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Technique for the Repair of Diaphragmatic Eventration

1996; Elsevier BV; Volume: 62; Issue: 3 Linguagem: Inglês

10.1016/s0003-4975(96)00530-9

1552-6259

Jérôme Mouroux, B. Padovani, Nancy Poirier, Daniel Benchimol, André Bourgeon, Jean Deslauriers, H Richelme,

Soft tissue tumor case studies

In contrast to the large thoracotomy incisions required by standard surgical techniques for repair of diaphragmatic eventration, the procedure we developed can be performed by video-assisted thoracoscopy, thus offering patients the advantages of a minimally invasive operation. Using two superposed series of transverse back-and-forth continuous sutures, the diaphragm is invaginated, then stretched. The first suture line holds the diaphragm down and maintains the excess within the abdomen; the second suture line places the desired tension on the diaphragmatic dome. Successful repair of 3 cases by this technique is described. In contrast to the large thoracotomy incisions required by standard surgical techniques for repair of diaphragmatic eventration, the procedure we developed can be performed by video-assisted thoracoscopy, thus offering patients the advantages of a minimally invasive operation. Using two superposed series of transverse back-and-forth continuous sutures, the diaphragm is invaginated, then stretched. The first suture line holds the diaphragm down and maintains the excess within the abdomen; the second suture line places the desired tension on the diaphragmatic dome. Successful repair of 3 cases by this technique is described. Routine surgical techniques for repair of diaphragmatic eventration can be classed in two categories—phrenoplicature and incision followed by double breast suture [1.Dor J. Richelme H. Aubert J. Boyer R. L'éventration diaphragmatique.J Chir. 1969; 97: 399-432PubMed Google Scholar]—both of which require full thoracotomy. The technique we have developed has the advantage of being compatible with video-assisted thoracic surgery. The diaphragm is invaginated then stitched using two superposed transverse continuous sutures. The first suture line holds the diaphragm down and maintains the excess within the abdomen, and the second suture line complete the repair by placing the desired tension on the diaphragmatic dome. We describe the successful repair of our first 3 cases of diaphragmatic eventration using this technique.Patients and TechniqueSince 1992, three patients (2 men and 1 woman) aged 33, 63, and 68 years were treated in our institution (Dépar-tement de Chirurgie Thoracique, Hôpital Pasteur, Nice, France) using this repair of diaphragmatic eventration. All were victims of a severe chest trauma (1 automobile accident, 1 fall down a flight of stairs, and 1 fall) that had occurred 2, 6, and 11 years earlier. Eventration occurred on the left side in all 3 patients. All patients presented dyspnea, 1 patient had epigastric pain, and another patient had recurrent palpitations. Pulmonary function tests were abnormal in all 3 patients (Table 1). Diaphragmatic mobility was less than one intercostal space at fluoroscopy.Table 1Pulmonary Function TestsPatient No.Variable123PreoperativeFVC (% predicted)705366FEV1 (% predicted)525955Postoperative at 6 monthsFVC (% predicted)797578FEV1 (% predicted)657069FEV1 = forced expiratory volume in 1 second; FVC = forced vital capacity. Open table in a new tab The procedure was performed under general anesthesia with selective tracheobronchial intubation allowing pulmonary ventilatory exclusion. The stomach drained with a nasogastric tube. The patient was placed in the lateral decubitus position, with the surgeon standing behind. A 10-mm port (port 1) was placed in the fifth intercostal space on the postaxillary line used to introduce the optical unit (Fig. 1). A second port (port 2) was placed on the mammary line in the fifth intercostal space. Finally, a minithoracotomy (5 cm) was performed in the ninth or tenth intercostal space on the posterior axillary line.A endoscopic Duval forceps introduced through port 2 was used to grasp and push the apex of the eventration down into the abdomen. The invagination created a transverse fold from the minithoracotomy to the cardiophrenic angle behind the phrenic nerve. This fold was closed by a first suture line of nonresorbable material beginning at the periphery of the diaphragm closest to the minithoracotomy. The first stitch was knotted, with the free end held with a forceps. A superficial continuous suture was performed to avoid injury to the subdiaphragmatic organs. Once at