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A Simple Technique for the Thoracoscopic Plication of the Diaphragm
minimally invasive techniques A Simple Technique for the Thoracoscopic Plication of the Diaphragm* Znuke Hwang, MD; Jae Seung Shin, MD; Yang Hyun Cho, MD; Kyung Sun, MD; and In Sung Lee, MD
We describe a simple technique for video-assisted thoracoscopic plication in patients with diaphragmatic eventration. During the plication, which is performed with a continuous running suture, a surgical assistant maintains the continuous suture traction using a homemade hook through the port. The technique can be performed easily, without any kind of thoracotomy. (CHEST 2003; 124:376 –378) Key words: diaphragm; diaphragmatic eventration; thoracic surgery, video assisted; thoracoscopes; thoracoscopy Abbreviations: IC ⫽ inspiratory capacity; MVV ⫽ maximal voluntary volume; TLC ⫽ total lung capacity
of the diaphragm by thoracotomy is the P lication usual method used for diaphragmatic eventration. Recently, diaphragmatic plication by thoracoscopy became an acceptable alternative to this standard operative technique1,2; however, technical difficulties associated with thoracoscopic plication led to the adoption of minithoracotomy with thoracoscopic assistance.3 We describe a simple running suture technique for the thoracoscopic plication of diaphragmatic eventration.
Case Report A 43-year-old man presented to our clinic with progressive dyspnea on exertion, with a duration of several years. Chest radiographs showed elevation of the left diaphragm and displacement of the heart (Fig 1). A pulmonary function study showed a reduction in FVC (3.65 L, 82%), FEV1 (2.41 L, 70%), total lung *From the Department of Thoracic and Cardiovascular Surgery, Korea University Medical Center, Korea University College of Medicine, Seoul, Korea. Manuscript received October 17, 2002; revision accepted December 19, 2002. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (e-mail: [email protected]). Correspondence to: Jae Seung Shin, MD, Department of Thoracic and Cardiovascular Surgery, Ansan Hospital, Korea University Medical Center #516, Gojan-dong, Gyeonggi-do, 425-020, Korea; e-mail: [email protected] 376
Figure 1. Preoperative chest radiograph showing elevation of the left diaphragm and displacement of the heart. capacity (TLC) [5.29 L, 89%], inspiratory capacity (IC) [1.60 L, 54%], and maximal voluntary volume (MVV) [105 L/min, 71%; Table 1]. Minimally Invasive Techniques
Table 1—Change in Pulmonary Function After Thoracoscopic Plication of Diaphragmatic Eventration* Variables
Preoperative
FVC, L FEV1, L TLC, L IC, L MVV, L/min
3.65 (82) 2.41 (70) 5.29 (89) 1.60 (54) 105 (71)
3 mo 3.78 (88) 2.94 (89) 5.67 (99) 2.27 (77) 132 (92)
*Data are presented as No. (%).
The patient underwent video-assisted thoracoscopic plication of diaphragm. After inducing general anesthesia, the patient was intubated with a double-lumen endotracheal tube, and positioned in the lateral decubitus position. The stomach was drained with a nasogastric tube, and the patient was positioned head up to displace the intra-abdominal organs downward. Four ports were used; an 11.5-mm port for a 10-mm, 0°, rigid thoracoscope (Karl Storz GmbH; Tuttlingen, Germany) was placed in the fifth intercostal space at the midaxillary line. An operator inserted two 5-mm ports in the eight and ninth intercostal space at the posterior axillary line, and an additional 11.5-mm port was made in the sixth intercostal space at the anterior axillary line. The lung was deflated, and the entire hemithorax was inspected. The phrenic nerve was of normal appearance. The redundant diaphragm was invaginated with a straight probe, and the diaphragm was progressively inverted with continuous running monofilament suture (2/0 polypropylene; Ethicon Ltd; Edinburgh, UK) from the anterolateral to the posteromedial costophrenic recess. During the continuous running suture, it is important to keep the
suture under tension. The surgical assistant pulled the suture out of the thorax using a homemade hook through the port at the anterior axillary line (Fig 2). Suture traction in the anterior direction by an assistant allowed the suturing of the posteromedial recess to be performed more easily. At the end of procedure, the diaphragm was tense to palpation. A single 28F chest tube was placed through the port at the anterior axillary line. The patient was extubated in the operating room, and the chest tube was removed on the first postoperative day. After operation, the chest radiographs showed improved left lower lobe expansion and flattening of the diaphragm. In addition, the patient did not complain of dyspnea on exertion or postoperative pain. The patient was discharged on the fourth postoperative day. A pulmonary function study performed 3 months after surgery showed an improvement in FVC (3.78 L, 88%), FEV1 (2.94 L, 89%), TLC (5.67 L, 99%), IC (2.27 L, 77%), and MVV (132 L/min, 92%; Table 1).
