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A Simple and Effective Technique for Diaphragm Plication

Monday, April 29, 2024

Mikilps-Mikgelbs R, Gaidukova M, Siliņš I. A Simple and Effective Technique for Diaphragm Plication. April 2024. doi:10.25373/ctsnet.25715187

The patient in this case is a sixty-year-old woman with increasing shortness of breath, especially in a horizontal position. She was diagnosed with right-sided diaphragmatic paralysis. Surgeons suspected trauma or a viral infection to be the possible causes, but exact etiology was not clear. Observation did not result in any functional or radiological improvement and surgical repair was proposed. 

The patient underwent diaphragmatic plication via uniportal VATS approach. A single 3 cm incision was made at the level of the sixth intercostal space on the midaxillary line. The team’s instrument kit included a 10 mm 30 degree thoracoscope, endoscopic needle holder, curved suction, and lung grasper. A plastic wound retractor was inserted for better access and wound protection. We used 2-0 nonabsorbable, braided suture material to plicate the diaphragm with multiple horizontal mattress sutures. These sutures were reinforced with polymer pledgets on both sides. Suturing continued until sufficient tension and position of the diaphragm was achieved. 

A subpleural catheter was inserted for continuous infusion of local anesthetic and a single 20 Fr tube was used for postoperative fluid drainage. The patient experienced an uneventful postoperative period with relief of her symptoms. A chest x-ray and spirometry one month after surgery demonstrated significant improvement.


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Nice video, and I appreciate seeing a video from Riga! Question for your team, I do an sig number of VATS and robotic plications. In fact we published this video here a few years back We used 2-0 EThibond as well. The main reason is that we find tying, and keeping tension with knot pusher or finger hard. CorKNot was offering a nice solution. Unfortunately in our follow up we had a few patients who failed. When taken back to surgery we found those sutures were breaking, and plication would fail. Especially in obese men. We have now switched to #2 ethibond.
Thank You for Your comment! Actually, we have had no issues with this suture material and we do see our patients after the operation. However, our experience is limited and I have to agree that the bigger suture would be more durable for obese patients. Previously, we did VATS plications with running prolene suture and in the end reinforced the suture line with ethibond. But after some reports, that with the time prolene breaks in pieces, we switched to this technique.

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