Tutorial
Video-assisted thoracoscopic diaphragmatic plication
The authors demonstrate a video-assisted thoracoscopic surgical technique for diaphragmatic plication, which is used to treat acquired diaphragmatic paralysis resulting from injury to the phrenic nerve. The objective of the surgical procedure is to return the abdominal contents to their normal position and restore optimal lung expansion by reducing the size of the diaphragmatic surface. Successful diaphragmatic plication improves lung function, reduces dyspnea, and restores quality of life.
The diaphragm is the main breathing muscle, and contraction of the diaphragm is vital for ventilation. Any disease or injury that interferes with diaphragmatic innervation, contractile muscle function, or mechanical coupling to the chest wall can cause diaphragm dysfunction. Diaphragm dysfunction is associated with dyspnea, intolerance to exercise, sleep disturbances, and hypersomnia, and has a potential impact on mortality [1].
The cause of diaphragm dysfunction can be congenital or acquired. Acquired diaphragmatic paralysis can result from injury to the phrenic nerve, usually after cardiac or thoracic surgery [2]. Diaphragmatic plication is the standard treatment for symptomatic diaphragmatic eventration in adults, and video-assisted thoracoscopic surgery (VATS) is the most recommended approach [3].
In this video tutorial, we present a case of postoperative diaphragmatic paralysis treated by VATS using 3 ports.
1 - Patient presentation (0:17)
A 62-year-old male patient, who had a history of hypothyroidism, was referred to the authors' service for progressive dyspnea of 1 year of evolution. No history of trauma, cancer, relevant viral infections, or other history.
Diaphragmatic paralysis was observed on chest radiography and CT. No lymphadenopathy or tumor lesions were observed in the mediastinum.
After consultation and discussion, we decided to perform a VATS diaphragmatic plication.
2 - Preoperative imaging, patient positioning, and port placement (0:44)
The abnormal elevation of the left diaphragm was clearly visible on the preoperative chest X-ray and CT.
We positioned the patient in the left lateral position, with the left arm abducted, and placed 3 ports: A 10-mm port for the trocar and the video camera was placed in the 8th intercostal space on the midaxillary line; a 20-mm working port was placed in the 7th intercostal space on the posterior axillary line; and a 10-mm port was placed in the 6th intercostal space on the anterior axillary line.
3 - First plane of the plication (1:22)
We visualized the height of the diaphragm and performed the first release of the adhesions between the diaphragm and the chest wall and lung parenchyma. Once the diaphragm was released, we placed a Foerster clamp through the anterior port and pressed the diaphragm down, creating the space for the plication to take place. This maneuver is key because it allows the surgeon to define the edges of the plication.
Through the posterior working port we used a continuous Prolene 3.0 suture in the lateral posterior to medial anterior direction.
4 - Second plane of the plication (2:47)
After the first suture plane, we created a second plane in the same way, overlapping the diaphragm until reaching a suitable height. In this step we normally use the Foerster clamp again, depending on how large the diaphragmatic surface is.
When the surgery was completed, we checked the sutures through the posterior working port.
The duration of the surgery was an hour and a half. The patient was discharged on the 2nd postoperative day.
5 - Postoperative radiography (3:44)
We show the postoperative chest X-ray.
Access to the diaphragm can be obtained through the chest or the abdomen, and either approach can be made with open or minimally invasive techniques. The VATS approach can be performed using 2, 3, or 4 ports, and plication techniques include continuous sutures (our preferred technique), interrupted stitches, or staples.
Thoracoscopic diaphragm plication is an excellent minimally invasive alternative to thoracotomy plication; mid-term and long-term follow-up data suggest that it is as effective as the open approach [4, 5]. Today, in advanced thoracic surgery centers, the treatment of choice should be diaphragmatic plication using the VATS technique. It is as safe and effective as a thoracotomy in correcting the clinical defects of diaphragmatic paralysis, and it offers postoperative benefits such as reduced pain, faster recovery, and shorter hospital stays.
1. Ricoy J, Rodríguez-Núñez N, Álvarez-Dobaño JM, Toubes ME, Riveiro V, Valdés L. Diaphragmatic dysfunction. Pulmonology. 2019;25(4):223–235.
PubMed Abstract | Publisher Full Text
2. ElSaegh MM, Ismail N, Dunning J. VATS Diaphragm Plication. Surg Technol Int. 2016;28:222–225.
PubMed Abstract
3. Rombola ́ CA, et al. Tratamiento de la eventracion diafragmatica en adultos mediante plicatura diafragmatica asistida por videotoracoscopia. Es una tecnica difundida en nuestro medio. Revision de la literatura, resultados de una encuesta nacional. Cir Esp. 2014.
PubMed Abstract | Publisher Full Text
4. Podgaetz E, Garza-Castillon R Jr, Andrade RS. Best Approach and Benefit of Plication for Paralyzed Diaphragm. Thorac Surg Clin. 2016;26(3):333–346.
PubMed Abstract | Publisher Full Text
5. Freeman RK, Van Woerkom J, Vyverberg A, Ascioti AJ. Long-term follow-up of the functional and physiologic results of diaphragm plication in adults with unilateral diaphragm paralysis. Ann Thorac Surg. 2009;88(4):1112–1117.
PubMed Abstract | Publisher Full Text
None declared.
Authors
Manuel España, Ignacio Sastre, Carla A. Franco, Quintana Emilia, Roberto Ceballos, and Mario E. F. Bustos
Author Affiliations
Thoracic Surgery Department,
Hospital Privado Universitario de Córdoba,
Córdoba, Argentina
Corresponding Author
Manuel España
Thoracic Surgery Department,
Hospital Privado Universitario de Córdoba,
Córdoba, Argentina
Phone: +54 (351) 5204798
Email: imaesis17@gmail.com
© The Author 2021. Published by MMCTS on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
