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Technique of Video-Assisted Thoracoscopic Surgery Diaphragm Plication

  • Shanda H. Blackmon
    Correspondence
    Address reprint requests to Shanda H. Blackmon, MD, MPH, FACS, Section of Thoracic Surgery, The Methodist Hospital, 6550 Fannin Street, Smith Tower, Suite 1661, Houston, TX 77030
    Affiliations
    Weill Cornell Medical College, Section of Thoracic Surgery, The Methodist Hospital, Houston, Texas
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      The diaphragm is a musculoaponeurotic structure that works as the most important respiratory muscle in the body. It separates the negative-pressure thoracic cavity from the positive-pressure abdominal cavity. This article reviews the fundamental minimally invasive approaches to diaphragm plication and technical details of positioning, port placement, suturing, and management. Diaphragmatic paralysis, the most common reason for plication, results from trauma, systemic disease, or neurologic loss of control of the phrenic nerve. Symptoms depend on the degree of injury, bilaterality, degree of underlying lung disease, and overall health of the patient. Positive pressure (continuous or bilevel) assistance or ventilator support may be warranted in more severe cases.
      The clinical evaluation of a patient with diaphragm paralysis includes careful examination, imaging, respiratory evaluation, and, sometimes, electromyography. A careful, detailed history of the onset, timing of paralysis, and severity will allow the surgeon to determine the likelihood of spontaneous recovery and the cause of the paralysis. Imaging should be performed with a contrast-enhanced high-resolution thoracic computed tomographic scan with 3-dimensional reconfiguration showing the coronal images from the anteroposterior and lateral views. Supine and upright pulmonary function tests should be performed to determine the degree of respiratory compromise. Tests performed before the injury also may be helpful to review, if they are available. Having the patient perform a “sniff” test confirms the diagnosis, demonstrating a lack of elevation with deep inspiration on the affected side.
      • Nason L.K.
      • Walker C.M.
      • McNeeley M.F.
      • et al.
      Imaging of the diaphragm: Anatomy and function.
      Many patients with unilateral diaphragm paralysis will not have symptoms to warrant the risk of a repair. Patients should be evaluated for malignancy, active infection, and inflammation before being offered diaphragm plication. After all the data have been reviewed, to be offered diaphragm plication at our institution, patients must exhibit lifestyle-limiting dyspnea, evidence of severe impairment seen from respiratory function testing, and lack of improvement with observation.
      • Celik S.
      • Celik M.
      • Aydemir B.
      • et al.
      Long-term results of diaphragmatic plication in adults with unilateral diaphragm paralysis.
      Unilateral diaphragm paralysis is treated differently than bilateral diaphragm paralysis. The illustrations (Figure 1, Figure 2, Figure 3, Figure 4, Figure 5, Figure 6) address unilateral diaphragm paralysis and the author's surgical approach to plication. The goal of plication is to convert the redundant loose diaphragm into a rigid, flat, immobile structure that will allow the compensatory respiratory musculature to have an enhanced effect. By eliminating the paradoxical movement of a previously paralyzed muscle, the negative pressure inside the chest is greater, once the patient is extubated.
      Figure thumbnail gr1
      Figure 1Scout view of unilateral right-sided hemi-diaphragm paralysis before repair. This chest radiograph is helpful in determining the degree of paralysis and live fluoroscopy will show if the diaphragm moves with deep inspiration (the “sniff test”).
      Figure thumbnail gr2
      Figure 2Single-patient imaging series: (A) before plication of right hemi-diaphragm chest radiograph, and (B) after plication of right hemi-diaphragm chest radiograph.
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      Figure 3VATS port arrangement for diaphragm plication. Two of the ports may be placed in the 5th intercostal space: 1 anterior port in front of the anterior axillary line and another beneath the tip of the scapula. The 3rd port is placed in the 8th intercostal space, in between the 2 other ports, and is typically larger and used as a utility port. Triangulation of the ports limits instrument crossing. ICS, intercostal space.
      Figure thumbnail gr4a
      Figure 4Different plication techniques: (A) running suture, (B) 6-10 interrupted pledgeted suture technique, (C) imbricated suture technique, (D) multiple rows of plications, and (E) photograph of the multiple-row technique (author preference). (Color version of figure is available online at http://www.optechtcs.com.)
      Figure thumbnail gr4b
      Figure 4Different plication techniques: (A) running suture, (B) 6-10 interrupted pledgeted suture technique, (C) imbricated suture technique, (D) multiple rows of plications, and (E) photograph of the multiple-row technique (author preference). (Color version of figure is available online at http://www.optechtcs.com.)
      Figure thumbnail gr5
      Figure 5VATS port arrangement for endo-suturing assist device or a laparoscopic needle driver. The camera is off to 1 side and the 2 other ports are used for passage of the needle driver and the suturing device.
      Figure thumbnail gr6
      Figure 6Laparoscopic right-sided port arrangement including (A) surgeon position and trocar placement and (B) abdominal surface of the diaphragm with plication sutures in 2 directions. Interrupted rows are shown here without pledgets, but the use of pledgets may prevent the suture from pulling through the diaphragm and is recommended.
      There are now several alternative, possibly less painful, approaches than the traditional approach through the 7th to 8th intercostal space thoracotomy. These include video-assisted thoracoscopic surgery (VATS), laparoscopic, or robotic approaches. Our institution prefers the VATS approach, although we have performed all of the above listed approaches for a variety of reasons. There are only small, single-institution case series of the more minimally invasive techniques, and, although the results are favorable, one must be aware of the relative novelty of this approach.
