Pulmonary Re-Expansion After Diaphragmatic Plication

In this video, the authors present a diaphragmatic plication. Diaphragm paralysis can have a wide variety of causes such as trauma, malignant pathologies, or infectious diseases. Sometimes it can be idiopathic. Usually, the patient presents with dyspnea, thoracic pain, and persistent dry cough. The investigations performed range from chest x-rays and computed tomography (CT) scans to lung function tests and magnetic resonance imaging.

A 78-year-old man presented to the authors’ clinic with severe dyspnea and a dry cough. He had a non-smoking habit and had previously experienced a thoracic trauma by falling and fracturing three ribs two years before, with no history of malignant pathologies. The preliminary lung function tests revealed a restrictive respiratory dysfunction and decreased saturation of oxygen in standby. The chest x-ray showed an elevated right diaphragmatic cupula with collapse of lower lobe of right lung and cervical spondylotic aspect. The authors chose to perform a video-assisted thoracoscopic (VATS) diaphragmatic plication.

First, the authors created an optical port on the sixth intercostal space on the anterior axillary line and then a utility port on the sixth intercostal space on the posterior axillary line. After assessing the diaphragm’s thickness and the thoracic cavity, the authors decided to convert from VATS to a sixth intercostal space thoracotomy to allow for a better exposure. Then they proceeded to a diaphragmatic plication with double layer “U” shaped non-absorbable interrupted sutures, constantly ensuring that no harm was done to the underlying structures.

After complete re-expansion, the right lung did not fill the entire newly formed right thoracic cavity. The right hemidiaphragm was left tight and as flat as possible. A 28 French chest tube was placed and connected to active aspiration system. At the one-year postoperative follow-up visit, the CT scan showed a leveled diaphragm, with comparable thickness right to left, and an improved right lower lobe aspect. All values of spirometry tests improved after the surgery. Clinical and physiological improvements were present early on after surgical plication of the right hemidiaphragm and continued to be maintained one year after surgery.

Diaphragmatic plication is the elective surgical procedure for symptomatic unilateral diaphragmatic paralysis. Despite pulmonary re-expansion being complete, in this case the lung didn’t occupy the new formed thoracic cavity entirely. This issue was naturally adjusted in time, showing on the follow-up chest x-ray a compensatory mediastinal shift to the right.

The authors believe that this case is particularly instructive for the thoracic surgery resident. VATS is an established and feasible approach for the diaphragmatic plication procedure, but the surgeon should always be ready and confident to convert to thoracotomy in cases such as this one since the exposure of the diaphragm and access to tighten the knots are essential for a successful procedure. There is of course this pressure and ambition of the minimally invasive and video- or robotic-assisted era that surgeons now are facing, but converting should not be looked at as failure but rather as an adjustment to deliver the best possible surgical outcome.

Suggested Reading

1. Horvat T. Tratat de Chirurgie. Academiei Romane; 2008. Chirurgie Toracica; vol 4.
2. LoCicero J III, Feins RH, Colson YL, Rocco G. Shields’ General Thoracic Surgery. 8th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2018.
3. Gibson GJ. Diaphragmatic paresis: pathophysiology, clinical features, and investigation. Thorax. 1989;44(11):960-970.