the cardiophrenic angle, the sutures were drawn tight while the Duval forceps used to push the diaphragm downward was removed. A row of return stitches was made along the same axis and the suture tied with the free end of the first knot. During placement of these return stitches, the suture material was kept taut by the assistant using a forceps introduced through port 2. The tension applied in this manner facilitated grasping of the edges of the fold to be sutured. A second back-and-forth series of continuous sutures was made in the same fashion, burying the first series of suture lines and applying the desired tension on the repaired diaphragm. At the end of the procedure, a 28F Charrie're chest tube is inserted through port 2 and connected to an aspiration system. The other incisions were closed.ResultsThere were no operative incidents. Breathing exercises were started the day after operation, and the chest tube was removed after 3 to 5 days. Pneumonia of the lower right lobe developed in 1 patient but responded to antibiotics. The duration of hospitalization was 6, 7, and 12 days, respectively. The diaphragm remained in anatomic position on the chest roentgenograms at discharge. At long-term follow-up all 3 patients were asymptomatic and had improved pulmonary function (see Table 1). No recurrences have been observed radiologically 17, 20, and 30 months, respectively, after the procedure (Fig. 2).Fig. 2(A) Chest radiograph of left eventration before intervention. (B) Chest radiograph in the same patient 3 months after the operation.View Large Image Figure ViewerDownload Hi-res image Download (PPT)CommentThe indications and methods for surgical repair of diaphragmatic eventration have been the subject of many reports [1.Dor J. Richelme H. Aubert J. Boyer R. L'éventration diaphragmatique.J Chir. 1969; 97: 399-432PubMed Google Scholar, 2.Chin E.F. Lynn R.B. Surgery of eventration of the diaphragm.J Thorac Surg. 1956; 32: 6-14Abstract Full Text PDF PubMed Google Scholar, 3.McNamara J.J. Paulson D.L. Urschel H.C. Razzuk M.A. Eventration of diaphragm.Surgery. 1968; 64: 1013-1021PubMed Google Scholar, 4.Ribet M. Linder J.L. Plication of the diaphragm for eventration or paralysis.Eur J Cardiothorac Surg. 1992; 6: 357-360Crossref PubMed Scopus (49) Google Scholar]. With the advent of minimally invasive surgery, repair of this functional pathology by a large thoracotomy incision appears anachronistic. This can be explained by the fact that most common techniques require wide exposure. The technique we propose has the merit of being compatible with video-assisted thoracic surgery, which limits the aesthetic impact and facilitates respiratory reeducation [5.Miller Jr., J.I. Therapeutic thoracoscopy: new horizons for an established procedure.Ann Thorac Surg. 1991; 52: 1036-1037Abstract Full Text PDF PubMed Scopus (42) Google Scholar].Several technical points merit mention. Invagination of the eventration must create two transverse edges so that the suture lines are located at approximately the same distance from the anterolateral and posterolateral diaphragmatic insertions. The position and the orientation of the forceps inserted through port 2, which is used to grasp the apex of the eventration, are thus very important. The overall view of the diaphragm afforded by the optical unit introduced through port 1 is thus particularly helpful. The thoracotomy incision must be made near the diaphragmatic insertions; otherwise, it can be difficult to start suturing. The ninth or tenth intercostal spaces are the most suitable sites.Use of continuous stitches, which best distribute the tension on the suture line, allows fine stitches on the edges of the tissues and avoids injury to intraperitoneal organs. The tension obtained with the second suture line appears adequate both intraoperatively and on radiographs (see Fig. 2). A third suture line might conceivably be needed and is technically feasible.Two situations contraindicate use of this technique: the existence of extensive pleuropulmonary adhesions and the need to reinforce the diaphragm with a synthetic material. These situations are rarely predictable preoperatively. The level and the extent of the thoracotomy incision and the best technique for diaphragmatic repair can only be decided after exploration through port 1 and, if necessary, through port 2.Despite our limited follow-up with this technique, preliminary clinical, radiologic, and functional results are promising. Additional prospective studies are nevertheless required to compare the procedure with traditional techniques for repair of