Thoracoscopic Diaphragmatic Plication Research Articles

Editorial to “Improvement in respiratory function and exercise tolerance following video‐assisted thoracoscopic diaphragm plication for symptomatic iatrogenic persistent diaphragm paralysis after radiofrequency catheter ablation”—An essential respiratory physiology every electrophysiologist should know‐

Editorial to “Improvement in respiratory function and exercise tolerance following video‐assisted thoracoscopic diaphragm plication for symptomatic iatrogenic persistent diaphragm paralysis after radiofrequency catheter ablation”—An essential <scp>respiratory physiology</scp> every <scp>electrophysiologist</scp> should know‐

Improvement in respiratory function and exercise tolerance following video‐assisted thoracoscopic diaphragm plication for symptomatic iatrogenic persistent diaphragm paralysis after radiofrequency catheter ablation

Improvement in respiratory function and exercise tolerance following video‐assisted thoracoscopic diaphragm plication for symptomatic iatrogenic persistent diaphragm paralysis after radiofrequency catheter ablation

Robotic Diaphragm Plication

Acquired unilateral hemidiaphragm elevation is characterised by dyspnoea, which is typically aggravated when lying down, bending over or during swimming. The most common causes are idiopathic or due to injury to the phrenic nerve during cervical or cardio-thoracic surgery. To date, surgical diaphragm plication remains the only effective treatment. The aim of the procedure is to plicate the diaphragm to restore its tension and thus improve breathing mechanics, increase the available space for the lung and reduce compression from abdominal organs. In the past, various techniques using open and minimally invasive approaches have been described. Robot-assisted thoracoscopic diaphragm plication combines the advantages of a minimally invasive approach with excellent visualisation and freedom of movement. It was shown to be a safe technique which is easy to establish and can significantly improve pulmonary function.

Comparative Study of Thoracoscopic and Modified Small Incision Repair for Congenital Diaphragmatic Eventration in Children.

Background: Thoracoscopic diaphragmatic plication has gained popularity in the treatment of congenital diaphragmatic eventration (CDE), but the therapeutic effect and prognosis have rarely been compared with nonendoscopic surgery. Materials and Methods: The medical records of 77 children who had received treatment for CDE in our institution from September 2006 to January 2019 were retrospectively analyzed. According to the repair approach, the children were divided into a thoracoscopic plication group and a modified small incision plication group. The perioperative characteristics and follow-up details after diaphragm plication were compared between the two groups. Results: Among 77 children with CDE, 44 cases were in the thoracoscopic plication group and 33 cases were in the modified small incision plication group. All the cases of CDE were unilateral, with 13 cases on the left side and 64 cases on the right side. There were no differences in the preoperative characteristics between the two groups. The modified small incision plication group had a higher bleeding volume (P = .000) and a greater proportion of patients needing chest drainage (P = .000), whereas the differences in the total and postoperative hospital stays (P = .088, P = .247, respectively) did not significantly differ between the two groups. There were no differences in postoperative improvement in the location of the diaphragm between the two groups or between the right and left lesions (P = .438, P = .677, respectively). The total follow-up time was 2-11 years. No recurrence was reported during this period in either of the groups, but the incidence of postoperative thoracic deformities was higher in the modified small incision plication group (P = .013). Conclusions: Compared with the modified small incision plication, thoracoscopic plication has the advantages of smaller blood loss, a low percentage of intrathoracic drainage tube usage, and no occurrence of thoracic deformities.

The feasibility and safety of same-day surgery for diaphragmatic eventration by minithoracotomy in children.

The diaphragmatic plication procedure by thoracoscopy has gradually become standard treatment for diaphragmatic eventration (DE). However, thoracoscopic diaphragmatic plication is difficult to manipulate and the surgical learning curve is long. This study aimed to demonstrate the feasibility and safety of same-day surgery for DE by minithoracotomy in children. From December 2017 to December 2019, we included 22 patients who underwent diaphragmatic plication of DE in the Department of Pediatric Thoracic Surgery at the Guangzhou Women and Children's Medical Center. A total of 10 patients underwent diaphragmatic plication by minithoracotomy and 12 patients underwent thoracoscopic plication. The perioperative condition and postoperative follow-up were evaluated, respectively. The age, sex, and weight were no different in the minithoracotomy group versus the thoracoscopy group (P > 0.05). The intraoperative time, blood loss volume, and postoperative hospital stay of the minithoracotomy group were significantly less than that of the thoracoscopy group (31.10 ± 4.70min vs. 72.08 ± 22.8min; 1.20 ± 0.42ml vs. 2.58 ± 1.67ml; and 1.00 ± 0.00days vs. 6.00 ± 2.95days, respectively, all P < 0.05). The eventration levels in these two groups were significantly different in the perioperative and postoperative periods as detected by chest X-ray. No chest tubes were inserted and no recurrence of DE occurred in the thoracoscopy group through the postoperative follow-up of at least 6months. Same-day surgery by minithoracotomy as a treatment for DE was feasible and safe with less operative time, less blood loss, and low recurrence. Same-day surgery for DE was attributed to a quick recovery. More prospective studies are necessary to further explore the consequences of same-day surgery for DE by minithoracotomy.