Discussion In recent years, many minimally invasive techniques have been introduced for treating diaphragmatic eventration. The thoracoscopic plication has some advantages compared with plication using thoracotomy. Firstly, it can justify earlier surgical repair of diaphragmatic paralysis. Secondly, it allows surgeons to easily find the possible cause of diaphragmatic eventration. Purely thoracoscopic techniques have been reported,1,2 and many suture techniques have been used for the thoracoscopic plication, eg, the double-
Figure 2. The surgical assistant maintained suture tension by applying continuous suture traction using a homemade hook. www.chestjournal.org
CHEST / 124 / 1 / JULY, 2003
377
suture technique,1 multiple U-stitches,2 endostaplers,4 and the continuous running suture technique.3,5 The difficulty encountered while using the continuous running suture technique in purely thoracoscopic surgery involved maintaining adequate suture tension. This difficulty has encouraged many surgeons to plicate the diaphragm using a thoracotomy or a working incision.3,5,6 We designed a simple steel wire hook for taking the suture out of the thorax through the port. This small hook allows the surgical assistant to maintain suture tension by applying continuous suture traction. By using this homemade hook, we were able to maintain sufficient suture tension easily during purely thoracoscopic surgery. Despite our limited follow-up, the patient has experienced no symptoms related to the diaphragmatic eventration and the integrity of the diaphragm has been maintained. Among changes in pulmonary function, the improvements of FEV1, MVV, and TLC were remarkable compared with the previous study.2 In summary, we performed thoracoscopic plication of the diaphragm using the continuous running
378
suture technique without any kind of minithoracotomy. A homemade hook proved useful to maintain suture tension. The patient has since tolerated exercise well and shown improvements in pulmonary function, despite a limited follow-up. References 1 Mouroux J, Padovani B, Poirier NC, et al. Technique for the repair of diaphragmatic eventration. Ann Thorac Surg 1996; 62:905–907 2 Suzumura Y, Terada Y, Sonobe M, et al. A case of unilateral diaphragmatic eventration treated by plication with thoracoscopic surgery. Chest 1997; 112:530 –532 3 Lai DTM, Paterson HS. Mini-thoracotomy for diaphragmatic plication with thoracoscopic assistance. Ann Thorac Surg 1999; 68:2364 –2365 4 Moon SW, Wang YP, Kim YW, et al. Thoracoscopic plication of diaphragmatic eventration using endostaplers. Ann Thorac Surg 2000; 70:299 –300 5 Van Smith C, Jacobs JP, Burke RP. Minimally invasive diaphragm plication in an infant. Ann Thorac Surg 1998; 65:842– 844 6 Gharagozloo F, McReynolds SD, Snyder L. Thoracoscopic plication of the diaphragm. Surg Endosc 1995; 9:1204 – 1206
Minimally Invasive Techniques
We describe a simple technique for video-assisted thoracoscopic plication in patients with diaphragmatic eventration. During the plication, which is performed with a continuous running suture, a surgical assistant maintains the continuous suture traction using a homemade hook through the port. The technique can be performed easily, without any kind of thoracotomy. (CHEST 2003; 124:376 –378) Key words: diaphragm; diaphragmatic eventration; thoracic surgery, video assisted; thoracoscopes; thoracoscopy Abbreviations: IC ⫽ inspiratory capacity; MVV ⫽ maximal voluntary volume; TLC ⫽ total lung capacity
of the diaphragm by thoracotomy is the P lication usual method used for diaphragmatic eventration. Recently, diaphragmatic plication by thoracoscopy became an acceptable alternative to this standard operative technique1,2; however, technical difficulties associated with thoracoscopic plication led to the adoption of minithoracotomy with thoracoscopic assistance.3 We describe a simple running suture technique for the thoracoscopic plication of diaphragmatic eventration.
Case Report A 43-year-old man presented to our clinic with progressive dyspnea on exertion, with a duration of several years. Chest radiographs showed elevation of the left diaphragm and displacement of the heart (Fig 1). A pulmonary function study showed a reduction in FVC (3.65 L, 82%), FEV1 (2.41 L, 70%), total lung *From the Department of Thoracic and Cardiovascular Surgery, Korea University Medical Center, Korea University College of Medicine, Seoul, Korea. Manuscript received October 17, 2002; revision accepted December 19, 2002. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (e-mail: [email protected]). Correspondence to: Jae Seung Shin, MD, Department of Thoracic and Cardiovascular Surgery, Ansan Hospital, Korea University Medical Center #516, Gojan-dong, Gyeonggi-do, 425-020, Korea; e-mail: [email protected] 376
Figure 1. Preoperative chest radiograph showing elevation of the left diaphragm and displacement of the heart. capacity (TLC) [5.29 L, 89%], inspiratory capacity (IC) [1.60 L, 54%], and maximal voluntary volume (MVV) [105 L/min, 71%; Table 1]. Minimally Invasive Techniques
Table 1—Change in Pulmonary Function After Thoracoscopic Plication of Diaphragmatic Eventration* Variables
Preoperative
FVC, L FEV1, L TLC, L IC, L MVV, L/min
3.65 (82) 2.41 (70) 5.29 (89) 1.60 (54) 105 (71)
3 mo 3.78 (88) 2.94 (89) 5.67 (99) 2.27 (77) 132 (92)
*Data are presented as No. (%).
