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Ann Thorac Surg 1999;68:2364-2365
© 1999 The Society of Thoracic Surgeons

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How to Do It

Mini-thoracotomy for diaphragmatic plication with thoracoscopic assistance

^a Department of Cardiothoracic Surgery, Westmead Hospital, Sydney, Australia

Address reprint requests to Dr Paterson, Department of Cardiothoracic Surgery, Westmead Hospital, Hawkesbury Rd, Westmead, NSW 2145, Australia

	Abstract

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We describe a technique of mini-thoracotomy to plicate the paralyzed hemidiaphragm with thoracoscopic assistance. Most of the hemidiaphragm can be plicated expeditiously under direct vision with light derived from a posterior thoracoscope placed in the auscultatory triangle. Videoscopic vision is employed only occasionally when the view of the posteromedial hemidiaphragm is obscured. Continuous suture traction can be easily applied through the mini-thoracotomy, thus maintaining suture tension and enabling maximal inversion of the elevated hemidiaphragm.

	Introduction

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In adults, left phrenic nerve paralysis has been associated with the use of ice slush for topical hypothermia and internal mammary artery harvest [1]. The right phrenic nerve is at risk of injury during high mobilization of the right internal thoracic artery, in redo heart surgery and in heart procedures performed through a right thoracotomy. Whereas left phrenic nerve palsy usually results in minimal morbidity, right phrenic nerve palsy is more likely to be symptomatic with respiratory dysfunction.

Plication of the paralyzed hemidiaphragm may alleviate the symptom of dyspnea by reducing paradoxical movement of the hemidiaphragm [2]. In this report, we describe a technique of mini-thoracotomy to plicate the paralyzed hemidiaphragm with thoracoscopic assistance.

	Technique

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The lungs are isolated with a double-lumen endotracheal tube. The patient is positioned in the lateral decubitus position. The xiphoid process marks the level of the dome of the diaphragm, which serves as a guide for the lateral thoracotomy skin incision. A 7-cm lateral skin incision for the miniature lateral thoracotomy is made at the level of the xiphoid process posterior to the nipple (Fig 1). The pleural cavity is entered in the intercostal space directly in line with the skin incision and the lung is deflated. A small chest retractor such as the Tuffier retractor (Kaisers Surgical Instruments, Perth, W.A., Australia) is inserted in the intercostal space. The elevated hemidiaphragm is directly visible through the lateral thoracotomy placed at the level of the xiphoid process. Pleural adhesions to the diaphragm are divided if present. A 10-mm port is inserted through the auscultatory triangle (Fig 1) and a 0-degree scope is introduced into the posterior pleural cavity.

View larger version (27K): [in this window] [in a new window]   Fig 1. The patient is positioned in the lateral decubitus position. The incision for the miniature lateral thoracotomy is placed at the level of the xiphoid process posterior to the nipple. The posterior thoracoscope is inserted through the auscultatory triangle.

The diaphragm is progressively inverted with successive rows of continuous monofilament suture (1-Nylon, Ethicon Inc, Somerville, NJ), running back and forth between the anterolateral costophrenic recess near the anterior end of the thoracotomy and the posteromedial costophrenic recess. During plication, the surgical assistant maintains suture tension by applying continuous suture traction through the mini-thoracotomy, ensuring that the plicated diaphragm is rendered taut. Plication of the hemidiaphragm is deemed complete when the dome of the diaphragm has been flattened under maximum tension. A prophylactic intercostal drain is inserted and the wound is closed.

	Comment

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The majority of adult patients with symptomatic phrenic nerve palsy after cardiac operations will experience some clinical improvement either due to return of diaphragmatic function [3] or recruitment of other inspiratory muscles. For the symptomatic adult with disabling and persistent dyspnea, plication of the hemidiaphragm can provide subjective and objective improvement in respiratory function [4].

Plication of the hemidiaphragm has been performed traditionally through the bed of the eighth rib or eighth intercostal space [5]. Using our technique of thoracoscopic assistance, operative repair can be accomplished under direct vision through a mini-thoracotomy with the attendant benefits of reduced analgesic requirements, cosmesis, and maximal preservation of intercostal muscles for respiration in the absence of diaphragmatic function. Purely thoracoscopic techniques for diaphragmatic plication have been reported, but they can be technically difficult [6]. With a mini-thoracotomy and thoracoscopic lighting, most of the diaphragm can be viewed directly with ease, plication can be performed expeditiously using three-dimensional vision, and diaphragmatic suture tension can be maintained by direct traction through the wound. Videoscopic vision is employed only occasionally when the view of the posterior diaphragm is obscured.

The technique of mini-thoracotomy for diaphragmatic plication with thoracoscopic assistance combines the advantages of both the open procedure and thoracoscopy. We used this technique between August 1996 and August 1998 in 5 patients with symptomatic phrenic nerve paralysis. Good symptomatic relief was achieved in all patients. The postoperative chest roentgenogram showed a flattened diaphragm, confirming successful plication (Figs 2A, 2B). There was minimal operative morbidity and no mortality. Chest drains were removed on the first postoperative day and the mean postoperative hospital stay was 4 days. Epidural analgesia was not used and the mean operative time was 55 minutes. We recommend that the technique of mini-thoracotomy for diaphragmatic plication with thoracoscopic assistance should be considered as an alternative to either conventional open or thoracoscopic repair for management of the paralyzed hemidiaphragm.

View larger version (92K): [in this window] [in a new window]   Fig 2. (A) Chest roentgenogram showing elevation of the right hemidiaphragm as a result of right phrenic nerve palsy. (B) Postoperative chest roentgenogram showing flattening of the previously elevated hemidiaphragm, thus demonstrating adequate plication of the paralyzed hemidiaphragm.

	References

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1. Curtis J.J., Nawarawong W., Walls J.T., et al. Elevated hemidiaphragm after cardiac operations. Ann Thorac Surg 1989;48:764-768.[Abstract]
2. Schwartz M.Z., Filler R.M. Plication of the diaphragm for symptomatic phrenic nerve paralysis. J Pediatr Surg 1978;13:259-263.[Medline]
3. Fackler C.D., Perret G.E., Bedell G.N. Effect of unilateral phrenic nerve section on lung function. J Appl Physiol 1967;23:923-926.[Free Full Text]
4. Graham D.R., Kaplan D., Evans C.C., Hind C.R., Donnelly R.J. Diaphragmatic plication for unilateral diaphragmatic paralysis. Ann Thorac Surg 1990;49:248-251.[Abstract]
5. Shields T.W. Diaphragmatic function, diaphragmatic paralysis and eventration of the diaphragm. In: Shields T.W., ed. General thoracic surgery. Philadelphia: William and Wilkins, 1994:607-611.
6. Mouroux J., Padovani B., Poirier N.C., et al. Technique for the repair of diaphragmatic eventration. Ann Thorac Surg 1996;62:905-907.[Abstract/Free Full Text]

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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): David T.M. Lai Hugh S. Paterson Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Lai, D. T.M. Articles by Paterson, H. S. Search for Related Content PubMed PubMed Citation Articles by Lai, D. T.M. Articles by Paterson, H. S.