diaphragmatic eventration. Routine surgical techniques for repair of diaphragmatic eventration can be classed in two categories—phrenoplicature and incision followed by double breast suture [1.Dor J. Richelme H. Aubert J. Boyer R. L'éventration diaphragmatique.J Chir. 1969; 97: 399-432PubMed Google Scholar]—both of which require full thoracotomy. The technique we have developed has the advantage of being compatible with video-assisted thoracic surgery. The diaphragm is invaginated then stitched using two superposed transverse continuous sutures. The first suture line holds the diaphragm down and maintains the excess within the abdomen, and the second suture line complete the repair by placing the desired tension on the diaphragmatic dome. We describe the successful repair of our first 3 cases of diaphragmatic eventration using this technique. Patients and TechniqueSince 1992, three patients (2 men and 1 woman) aged 33, 63, and 68 years were treated in our institution (Dépar-tement de Chirurgie Thoracique, Hôpital Pasteur, Nice, France) using this repair of diaphragmatic eventration. All were victims of a severe chest trauma (1 automobile accident, 1 fall down a flight of stairs, and 1 fall) that had occurred 2, 6, and 11 years earlier. Eventration occurred on the left side in all 3 patients. All patients presented dyspnea, 1 patient had epigastric pain, and another patient had recurrent palpitations. Pulmonary function tests were abnormal in all 3 patients (Table 1). Diaphragmatic mobility was less than one intercostal space at fluoroscopy.Table 1Pulmonary Function TestsPatient No.Variable123PreoperativeFVC (% predicted)705366FEV1 (% predicted)525955Postoperative at 6 monthsFVC (% predicted)797578FEV1 (% predicted)657069FEV1 = forced expiratory volume in 1 second; FVC = forced vital capacity. Open table in a new tab The procedure was performed under general anesthesia with selective tracheobronchial intubation allowing pulmonary ventilatory exclusion. The stomach drained with a nasogastric tube. The patient was placed in the lateral decubitus position, with the surgeon standing behind. A 10-mm port (port 1) was placed in the fifth intercostal space on the postaxillary line used to introduce the optical unit (Fig. 1). A second port (port 2) was placed on the mammary line in the fifth intercostal space. Finally, a minithoracotomy (5 cm) was performed in the ninth or tenth intercostal space on the posterior axillary line.A endoscopic Duval forceps introduced through port 2 was used to grasp and push the apex of the eventration down into the abdomen. The invagination created a transverse fold from the minithoracotomy to the cardiophrenic angle behind the phrenic nerve. This fold was closed by a first suture line of nonresorbable material beginning at the periphery of the diaphragm closest to the minithoracotomy. The first stitch was knotted, with the free end held with a forceps. A superficial continuous suture was performed to avoid injury to the subdiaphragmatic organs. Once at the cardiophrenic angle, the sutures were drawn tight while the Duval forceps used to push the diaphragm downward was removed. A row of return stitches was made along the same axis and the suture tied with the free end of the first knot. During placement of these return stitches, the suture material was kept taut by the assistant using a forceps introduced through port 2. The tension applied in this manner facilitated grasping of the edges of the fold to be sutured. A second back-and-forth series of continuous sutures was made in the same fashion, burying the first series of suture lines and applying the desired tension on the repaired diaphragm. At the end of the procedure, a 28F Charrie're chest tube is inserted through port 2 and connected to an aspiration system. The other incisions were closed. Since 1992, three patients (2 men and 1 woman) aged 33, 63, and 68 years were treated in our institution (Dépar-tement de Chirurgie Thoracique, Hôpital Pasteur, Nice, France) using this repair of diaphragmatic eventration. All were victims of a severe chest trauma (1 automobile accident, 1 fall down a flight of stairs, and 1 fall) that had occurred 2, 6, and 11 years earlier. Eventration occurred on the left side in all 3 patients. All patients presented dyspnea, 1 patient had epigastric pain, and another patient had recurrent palpitations. Pulmonary function tests were abnormal in all 3 patients (Table 1). Diaphragmatic mobility was less than one intercostal space at fluoroscopy. FEV1 = forced expiratory volume in 1 second; FVC = forced vital capacity. The procedure