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Robotic Diaphragm Plication

Monday, June 15, 2015

This video documents the author's technique for robotic diaphragm plication. The robot is docked below the patient. Ten horizontal mattress sutures are placed in the chest under CO2. A 4-port technique is used.

Figure 1: Pre-operative CXR of the patient shows a left-sided paralyzed diaphragm.

Figure 2: Post-operative day two CXR of the patient after the diaphragm plication.

 

Comments

Nice video! I have been doing these VATS, but will try with a robot. Another idea, is I have been using the CorKnot to tie. Saves time, and generates good snug knots. Thank you! sasha
An excellent presentation. On occasions where the hemidiaphragm has been paralysed for many years and is transparently thin, I have found that it is difficult to have enough decent tissue to provide a secure plication. Sutures would esily taer through such tissue and, as a result, I would place mesh above the diaphragm to effect a strong abdominal-thoracic barrier. What do you consider appropriate in these situations? Kind regards, Craig Jurisevic South Australia
Thanks for your question. I have heard of mesh repair but not yet had a diaphragm thin enough that i felt would need it. I saw a video by todd demmy once doing a VATS EPP !! He replaced the diaphragm completely by VATS. amazing but took 16 hours !! So I imagine it would easily be possible. I would favour a biological patch like permacol. How about you ?
Thank you for your reply. I have used a Prolene based mesh on most occasions and this requires a thoracotomy with fixation to the ribs, cartilages and medial aspect of the central tendon. It is a relatively quick procedure, (90 mins or so) but carries all the morbidity associated with a thoracotomy. The thin right hemidiaphragm in the larger patients is an issue with the VAT approach in that it is difficult to push the liver down far enough or fixate the diaphragm firmly enough to prevent paradoxical movement during respiration and manouvers which increase intraabdominal pressure. Right sided paralysis tends to cause significantly more respiratory compromise than left due to the mass off the liver and the relatively greater loss of functioning lung and I tend to repair right hemidiaphragms more than left. I think the best approach is to plicate the diaphragm videscopically as early as possible before the muscular diaphragm becomes too thin and your robotic approach is an excellent treatment option. Thank you again.
Yet another convincing diaphragmatic plication from Joel. The robot has the edge over VATS when it comes to stitching inside the chest, no doubt. I was wondering if the lack of tactile sensation posed any difficulty in gauging how tight the repair is. We have adopted Joel's technique (with his personal help) in Southampton General Hospital with great success. I strongly believe that minimal access plication should be the first choice, and thoractomy reserved for the complicated cases and redos after failures.

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