151: Plication of the Diaphragm from Below

Introduction

The abdominal approach for diaphragmatic plication is appropriate in properly selected patients. Open transabdominal plication has been described for unilateral or bilateral diaphragmatic eventration or paralysis in children,¹ but very few data are available on the results of open transabdominal plication in adults. Laparoscopic diaphragm plication was initially described by Hüttl et al. in a report of three patients.² We reported our experience with 25 patients demonstrating that the laparoscopic approach to diaphragm plication results in significant short- and mid-term improvements in symptoms, quality of life, and pulmonary function tests (PFTs) in patients with hemidiaphragm paralysis or eventration.³

General Principles

The choice of access for diaphragmatic plication is primarily guided by surgeon experience and preference. The minimally invasive approach is preferred over an open approach, since it is associated with less morbidity, although no direct comparisons between open and minimally invasive plication have been reported in the literature. As a general rule, the anterior portion of the hemidiaphragm is easier to access via the abdomen, whereas the posterior portion is more approachable through the chest. Finally, regardless of approach, proper patient selection, safety, and tight imbrication of the entire hemidiaphragm are essential.

The theoretical advantages of a transabdominal approach in comparison with a transthoracic approach are (a) easy intraoperative positioning (supine vs. lateral decubitus), (b) selective ventilation is unnecessary, (c) the abdominal cavity offers ample operating room, (d) there is direct visualization of the intraabdominal organs which reduces the risk of injury during imbrication, and (e) there is less postoperative pain. Disadvantages of transabdominal plication include difficult visualization of the posterior portion of the hemidiaphragm, potential splenic or liver laceration, and technical challenges in centrally obese patients.

Patient Selection

The potential candidate for diaphragmatic plication must have dyspnea that cannot be solely attributed to another process (e.g., poorly controlled primary lung or heart disease) and must have an elevated hemidiaphragm on a posteroanterior and lateral (PA/LAT chest x-ray. Since the only goal of diaphragm plication is to treat dyspnea; operative intervention is indicated exclusively for symptomatic patients. An elevated hemidiaphragm or paradoxical motion per se do not warrant surgery in the absence of significant dyspnea.

Relative contraindications to laparoscopic diaphragm plication are previous extensive abdominal surgery, BMI >35 for females and BMI >30 to 35 for males, and certain neuromuscular disorders. Ideally, morbidly obese patients should be evaluated for medical or surgical bariatric treatment prior to plication, since dyspnea may improve after significant weight loss and a plication may no longer be warranted. Any type of plication is challenging in the morbidly obese patient: the degree of plication may be compromised due to technical difficulties, the relief of dyspnea may be limited, and complications are likely. Patients with neuromuscular disorders should be approached with extreme caution; the symptomatic improvement is moderate at best, and complications are common. An individualized ...