Thoracoscopic Approach to Eventration of the Diaphragm



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.



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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.


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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.


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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






  • 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 [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, 2022]. The main complications include pneumonia, pleural effusions, and abdominal organ injury. Phrenic nerve injury, although rare, is usually of clinical insignificance.


Summary






  • 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.

Oct 25, 2017 | Posted by in PEDIATRICS | Comments Off on Thoracoscopic Approach to Eventration of the Diaphragm
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