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.
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.
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.
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
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.
Ports must be placed cephalad enough to allow suturing.
Before suturing it is important to lift the diaphragm off underlying structures like spleen or liver.
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 . 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.
Diaphragmatic eventration can be congenital or acquired, although “true” congenital form is very rare.
Symptomatic eventration with respiratory distress warrants surgical correction.
Thoracoscopic diaphragmatic plication to render diaphragm taut is preferred with an excellent result.