Diaphragmatic Plication—Video 32

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CHAPTER 32 Diaphragmatic Plication—Video 32

Robert J. McKenna, Jr.

Introduction

Plication of a paralyzed diaphragm can relieve dyspnea and substantially improve pulmonary function. The procedure is underused and may be performed well as video-assisted thoracic surgery (VATS). The diaphragm absorbs the pleural fluid created daily in the pleural space, and when the diaphragm is plicated well, there is much less absorptive surface. Patients may drain a surprisingly large amount of fluid postoperatively through the chest tube, and the hospital stay may be 1 week.

Video-Assisted Diaphragmatic Plication

Step 1. Incisions

♦ Exposure: The procedure is usually performed through three incisions (Figure 32-1) (see Video 32-1).

♦ Incision 1: Make a 2-cm incision in the mid-clavicular line in about the sixth intercostal space. This is usually one space below the mammary crease. This incision is used for suturing the diaphragm.

♦ Incision 2: Make a 1-cm incision (used for the trocar and thoracoscope) in the mid-axillary line in the eighth intercostal space. Although we normally use a short reusable trocar for this procedure, we typically use a longer disposable trocar because the diaphragm touches the lens until it is pushed caudally and plicated. Initially, the incision seems too low because the diaphragm is so high, but the low positioning of the thoracoscope helps in creating a very tight plication with maximal downward displacement of the paralyzed diaphragm.

♦ Incision 3: Make a 1-cm incision in the auscultatory space. This is usually 4 fingerbreadths below the tip of the scapula and halfway toward the spine. This incision is used to apply downward pressure on the diaphragm.

Figure 32-1 Incisions used to plicate the diaphragm.

Step 2. Pressure on the Diaphragm

♦ Exposure: Push the diaphragm caudally.

♦ Aim the thoracoscope toward the apex of the chest with the 30-degree lens pointed anteriorly.

♦ Through the incision in the auscultatory incision, apply downward pressure with a ring forceps on the diaphragm (Figure 32-2).

Figure 32-2 A and B, The ring forceps are in position to compress the diaphragm and, after compressing the diaphragm, to facilitate the plication.

Step 3. Plication of the Diaphragm

♦ Exposure: Push the diaphragm caudally.

♦ Aim the thoracoscope apically with the 30-degree lens pointed anteriorly.

♦ Pass a needle driver with 0 Prolene suture or the Endostitch (Covidien, Norwalk, Conn) through the mid-clavicular line to start the plication anteriorly (Figure 32-3).

♦ The ring forceps from a posterior direction indents the diaphragm for the plication.

♦ Suturing proceeds anteromedially to posterolaterally. The suture grabs a 1-cm purchase of the diaphragm on both sides of the indented diaphragm. Tie the suture extracorporeally, and pull the tail through incision 1. Retract the tail of the suture to help with exposure.

♦ The initial sutures are the most difficult to place because the space is small.

♦ As the plication proceeds, compress areas of the diaphragm with a ring forceps from a posterior direction. Multiple layers of suture are placed so the first layer creates a small plication.

♦ The suture is run anteriorly to posteriorly and then back anteriorly to be tied to the tail of the suture.

♦ The plications continue until the diaphragm is very tight (Figure 32-4).

Figure 32-3 The needle driver is inserted through the anteroinferior incision to start the plication anteriorly.

Figure 32-4 A, The diaphragm is elevated before the plication. B, The diaphragm has been displaced by the plication.

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Atlas of Minimally Invasive Thoracic Surgery (Vats)