Surgical treatment of 125 cases of congenital diaphragmatic eventration in a single institution

BackgroundThis study sought to investigate the clinical characteristics of congenital diaphragmatic eventration (CDE) and to compare the efficacies of thoracoscopy and traditional open surgery in infants with CDE.MethodsWe retrospectively analyzed the clinical data of 125 children with CDE (90 boys, 35 girls; median age: 12.2 months, range: 1 h-7 years; body weight: 1.99–28.5 kg, median body weight: 7.87 ± 4.40 kg) admitted to our hospital in the previous 10 years, and we statistically analyzed their clinical manifestations and surgical methods.ResultsA total of 108 children in this group underwent surgery, of whom 67 underwent open surgery and 41 underwent thoracoscopic diaphragmatic plication. A total of 107 patients recovered well postoperatively, except for 1 patient who died due to respiratory distress after surgery. After 1–9.5 years of follow-up, 107 patients had significantly improved preoperative symptoms. During follow-up, the location of the diaphragm was normal, and no paradoxical movement was observed. Eleven of the 17 children who did not undergo surgical treatment did not have a decrease in diaphragm position after 1–6 years of follow-up. The index data on the operation time, intraoperative blood loss, chest drainage time, postoperative mechanical ventilation time, postoperative hospital stay and postoperative CCU admission time were better in the thoracoscopy group than in the open group. The difference between the two groups was statistically significant (P < 0.05).ConclusionsThe clinical symptoms of congenital diaphragmatic eventration vary in severity. Patients with severe symptoms should undergo surgery. Both thoracoscopic diaphragmatic plication and traditional open surgery can effectively treat congenital diaphragmatic eventration, but compared with open surgery, thoracoscopic diaphragmatic plication has the advantages of a short operation time, less trauma, and a rapid recovery. Thus, thoracoscopic diaphragmatic plication should be the first choice for children with congenital diaphragmatic eventration.

Application of an Extracorporeal-Assisted Intracorporeal Sliding Knot-Tying Technique in Minimally Invasive Surgery in Children.

Background: A retrospective study was carried out to determine the feasibility and safety of an extracorporeal-assisted intracorporeal sliding knot-tying technique in minimally invasive surgery in children. Materials and Methods: From June 2009 to December 2017, a total of 333 cases of pediatric minimally invasive surgery were performed using the extracorporeal-assisted intracorporeal sliding knot-tying technique. Polyester, polyglactin, and polydioxanone sutures were used for suturing and knotting. The average time used for knotting was recorded during the surgery. The patients were followed up for unraveled knots and recurrence of the diseases. Results: All 333 surgical procedures were performed successfully, including 152 cases of thoracoscopic diaphragmatic hernia repair, 151 cases of thoracoscopic diaphragmatic plication, 7 cases of thoracoscopic esophageal anastomosis, and 23 cases of laparoscopic esophageal hiatal hernia fundoplication. No serious complications or mortalities were observed. Twelve-month to 9-year follow-up showed that all pediatric patients recovered well and no recurrence or unraveled knots were found. Conclusions: This new knot-tying technique is safe and feasible for various minimally invasive endoscopic surgeries, especially for suturing tissues under tension, such as thoracoscopic diaphragmatic hernia repair, laparoscopic esophageal hiatal hernia repair, and fundoplication. All types of sutures can be used for this knot-tying technique. It is easy to learn and can be quickly mastered by doctors with endoscopic surgery experience.

