HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Jeffrey P. Jacobs Redmond P. Burke Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Van Smith, C. Articles by Burke, R. P. Search for Related Content PubMed PubMed Citation Articles by Van Smith, C. Articles by Burke, R. P.

Ann Thorac Surg 1998;65:842-844
© 1998 The Society of Thoracic Surgeons

---

Case Reports

Minimally Invasive Diaphragm Plication in an Infant

Division of Cardiovascular Surgery, Miami Children’s Hospital, Miami, Florida, USA

Accepted for publication October 21, 1997.

Dr Burke, Division of Cardiovascular Surgery, Miami Children’s Hospital, 3200 SW 60th Court, Suite 102, Miami, FL 33155-4069.

	Abstract

Top Abstract Introduction Comment References

 
We report the use of video-assisted thoracic surgery to plicate the diaphragm after phrenic nerve injury associated with an operation for congenital heart disease. Right diaphragm paresis developed in a cyanotic newborn girl with pulmonary atresia and intact ventricular septum after a right modified Blalock-Taussig shunt. Diaphragm plication was performed endoscopically and the patient recovered. Refinement of technique and instrumentation may allow wider application of video-assisted thoracoscopic plication of the diaphragm in neonatal and pediatric patients.

	Introduction

Top Abstract Introduction Comment References

 
Diaphragmatic paralysis secondary to phrenic nerve injury (PNI) can cause life-threatening respiratory distress in infants. Unlike adults, infants are placed at serious risk of complications of PNI due to weak intercostal muscles, a recumbent position, and small airways, which can easily become obstructed [1]. These factors reduce vital capacity and subsequently increase morbidity. Because older children and adults are often able to overcome diaphragmatic paralysis without medical intervention, the actual incidence of PNI may be higher than reported. Since the first published case of PNI in 1901, the majority of reported cases have resulted from birth trauma [2]. The increasing number of cardiothoracic surgical procedures has led to a rise in PNI [3].

Diaphragmatic paralysis is often suspected when prolonged periods of mechanical ventilation are associated with elevation of the hemidiaphragm on chest radiographs. The diagnosis can be confirmed by fluoroscopy or ultrasound. Treatment strategies for diaphragmatic paralysis include extended mechanical ventilation, allowing time for the phrenic nerve to recover, and plication of the diaphragm [4]. Although plication exposes the patient to another operation, it also allows for decreased length of mechanical ventilation and more rapid postoperative recovery. With the advent of video-assisted thoracic surgery (VATS), a minimally invasive procedure could further reduce the risks and complications of the surgical approach. By avoiding the chest wall trauma of classic plication via thoracotomy, an effective minimally invasive diaphragm plication might maximize recovery of respiratory function by minimizing chest wall pain and mechanical dysfunction.

A cyanotic 3-kg newborn girl with pulmonary atresia with intact ventricular septum, severe tricuspid stenosis, hypoplastic right ventricle, patent foramen ovale, patent ductus arteriosus, single left main coronary artery, and right coronary artery arising from left coronary with a fistula to the right ventricle underwent a 3.5-mm right modified Blalock-Taussig shunt. This repair was complicated by paralysis of the right hemidiaphragm resulting in ventilator dependence.

Video-assisted thoracic surgery was used to perform diaphragm plication. Two ports were used. A 4-mm 30-degree angled scope was placed in the midaxillary line above the diaphragm. A retractor was advanced through a posterior trocar to retract the lower lobe superiorly. Under endoscopic guidance, a 2-cm working incision was placed at the level of the diaphragm in the midaxillary line. The ribs were not spread. The paretic diaphragm was invaginated with a straight probe (Fig 1). An intracorporeal suture line was constructed, beginning in the central tendon and suturing toward the lateral chest wall (Fig 2). The suture was anchored at the chest wall, a thoracostomy tube was inserted, and the incisions were closed. The child was extubated on postoperative day 1, the respiratory rate returned to normal, and the patient began feeding and gaining weight. The child later underwent bidirectional cavopulmonary anastomosis at 8 months of age and is currently alive and well 13 months after VATS diaphragm plication.