was performed under general anesthesia with selective tracheobronchial intubation allowing pulmonary ventilatory exclusion. The stomach drained with a nasogastric tube. The patient was placed in the lateral decubitus position, with the surgeon standing behind. A 10-mm port (port 1) was placed in the fifth intercostal space on the postaxillary line used to introduce the optical unit (Fig. 1). A second port (port 2) was placed on the mammary line in the fifth intercostal space. Finally, a minithoracotomy (5 cm) was performed in the ninth or tenth intercostal space on the posterior axillary line. A endoscopic Duval forceps introduced through port 2 was used to grasp and push the apex of the eventration down into the abdomen. The invagination created a transverse fold from the minithoracotomy to the cardiophrenic angle behind the phrenic nerve. This fold was closed by a first suture line of nonresorbable material beginning at the periphery of the diaphragm closest to the minithoracotomy. The first stitch was knotted, with the free end held with a forceps. A superficial continuous suture was performed to avoid injury to the subdiaphragmatic organs. Once at the cardiophrenic angle, the sutures were drawn tight while the Duval forceps used to push the diaphragm downward was removed. A row of return stitches was made along the same axis and the suture tied with the free end of the first knot. During placement of these return stitches, the suture material was kept taut by the assistant using a forceps introduced through port 2. The tension applied in this manner facilitated grasping of the edges of the fold to be sutured. A second back-and-forth series of continuous sutures was made in the same fashion, burying the first series of suture lines and applying the desired tension on the repaired diaphragm. At the end of the procedure, a 28F Charrie're chest tube is inserted through port 2 and connected to an aspiration system. The other incisions were closed. ResultsThere were no operative incidents. Breathing exercises were started the day after operation, and the chest tube was removed after 3 to 5 days. Pneumonia of the lower right lobe developed in 1 patient but responded to antibiotics. The duration of hospitalization was 6, 7, and 12 days, respectively. The diaphragm remained in anatomic position on the chest roentgenograms at discharge. At long-term follow-up all 3 patients were asymptomatic and had improved pulmonary function (see Table 1). No recurrences have been observed radiologically 17, 20, and 30 months, respectively, after the procedure (Fig. 2). There were no operative incidents. Breathing exercises were started the day after operation, and the chest tube was removed after 3 to 5 days. Pneumonia of the lower right lobe developed in 1 patient but responded to antibiotics. The duration of hospitalization was 6, 7, and 12 days, respectively. The diaphragm remained in anatomic position on the chest roentgenograms at discharge. At long-term follow-up all 3 patients were asymptomatic and had improved pulmonary function (see Table 1). No recurrences have been observed radiologically 17, 20, and 30 months, respectively, after the procedure (Fig. 2). CommentThe indications and methods for surgical repair of diaphragmatic eventration have been the subject of many reports [1.Dor J. Richelme H. Aubert J. Boyer R. L'éventration diaphragmatique.J Chir. 1969; 97: 399-432PubMed Google Scholar, 2.Chin E.F. Lynn R.B. Surgery of eventration of the diaphragm.J Thorac Surg. 1956; 32: 6-14Abstract Full Text PDF PubMed Google Scholar, 3.McNamara J.J. Paulson D.L. Urschel H.C. Razzuk M.A. Eventration of diaphragm.Surgery. 1968; 64: 1013-1021PubMed Google Scholar, 4.Ribet M. Linder J.L. Plication of the diaphragm for eventration or paralysis.Eur J Cardiothorac Surg. 1992; 6: 357-360Crossref PubMed Scopus (49) Google Scholar]. With the advent of minimally invasive surgery, repair of this functional pathology by a large thoracotomy incision appears anachronistic. This can be explained by the fact that most common techniques require wide exposure. The technique we propose has the merit of being compatible with video-assisted thoracic surgery, which limits the aesthetic impact and facilitates respiratory reeducation [5.Miller Jr., J.I. Therapeutic thoracoscopy: new horizons for an established procedure.Ann Thorac Surg. 1991; 52: 1036-1037Abstract Full Text PDF PubMed Scopus (42) Google Scholar].Several technical points merit mention. Invagination of the eventration must create two transverse edges so that the suture lines are located at approximately the