ATS
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

This Article
Right arrow Abstract Freely available
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Jérôme Mouroux
Nancy Claire Poirier
Jean Deslauriers
Henri Richelme
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Mouroux, J.
Right arrow Articles by Richelme, H.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Mouroux, J.
Right arrow Articles by Richelme, H.

Ann Thorac Surg 1996;62:905-907
© 1996 The Society of Thoracic Surgeons

How To Do It

Technique for the Repair of Diaphragmatic Eventration

Jérôme Mouroux, MD, Bernard Padovani, MD, Nancy Claire Poirier, MD, Daniel Benchimol, MD, André Bourgeon, MD, Jean Deslauriers, MD, Henri Richelme, MD

Département de Chirurgie Thoracique, Hôpital Pasteur, Nice, France

Accepted for publication May 23, 1996.


   Abstract
Top
 Footnotes
 Abstract
Introduction
 Patients and Technique
 Results
 Comment
 References
 
In contrast to the large thoracotomy incisions required by standard surgical techniques for repair of diaphragmatic eventration, the procedure we developed can be performed by video-assisted thoracoscopy, thus offering patients the advantages of a minimally invasive operation. Using two superposed series of transverse back-and-forth continuous sutures, the diaphragm is invaginated, then stretched. The first suture line holds the diaphragm down and maintains the excess within the abdomen; the second suture line places the desired tension on the diaphragmatic dome. Successful repair of 3 cases by this technique is described.


   Introduction
Top
 Footnotes
 Abstract
 Introduction
Patients and Technique
 Results
 Comment
 References
 
Routine surgical techniques for repair of diaphragmatic eventration can be classed in two categories-phrenoplicature and incision followed by double breast suture [1]-both of which require full thoracotomy. The technique we have developed has the advantage of being compatible with video-assisted thoracic surgery. The diaphragm is invaginated then stitched using two superposed transverse continuous sutures. The first suture line holds the diaphragm down and maintains the excess within the abdomen, and the second suture line complete the repair by placing the desired tension on the diaphragmatic dome. We describe the successful repair of our first 3 cases of diaphragmatic eventration using this technique.


   Patients and Technique
Top
 Footnotes
 Abstract
 Introduction
 Patients and Technique
Results
 Comment
 References
 
Since 1992, three patients (2 men and 1 woman) aged 33, 63, and 68 years were treated in our institution (Département de Chirurgie Thoracique, Hôpital Pasteur, Nice, France) using this repair of diaphragmatic eventration. All were victims of a severe chest trauma (1 automobile accident, 1 fall down a flight of stairs, and 1 fall) that had occurred 2, 6, and 11 years earlier. Eventration occurred on the left side in all 3 patients. All patients presented dyspnea, 1 patient had epigastric pain, and another patient had recurrent palpitations. Pulmonary function tests were abnormal in all 3 patients (Table 1Go). Diaphragmatic mobility was less than one intercostal space at fluoroscopy.


View this table:
[in this window]
[in a new window]
  		Table 1. . Pulmonary Function Tests
 
The procedure was performed under general anesthesia with selective tracheobronchial intubation allowing pulmonary ventilatory exclusion. The stomach drained with a nasogastric tube. The patient was placed in the lateral decubitus position, with the surgeon standing behind. A 10-mm port (port 1) was placed in the fifth intercostal space on the postaxillary line used to introduce the optical unit (Fig 1Go). A second port (port 2) was placed on the mammary line in the fifth intercostal space. Finally, a minithoracotomy (5 cm) was performed in the ninth or tenth intercostal space on the posterior axillary line.



View larger version (81K):
[in this window]
[in a new window]
  		Fig 1. . (A) Position of the two thoracoscopic ports: PORT 1 for the thoracoscope and PORT 2, site of insertion of the forceps used to grasp the apex of the eventration. A minithoracotomy is made over the ninth intercostal space (ics) for the suturing of the diaphragm. (B) With the use of a Duval forceps, the apex of the eventration is pushed down toward the abdomen. (C) The created transverse fold of diaphragm is sutured with nonabsorbable material. (D) Completed operation.

