Adult Chest Surgery

Chapter 129. Surgical Plication of the Diaphragm for Paralysis and Eventration 

Both paralysis and eventration of the diaphragm are caused by a weakness of the diaphragmatic musculature that interferes with normal diaphragmatic function, resulting in respiratory compromise. The former is usually caused by dysfunction or iatrogenic interruption of the ipsilateral phrenic nerve, whereas the latter is more commonly because of congenital absence of functional diaphragmatic musculature. Adult patients with paralysis may have minimal or no signs of respiratory distress, whereas infants and children may present with total respiratory collapse. Although the etiology of these two processes may differ, the pathophysiology is similar, and both problems can be corrected with similar surgical techniques. Wood proposed plication of the diaphragm as a treatment for the compromised patient in 1916,but it was not until 1923 that Morrison reported the first successful surgical plication of the diaphragm.The goal of surgical plication is to stabilize the diaphragm by preventing paradoxical movement during inspiration. The technique is indicated in patients with eventration, diaphragmatic paralysis with ventilatory dependence, or symptomatic dyspnea.

GENERAL PRINCIPLES AND PATIENT SELECTION

Surgical intervention for congenital eventration should be offered only after a thorough evaluation has confirmed the diagnosis of diaphragmatic eventration and identified any associated anomalies. Seventy percent of affected patients have an associated congenital anomaly, such as an undescended testicle, abdominal visceral transposition, cleft palate, hypoplastic arch disorder, patent ductus arteriosus, ventricular septal defect, coarctation of the aorta, gastric volvulus, cleft lip and palate, arthrogryposis multiplex congenita, Werdnig-Hoffmann disease, hemivertebrae, horseshoe kidney, or trisomy 18 syndrome.Lung hypoplasia in association with any of these congenital defects is a particular concern.

Most cases of diaphragm dysfunction in children are managed without the necessity of surgical intervention. The first step is supportive care, which includes oxygen (at or above 92% saturation), elevation of the head, and nasoenteric feeding if aspiration is a concern. Continuous positive airway pressure can be added to reduce paradoxical movement of the diaphragm.The nasoenteric feeding tube is weaned gradually as the infant grows and the rib cage and other musculature begin to mature. Parenteral nutrition may be needed if there is gastroesophageal reflux. The use of prophylactic antibiotics is controversial, however, and should be considered only on a case-by-case basis.

If the eventration is sufficiently large that adequate ventilation becomes a critical concern, surgical treatment is warranted. Surgical repair is an emergent procedure in newborns with respiratory compromise. The infant should be intubated and surgical plication performed early.4,5 If phrenic nerve injury is suspected without identifiable cause, spontaneous recovery may occur, but surgery is recommended if diaphragmatic function on fluoroscopy fails to return within 2 weeks.Early intervention in neonates may prevent the complications of long-term ventilatory insufficiency because the rate of atelectasis or pneumonia will continue to increase over time, amplifying the potential risks of surgery.6,7 Recently, this approach has gained greater acceptance,especially in patients in whom the paralysis is caused by a complication of surgery for a congenital heart defect.Seventy-five percent of these patients will require plication.

Adults with unilateral or occasionally with bilateral diaphragmatic paralysis are not likely to have symptoms related to their pathology. Conservative management is usually indicated. Patients with persistent symptoms related to diaphragmatic dysfunction are candidates for plication. In a small series of adults, all patients demonstrated clinical evidence of improvement in pulmonary function after surgical repair, and the improvement was sustained for years.10 Excellent results are achieved in highly selected patients when plication is used for unilateral diaphragmatic paralysis.

Plication is achieved by placing layers of sutures with or without Teflon pledgets in rows at the periphery of the diaphragm along the rib cage. The operation can be performed either by thoracotomy or thoracoscopy. It is important to avoid under- or overcorrection of the defect.11 The goal of surgical plication is to provide tension on the diaphragm to prevent paradoxical chest wall motion. After plication, the diaphragm is displaced inferiorly by one or two intercostal levels. The plicated, paralyzed diaphragm prevents the encroachment of abdominal viscera into the ipsilateral chest on inspiration.11 As a result, the contralateral diaphragm creates sufficient negative intrathoracic pressure to inflate the contralateral lung adequately. This, in turn, reduces the work of ventilation by preventing lung displacement and increasing lung volume. Atelectasis and its consequential shunting are corrected, and the patient experiences improved exercise performance and pulmonary function.12

PREOPERATIVE ASSESSMENT

In a neonate with suspected eventration, determination of the degree of diaphragmatic involvement (either total or partial) should be performed as part of the routine preoperative planning. The diagnosis is critical and may be difficult, requiring the use of multiple diagnostic studies. An infant with respiratory distress may have a chest radiograph revealing elevation of the diaphragm. Ultrasound and fluoroscopy typically will show little or no diaphragmatic movement or at times paradoxical movement.

