous neuromuscular tests, a phrenic pacing may be proposed to wean them from respirator. Two main indications have been validated: high-level tetraplegia above C3 and congenital alveolar hypoventilation from central origin. After progressive reconditioning of the diaphragm muscles following phrenic pacing at thoracic level, more than 90% of patients can be weaned from respirator within a few weeks. This weaning improves the quality of life with more physiological breathing, restored olfaction, better sleep and better speech. The positive impact of diaphragm stimulation has also been evaluated in other degenerative neurological diseases, particularly the amyotrophic lateral sclerosis. For either central or peripheral diaphragm dysfunctions, a successful surgical treatment lies on a strict preoperative selection of patients.
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Affiliation(s)
- F Le Pimpec-Barthes
- Service de chirurgie thoracique oncologique et générale, transplantation pulmonaire, hôpital européen Georges-Pompidou, université Paris-Descartes, 20, rue Leblanc, 75908 Paris cedex 15, France.
| | - C Pricopi
- Service de chirurgie thoracique oncologique et générale, transplantation pulmonaire, hôpital européen Georges-Pompidou, université Paris-Descartes, 20, rue Leblanc, 75908 Paris cedex 15, France
| | - P Mordant
- Service de chirurgie thoracique oncologique et générale, transplantation pulmonaire, hôpital européen Georges-Pompidou, université Paris-Descartes, 20, rue Leblanc, 75908 Paris cedex 15, France
| | - A Arame
- Service de chirurgie thoracique oncologique et générale, transplantation pulmonaire, hôpital européen Georges-Pompidou, université Paris-Descartes, 20, rue Leblanc, 75908 Paris cedex 15, France
| | - A Badia
- Service de chirurgie thoracique oncologique et générale, transplantation pulmonaire, hôpital européen Georges-Pompidou, université Paris-Descartes, 20, rue Leblanc, 75908 Paris cedex 15, France
| | - B Grand
- Service de chirurgie thoracique oncologique et générale, transplantation pulmonaire, hôpital européen Georges-Pompidou, université Paris-Descartes, 20, rue Leblanc, 75908 Paris cedex 15, France
| | - P Bagan
- Service de chirurgie thoracique oncologique et générale, transplantation pulmonaire, hôpital européen Georges-Pompidou, université Paris-Descartes, 20, rue Leblanc, 75908 Paris cedex 15, France
| | - A Hernigou
- Service de radiologie, hôpital européen Georges-Pompidou, université Paris-Descartes, 75908 Paris cedex 15, France
| | - M Riquet
- Service de chirurgie thoracique oncologique et générale, transplantation pulmonaire, hôpital européen Georges-Pompidou, université Paris-Descartes, 20, rue Leblanc, 75908 Paris cedex 15, France
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Visouli AN, Mpakas A, Zarogoulidis P, Machairiotis N, Stylianaki A, Katsikogiannis N, Tsakiridis K, Courcoutsakis N, Zarogoulidis K. Video assisted thoracoscopic plication of the left hemidiaphragm in symptomatic eventration in adulthood. J Thorac Dis 2013; 4 Suppl 1:6-16. [PMID: 23304437 DOI: 10.3978/j.issn.2072-1439.2012.s001] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2012] [Accepted: 11/22/2012] [Indexed: 11/14/2022]
Abstract
Diaphragmatic eventration is a rare congenital developmental defect of the muscular portion of the diaphragm, which appears attenuated and membranous, maintaining its normal attachments and its anatomical continuity. It has been attributed to abnormal myoblast migration to the septum transversum and the pleuroperitoneal membrane. Eventration can be unilateral or bilateral, partial or complete. It is more common in males, and involves more often the left hemidiaphragm. Eventration results in diaphragmatic elevation (cephalad displacement). Most adults are asymptomatic and the diagnosis is incidentally made by chest radiography. The commonest symptom in the adults is dyspnoea, while orthopnoea, mild hypoxemia, tachypnoea, respiratory alkalosis, palpitations, and non specific gastrointestinal symptoms may be present. Surgery is indicated only in the presence of symptoms. The established surgical treatment is diaphragmatic plication. Various techniques and approaches have been employed. We present a simple surgical technique of a 3-port video assisted thoracoscopic plication of the left hemidiaphragm in the adult.
