Interact CardioVasc Thorac Surg 2007;6:280-281. doi:10.1510/icvts.2006.147587
© 2007 European Association of Cardio-Thoracic Surgery
Work in progress report - Thoracic general |
Thoracoscopic diaphragmatic plication using three 5 mm ports
Do Hyung Kim,
Jung Joo Hwang and
Kil Dong Kim*
Department of Thoracic and Cardiovascular Surgery, Eulji University Hospital, 1306 Dunsan dong Seo gu Daejeon, Daejeon, Republic of Korea
Received 31 October 2006;
received in revised form 12 February 2007;
accepted 13 February 2007
 Presented at the joint 20th Annual Meeting of the European Association for Cardio-thoracic Surgery and the 14th Annual Meeting of the European Society of Thoracic Surgeons, Stockholm, Sweden, September 10–13, 2006.
*Corresponding author. Tel.: +82-42-611-3155; fax: +82-42-611-3867.
E-mail address: kdkimmd{at}eulji.ac.kr (K.D. Kim).
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Abstract
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Thoracoscopic plication is the most effective treatment for diaphragmatic enventration. However, the conventional thoracoscopic plication procedure introduced by Mouroux in 1996 has some disadvantages. We improved and simplified the Mouroux technique with the patient in the head up position, CO2 insufflations and figure-of-eight sutures. These were possible to perform by pure thoracoscopic surgery using three 5 mm ports without the requirement for open thoracotomy.
Key Words: Diaphragm; Eventration; Plication; Thoracoscope
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1. Introduction
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Thoracoscopic diaphragmatic plication is an acceptable alternative to standard thoracotomy. Mouroux introduced the procedure in 1996 [1]. However, the technique did not gain general acceptance. Most surgeons prefer thoracotomy to VATS. The Mouroux technique is technically difficult and associated with inadvertent abdominal organ injuries. In addition, the superficial running sutures are not strong enough to sustain the force of intra-abdominal pressure [2, 3]. We have modified this procedure by orienting the patient in the head up position, using CO2 insufflations and interrupted figure-of-eight sutures to overcome the disadvantages of the Mouroux technique.
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2. Subjects and methods
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2.1. Patient characteristics
Between March 2005 and March 2006, four patients with diaphragmatic paralysis had surgery. There was one male and three female patients. The mean age was 49.5±10.2 years (range, 34–62 years). All of the patients experienced symptoms related to the abnormality including dyspnea (n=4) and palpitations (n=3). Diaphragmatic paralysis was left-sided in three patients and right-sided in one patient.
2.2. Technique
All patients had general anesthesia with double lumen intubation. Patients were placed in the full lateral decubitus position and the surgical table was tilted head up as much as possible in order for the abdominal organs to descend. The lung was deflated before port insertion. One 5 mm port was inserted into the fifth intercostal space on the posterior axillary line for the camera. Two 5 mm ports were inserted at the ninth intercostal space on the posterior axillary line for the instrument (Fig. 1a). In addition, approximately 1500–2500 cc of CO2 gas was insufflated into the thoracic cavity to compress the diaphragm. We insufflated the maximum possible amount of CO2 gas if the vital signs were stable. The head up position and CO2 insufflations expanded the thoracic cavity to the degree that allowed the operator to lift up the diaphragm and to perform full thickness suturing (Fig. 1b). Two pleats were prepared and approximated so that the degree of plication could be determined and the slack of the diaphragm positioned under the suture line. After this, figure-of-eight full thickness sutures were provided at the middle portion of the diaphragm (Fig. 1c). Then, an additional 2–3 figure-of-eight sutures were placed postero-laterally and antero-medially (Fig. 1d) (Video 1). After bleeding control, 20 fr chest tubes, one right angled and one straight, were inserted through the two working ports.
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Fig. 1. Surgical procedure for diaphragmatic plication: (a) one 5 mm port was inserted into the fifth intercostal space on the posterior axillary line for the camera. Two 5 mm ports were inserted into the 9th intercostal space on the posterior axillary line for the instrument; (b) the head up position was used so that the abdominal organs would descend and approximately 1500–2500 cc of CO2 gas was insufflated into the thoracic cavity to compress the diaphragm. (c) Figure-of-eight sutures were used in the middle portion of the diaphragm; (d) an additional 2–3 figure-of-eight sutures were provided postero-laterally and antero-medially. ICS: intercostal space.