Partial diaphragmatic eventration can be difficult to differentiate from an anterior mediastinal mass on a chest x-ray. Ultrasound may be beneficial in making this distinction because the hypoechoic diaphragmatic membrane is better visualized on high-resolution sonography. CT scanning and MRI also can be useful in making the differential diagnosis.13

Prenatal ultrasonography sometimes is useful in differentiating eventration from congenital diaphragmatic hernia and may identify associated congenital heart defects. Such prenatal diagnosis may improve management by prompting transfer for birth to a facility where pediatric surgical and critical care facilities are immediately available.13 Prenatal differentiation can be difficult, however, because hernia and eventration often exhibit similar findings.14,15 Prenatal MRI may assist in making the correct diagnosis by identifying the membrane,16 and ultrasound may be useful in making the distinction between hernia and eventration. Tumors can be ruled out by their mixed echogenicity and lack of peristalsis.17 Coronal and sagittal CT scanning and MRI may assist in diagnosis. Bronchography is used to identify associated tracheobronchial abnormalities. Angiography may reveal the presence of pulmonary hypoplasia.18 Other potential diagnoses to consider in the newborn and infant are tension pneumothorax and traumatic rupture of the diaphragm.

In the newborn with suspected phrenic nerve injury, it is absolutely necessary to assess for alternative causes of pulmonary insufficiency before planning a surgical plication. This evaluation should include complete assessment of the course of the phrenic nerve.

In adults with evidence of diaphragmatic paralysis, a thorough investigation to identify the cause of dyspnea and the relationship of the dyspnea to diaphragmatic dysfunction should be performed. A thorough clinical history and a chest radiograph within the last 1–2 years may be very helpful. Chest and abdominal CT scans are useful studies for identifying the course of the phrenic nerve, studying the lung parenchyma, and evaluating for thoracic or abdominal disease. The search for a reversible or temporary source of dysfunction is mandatory.

TECHNIQUE

Anesthesia

The conduct of anesthesia during surgical plication is critical and requires an anesthetist experienced with single-lung ventilation and anesthesia for pediatric patients. Before the induction of anesthesia, a single dose of prophylactic antibiotics is given, and antiembolic stockings or sequential compression devices are placed to reduce the risk of thromboembolism. A double-lumen endotracheal tube is placed, and the position is verified with direct fiberoptic bronchoscopy. Invasive hemodynamic monitoring lines are placed and include an arterial line and central venous pressure monitors. A nasogastric tube is placed to decompress the stomach and reduce the risk of aspiration. A Foley catheter is placed to monitor urinary output.

Surgical Management

OPEN APPROACH

The surgical approach for eventration or paralysis differs from the approach for hernia. Hernias are repaired by an abdominal approach (see Chap. 130), whereas unilateral eventration or paralysis is repaired transthoracically. For plication of the diaphragm, the patient is placed in the lateral decubitus position with the aid of a vacuum beanbag. A low posterolateral thoracotomy is performed through the eighth intercostal space. The ipsilateral lung is deflated and retracted superiorly. A lysis of any adhesions is performed, and a thorough examination of the diaphragm is completed to determine the extent of eventration as well as to identify any normal diaphragmatic musculature. The weakened area of the diaphragm, once identified, is grasped with a Babcock clamp and elevated to determine the orientation of suture repair lines (Fig. 129-1). A linear row of pledgeted nonabsorbable horizontal mattress sutures is placed in a radial fashion. During this step of the procedure, it is imperative to pay great attention to preventing injury to any of the abdominal organs or branches of the phrenic nerve. When a sufficient series of stitches is placed, the sutures are tightened, and the weakened area of diaphragm is drawn up in a series of pleats. The goal of the plication is a taut diaphragm. If the diaphragm is not taut after the sutures are tightened, additional stitches can be placed to draw more of the diaphragmatic tissue into the pleats. At completion of the operation, excess diaphragm tissue is reconfigured, and the diaphragm is flattened at the base of the thorax. If the abdominal cavity is too restrictive to permit intraperitoneal return of the abdominal organs, a temporary ventral hernia may be created and then closed after the abdominal wall musculature has relaxed. Chest tubes are placed to drain fluid or air that accumulates.

Figure 129-1.

 

The weakened area is identified (A), grasped with a Babcock clamp (B), and lifted to determine placement and orientation of suture lines. C. Linear rows of pledgeted nonabsorbable horizontal mattressed sutures are placed through the weak spot in the diaphragm. D. The suture is tightened and the weakened tissues are gathered into pleats, creating a taut diaphragmatic surface.

In the case of bilateral or infracardiac eventration, an abdominal approach is preferred. A similar technique is used through an abdominal incision. Acquired neonatal eventration may be treated by an abdominal approach or, when the diagnosis of hernia cannot be excluded, by a thoracic approach. In the case of phrenic nerve injury, the thoracic approach is superior because it best demonstrates the anatomic distribution of the phrenic nerve.

