Diaphragmatic plication: current evidence and techniques in the management of the elevated hemidiaphragm

Abstract

: Diaphragm plication is the preferred surgical intervention for elevation of the hemidiaphragm. This can be a consequence of trauma, damage to the phrenic nerve, or congenital eventration. There are numerous surgical approaches to diaphragmatic plication including open thoracic, open abdominal, minimally invasive transthoracic, minimally invasive transabdominal, and robotic assisted. All approaches are acceptable practices, but there has been a shift to more minimally invasive and video-assisted approaches. In this clinical practice review, we have assessed the current evidence and techniques used for hemidiaphragm elevation. Most evidence assessing the various techniques comes in the form of case studies, case series, and small institutional studies. Video-assisted thoracoscopic surgery is a commonly employed technique associated with positive outcomes as evidenced by improvement of pulmonary function test following the procedure, fewer chest tube days, decrease in self-reported dyspnea, and short hospital stays. Laparoscopic plication is also an acceptable technique. Multiple case studies showed overall positive outcomes with limited morbidity. Robotic assisted approaches were also reviewed. These interventions were shown to improve spirometry values and dyspnea scores. Minimal data exist on open abdominal approaches, and there are not currently enough data to assess their effectiveness. Open thoracic approaches were associated with improvements in spirometry as well as dyspnea scores. All surgical approaches discussed are acceptable strategies for the treatment of the elevated hemidiaphragm. No one intervention appears to be superior, but minimally invasive approaches have become more popular. The success of these procedures is largely believed to be based on surgeon preference and level of expertise.