Video assisted thoracoscopic plication of the left hemidiaphragm in symptomatic eventration in adulthood

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

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

Comparison of short-term outcomes of video-assisted thoracoscopic (VATS) plication of diaphragmatic eventration - a six-year prospective cohort study

Diaphragmatic eventration is one of the rarest conditions characterized by elevation of the hemidiaphragm while maintaining its normal attachments. In recent years, video-assisted thoracoscopic surgery (VATS) has gained popularity for diaphragmatic surgery. In this study, we share our experience over six years with VATS plication of diaphragmatic eventration. We conducted a prospective study at our institute for six years from April 2016 to March 2021, which included 37 symptomatic patients with diaphragmatic eventration. The sample size reported in this study is one of the largest to date for VATS diaphragmatic plication. Of these, 18 patients underwent combined stapler and suture plication, and 19 patients underwent single modality approach (10-stapled resection, 9-suture alone plication). All patients were followed-up for a minimum of 2 years. Comparative analysis of the combined approach and the single modality approach was performed. The mean operative time was significantly longer with the combined approach (p value < 0.01). However, there was no difference in postoperative pain (p value = 0.50), analgesia requirement (p value = 0.72), or pleural drainage (p value = 0.32) between the two approaches. Although not statistically significant, the combined approach had fewer post-operative complications (p value = 0.32). Besides, the Single modality approach resulted in one recurrence (p value = 0.32) and one mortality (p value = 0.32). VATS diaphragmatic plication using staplers and/or sutures is safe and efficacious in the management of diaphragmatic eventration. Surgeons should consider using both staplers and sutures whenever possible, rather than selecting one over the other.

Successful treatment of phrenic nerve injury with diaphragmatic plication 5 years after onset: A case report

Diaphragmatic paralysis due to phrenic nerve injury is an occasional complication of cardiothoracic surgery. Although diaphragmatic plication is widely used to treat patients with severe irreversible symptoms, its surgical indication and timing remain controversial. Here, we present a rare case of diaphragmatic paralysis in a 65-year-old woman who underwent cardiac surgery and whose respiratory symptoms worsened despite >5 years of conservative management. Consequently, she underwent diaphragmatic plication using an endostapler to resect the redundant diaphragm, followed by over-suturing of all staple lines. She was discharged without any complications and her symptoms and chest radiography and spirometry results improved postoperatively.

Heart on the left, diaphragm on the right: A case of congenital diaphragmatic eventration

Congenital Diaphragmatic Eventration (DE) requires a prompt diagnosis to avert the potentially life-threatening complications. Herein, a 5-month-old male presented with recurrent respiratory infections due to a right-sided diaphragmatic eventration. Misdiagnosed from previous medical visits, timely surgical intervention by thoracoscopic plication of the diaphragm was crucial for our patient's survival.

Case report of eventration of diaphragm due to an unknown febrile illness causing phrenic nerve palsy and other multiple nerve palsies

INTRODUCTION

Diaphragmatic eventration can be congenital or acquired. Diagnosis is delayed due to no symptoms or very mild ones and is generally done by imaging modalities. This condition is managed by plication of the affected part of diaphragm by various surgical approaches.

PRESENTATION OF CASE

A forty seven years lady presented with one year long history of abdominal pain, bloating and fullness after meals who was being treated in line of peptic acid disorder. She had developed bilateral foot drop after typhoid fever at seventeen years of age. Clinical examination and imaging with chest x-ray, chest ultrasound and computed tomography scan suggested eventration of left hemidiaphragm. Plication of eventration of left hemidiaphragm was done via mini thoracotomy of the left thorax. There were no postoperative complications and she was discharged on the sixth postoperative day.

DISCUSSION

Acquired eventration of diaphragm is commonly due to traumatic phrenic nerve palsy but rarely can be associated with a history of infection causing nerve palsies. Thoracic ultrasound is an emerging modality for diagnosis supporting X-rays and CT Scans. Plication of eventration with minimally invasive techniques has less number of hospital stay and less pain compared to open approaches.

CONCLUSION

Non-traumatic diaphragmatic eventration due to acquired phrenic nerve palsy following an unknown febrile illness is a rare case to be reported in Nepal. The aim of treatment is expansion of intra-thoracic space which is done by plication of the diaphragm.

Isolated traumatic phrenic nerve injury treated with video-assisted thoracoscopic diaphragmatic plication-a case report

Isolated traumatic phrenic nerve injury resulting from a stab wound to the neck is very rare. Herein, we report the case of a patient who was accidentally stabbed with garden shears that pierced her neck and penetrated the spinal canal. She sustained a right phrenic nerve injury complicated by diaphragm palsy and subsequent respiratory distress. We successfully treated the patient with video-assisted thoracoscopic diaphragm plication.

Congenital unilateral diaphragmatic eventration in an adult: A rare case presentation

We present a rare case of 32year old female with congenital diaphragmatic eventeration female presenting in an adult. She had symptoms of intermittent dyspnea and occasional epigastric discomfort. Patient had no previous history of trauma. Physical examination showed bowel sound involving the left hemithorax. Imaging modalities confirmed the diagnosis of a congenital left diaphragmatic eventeration. Patient underwent plication of the diaphragm using the abdominal approach. Intra-operatively, the left diaphragm was attenuated. Plication was done with 1st layer of imbricating silk heavy sutures buttressed by a second layer of interrupted absorbable sutures. She post-operatively had atelectasis on the left lung. Incentive spirometry and deep breathing exercises were started with resolution of the atelectasis after 1 week post-operatively. Patient had an unremarkable post-operative stay with resolution of symptoms. There are reports that diaphragmatic eventration diagnosed even as late 70 years old, highlighting the dogma that this is an asymptomatic disorder does not need all the time surgical therapy. But we still recommend surgical therapy as soon as diagnosis is confirmed. In this patient, there was no recurrence of symptoms after a follow-up of 2 years. Whether surgery indeed improved lung functions in these vastly asymptomatic patients, these questions could be an active area of research in the long term outcomes of these patients.

Complete eventration of right hemidiaphragm: A rare presentation

Eventration of the diaphragm is a term used to describe an abnormal elevation of part or whole of the hemidiaphragm, where the whole or part of the diaphragm is made up of a thin fibro membranous sheet replacing normal diaphragmatic musculature. Complete and partial eventration both can occur, however, complete eventration of the right hemidiaphragm in an adult female, as presented in this patient, is rarely seen.

Surgical Outcomes of Pneumatic Compression Using Carbon Dioxide Gas in Thoracoscopic Diaphragmatic Plication

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.

Video-assisted minimally invasive diaphragmatic plication: feasibility of a recognized procedure through an uncharacteristic hybrid approach

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.

Left Sided Hydro-pneumothorax in a Operated Case of Left Diaphragmatic Hernia Repair: A Diagnostic Dilemma

Diaphragmatic hernia in adults often presents with overlapping respiratory and abdominal symptoms. They may be simple diaphragmatic eventrations or undiagnosed Bochdalek's hernias or may even be of post traumatic variety. Diaphragmatic hernias may be asymptomatic, present only with respiratory symptoms, or may present with obstruction and strangulation of involved bowel loops with faeco-pneumothorax. The index case was operated for open diaphragmatic hernia repair six years back and admitted for breathlessness with absence of abdominal signs and symptoms. Patient subsequently developed hydro-pneumothorax during conservative management. Emergency laparotomy revealed a gastric ulcer which perforated into the left chest giving rise to hydro-pneumothorax. In present study we would like to report how this unusual presentation led to dilemma in diagnosis and surgical intervention thus increasing the morbidity and mortality of the patient at our institute.