View larger version (1K): [in this window] [in a new window]   The redundant diaphragm is clearly visualized. The paretic diaphragm is invaginated with a straight probe. An intracorporeal suture line is constructed, beginning in the central tendon.

View larger version (1K): [in this window] [in a new window]   The completed intracorporeal suture line and plicated diaphragm are visualized.

	Comment

Top Abstract Introduction Comment References

The advantages of VATS versus thoracotomy are improved visualization and reduced tissue trauma [8]. This is of special importance in the pediatric population, where size constraints are extreme and immature tissue is susceptible to mechanical injury. In the past, patients were rarely considered for diaphragm plication unless their respiratory dysfunction rendered them ventilator dependent. The minimally invasive nature of the VATS approach may justify earlier surgical repair in patients with failure to thrive due to diaphragm paresis and tachypnea. One constant disadvantage of diaphragm plication has been the inherent trauma associated with a thoracotomy incision. A minimally invasive approach could reduce this morbidity. Rapid plication, performed early in the postoperative course, might result in decreased intensive care unit stay, decreased hospital stay, decreased costs, and a lower risk of infection. The VATS approach also allows the surgeon to inspect the course of the phrenic nerve, identify a potential area of injury, and predict the likelihood of ultimate functional recovery.

With proper training and operative experience, the VATS diaphragmatic plication may offer the surgeon an improved technique for the treatment of PNI as well as diaphragm eventration. As with all emerging minimally invasive procedures, the technique must be validated by rigorous comparison with the established open surgical approach.

	References

Top Abstract Introduction Comment References

 

1. Hong-Xu Z, D’Agostino RS, Pitlick PT, Shumway NE, Miller DC Phrenic nerve injury complicating closed cardiovascular surgical procedures for congenital heart disease. Ann Thorac Surg 1985;39:445-449.[Abstract]
2. Greene W, L’Heureux P, Hunt CE Paralysis of the diaphragm. Am J Dis Child 1975;129:1402-1405.[Abstract/Free Full Text]
3. Shoemaker R, Palmer G, Brown JW, King H Aggressive treatment of acquired phrenic nerve paralysis in infants and small children. Ann Thorac Surg 1981;32:251-259.
4. Mickell JJ, Oh KS, Siewers RD, et al. Clinical implications of postoperative unilateral phrenic nerve paralysis. J Thorac Cardiovasc Surg 1978;76:297-304.[Abstract]
5. Burke RP, Michielon G, Wernovsky G Video-assisted cardioscopy in congenital heart operations. Ann Thorac Surg 1994;58:864-868.[Abstract]
6. Mouroux J, Padovani B, Poirier NC, et al. Technique for the repair of diaphragmatic eventration. Ann Thorac Surg 1996;62:905-907.[Abstract/Free Full Text]
7. Burke RP, Chang AC Video-assisted thoracoscopic division of a vascular ring in an infant: a new operative technique. J Cardiac Surg 1993;8:537-540.[Medline]
8. Burke RP, Wernovsky G, van der Velde M, Hansen D, Castañeda AR Video-assisted thoracoscopic surgery for congenital heart disease. J Thorac Cardiovasc Surg 1995;109:499-508.[Abstract/Free Full Text]

This article has been cited by other articles:

				L. A. Bockeria, A. Kim, D. Ryabtsev, and T. Grygoryants ICVTS on-line discussion A Diaphragmatic plication as a complication in cardiac surgery Interactive CardioVascular and Thoracic Surgery, June 1, 2007; 6(3): 282 - 282. [Full Text] [PDF]

				R. K. Freeman, T. C. Wozniak, and E. B. Fitzgerald Functional and physiologic results of video-assisted thoracoscopic diaphragm plication in adult patients with unilateral diaphragm paralysis. Ann. Thorac. Surg., May 1, 2006; 81(5): 1853 - 1857. [Abstract] [Full Text] [PDF]

				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]

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

				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]

				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]

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Jeffrey P. Jacobs Redmond P. Burke Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Van Smith, C. Articles by Burke, R. P. Search for Related Content PubMed PubMed Citation Articles by Van Smith, C. Articles by Burke, R. P.