Ann Thorac Surg 2003;76:234-236
© 2003 The Society of Thoracic Surgeons
Original article: general thoracic
Video-assisted diaphragm plication in children
Michael H. Hines, MDa*
a Department of Cardiothoracic Surgery, Brenner Children’s Hospital, Wake Forest University/Baptist Medical Center, Winston-Salem, North Carolina, USA
* Address reprint requests to Dr Hines, Department of Cardiothoracic Surgery, Brenner Children’s Hospital, Medical Center Blvd, Winston-Salem, NC 27157, USA.
e-mail: mhines{at}wfubmc.edu
Presented at the Video Session of the Forty-eighth Annual Meeting of the Southern Thoracic Surgical Association, San Antonio, TX, Nov 8–10, 2001.
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Abstract
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BACKGROUND: Diaphragm paralysis after cardiac surgery may be secondary to phrenic nerve injury by ice, electrocautery, or dissection. Although most are asymptomatic, some patients, particularly children, have significant respiratory compromise. Video-assisted plication may offer more rapid improvement and recovery than thoracotomy in pediatric patients.
METHODS: We performed five procedures. The diaphragm was elevated, clamped, oversewn, and tacked down into the pleural gutter. The procedure was performed on 2 infants after repair of total anomalous pulmonary venous connection, on 1 child after the Fontan procedure, on 1 child after repair of tetralogy of Fallot, and on 1 child with congenital eventration. Indications included ventilator dependency, post-Fontan protein losing enteropathy with elevated venous pressures and chronic right lower lobe collapse, persistent atelectasis with recurrent pneumonias, and asymptomatic severe eventration.
RESULTS: Ventilator-dependent patients were extubated after 2 and 3 days. The remaining patients were immediately extubated. One patient was discharged the day of surgery and 2 were discharged at 1 and 3 days postoperatively. The remaining 2 were discharged on postoperative day 30 and 45 after continued issues with feeding and prematurity. The child with the eventration had rapid expansion and growth of the left lung over the next few weeks with a normal chest radiograph 3 weeks later. The child with recurrent pneumonia reexpanded her left lower lobe and remains free of infection. There were no wound infections, lung or vascular injuries, or complications from the procedure. All the patients had successful flattening of the hemidiaphragm as documented by chest radiograph, with successful lung reexpansion.
CONCLUSIONS: Video-assisted plication of paralyzed diaphragms is effective and safe, involves less morbidity, and has quicker recovery times than traditional open techniques.
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Introduction
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Loss of normal physiologic motion of the diaphragm has been shown to impair respiratory dynamics in both children and adults [1–4]. Although many patients remain asymptomatic, others have significant dyspnea with exertion or can be ventilator dependent, particularly children. The etiology of the diaphragmatic dysfunction may be true eventration with thinning and loss of normal musculature of the diaphragm or can be secondary to injury to the phrenic nerve [1–5]. Injuries may be related to traction of the nerve during birth or iatrogenic during surgical dissection, electrocautery, or ice placement commonly used with open cardiac procedures. In addition, malignant invasion of the nerve can also lead to diaphragm paralysis. With loss of phrenic nerve function, the diaphragm motion is paradoxical, not only preventing expansion of the frequently collapsed lower lobe but also impairing proper inflation of the ipsilateral upper lobe, and to some extent the contralateral lung. The incidence among adults after cardiac surgery is unclear as most patients remain asymptomatic and the problem frequently resolves with time. In children undergoing cardiac procedures, reports range from 1.5% to 10% [2–4]. It is well documented in the literature that symptomatic patients, including those failing to wean from mechanical ventilation, can benefit from surgical plication of the effected diaphragm [1, 2, 6–9]. Additional follow-up has shown this to be not only effective and sustained, but also to not produce any long-term impairment of diaphragm development or respiratory function [6, 7, 10, 11].
The vast majority of reports involve a posterolateral thoracotomy with plication or reduction of the redundant muscle. With the advancements of endoscopic surgery, video-assisted plication of the diaphragm is now possible offering the well-documented advantages of minimally invasive surgery [12, 13] to these patients. Presently there are two reports of video-assisted repairs using one or two ports and a "minithoracotomy" [14, 15], as well as three individual case reports of repairs using port access [16, 17, 18]. Here we describe our technique and experience with five pediatric patients.