 
A endoscopic Duval forceps introduced through port 2 was used to grasp and push the apex of the eventration down into the abdomen. The invagination created a transverse fold from the minithoracotomy to the cardiophrenic angle behind the phrenic nerve. This fold was closed by a first suture line of nonresorbable material beginning at the periphery of the diaphragm closest to the minithoracotomy. The first stitch was knotted, with the free end held with a forceps. A superficial continuous suture was performed to avoid injury to the subdiaphragmatic organs. Once at the cardiophrenic angle, the sutures were drawn tight while the Duval forceps used to push the diaphragm downward was removed. A row of return stitches was made along the same axis and the suture tied with the free end of the first knot. During placement of these return stitches, the suture material was kept taut by the assistant using a forceps introduced through port 2. The tension applied in this manner facilitated grasping of the edges of the fold to be sutured. A second back-and-forth series of continuous sutures was made in the same fashion, burying the first series of suture lines and applying the desired tension on the repaired diaphragm. At the end of the procedure, a 28F Charrière chest tube is inserted through port 2 and connected to an aspiration system. The other incisions were closed.


   Results
Top
 Footnotes
 Abstract
 Introduction
 Patients and Technique
 Results
Comment
 References
 
There were no operative incidents. Breathing exercises were started the day after operation, and the chest tube was removed after 3 to 5 days. Pneumonia of the lower right lobe developed in 1 patient but responded to antibiotics. The duration of hospitalization was 6, 7, and 12 days, respectively. The diaphragm remained in anatomic position on the chest roentgenograms at discharge. At long-term follow-up all 3 patients were asymptomatic and had improved pulmonary function (see Table 1Go). No recurrences have been observed radiologically 17, 20, and 30 months, respectively, after the procedure (Fig 2Go).



View larger version (16K):
[in this window]
[in a new window]
  		Fig 2. . (A) Chest radiograph of left eventration before intervention. (B) Chest radiograph in the same patient 3 months after the operation.

 

   Comment
Top
 Footnotes
 Abstract
 Introduction
 Patients and Technique
 Results
 Comment
References
 
The indications and methods for surgical repair of diaphragmatic eventration have been the subject of many reports [1–4]. With the advent of minimally invasive surgery, repair of this functional pathology by a large thoracotomy incision appears anachronistic. This can be explained by the fact that most common techniques require wide exposure. The technique we propose has the merit of being compatible with video-assisted thoracic surgery, which limits the aesthetic impact and facilitates respiratory reeducation [5].

Several technical points merit mention. Invagination of the eventration must create two transverse edges so that the suture lines are located at approximately the same distance from the anterolateral and posterolateral diaphragmatic insertions. The position and the orientation of the forceps inserted through port 2, which is used to grasp the apex of the eventration, are thus very important. The overall view of the diaphragm afforded by the optical unit introduced through port 1 is thus particularly helpful. The thoracotomy incision must be made near the diaphragmatic insertions; otherwise, it can be difficult to start suturing. The ninth or tenth intercostal spaces are the most suitable sites.

Use of continuous stitches, which best distribute the tension on the suture line, allows fine stitches on the edges of the tissues and avoids injury to intraperitoneal organs. The tension obtained with the second suture line appears adequate both intraoperatively and on radiographs (see Fig 2Go). A third suture line might conceivably be needed and is technically feasible.

Two situations contraindicate use of this technique: the existence of extensive pleuropulmonary adhesions and the need to reinforce the diaphragm with a synthetic material. These situations are rarely predictable preoperatively. The level and the extent of the thoracotomy incision and the best technique for diaphragmatic repair can only be decided after exploration through port 1 and, if necessary, through port 2.

Despite our limited follow-up with this technique, preliminary clinical, radiologic, and functional results are promising. Additional prospective studies are nevertheless required to compare the procedure with traditional techniques for repair of diaphragmatic eventration.


   Footnotes
Top
 Footnotes
Abstract
 Introduction
 Patients and Technique
 Results
 Comment
 References
 
Address reprint requests to Dr Mouroux, Service de Chirurgie Thoracique, Hôpital Pasteur, 30, av de la Voie Romaine, BP 69, 06002 Nice Cedex 1, France.


   References
Top
 Footnotes
 Abstract
 Introduction
 Patients and Technique
 Results
 Comment
 References
 

  1. Dor J, Richelme H, Aubert J, Boyer R. L'éventration diaphragmatique. J Chir 1969;97:399–432.
  2. Chin EF, Lynn RB. Surgery of eventration of the diaphragm. J Thorac Surg 1956;32:6–14.
  3. McNamara JJ, Paulson DL, Urschel HC, Razzuk MA. Eventration of diaphragm. Surgery 1968;64:1013–21.[Medline]
  4. Ribet M, Linder JL. Plication of the diaphragm for eventration or paralysis. Eur J Cardiothorac Surg 1992;6:357–60.[Abstract]
  5. Miller JI Jr. Therapeutic thoracoscopy: new horizons for an established procedure. Ann Thorac Surg 1991;52:1036–7.[Medline]