same distance from the anterolateral and posterolateral diaphragmatic insertions. The position and the orientation of the forceps inserted through port 2, which is used to grasp the apex of the eventration, are thus very important. The overall view of the diaphragm afforded by the optical unit introduced through port 1 is thus particularly helpful. The thoracotomy incision must be made near the diaphragmatic insertions; otherwise, it can be difficult to start suturing. The ninth or tenth intercostal spaces are the most suitable sites.Use of continuous stitches, which best distribute the tension on the suture line, allows fine stitches on the edges of the tissues and avoids injury to intraperitoneal organs. The tension obtained with the second suture line appears adequate both intraoperatively and on radiographs (see Fig. 2). A third suture line might conceivably be needed and is technically feasible.Two situations contraindicate use of this technique: the existence of extensive pleuropulmonary adhesions and the need to reinforce the diaphragm with a synthetic material. These situations are rarely predictable preoperatively. The level and the extent of the thoracotomy incision and the best technique for diaphragmatic repair can only be decided after exploration through port 1 and, if necessary, through port 2.Despite our limited follow-up with this technique, preliminary clinical, radiologic, and functional results are promising. Additional prospective studies are nevertheless required to compare the procedure with traditional techniques for repair of diaphragmatic eventration. The indications and methods for surgical repair of diaphragmatic eventration have been the subject of many reports [1.Dor J. Richelme H. Aubert J. Boyer R. L'éventration diaphragmatique.J Chir. 1969; 97: 399-432PubMed Google Scholar, 2.Chin E.F. Lynn R.B. Surgery of eventration of the diaphragm.J Thorac Surg. 1956; 32: 6-14Abstract Full Text PDF PubMed Google Scholar, 3.McNamara J.J. Paulson D.L. Urschel H.C. Razzuk M.A. Eventration of diaphragm.Surgery. 1968; 64: 1013-1021PubMed Google Scholar, 4.Ribet M. Linder J.L. Plication of the diaphragm for eventration or paralysis.Eur J Cardiothorac Surg. 1992; 6: 357-360Crossref PubMed Scopus (49) Google Scholar]. With the advent of minimally invasive surgery, repair of this functional pathology by a large thoracotomy incision appears anachronistic. This can be explained by the fact that most common techniques require wide exposure. The technique we propose has the merit of being compatible with video-assisted thoracic surgery, which limits the aesthetic impact and facilitates respiratory reeducation [5.Miller Jr., J.I. Therapeutic thoracoscopy: new horizons for an established procedure.Ann Thorac Surg. 1991; 52: 1036-1037Abstract Full Text PDF PubMed Scopus (42) Google Scholar]. Several technical points merit mention. Invagination of the eventration must create two transverse edges so that the suture lines are located at approximately the same distance from the anterolateral and posterolateral diaphragmatic insertions. The position and the orientation of the forceps inserted through port 2, which is used to grasp the apex of the eventration, are thus very important. The overall view of the diaphragm afforded by the optical unit introduced through port 1 is thus particularly helpful. The thoracotomy incision must be made near the diaphragmatic insertions; otherwise, it can be difficult to start suturing. The ninth or tenth intercostal spaces are the most suitable sites. Use of continuous stitches, which best distribute the tension on the suture line, allows fine stitches on the edges of the tissues and avoids injury to intraperitoneal organs. The tension obtained with the second suture line appears adequate both intraoperatively and on radiographs (see Fig. 2). A third suture line might conceivably be needed and is technically feasible. Two situations contraindicate use of this technique: the existence of extensive pleuropulmonary adhesions and the need to reinforce the diaphragm with a synthetic material. These situations are rarely predictable preoperatively. The level and the extent of the thoracotomy incision and the best technique for diaphragmatic repair can only be decided after exploration through port 1 and, if necessary, through port 2. Despite our limited follow-up with this technique, preliminary clinical, radiologic, and functional results are promising. Additional prospective studies are nevertheless required to compare the procedure with traditional techniques for repair of diaphragmatic eventration.