Physical Address
304 North Cardinal St.
Dorchester Center, MA 02124
Minimally Invasive Diaphragmatic Plication
Access the accompanying videos for this chapter online. Available on ExpertConsult.com .
Paralysis or eventration of the diaphragm is a relatively uncommon problem in infants and children, but one that can cause significant respiratory distress. Eventration may be congenital in origin, or it may result from iatrogenic injury, either from birth trauma or from injury to the phrenic nerves during cardiac surgery. When there is significant compromise to pulmonary function, diaphragmatic plication should be considered to allow better expansion of the affected lower lobe. Both laparoscopic and thoracoscopic plication are minimally invasive approaches for dealing with this problem and significantly decrease the morbidity compared with an open approach. Initially we preferred a laparoscopic approach because the abdomen affords increased workspace. However, with greater experience, we have adopted a thoracoscopic approach unless there are significant contraindications to entering the ipsilateral chest, such as severe respiratory compromise.
Indications for Workup and Operation
The indication for operative correction is an elevated hemidiaphragm with evidence of lung compression or atelectasis, which may be segmental or lobar. The elevated diaphragm is usually associated with some degree of respiratory compromise, which can be quite severe in some patients. The goals of intervention range from an attempt to improve pulmonary function enough to allow a patient to be weaned from a ventilator to improving function enough to relieve dyspnea on exertion or an oxygen requirement. The advent of minimally invasive surgery has allowed a more liberal use of this operation.
The workup includes a routine chest radiograph that shows an elevated hemidiaphragm and mediastinal shift, as well as pulmonary function testing (in older patients) that shows a restrictive pattern. Confirmation of a paralyzed diaphragm can be obtained with ultrasound or fluoroscopy, with demonstration of paradoxical motion of the diaphragm. In some cases, it can be difficult to differentiate an eventration from a diaphragmatic hernia with a thick sac. However, these are probably variations of the same developmental defect, and they are often treated similarly.
Operative Technique
You're Reading a Preview
Become a Clinical Tree membership for Full access and enjoy Unlimited articles
If you are a member. Log in here