AB 62. Video assisted thoracoscopic plication of the left hemidiaphragm in symptomatic eventration in adulthood
Background: Diaphragmatic eventration is a rare (incidence <0.05%) congenital developmental defect of the muscular portion of the diaphragm, which maintains its normal attachments (to dorsolumbar spine, ribs, sternum). Eventration results in diaphragmatic elevation (cephalad displacement). It can be unilateral or bilateral, partial or complete. It is more common in males, and involves more often the left hemidiaphragm. Surgery is indicated only in the presence of symptoms. The commonest symptom is dyspnoea. We present a video assisted thoracoscopic plication of the left hemidiaphragm in a symptomatic patient.
Patients and methods: A 47-year old woman presented with nonspecific gastrointestinal symptoms (dyspnoea and bloating after small meals, despite continuous gastrokinetic drug consumption), dyspnoea on exertion, and limited physical activity since childhood. A known left hemidiaphragm elevation (8 cm higher than the right) was confirmed on chest radiography. Intraoperatively, the hemidiaphragm appeared thin, fully deprived of muscular layer, with a cephalad displacement. A 3 port video assisted thoracoscopic postero-anterior plication of the left hemidiaphragm was performed. The plicated area was further reinforced by suturing of a bovine pericardial patch.
Results: The patient had an excellent postoperative recovery. She was extubated in theatre, transferred to the ward without need of oxygen supplementation, received liquid oral feeding 8 hours postoperatively, underwent full mobilization and was discharged home on the 3rd postoperative day. She discontinued gastrokinetic medication (8th postoperative day). One month postoperatively the Forced Expiratory Volume in 1 second was increased by 25% and the Forced Vital Capacity by 11% in comparison to preoperative measurements. One year postoperatively she remains well; reporting increased physical activity, and absence of dyspnoea and gastrointestinal symptoms, while weight gain was noted.
Conclusions: Retrospective studies showed that minimally invasive plication was equally effective to open techniques, being associated with decreased morbidity, and functional improvement that is maintained for at least 4 years. Disadvantages attributed to the method include requirement of single lung ventilation and technical difficulty due to limited space by the thoracic wall and the cephalad diaphragmatic displacement. In our opinion, thoracoscopic hemidiaphragmatic plication is an excellent minimally invasive alternative to open plication, providing good early and medium term results.