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3. Results
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The mean operation time was 56±10.4 min (range 44–82 min). There was no mortality. There was prolonged air leakage, for more than 7 days, in one patient who had moderate adhesions between the lung and the chest wall. Re-expansion pulmonary edema developed in one case and 3 days of ventilator support was provided. We did not think that the CO2 insufflations caused the re-expansion pulmonary edema because we used one lung ventilation during surgery and evacuated all of the gas before expansion of the lung. The cause might have been abrupt expansion of a chronic collapsed lung due to diaphragmatic eventration. The mean hospital stay was 5.8±5.8 days (range, 4–9 days). The mean follow-up duration was 17.3±5.0 months (range, 9–22 months). All patients had their symptoms relieved and there was no recurrence of eventration at the six-month postoperative follow up. Three patients were available for 12-month follow up; the diaphragm was slightly elevated in one case. However, there was no recurrence requiring additional surgery.
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4. Discussion
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Gharagozloo et al. [4] first reported thoracoscopic plication of the diaphragm in 1995. This procedure was not technically different from conventional plication except for the introduction of video for visualization. In 1996, Mouroux et al. [1] reported a more technically applicable thoracoscopic plication procedure. For this new approach the diaphragm was pushed down to obtain sufficient space and to make a pleat. In addition, the slack of the diaphragm was located into the abdomen instead of the thoracic cavity and superimposed superficial running sutures were used. This technique was an improvement compared to the prior thoracoscopic plication technique. However, there were technical difficulties that required improvement before it could be generally accepted. First, when the diaphragm is pushed down, the gap between the diaphragm and the abdominal organs is decreased and the contact surface is increased, which increases the risk of inadvertent abdominal injuries. Second, many surgeons believe that interrupted full layer sutures are better than running sutures for prevention of recurrence due to suture line break down. Third, an expert assistant is necessary to maintain adequate suture tension while using the continuous running suture technique during thoracoscopic surgery [5, 6].
We modified the Mouroux technique to resolve these problems. First, we did not use the port, which was used to push down the diaphragm. Instead, we gained enough space by the head up position and CO2 insufflations. The head up position caused the abdominal organs to descend and the high volume CO2 insufflations pushed the diaphragm down. Second, we replaced the superimposed running sutures with an interrupted full thickness figure-of-eight suture. We thought that a full thickness interrupted suture was better than a running suture and applied a figure-of-eight suture that had the advantages of the interrupted suture while reducing the number of knots. These modifications made plication easy with VATS, so that an expert assistant and open thoracotomy was not necessary and pure thoracoscopic surgery was possible.
In conclusion, the ideal placement for the slack of the diaphragm is positioned under the suture line in VATS plication. However, pushing down the diaphragm and superficial continuous sutures are not technically feasible in VATS plication. Therefore, we recommend our modification to make this procedure easier, safer and less invasive.
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References
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- Mouroux J, Padovani B, Poirier NC, Benchimol D, Bourgeon A, Deslauriers J, Richelme H. Technique for the repair of diaphragmatic eventration. Ann Thorac Surg 1996; 62:905–907.[Abstract/Free Full Text]
- Abraham MK, Menon SS, S BP. Thoracoscopic repair of eventration of diaphragm. Indian Pediatr 2003; 40:1088–1089.[Medline]
- Deslauriers J. Eventration of diaphragm. Chest Surg Clin N Am 1998; 8:315–330.[Medline]
- Gharagozloo F, McReynolds SD, Snyder L. Thoracoscopic placation of the diaphragm. Surg Endosc 1995; 9:1204–1206.[Medline]
- Hwang ZS, Shin JS, Cho YH, Sun K, Lee IS. A simple technique for the thoracoscopic plication of the diaphragm. Chest 2003; 124:376–378.[CrossRef][Medline]
- Arca MJ, Barnhart DC, Lelli JL Jr, Greenfeld J, Harmon CM, Hirschl RB, Teitelbaum DH. Early experience with minimally invasive repair of congenital diaphragmatic hernias: results and lessons learned. J Pediatr Surg 2003; 38:1563–1568.[CrossRef][Medline]
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Abstract
1. Introduction