      The VATS approach typically involves the placement of at least 3 trocars (Fig 3); 1 for the camera and the other 2 for suturing. Because patient positioning is essential, flexing the table to open the intrathoracic space facilitates access to the chest cavity. Permanent monofilament suture (at least 2-0 Prolene or thicker) or pledgeted permanent suture should be used. Taking down the inferior pulmonary ligament will provide additional working space, allowing the lung to be retracted toward the apex of the chest. Caution should be used when applying traumatic pressure/retraction/injury to underlying organs (liver [right], spleen, or colon [left]) or deep suture bites that may incorporate structures into the other side of the diaphragm. If an injury is suspected, the surgeon should place a port on the opposite side of the diaphragm to check the hidden organs for signs of injury. Left-sided thoracoscopic anterior ports should be shifted slightly more posterior than right-sided anterior ports, to prevent pericardial interference. Insufflation with CO2 gas allows rapid deflation of the ipsilateral side of the lung at the beginning of the case, but 10 mm Hg pressure should not be exceeded and its use should be only at the beginning of the case. A percutaneous suture passer may be used to keep the folds of the diaphragm retracted (holding suture) when approaching the diaphragm through either the thoracoscopic or the laparoscopic approach, and used to minimize the number of ports needed for holding the diaphragm in place. Unlike diaphragm repair with an intact phrenic nerve, plication of a paralyzed diaphragm does not require positioning of the sutures in a certain pattern to avoid interruption of the phrenic nerve.
      There are basically 3 techniques that may be used to plicate, as follows: the continuous row of a running suture anchored by the pledgets (Fig. 4A), an interrupted row of pledgeted sutures (Fig. 4B), or an imbricated plication with a running or interrupted nonpledgeted suture (Fig. 4C). More than 1 layer may also be used when creating the plication, especially if the diaphragm seems loose after the first row of plication. The author recommends multiple rows of interrupted pledgeted sutures in the event a suture breaks or a knot becomes untied. The multiple rows, much like smocking, are more likely to hold if 1 row does not hold. New suturing devices are now available to assist in passing the needle more efficiently. A reverse Trendelenburg position facilitates positioning of abdominal organs toward the pelvis and limits the pressure against the diaphragm. When using pledgets, tying a knot on the end of the suture prevents the pledget from slipping off of the suture during plication. A Maryland dissector is useful to hold onto the pledgets. Placement of a nasogastric tube will facilitate exposure of the diaphragm and decompress a distended stomach, regardless of approach (laparoscopic or thoracoscopic).
      The laparoscopic approach is another attractive option for patients with diaphragm paralysis who have had previous surgery in the thoracic cavity and who may be expected to have extensive scar tissue.
      • Groth S.S.
      • Rueth N.M.
      • Kast T.
      • et al.
      Laparoscopic diaphragmatic plication for diaphragmatic paralysis and eventration: An objective evaluation of short-term and midterm results.
      Surgeons should be familiar with both a laparoscopic approach and a thoracoscopic approach, because many of these repairs require passage of a scope into the other cavity to make sure organs on the other side are intact and not damaged. The surgery can be performed with the patient in the supine position or in the dorsal lithotomy position (Fig. 6A). With the surgeon standing between the patient's legs, a more direct and straight approach to the diaphragm may be achieved. An alternate position is for the surgeon to stand to the opposite side to be plicated. Retraction of the spleen can be achieved with a fan retractor, and the omentum may be retracted when redundant with a temporary or absorbable endo-loop is passed through the abdominal wall with a suture passer and held in place with a hemostat instead of an additional port for more retraction. A laparoscopic approach is more difficult on the right side because of the location of the liver. When approaching the diaphragm from the abdomen, it is possible to plicate in more than 1 direction (Fig 6B), especially when a particular area seems loose. Caution should be used because of inadvertent damage to hidden thoracic structures when passing sutures from the abdominal side. If the needle is passed too deep, the lung may be damaged, causing a pneumothorax. This can be treated with the simple placement of a chest tube, but one must plan ahead and prepare the chest into the field before beginning the case. Creating a small pneumothorax will facilitate delivery of the diaphragm toward the abdomen side to make plication easier. The spleen is most often damaged during left-sided plication from a laparoscopic approach.
      • Pathak S.
      • Page R.D.
      Splenic injury following diaphragmatic plication: An avoidable life-threatening complication.
      To avoid splenic injury, grasping near the hilum for mobilization should be avoided and instead large retracting devices should be used to push the organ toward the pelvis.

      Conclusions

      In conclusion, diaphragm plication can be performed through many different approaches, and a minimally invasive approach may be less painful and may result in improved recovery and a shorter hospital stay. Dyspnea and spirometry scoring may be improved with a durable plication.
      • Freeman R.K.
      • Van Woerkom J.
      • Vyverberg A.
      • et al.
      Long-term follow-up of the functional and physiologic results of diaphragm plication in adults with unilateral diaphragm paralysis.
      • Ko M.A.
      • Darling G.E.
      Acquired paralysis of the diaphragm.
      • Gazala S.
      • Hunt I.
      • Bédard E.L.
      Diaphragmatic plication offers functional improvement in dyspnoea and better pulmonary function with low morbidity.
      • Groth S.S.
      • Andrade R.S.
      Diaphragm plication for eventration or paralysis: A review of the literature.

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