This article has been cited by other articles:


Home page
 ICVTSHome page
D. H. Kim, J. Joo Hwang, and K. D. Kim
Thoracoscopic diaphragmatic plication using three 5 mm ports
Interactive CardioVascular and Thoracic Surgery, June 1, 2007; 6(3): 280 - 281.
[Abstract] [Full Text] [PDF]

Home page
 J. Thorac. Cardiovasc. Surg.Home page
A. Di Giorgio, C. L. Cardini, P. Sammartino, S. Sibio, and E. Naticchioni
Dual-layer sandwich mesh repair in the treatment of major diaphragmatic eventration in an adult
J. Thorac. Cardiovasc. Surg., July 1, 2006; 132(1): 187 - 189.
[Full Text] [PDF]

Home page
 Ann. Thorac. Surg.Home page
J. Mouroux, N. Venissac, F. Leo, M. Alifano, and F. Guillot
Surgical Treatment of Diaphragmatic Eventration Using Video-Assisted Thoracic Surgery: A Prospective Study
Ann. Thorac. Surg., January 1, 2005; 79(1): 308 - 312.
[Abstract] [Full Text] [PDF]

Home page
 ChestHome page
F. Leo, N. Venissac, F. Morales, A. Rodriguez, J. Mouroux, and J. S. Shin
Plication for Diaphragmatic Eventration: A Simple Technique, Not a Simple Problem
Chest, March 1, 2004; 125(3): 1170 - 1171.
[Full Text] [PDF]

Home page
 Ann. Thorac. Surg.Home page
Y. Deng, K. Byth, and H. S. Paterson
Phrenic nerve injury associated with high free right internal mammary artery harvesting
Ann. Thorac. Surg., August 1, 2003; 76(2): 459 - 463.
[Abstract] [Full Text] [PDF]

Home page
 Ann. Thorac. Surg.Home page
M. H. Hines
Video-assisted diaphragm plication in children
Ann. Thorac. Surg., July 1, 2003; 76(1): 234 - 236.
[Abstract] [Full Text] [PDF]

Home page
 ChestHome page
Z. Hwang, J. S. Shin, Y. H. Cho, K. Sun, and I. S. Lee
A Simple Technique for the Thoracoscopic Plication of the Diaphragm
Chest, July 1, 2003; 124(1): 376 - 378.
[Abstract] [Full Text] [PDF]

Home page
 Arch SurgHome page
C. L. Leslie
Image of the Month
Arch Surg, October 1, 2001; 136(10): 1211 - 1212.
[Full Text] [PDF]

Home page
 Ann. Thorac. Surg.Home page
S.-W. Moon, Y.-P. Wang, Y.-W. Kim, S.-B. Shim, and W. Jin
Thoracoscopic plication of diaphragmatic eventration using endostaplers
Ann. Thorac. Surg., July 1, 2000; 70(1): 299 - 300.
[Abstract] [Full Text] [PDF]

Home page
 Asian Cardiovasc. Thorac. Ann.Home page
L. R. Sajja, A. Farooqi, R. B. Yarlagadda, M. S. Shaik, L. R. Sajja, A. Farooqi, R. B. Yarlagadda, and M. S. Shaik
Surgical Management of Eventration of Diaphragm in an Elderly Patient
Asian Cardiovasc Thorac Ann, June 1, 2000; 8(2): 180 - 182.
[Abstract] [Full Text] [PDF]

Home page
 Ann. Thorac. Surg.Home page
D. T.M. Lai and H. S. Paterson
Mini-thoracotomy for diaphragmatic plication with thoracoscopic assistance
Ann. Thorac. Surg., December 1, 1999; 68(6): 2364 - 2365.
[Abstract] [Full Text] [PDF]

Home page
 Ann. Thorac. Surg.Home page
C. Van Smith, J. P. Jacobs, and R. P. Burke
Minimally Invasive Diaphragm Plication in an Infant
Ann. Thorac. Surg., March 1, 1998; 65(3): 842 - 844.
[Abstract] [Full Text] [PDF]

This Article
Right arrow Abstract Freely available
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Jérôme Mouroux
Nancy Claire Poirier
Jean Deslauriers
Henri Richelme
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Mouroux, J.
Right arrow Articles by Richelme, H.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Mouroux, J.
Right arrow Articles by Richelme, H.

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
ANN THORAC SURG ASIAN CARDIOVASC THORAC ANN EUR J CARDIOTHORAC SURG
J THORAC CARDIOVASC SURG ICVTS ALL CTSNet JOURNALS