THORACOSCOPIC APPROACH

The thoracoscopic approach to diaphragm plication is similar to the open technique. Preoperative evaluation and preparation are the same as for an open plication. Two techniques for thoracoscopic plication have been described. The first technique creates a single pleat in the diaphragm with the use of a single running stitch; the second technique creates multiple pleats and is similar to the open procedure with respect to suture placement. Thoracoscopy requires the use of the lateral decubitus position and single-lung ventilation. A nasogastric tube is place for gastric drainage. Following plication of the diaphragm, an intercostal nerve block is performed, and chest tubes are placed.19

SINGLE-PLEAT TECHNIQUE

Two ports are placed, one in the fifth intercostal space in the posterior axillary line and the second in the midclavicular line in the fifth intercostal space (Fig. 129-2). A 5-cm minithoracotomy at the ninth or tenth intercostal space in the posterior axillary line is made. By using an endoscopic instrument to depress the diaphragm into the abdomen, two rows of continuous suture are placed from lateral to medial on either side of the diaphragm invagination. The suture is tied in place, creating a fold in the diaphragm while tightening and lowering the diaphragm into the abdomen.

Figure 129-2.

 

A. Ideal placement of incisions for the thoracoscopic approach to single-pleat technique. B. Note the use of a single running stitch, which is pulled taut (C) to close up the defect and strengthen the diaphragm.

MULTIPLE-PLEAT TECHNIQUE20

Three 10-mm ports are placed (Fig. 129-3). The first two are in the eighth intercostal space at the midclavicular line and the midaxillary line. The third port is placed midway between the spine and the posterior aspect of the scapula in the sixth intercostal space. A series of six to eight parallel horizontal mattress sutures is placed along a radial plane. The radial sutures create tension and achieve plication of the diaphragm.

Figure 129-3.

 

A. Ideal placement of incisions for thoracoscopic approach using multiple pleat technique. B. Similar to the open approach, parallel rows of horizontal mattress sutures are placed and drawn together.

POSTOPERATIVE CARE

The postoperative course may vary depending on the duration and severity of symptoms prior to surgical interventions. Prophylactic antibiotics should be discontinued within the first postoperative day. Patients who required ventilatory support before surgery may require additional support in the immediate postoperative period. The ventilator should be weaned as tolerated and should be assisted by the improved pulmonary mechanics. Patients who did not require support preoperatively may be extubated immediately; however, they should be monitored carefully. Chest tubes can be removed as long as there is no evidence of air leak from the lungs and pulmonary effluent is not likely to accumulate. In older children and adult patients, measures should be taken to ensure good pulmonary toilet, including incentive spirometry and early ambulation.

PROCEDURE-SPECIFIC COMPLICATIONS

Complications of the procedure are related to surgical technique. Inadequate tension on the diaphragm may permit continued paradoxical muscle motion and no improvement in symptomatology. Too much plication and tension may result in disruption of the suture lines and failure of the repair. Stitches placed too deeply through the diaphragm may result in injury to any of the abdominal viscera and lead to the potential of perforation and intraabdominal sepsis.

RESULTS

With respect to cases of congenital eventration, in the short term, low mortality and morbidity can be expected, and long term, one can anticipate a complete recovery.21 The prognosis after repair depends on the degree of pulmonary hypoplasia and the presence and severity of other congenital anomalies. In children without associated anomalies, extubation should be possible in over 80% of patients within the first 2–3 days.22 The mortality and morbidity should be exceedingly low. There are no apparent developmental problems associated with correction. The diaphragm continues to grow in relation to the other side. Long term, the mediastinum stabilizes with surgery, and pulmonary problems have not been noted.23

Most newborns with acquired eventration owing to phrenic nerve injury will recover without surgery in 6–12 months. Nearly all patients who have phrenic nerve injury at birth will experience return of function, even years later.24 The best results for neonatal plication occur when the dysfunction occurs after cardiac surgery25 and may not correlate with the improvement in diaphragm function.26 Ventilatory support is usually necessary for 1 week after surgery if the primary problem is related to the diaphragm. Surgical mortality is low. Development following the procedure proceeds normally, and there are no recurrences and no respiratory compromise.27

In the carefully selected adult patients in whom phrenic nerve dysfunction is corrected, the procedure has low morbidity and mortality with clear long-term improvement in lung function.28,29

SUMMARY

Surgery for dysfunction of the diaphragm resulting from congenital eventration or acquired nerve injury is similar. Plication of the diaphragm tightens the diaphragm by lowering it one to two rib spaces. The goal of the surgery is to stabilize the diaphragm and to prevent paradoxical chest wall motion, thereby improving respiratory mechanics. Cases of congenital eventration are unlikely to resolve spontaneously, whereas acquired injuries in the infant and adult often improve without surgical intervention. Prognosis after surgery is good and is not associated with any long-term sequelae.28

CASE HISTORY

A full-term infant was born with signs of respiratory compromise. Chest radiography demonstrated elevation of the left hemidiaphragm. Bedside ultrasonography demonstrated paradoxical movement of the left diaphragm. The child was managed with conservative measures, and the presumed phrenic nerve dysfunction improved in approximately 10 days.

EDITOR'S COMMENT

Fortunately, most cases of acquired eventration from phrenic nerve paralysis do not require surgery. Regardless of the approach–open or thoracoscopic–a fine line separates a successful repair from a failed repair. Too much laxity or too much tension can have the same poor long-term result.

–LZ

REFERENCES

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2. Morrison J: Eventration of the diaphragm due to unilateral phrenic nerve paralysis. Arch Radiol Electrother 28:72–5, 1923. 

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