The conduct of anesthesia during surgical plication is critical and requires an anesthetist experienced with single-lung ventilation and anesthesia for pediatric patients. Before the induction of anesthesia, a single dose of prophylactic antibiotics is given, and antiembolic stockings or sequential compression devices are placed to reduce the risk of thromboembolism. A double-lumen endotracheal tube is placed, and the position is verified with direct fiberoptic bronchoscopy. Invasive hemodynamic monitoring lines are placed and include an arterial line and central venous pressure monitors. A nasogastric tube is placed to decompress the stomach and reduce the risk of aspiration. A Foley catheter is placed to monitor urinary output.
The surgical approach for eventration or paralysis differs from the approach for hernia. Hernias are repaired by an abdominal approach (see Chap. 130), whereas unilateral eventration or paralysis is repaired transthoracically. For plication of the diaphragm, the patient is placed in the lateral decubitus position with the aid of a vacuum beanbag. A low posterolateral thoracotomy is performed through the eighth intercostal space. The ipsilateral lung is deflated and retracted superiorly. A lysis of any adhesions is performed, and a thorough examination of the diaphragm is completed to determine the extent of eventration as well as to identify any normal diaphragmatic musculature. The weakened area of the diaphragm, once identified, is grasped with a Babcock clamp and elevated to determine the orientation of suture repair lines (Fig. 129-1). A linear row of pledgeted nonabsorbable horizontal mattress sutures is placed in a radial fashion. During this step of the procedure, it is imperative to pay great attention to preventing injury to any of the abdominal organs or branches of the phrenic nerve. When a sufficient series of stitches is placed, the sutures are tightened, and the weakened area of diaphragm is drawn up in a series of pleats. The goal of the plication is a taut diaphragm. If the diaphragm is not taut after the sutures are tightened, additional stitches can be placed to draw more of the diaphragmatic tissue into the pleats. At completion of the operation, excess diaphragm tissue is reconfigured, and the diaphragm is flattened at the base of the thorax. If the abdominal cavity is too restrictive to permit intraperitoneal return of the abdominal organs, a temporary ventral hernia may be created and then closed after the abdominal wall musculature has relaxed. Chest tubes are placed to drain fluid or air that accumulates.
The weakened area is identified (A), grasped with a Babcock clamp (B), and lifted to determine placement and orientation of suture lines. C. Linear rows of pledgeted nonabsorbable horizontal mattressed sutures are placed through the weak spot in the diaphragm. D. The suture is tightened and the weakened tissues are gathered into pleats, creating a taut diaphragmatic surface.
In the case of bilateral or infracardiac eventration, an abdominal approach is preferred. A similar technique is used through an abdominal incision. Acquired neonatal eventration may be treated by an abdominal approach or, when the diagnosis of hernia cannot be excluded, by a thoracic approach. In the case of phrenic nerve injury, the thoracic approach is superior because it best demonstrates the anatomic distribution of the phrenic nerve.
The thoracoscopic approach to diaphragm plication is similar to the open technique. Preoperative evaluation and preparation are the same as for an open plication. Two techniques for thoracoscopic plication have been described. The first technique creates a single pleat in the diaphragm with the use of a single running stitch; the second technique creates multiple pleats and is similar to the open procedure with respect to suture placement. Thoracoscopy requires the use of the lateral decubitus position and single-lung ventilation. A nasogastric tube is place for gastric drainage. Following plication of the diaphragm, an intercostal nerve block is performed, and chest tubes are placed.19
Two ports are placed, one in the fifth intercostal space in the posterior axillary line and the second in the midclavicular line in the fifth intercostal space (Fig. 129-2). A 5-cm minithoracotomy at the ninth or tenth intercostal space in the posterior axillary line is made. By using an endoscopic instrument to depress the diaphragm into the abdomen, two rows of continuous suture are placed from lateral to medial on either side of the diaphragm invagination. The suture is tied in place, creating a fold in the diaphragm while tightening and lowering the diaphragm into the abdomen.
A. Ideal placement of incisions for the thoracoscopic approach to single-pleat technique. B. Note the use of a single running stitch, which is pulled taut (C) to close up the defect and strengthen the diaphragm.
Three 10-mm ports are placed (Fig. 129-3). The first two are in the eighth intercostal space at the midclavicular line and the midaxillary line. The third port is placed midway between the spine and the posterior aspect of the scapula in the sixth intercostal space. A series of six to eight parallel horizontal mattress sutures is placed along a radial plane. The radial sutures create tension and achieve plication of the diaphragm.
A. Ideal placement of incisions for thoracoscopic approach using multiple pleat technique. B. Similar to the open approach, parallel rows of horizontal mattress sutures are placed and drawn together.