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Material and methods
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Patient population
Five patients were found on chest radiography to have an elevated diaphragm, and paradoxical motion was confirmed by either ultrasonography or fluoroscopic examination. They are briefly described in Table 1.
Surgical technique
Under general anesthesia the patients were stabilized in the standard lateral position. The lung was retracted with an endoscopic fan retractor and a 30-degree angled scope (either 2.7 or 4 mm) was placed through a 3- or 4-mm port placed in the lateral chest near the tip of the scapula, in approximately the fourth interspace. Two additional ports (3 or 4 mm) were placed in the third or fourth interspace anteriorly toward the axilla and in the fifth interspace posteriorly behind the scapula. These were used for a grasper and a posterior lung retractor. After inspection of the diaphragm, a site was selected on the midlateral chest corresponding to the "base" of the diaphragm. This usually was around the ninth interspace. An additional port was then placed one interspace above this. The lowest port was used to clamp and hold the redundant diaphragm during suturing.
Long thin vascular clamps were used and guided through the lowest port over the dome of the diaphragm. The dome was grasped and pulled superiorly through the partially opened jaws of the clamp, preventing entering of any abdominal viscera. With the clamp applied, the base of the redundant tissue was sewn with a double-layer running horizontal mattress suture using 4-0 or 5-0 polypropylene sutures. One patient required a second plication for remaining redundancy, and the patient with the congenital eventration required three large plications to achieve sufficient tension of the diaphragm. The plicated segment was then pulled down into the lateral recess of the pleural space and sutured in place to assure adequate tension and flattening. The lung was reexpanded and the instrumentation and ports removed. Only the first patient had a chest tube left in place. The other four had chest tubes removed under positive pressure ventilation and gentle suction in the operating room. The child with the eventration had a tube placed later for residual air and failure of the left lung to reexpand.
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Results
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All 5 patients had successful plication of the effected hemidiaphragm. There was no mortality. Except for the late elective insertion of a chest tube there were no surgical complications. Three patients were extubated in the operating room. The 2 infants who were ventilator dependent were successfully extubated on postoperative day 2 and 3. One patient was discharged the afternoon of surgery, and 2 were discharged on postoperative day 1 and 3. The remaining 2 infants were discharged on postoperative day 30 and 45 after additional time in the neonatal intensive care unit for feeding issues and prematurity. Postoperative chest radiographs showed flattening of the diaphragm in all patients.
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Comment
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Advances in endoscopic technology and techniques now allow us to reproduce standard thoracic surgical procedures through completely thoracoscopic approaches. The benefits of minimally invasive surgery are well documented from the standpoint of pain, cosmetic results, pulmonary function, and morbidity [12, 13]. It has also been well demonstrated that whereas most patients with postoperative or traumatic paralysis of the diaphragm remain asymptomatic, a small subset of patients essentially requires all available lung function. That is primarily seen in the presence of underlying pulmonary disease or in infants and children less than 2 years of age who tolerate the functional loss of one side very poorly [1–4]. It has been hypothesized that this poor tolerance is due to a difference in respiratory mechanics in children [9]; however, this author believes it is related to a relative underdevelopment of the infant lung. There is a decreased alveolar to lung mass ratio in infants and small children that limits the available surface area for gas exchange and increases up to about 8 years of age, with the proliferation and development of alveolar branching gradually increasing respiratory surface area.
When the plication is performed through a thoracotomy, the beneficial effects are delayed, being masked by the concurrent loss of pulmonary function seen with the pain of the thoracotomy, and thereby delaying recovery. With the minimal effects on pulmonary function seen with thoracoscopy, the benefits of the plication are immediately realized, as demonstrated by 2 of our patients released within 24 hours of surgery.
The flexibility of this technique allows sewing through several of the ports to achieve the best angle of approach. In our experience, clamping the diaphragm to exclude the abdominal viscera and plicating the base and tacking the redundant tissue into the pleural gutter is the preferred method, as described in previous open techniques, and has proved to be achievable through the endoscopic approach as with these 5 patients.
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References
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Abstract
Introduction