The patient underwent video-assisted thoracoscopic plication of diaphragm. After inducing general anesthesia, the patient was intubated with a double-lumen endotracheal tube, and positioned in the lateral decubitus position. The stomach was drained with a nasogastric tube, and the patient was positioned head up to displace the intra-abdominal organs downward. Four ports were used; an 11.5-mm port for a 10-mm, 0°, rigid thoracoscope (Karl Storz GmbH; Tuttlingen, Germany) was placed in the fifth intercostal space at the midaxillary line. An operator inserted two 5-mm ports in the eight and ninth intercostal space at the posterior axillary line, and an additional 11.5-mm port was made in the sixth intercostal space at the anterior axillary line. The lung was deflated, and the entire hemithorax was inspected. The phrenic nerve was of normal appearance. The redundant diaphragm was invaginated with a straight probe, and the diaphragm was progressively inverted with continuous running monofilament suture (2/0 polypropylene; Ethicon Ltd; Edinburgh, UK) from the anterolateral to the posteromedial costophrenic recess. During the continuous running suture, it is important to keep the
suture under tension. The surgical assistant pulled the suture out of the thorax using a homemade hook through the port at the anterior axillary line (Fig 2). Suture traction in the anterior direction by an assistant allowed the suturing of the posteromedial recess to be performed more easily. At the end of procedure, the diaphragm was tense to palpation. A single 28F chest tube was placed through the port at the anterior axillary line. The patient was extubated in the operating room, and the chest tube was removed on the first postoperative day. After operation, the chest radiographs showed improved left lower lobe expansion and flattening of the diaphragm. In addition, the patient did not complain of dyspnea on exertion or postoperative pain. The patient was discharged on the fourth postoperative day. A pulmonary function study performed 3 months after surgery showed an improvement in FVC (3.78 L, 88%), FEV1 (2.94 L, 89%), TLC (5.67 L, 99%), IC (2.27 L, 77%), and MVV (132 L/min, 92%; Table 1).
Discussion In recent years, many minimally invasive techniques have been introduced for treating diaphragmatic eventration. The thoracoscopic plication has some advantages compared with plication using thoracotomy. Firstly, it can justify earlier surgical repair of diaphragmatic paralysis. Secondly, it allows surgeons to easily find the possible cause of diaphragmatic eventration. Purely thoracoscopic techniques have been reported,1,2 and many suture techniques have been used for the thoracoscopic plication, eg, the double-
Figure 2. The surgical assistant maintained suture tension by applying continuous suture traction using a homemade hook. www.chestjournal.org
CHEST / 124 / 1 / JULY, 2003
377
suture technique,1 multiple U-stitches,2 endostaplers,4 and the continuous running suture technique.3,5 The difficulty encountered while using the continuous running suture technique in purely thoracoscopic surgery involved maintaining adequate suture tension. This difficulty has encouraged many surgeons to plicate the diaphragm using a thoracotomy or a working incision.3,5,6 We designed a simple steel wire hook for taking the suture out of the thorax through the port. This small hook allows the surgical assistant to maintain suture tension by applying continuous suture traction. By using this homemade hook, we were able to maintain sufficient suture tension easily during purely thoracoscopic surgery. Despite our limited follow-up, the patient has experienced no symptoms related to the diaphragmatic eventration and the integrity of the diaphragm has been maintained. Among changes in pulmonary function, the improvements of FEV1, MVV, and TLC were remarkable compared with the previous study.2 In summary, we performed thoracoscopic plication of the diaphragm using the continuous running
378
suture technique without any kind of minithoracotomy. A homemade hook proved useful to maintain suture tension. The patient has since tolerated exercise well and shown improvements in pulmonary function, despite a limited follow-up. References 1 Mouroux J, Padovani B, Poirier NC, et al. Technique for the repair of diaphragmatic eventration. Ann Thorac Surg 1996; 62:905–907 2 Suzumura Y, Terada Y, Sonobe M, et al. A case of unilateral diaphragmatic eventration treated by plication with thoracoscopic surgery. Chest 1997; 112:530 –532 3 Lai DTM, Paterson HS. Mini-thoracotomy for diaphragmatic plication with thoracoscopic assistance. Ann Thorac Surg 1999; 68:2364 –2365 4 Moon SW, Wang YP, Kim YW, et al. Thoracoscopic plication of diaphragmatic eventration using endostaplers. Ann Thorac Surg 2000; 70:299 –300 5 Van Smith C, Jacobs JP, Burke RP. Minimally invasive diaphragm plication in an infant. Ann Thorac Surg 1998; 65:842– 844 6 Gharagozloo F, McReynolds SD, Snyder L. Thoracoscopic plication of the diaphragm. Surg Endosc 1995; 9:1204 – 1206
Minimally Invasive Techniques