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Tsakiridis K, Visouli AN, Zarogoulidis P, Machairiotis N, Christofis C, Stylianaki A, Katsikogiannis N, Mpakas A, Courcoutsakis N, Zarogoulidis K. Early hemi-diaphragmatic plication through a video assisted mini-thoracotomy in postcardiotomy phrenic nerve paresis. J Thorac Dis 2013; 4 Suppl 1:56-68. [PMID: 23304442 DOI: 10.3978/j.issn.2072-1439.2012.s007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2012] [Accepted: 11/26/2012] [Indexed: 11/14/2022]
Abstract
New symptom onset of respiratory distress without other cause, and new hemi-diaphragmatic elevation on chest radiography postcardiotomy, are usually adequate for the diagnosis of phrenic nerve paresis. The symptom severity varies (asymptomatic state to severe respiratory failure) depending on the degree of the lesion (paresis vs. paralysis), the laterality (unilateral or bilateral), the age, and the co-morbidity (respiratory, cardiac disease, morbid obesity, etc). Surgical treatment (hemi-diaphragmatic plication) is indicated only in the presence of symptoms. The established surgical treatment is plication of the affected hemidiaphragm which is generally considered safe and effective. Several techniques and approaches are employed for diaphragmatic plication (thoracotomy, video-assisted thoracoscopic surgery, video-assisted mini-thoracotomy, laparoscopic surgery). The timing of surgery depends on the severity and the progression of symptoms. In infants and young children with postcardiotomy phrenic nerve paresis the clinical status is usually severe (failure to wean from mechanical ventilation), and early plication is indicated. Adults with postcardiotomy phrenic nerve paresis usually suffer from chronic dyspnoea, and, in the absence of respiratory distress, conservative treatment is recommended for 6 months -2 years, since improvement is often observed. Nevertheless, earlier surgical treatment may be indicated in non-resolving respiratory failure. We present early (25(th) day postcardiotomy) right hemi-diaphragm plication, through a video assisted mini-thoracotomy in a high risk patient with postcardiotomy phrenic nerve paresis and respiratory distress. Early surgery with minimal surgical trauma, short operative time, minimal blood loss and postoperative pain, led to fast rehabilitation and avoidance of prolonged hospitalization complications. The relevant literature is discussed.
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Affiliation(s)
- Kosmas Tsakiridis
- Cardiothoracic Department, St Luke's Hospital, Panorama, Thessaloniki, Greece
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Takahashi T, Okazaki T, Ochi T, Nishimura K, Lane GJ, Inada E, Yamataka A. Thoracoscopic plication for diaphragmatic eventration in a neonate. Ann Thorac Cardiovasc Surg 2012; 19:243-6. [PMID: 22971706 DOI: 10.5761/atcs.cr.12.01907] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
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.
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Affiliation(s)
- Tsubasa Takahashi
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, Tokyo, Japan.
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15
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Kim DH, Kim KD, Hwang JJ, Choi JH, Lee JW. Thoracoscopic Diaphragmatic Plication Using Three 5 mm Ports. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2010. [DOI: 10.5090/kjtcs.2010.43.5.513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Do Hyung Kim
- Department of Thoracic and Cardiovascular Surgery, Eulji University Hospital
| | - Kil-Dong Kim
- Department of Thoracic and Cardiovascular Surgery, Eulji University Hospital
| | - Jung-Joo Hwang
- Department of Thoracic and Cardiovascular Surgery, Eulji University Hospital
| | - Jin-Ho Choi
- Department of Thoracic and Cardiovascular Surgery, Eulji University Hospital
| | - Jun-Wan Lee
- Department of Thoracic and Cardiovascular Surgery, Eulji University Hospital
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Diaphragm plication for eventration or paralysis: a review of the literature. Ann Thorac Surg 2010; 89:S2146-50. [PMID: 20493999 DOI: 10.1016/j.athoracsur.2010.03.021] [Citation(s) in RCA: 72] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2009] [Revised: 03/01/2010] [Accepted: 03/04/2010] [Indexed: 12/11/2022]
Abstract
Although etiology and pathology of symptomatic diaphragm paralysis and eventration are distinct, their treatments are the same: to reduce dysfunctional caudal excursion of the diaphragm during inspiration by plication. Minimally invasive diaphragm plication techniques have emerged as equally effective and less morbid alternatives to open plication. This review focuses on the etiology, pathophysiology, diagnosis, and treatment of diaphragmatic eventration or paralysis in adults.
