Fig. 11.1.
Positioning of the patient in a lateral decubitus position with landmarks (scapular tip and intercostal spaces) cleared marked. From Rothenberg SS. Pediatric Thoracic Surgery. In: Pediatric Thoracic Surgery, Mario Lima, Ed. Springer 2013:63–70. Reprinted with permission.
Fig. 11.2.
Plication of the diaphragm. Nonabsorbable suture are passed multiple times through the diaphragm and tied (a), creating a taut diaphragmatic dome (b). From Puri P. Congenital Diaphragmatic Hernia and Eventration. In: Pediatric Surgery, Puri P. and Höllwarth ME, Eds. Springer Surgery Atlas Series 2006: 115–124. Reprinted with permission.
Fig. 11.3.
Thoracoscopic view of diaphragmatic plication. From Molinaro F., et al. Diaphragmatic Eventration. In: Pediatric Thoracic Surgery, Mario Lima, Ed. Springer 2013: 233–238. Reprinted with permission.
Fig. 11.4.
Care is taken not to damage the phrenic nerve, which runs in a medial to lateral course. From Puri P. Congenital Diaphragmatic Hernia and Eventration. In: Pediatric Surgery, Puri P. and Höllwarth ME, Eds. Springer Surgery Atlas Series 2006: 115–124. Reprinted with permission.
Pearls and Pitfalls
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It is important to make sure that there is sufficient diaphragm overlap during repair that it is taut, as muscle fibers stretch invariably and recurrence will ensue.
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Ports must be placed cephalad enough to allow suturing.
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Before suturing it is important to lift the diaphragm off underlying structures like spleen or liver.
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If it is unclear whether bowel or peritoneal organs are involved in the suture line, consider placing a laparoscope.
Postoperative Care and Potential Complications
If patients do not require mechanical ventilation preoperatively, the majority of them (60–100 %) will be successfully extubated either immediately at the conclusion of the surgery or by the end of the day [14, 15, 20]. Infants who require ventilator support prior to surgery can be successfully weaned off ventilator within a week [17]. If a chest tube is inserted during surgery, it should remain until the output becomes less than 20 mL/day. Aggressive pulmonary toilet will aide in re-expansion of the lung. Normal exertion is usually achieved within 1 week of surgery [17, 20]. Feeding can be restarted within 48 h. Surgical treatment is usually very effective with no observed recurrence 1–3 years after the thoracoscopic approach in multiple series [5, 14, 15, 20–22]. The main complications include pneumonia, pleural effusions, and abdominal organ injury. Phrenic nerve injury, although rare, is usually of clinical insignificance.
Summary
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Diaphragmatic eventration can be congenital or acquired, although “true” congenital form is very rare.
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Symptomatic eventration with respiratory distress warrants surgical correction.
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Thoracoscopic diaphragmatic plication to render diaphragm taut is preferred with an excellent result.
References
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2.
Chin EF, Lynn RB. Surgery of eventration of the diaphragm. J Thorac Surg. 1956;32(1):6–14.PubMed
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