PREOPERATIVE PLANNING

The three critical concepts in the preoperative planning for a diaphragmatic plication are to (1) make the diagnosis, (2) determine the presence and duration of symptoms, and (3) medically optimize other factors that may be contributing to dyspnea.

In symptomatic patients, diagnosis is usually established by the finding of an elevated hemidiaphragm on a chest radiograph. Portable radiographs taken in critically ill patients are significantly less specific for the diagnosis, especially if the degree of elevation is mild (less than 2 cm), but a high-quality film taken of a standing patient at full inspiration demonstrating significant elevation (e.g., several rib spaces) is usually sufficient to make the diagnosis without additional studies. When the diagnosis is in doubt, a fluoroscopic sniff test or ultrasound can be used to demonstrate limited or paradoxical diaphragmatic movement with full respiratory effort.

We obtain standing and supine pulmonary function tests where a restrictive pattern may worsen when supine, evidenced by a drop in vital capacity. However, PFTs are often nonspecific for the diagnosis and are rather used as an adjunct to a carefully taken history and physical examination in determining how the patient will tolerate single-lung ventilation during the planned procedure.

Ruling out and optimizing other concomitant sources of respiratory insufficiency (e.g., heart failure, interstitial lung disease, pneumonia, smoking, morbid obesity, reactive airway disease, etc.) is critical in the observational period as symptoms may resolve without the need for surgery when these factors are improved.

Standard preoperative planning otherwise includes a full chemistry panel, complete blood count, coagulation profile, and a recent chest radiograph (assists in determining the rib space for entry into the chest).

SURGERY

Positioning

After intubation with a dual-lumen endotracheal tube, a nasogastric tube is placed to decompress the stomach. The patient is then positioned in the standard decubitus position with the break of the operating room table near the level of the xiphoid or slightly lower. Steep Trendelenburg positioning aids in caudal displacement of the abdominal viscera and, therefore, the diaphragm by gravity, allowing for less tension on the sutures as the operation proceeds. In addition, placement of a thoracic epidural catheter for postoperative pain control is recommended, especially for patients undergoing an open procedure.

Open Transthoracic Diaphragmatic Plication

A posterolateral thoracotomy is made in the sixth, seventh, or eighth intercostal space depending on the degree of diaphragmatic elevation on preoperative imaging. The inferior pulmonary ligament is taken down sharply to improve the working space. The standard technique, thought to distribute tension most evenly over the diaphragm, is termed the accordion technique, in which multiple rows of nonabsorbable, pledgeted horizontal mattress sutures are placed in the diaphragm (Fig. 18.1). Using a double-armed suture of relatively large caliber (e.g., size 2-0 or 0 polypropylene monofilament or braided polyester), preloaded with a pledget midlength, multiple consecutive full-thickness bites are taken with each arm of the suture running in a straight line from posterior to anterior along the medial aspect of the diaphragm to create pleats, which are oriented in a medial-to-lateral axis. Once both arms of each suture are taken all the way to the anterior aspect of the diaphragm, the needles are placed through another pledget and the suture tied down. Additional sutures are placed parallel to the first row, working medial to lateral with each successive suture until the redundancy has been completely taken up and the diaphragm pleated down with an accordion-like topography. Care is taken to prevent inadvertently taking bites into hollow abdominal viscera and some surgeons advocate for opening the diaphragm at the central tendon, which allows direct visualization of the abdomen. The thoracotomy is closed in layers and a thoracostomy tube is left in place.

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