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Le Pimpec-Barthes F, Brian E, Vlas C, Gonzalez-Bermejo J, Bagan P, Badia A, Riquet M, Similowski T. [Surgical treatment of diaphragmatic eventrations and paralyses]. Rev Mal Respir 2010; 27:565-78. [PMID: 20610072 DOI: 10.1016/j.rmr.2010.01.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2009] [Accepted: 01/03/2010] [Indexed: 11/26/2022]
Abstract
Surgical treatment of eventration or paralysis of the diaphragm is symptomatic and non curative, and depends on whether the dysfunction is of peripheral or central origin. Elevation of a hemidiaphragm of peripheral origin, the most frequent situation, needs surgical treatment only in case of major functional effects (effort or positional dyspnoea, cardiac or digestive symptoms, or pain) that persists despite optimal conservative management. Selection of candidates for surgery depends on a thorough morphological and functional investigation of the neuromuscular and respiratory components. Surgical plication of the diaphragm through a lateral thoracotomy or by video-thoracoscopy is a recognized, safe and effective procedure. Its low morbidity and mortality, which are mainly associated with co-morbid factors, and its long-lasting functional benefit of around 100%, show that it is an effective procedure. In the case of bilateral dysfunction, occasional cases of bilateral plication have been reported. Some cases of diaphragmatic paralysis of central causation result in a life of ventilator dependence, even though the peripheral neuromuscular and respiratory systems are intact. In selected cases, following a complete functional investigation, phrenic nerve pacing may be attempted to achieve ventilator weaning. To date, there are two validated indications for this technique: Tetraplegia above C3 and alveolar hypoventilation of central cause. After thoracic implantation, a progressive reconditioning of the diaphragmatic muscle allows weaning from the ventilator in a few weeks in more than 90% of patients. Their quality of life is greatly improved thanks to independence from the ventilator, more physiological respiration, restoration of smell and better speech. Whether the diaphragmatic dysfunction is peripheral or central in origin, the success of surgical treatment depends on rigorous preoperative selection of patients.
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Affiliation(s)
- F Le Pimpec-Barthes
- Service de chirurgie thoracique, hôpital européen Georges-Pompidou, AP-HP, 20, rue Leblanc, 75908 Paris cedex 15, France
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18
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Abstract
Symptomatic diaphragmatic eventration is an uncommon condition and is sometimes impossible to distinguish clinically from paralysis. Patients who are asymptomatic require no treatment; patients who are symptomatic benefit significantly from diaphragm plication. The choice of plication approach is dependent upon the expertise of the surgeon.
