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Ann Thorac Surg 2000;70:299-300
© 2000 The Society of Thoracic Surgeons

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Case report

Thoracoscopic plication of diaphragmatic eventration using endostaplers

^a Department of Thoracic and Cardiovascular Surgery, College of Medicine, The Catholic University of Korea, Seoul, South Korea

Address reprint requests to Dr Moon, Department of Thoracic and Cardiovascular Surgery, Kang Nam St. Mary Hospital, 505 Banpo-Dong, Socho-Ku, Seoul 137-040, Republic of Korea
e-mail: swmoon{at}cmc.cuk.ac.kr

	Abstract

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Unilateral diaphragmatic eventration and paralysis require plication in cases of progressive dyspnea on exertion and recurrent respiratory infection. The patient, a 40-year-old woman, who had complained of worsening dyspnea on exertion and elevation of the left diaphragm on chest radiographs for 4 years, underwent plication by thoracoscopy with knifeless endostaplers. Improvements in pulmonary functions and dyspnea on exertion have been maintained for 14 months.

	Introduction

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Unilateral diaphragmatic eventration (UDE) and paralysis are not uncommon following head and neck operation or cardiovascular operation due to trauma to the phrenic nerve, and are also caused by motor neuron diseases, malignant tumors, and calcific tuberculous lymph nodes. Most patients affected are usually asymptomatic, but patients with significant pulmonary dysfunction or extremely high positioned diaphragms may be symptomatic and require plication of a UDE [1]. We performed thoracoscopic plication as a new method of minimally invasive operation for the patient with UDE.

A 40-year-old woman with dyspnea on exertion was referred to our clinic. Four years before, she had undergone laparotomy for appendicitis and did not hear about the abnormality on her chest radiograph and was asymptomatic at that time. Preoperative chest radiographs showed a high position of the left diaphragm and displacement of the heart (Fig 1A). Computed tomography of the neck and mediastinum did not show any possible organic lesions compressing the phrenic nerve. We provided the patient with thorough information on the procedures and received her informed consent. She underwent a thoracoscopic plication of diaphragm. Before she was taken to the operating room, we tried to perform a pneumoperitoneum to confirm whether there was adhesion between the left diaphragm and intraabdominal organs. However, the pneumoperitoneum failed because of the previous laparotomy for appendicitis. The stomach drained with a nasogastric tube. The procedure was performed under one lung anesthesia with a Univent (Phygon Univent Fuji Systems, Tokyo, Japan) to allow selective right lung ventilation. The patient was placed in the right lateral decubitus position. The patient was positioned head-up to displace the intraabdominal organs downward for an excellent view and easy manipulation of diaphragm. A 7-mm thoracoport for the thoracoscope was placed in the seventh intercostal space at the midaxillary line. Each of two 5-mm thoracoports in the eighth and ninth intercostal space at the posterior axillary line was inserted for lung and diaphragm manipulation. With the introduction of a 7-mm, 25-degree, rigid thoracoscope (Richard Wolf Medical Instruments, Rosemade, IL) and an endograsper, thoracoscopic exploring was carried out around the entire thoracic cavity and the course of the left phrenic nerve. The membrane-like diaphragm was easily extended upon being gripped with an endoscopic grasper, which meant no adhesion between the diaphragm and intraabdominal organs. An 11.5-mm fourth thoracoport for the introduction of endoscopic linear staplers was made in the tenth intercostal space on the anterior axillary line. While a portion of the redundant diaphragm was pulled and rolled with an endograsper and kept drawn tight, it was plicated with a knifeless endoscopic linear stapler (Multifire Endo GIA 35, Auto Suture, United States Surgical Corp, Norwalk, CT) with the redundant diaphragm left, not resected. After repeating five times the abovementioned procedure, we could palpate the desired tension on the repaired diaphragm without any redundancy. The chest tube was inserted through one of the thoracoports. The patient has tolerated exercise well with improvements in pulmonary functions (forced vital capacity, from 1.9 to 2.7 L; forced expiratory volume in 1 second, from 1.82 to 2.3 L/s; maximum voluntary ventilation, from 91 to 109 L/min) and normalization of the left diaphragm on chest radiographs (Fig 1B) for 14 months after the procedure.

View larger version (87K): [in this window] [in a new window]   Fig 1. Findings of preoperative (A) and postoperative (B) chest radiographs. The left diaphragm was markedly elevated before plication, but has maintained the normalization in its position for 14 months after plication.

	Comment

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Recently, there have been reports that thoracoscopy is effective in diagnosis and treatment for patients with diaphragmatic disorders [2, 3]. Thoracoscopic or minimally invasive operation for UDE, although relatively new and encouraging, may be an acceptable alternative to the conventional operative technique because it provides lower rates of morbidity. Also there are reports regarding plication of the diaphragmatic eventration with one or two rows of running sutures using thoracoscopy-assisted minithoracotomy ranging from 2 to 10 cm [3–6].

Our new technique shows that multiple plications can be performed for an even and tense diaphragm without thoracotomy. In this procedure, there are several technical considerations: first, the patient is head up about 30 degrees to displace abdominal organs downward for better view and easy manipulation. It is necessary that there be neither pleural adhesion nor subphrenic adhesion, which contraindicate thoracoscopic operation. Another prerequirement is the full relaxation of the abdominal wall and complete drainage of the stomach for better exposure of diaphragm.

However, because we have had no longer-term follow-up than 14 months to ascertain the ultimate integrity of the repaired diaphragm, our technique warrants further investigation to determine the cost-effectiveness and the safety of this approach.

	References

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1. Ribet M., Linder J.L. Plication of the diaphragm for unilateral eventration or paralysis. Eur J Cardiothorac Surg 1992;6:357-360.[Abstract]
2. Yamashita J.I., Iwasaki A., Kawahara K., Shirakusa T. Thoracoscopic approach to the diagnosis and treatment of diaphragmatic disorders. Surg Laparosc Endosc 1996;6:485-488.[Medline]
3. Symbus P., Hatcher C., Waldo W. Diaphragmatic eventration in infancy and childhood. Ann Thorac Surg 1997;24:113-119.[Abstract]
4. Suzumura Y., Terada Y., Sonobe M., Nagasawa M., Shindo T., Kitano M. A case of unilateral diaphragmatic eventration treated by plication with thoracoscopy surgery. Chest 1997;112:530-532.[Abstract/Free Full Text]
5. Smith C.V., Jacobs J.P., Burke R.P. Minimally invasive diaphragm plication in an infant. Ann Thorac Surg 1998;65:842-844.[Abstract/Free Full Text]
6. Mouroux J., Padovani B., Claire N., 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): Seok-Whan Moon Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Moon, S.-W. Articles by Jin, W. Search for Related Content PubMed PubMed Citation Articles by Moon, S.-W. Articles by Jin, W.