Chapter 169: Robotic Diaphragm Plication

INTRODUCTION

Diaphragmatic plication is commonly performed in symptomatic patients with diaphragmatic eventration or phrenic nerve paralysis. The history of this procedure dates back to 1923 when Morrison described the first plication on a 10-year-old girl who reported immediate postoperative relief.¹ The rationale behind plicating the lax diaphragm is that tightening the muscle makes it easier for the contralateral diaphragm to be more effective. Access through a thoracotomy is the gold standard. However, with the introduction of minimal-access surgery and robotic assistance, it is now possible to apply the basic tenets of open surgery principles utilizing smaller incisions. Multiple studies assessing minimal-access surgery in thoracic surgical procedures, including thoracoscopy and robotic assistance, have demonstrated shorter length of stay, decreased postoperative pain, and lower requirements for narcotics.^2–4 Therefore, we advocate utilizing robotic assistance for diaphragmatic plication when clinically indicated.

INDICATION FOR DIAPHRAGM PLICATION

Exertional dyspnea is the most common presenting symptom. Patients are thoroughly worked up to rule out any other cause contributing to their dyspnea.⁵ If no other pathologic problem is present to justify their symptoms, patients are referred for extensive physical therapy. In our practice, plication is offered to those symptomatic patients with diaphragm paralysis or eventration who complete a rehabilitation program and continue to be symptomatic without any other pathology to justify exertional dyspnea.

PREOPERATIVE EVALUATION

The main aim of the preoperative workup is usually to identify or rule out organic causes of dyspnea and diaphragm paralysis—specifically looking for, and treating, any evidence of primary lung disease, congestive heart failure (CHF), or morbid obesity. We prefer to get a baseline pulmonary function test (PFT) and use it to monitor postoperative progress over time. A sniff test is often performed to demonstrate a paralyzed hemi-diaphragm. We also obtain a CT of the chest to rule out the presence of a tumor that could be compressing the phrenic nerve, causing diaphragm paralysis.

ROBOTIC CREDENTIALING AND ACCREDITATION

Robotic credentialing is institution dependent. Operating surgeons must familiarize themselves with the robotic platform prior to the procedure. A combination of an online practical introduction, a cadaveric workshop, case observations, and performing the first few cases with proctor supervision is recommended prior to independent utilization of the system. This will help develop visual and technical skills to compensate for the loss of haptic feedback on the robotic platform.⁶

OPERATIVE TECHNIQUE

Positioning

The patient is placed in the lateral decubitus position. The table is flexed right above the level of the hip, and a reverse Trendelenburg position is obtained to level the thoracic cavity. An axillary roll is placed underneath to prevent brachial plexus injury.

Port Placement

We utilize three robotic ports (8 mm) and 1 assistant ...