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Affiliation(s)
- Shawn S Groth
- Department of Surgery, University of Minnesota, MMC 207, 420 Delaware Street, SE, Minneapolis, MN 55455, USA
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19
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Transperitoneal Laparoscopic Surgery Using Endostaplers for Adult Unilateral Diaphragmatic Eventration. Surg Laparosc Endosc Percutan Tech 2009; 19:e46-50. [DOI: 10.1097/sle.0b013e31819ca7ea] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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20
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Bedioui H, Bensafta Z. Volvulus gastrique: diagnostic et prise en charge thérapeutique. Presse Med 2008; 37:e67-76. [PMID: 17587536 DOI: 10.1016/j.lpm.2007.03.043] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2007] [Revised: 02/23/2007] [Accepted: 03/06/2007] [Indexed: 12/16/2022] Open
Abstract
Gastric volvulus is defined as an abnormal rotation of all or part of the stomach around one of its axes. It is a diagnostic emergency and therapeutic challenge because in acute forms it may lead to gastric strangulation with a high risk of ischemia and necrosis. Organoaxial and mesentericoaxial volvulus are distinguished according to the direction of rotation. The most common cause of gastric volvulus is hiatal hernia, but the principal predisposing factor is ligamentous laxity. The diagnosis is suspected when erect chest radiograph images show a high air-fluid level in the chest. Moreover a barium swallow is essential to confirm the diagnosis. Nonetheless, a computed tomography (CT) scan now provides a comprehensive description of the thoracic lesion, including stomach vitality. Gastric volvulus requires surgical treatment, specifically volvulus reduction, reintegration of the stomach into the abdominal cavity in cases of intrathoracic migration, and correction of causal factors. Resection of the hernial sac and the role of gastropexy for preventing recurrence remain controversial. Advances in laparoscopic surgery have made possible a laparoscopic approach to most cases of chronic gastric volvulus.
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Affiliation(s)
- Heykal Bedioui
- Service de chirurgie A, Hôpital La Rabta, Tunis, Tunisie.
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Kim DH, Joo Hwang J, Kim KD. Thoracoscopic diaphragmatic plication using three 5 mm ports☆. Interact Cardiovasc Thorac Surg 2007; 6:280-1. [PMID: 17669842 DOI: 10.1510/icvts.2006.147587] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Thoracoscopic plication is the most effective treatment for diaphragmatic enventration. However, the conventional thoracoscopic plication procedure introduced by Mouroux in 1996 has some disadvantages. We improved and simplified the Mouroux technique with the patient in the head up position, CO(2) insufflations and figure-of-eight sutures. These were possible to perform by pure thoracoscopic surgery using three 5 mm ports without the requirement for open thoracotomy.
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Affiliation(s)
- Do Hyung Kim
- Department of Thoracic and Cardiovascular Surgery, Eulji University Hospital, 1306 Dunsan dong Seo gu Daejeon, Daejeon, Republic of Korea
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22
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Di Giorgio A, Cardini CL, Sammartino P, Sibio S, Naticchioni E. Dual-layer sandwich mesh repair in the treatment of major diaphragmatic eventration in an adult. J Thorac Cardiovasc Surg 2006; 132:187-9. [PMID: 16798335 DOI: 10.1016/j.jtcvs.2006.02.033] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2006] [Accepted: 02/13/2006] [Indexed: 11/21/2022]
Affiliation(s)
- Angelo Di Giorgio
- Dipartimento di Chirurgia Pietro Valdoni, Università degli Studi di Roma La Sapienza, Rome, Italy.
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23
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Freeman RK, Wozniak TC, Fitzgerald EB. Functional and Physiologic Results of Video-Assisted Thoracoscopic Diaphragm Plication in Adult Patients With Unilateral Diaphragm Paralysis. Ann Thorac Surg 2006; 81:1853-7; discussion 1857. [PMID: 16631685 DOI: 10.1016/j.athoracsur.2005.11.068] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2004] [Revised: 11/06/2005] [Accepted: 11/22/2005] [Indexed: 10/24/2022]
Abstract
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.
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Affiliation(s)
- Richard K Freeman
- Department of Thoracic and Cardiovascular Surgery, St. Vincent Hospital, Indianapolis, Indiana, USA.
