INDICATIONS/CONTRAINDICATIONS

Laparoscopic diaphragmatic plication is a safe and effective operation in carefully selected patients. Laparoscopic diaphragm plication was first reported by Hüttl et al. in three patients. We reported our experience with laparoscopic hemidiaphragm plication in 25 patients, and found that laparoscopic diaphragm plication significantly improves dyspnea, quality of life, and pulmonary function tests (PFTs) in patients with unilateral diaphragm paralysis or eventration.

The approach for hemidiaphragm plication should be individualized by patient anatomy, comorbidities, and surgeon experience. Regardless of approach, proper patient selection, safety, and a tight imbrication of the entire hemidiaphragm are essential. A transabdominal approach offers some theoretical advantages and disadvantages over a transthoracic approach for diaphragmatic plication.

Advantages

Supine decubitus

Ventilation with single-lumen endotracheal tube

Ample working space within abdominal cavity

Direct visualization of intra-abdominal organs to prevent injury during imbrication

Less postoperative pain

Disadvantages

Difficulty visualizing the posterior portion of the hemidiaphragm

Potential splenic or liver laceration

Technically demanding operation in centrally obese patients

Prospective candidates for diaphragmatic plication must have dyspnea that cannot be solely attributed to another process (i.e., 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 merit surgery in the absence of significant dyspnea. Morbidly obese patients should be evaluated for medical or surgical weight loss prior to diaphragmatic plication, since dyspnea may improve after significant weight loss and plication may no longer be required. Technically, 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 may be more common than in normal BMI patients. Patients with neuromuscular disorders should be approached with extreme caution as their symptomatic improvement is moderate at best, and complications are common. It is necessary to approach patients with morbid obesity and neuromuscular disorders in an individualized multidisciplinary fashion to decide if a plication will improve the patient’s condition.

Relative contraindications to a laparoscopic approach to diaphragm plication include previous extensive abdominal surgery, BMI >35, and comorbidities that may worsen with pneumoperitoneum (e.g., chronic renal failure, history of deep venous thrombosis). Morbidly obese patients pose particular technical challenges due to hepatomegaly from steatosis or excessive omental fat in the left upper quadrant.

PREOPERATIVE PLANNING

Clinical Evaluation

The diagnosis of symptomatic hemidiaphragm paralysis or eventration is primarily clinical, and relies mostly on history, chest x-ray, and the physician’s clinical acuity.

The evaluation of a symptomatic patient with hemidiaphragmatic paralysis or eventration should include an objective assessment of dyspnea, physical examination, PFTs, and imaging studies.

A careful respiratory history on the duration and progression of dyspnea and orthopnea is essential. Any potential additional causes of dyspnea (e.g., morbid obesity, primary lung disease, heart failure, etc.) need to be investigated and corrected if possible, since dyspnea secondary to diaphragmatic paralysis or eventration is largely a diagnosis of exclusion.

All patients with dyspnea secondary to an elevated hemidiaphragm or eventration should fill out a standardized respiratory questionnaire to evaluate the severity of their symptoms as objectively as possible and to assess the response to treatment.

Pulmonary Function Tests

PFTs provide relative objectivity to the assessment of dyspneic patients with an elevated hemidiaphragm; however, PFTs are imprecise and do not correlate well with severity of dyspnea or response to plication. Diaphragm dysfunction reduces the compliance of the chest wall; hence, a restrictive pattern (i.e., low forced vital capacity [FVC] and low forced expiratory volume in 1 second [FEV₁]) is the norm.

The diaphragm is the principal inspiratory muscle; therefore, assessing inspiratory PFT parameters (i.e., maximum forced inspiratory flow [FIFmax]) may be of added value.

FVC should be measured in the upright and supine position; supine FVC in healthy individuals can decrease up to 20% from upright values, and supine lung volumes may decrease by 20% to 50% in patients with hemidiaphragmatic eventration or paralysis.

Imaging Studies

Chest x-ray

On standard full-inspiratory PA/LAT chest x-ray, the right hemidiaphragm is normally 1 to 2 cm higher than the left. Hemidiaphragm elevation can be a sign of diaphragmatic paralysis; however, this is nonspecific since a variety of pulmonary, pleural, and subdiaphragmatic processes can also elevate the hemidiaphragm. As a result, further studies may be necessary if an elevated hemidiaphragm is noted on a chest x-ray in the presence of dyspnea.

Fluoroscopic Sniff Test

During fluoroscopy, patients are instructed to sniff, and diaphragmatic excursion is evaluated. Normally, the diaphragm moves caudally, but in patients with hemidiaphragmatic paralysis, the diaphragm may (paradoxically) move cranially. Patients with diaphragmatic eventration, however, may also exhibit passive upward movement of the diaphragm when sniffing.

Stay updated, free articles. Join our Telegram channel

Join