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Abstract
OBJECTIVE Eventration of the diaphragm (ED) is defined as the abnormal elevation of the diaphragm. Although asymptomatic ED may be amenable to conservative treatment, symptomatic ED in children, either congenital or acquired, may require surgical treatment. This study evaluated the results of diaphragmatic plication in children with unilateral ED. METHODS Fifteen patients who had undergone diaphragmatic plication for ED between 1997 and 2003 were evaluated retrospectively. The diagnosis of ED was established by routine chest radiographs and fluoroscopy. Patients who failed to respond to nonoperative treatment were referred for surgery. Nine patients underwent diaphragmatic fluoroscopy 1-5 years following plication to assess function. RESULTS Indications for diaphragmatic plication were respiratory symptoms such as tachypnoea, dyspnoea, recurrent pneumonia and failure to thrive. In 14 patients, the position of the diaphragm was normal after plication, but the diaphragm was elevated without symptoms in one patient during postoperative follow-up. The motion of the diaphragm was investigated in nine patients. Fluoroscopic studies showed that the operated hemidiaphragm was immobile and there was no paradoxical motion. No return of symptoms was found during follow-up. CONCLUSION ED is the abnormal elevation of the diaphragm as a result of paralysis or aplasia of the muscular fibres. The abnormally elevated diaphragm may compress the ipsilateral lung, and with respiratory effort the mediastinum may shift towards the normal side. Therefore, diaphragmatic plication is performed to restore normal pulmonary parenchymal volume by replacing the diaphragm in its normal location. After plication, there was immediate remission of symptoms in most patients and decreasing symptoms were observed for a year in others. During follow-up, the location of the diaphragm was normal and no paradoxical movement was observed. Relapse of symptoms was not noted in patients with immobile diaphragms.
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Affiliation(s)
- Tugrul Tiryaki
- Pediatric Surgery Clinic, Social Security Institution Ankara Children's Hospital, Ankara, Turkey.
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Mouroux J, Venissac N, Leo F, Alifano M, Guillot F. Surgical treatment of diaphragmatic eventration using video-assisted thoracic surgery: a prospective study. Ann Thorac Surg 2005; 79:308-12. [PMID: 15620964 DOI: 10.1016/j.athoracsur.2004.06.050] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/11/2004] [Indexed: 10/26/2022]
Abstract
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.
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Affiliation(s)
- Jérôme Mouroux
- Service de Chirurgie Thoracique, CHU de Nice, Hôpital Pasteur, Nice, France
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Sato M, Hamada Y, Takada K, Tanano A, Tokuhara K, Hatano T. Thoracoscopic diaphragmatic procedures under artificial pneumothorax. Pediatr Surg Int 2005; 21:34-8. [PMID: 15480708 DOI: 10.1007/s00383-004-1259-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Diaphragmatic plication is technically simple using a conventional operative technique, but it requires a large skin incision and rib injury. We present an alternative technique for thoracoscopic plication of the diaphragm and evaluate the advantages of the procedure. Six patients (five with diaphragmatic eventration and one with diaphragmatic hernia with a sac) ranging in age from 8 to 20 months were treated by this method. Three of the six cases were right-sided, and three were left-sided. The operation was performed under artificial pneumothorax using carbon dioxide gas at 4 mmHg. Three trocars for laparoscopy were inserted at the 4th and 5th intercostal spaces. An adequate operative view was obtained by pressing the diaphragm throughout the operation. The eventrated diaphragm was plicated with several rows of nonabsorbable sutures in the anterolateral-to-posterolateral direction to prevent injury to the main phrenic nerve. A tight diaphragm was confirmed by decompressing the artificial pneumothorax. The technique was successfully performed in all cases, and the patients' postoperative courses were uneventful. During the operation, the hemodynamic effects of carbon dioxide gas at 4 mmHg were minimal. Over a mean follow-up period of 3.1 years (range, 1-6 years), no recurrence of diaphragmatic eventration was seen. Judging from the satisfactory postoperative course, this procedure is suitable for children with all forms of diaphragmatic eventration.
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Affiliation(s)
- Masahito Sato
- Department of Surgery, Otokoyama Hospital, Kansai Medical University, 19 Izumi, Otokoyama, Yawata-city, Kyoto 614-8366, Japan.
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Leo F, Venissac N, Morales F, Rodriguez A, Mouroux J. Plication for Diaphragmatic Eventration. Chest 2004; 125:1170; author reply 1170-1. [PMID: 15006990 DOI: 10.1378/chest.125.3.1170] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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