Thoracoscopic one-stage lobectomy and diaphragmatic plication for T3 lung cancer

BackgroundCombined resection of a phrenic nerve is occasionally required in T3 primary lung carcinomas invading the phrenic nerve to completely remove a malignant tumour, resulting in diaphragmatic paralysis. We describe the first case of thoracoscopic lobectomy and diaphragmatic plication as a one-stage surgery for lung cancer invading the phrenic nerve.Case presentationA 56-year-old woman with a T3N0M0 primary adenosquamous carcinoma in the left upper lobe presented with suspicious invasion to the anterior mediastinal fat tissue and left phrenic nerve and underwent left upper lobectomy, node dissection, and partial resection of the anterior mediastinal fat tissue with the left phrenic nerve. Furthermore, thoracoscopic diaphragmatic plication was performed as a concomitant procedure. The patient’s postoperative course was favourable, without any complications, and respiratory function was preserved for 1 year postoperatively.ConclusionsThoracoscopic one-stage lobectomy and diaphragmatic plication for T3 lung cancer invading the phrenic nerve is effective for preservation of postoperative pulmonary function.

Video-assisted thoracoscopic diaphragm plication using a running suture technique is durable and effective

ObjectiveSurgeons have hesitated to adopt minimally invasive diaphragm plication techniques because of technical limitations rendering the procedure cumbersome or leading to early failure or reduced efficacy. We sought to demonstrate efficacy and durability of our thoracoscopic plication technique using a single running suture. MethodsWe retrospectively reviewed patients who underwent our technique for diaphragm plication since 2008. We used a single, buttressed, double-layered, to-and-fro running suture with additional plicating horizontal mattress sutures as needed. ResultsEighteen patients underwent thoracoscopic plication from 2008 to 2015. There were no operative mortalities and 2 unrelated late deaths. Median hospital stay was 3 days (range, 1-12). Atrial fibrillation occurred in 1 patient (5.5%), pneumonia occurred in 2 patients (11%), reintubation occurred in 1 patient (5.5%), and ileus occurred in 1 patient (5.5%). Of 14 patients with complete follow-up, median follow-up was 29.4 months (range, 3.4-84.7). Significant increases between preoperative and postoperative pulmonary function tests (% predicted values) were found for mean forced expiratory volume in 1 second (73.5% ± 3.5% to 88.8% ± 4.5%, P = .002) and mean forced vital capacity (70.6% ± 3.5% to 82.3% ± 3.5%, P = .002). Preoperative mean Baseline Dyspnea Index was 8.1 ± 0.7. Mean Transitional Dyspnea Index 6 months postoperatively was 7.1 ± 0.6 (moderate to major improvement). Transitional Dyspnea Index at last contact (median 29.4 months postoperatively) was 7.2 ± 0.6 (P = .38). Compared with previously published results, this is at least equivalent. ConclusionsThoracoscopic diaphragm plication with a running suture is safe and achieves excellent early and long-term improvements. This addresses technical challenges of tying multiple interrupted sutures by video-assisted thoracoscopic surgery without any apparent compromise to efficacy or durability.

Surgical Outcomes of Pneumatic Compression Using Carbon Dioxide Gas in Thoracoscopic Diaphragmatic Plication.

BackgroundSurgical correction needs to be considered when diaphragm eventration leads to impaired ventilation and respiratory muscle fatigue. Plication to sufficiently tense the diaphragm by VATS is not as easy to achieve as plication by open surgery. We used pneumatic compression with carbon dioxide (CO2) gas in thoracoscopic diaphragmatic plication and evaluated feasibility and efficacy.MethodsEleven patients underwent thoracoscopic diaphragmatic plication between January 2008 and December 2013 in Pusan National University Hospital. Medical records were retrospectively reviewed, and compared between the group using CO2 gas and group without using CO2 gas, for operative time, plication technique, duration of hospital stay, postoperative chest tube drainage, pulmonary spirometry, dyspnea score pre- and postoperation, and postoperative recurrence.ResultsThe improvement of forced expiratory volume at 1 second in the group using CO2 gas and the group not using CO2 gas was 22.46±11.27 and 21.08±5.39 (p=0.84). The improvement of forced vital capacity 3 months after surgery was 16.74±10.18 (with CO2) and 15.6±0.89 (without CO2) (p=0.03). During follow-up (17±17 months), there was no dehiscence in plication site and relapse. No complications or hospital mortalities occurred.ConclusionThoracoscopic plication under single lung ventilation using CO2 insufflation could be an effective, safe option to flatten the diaphragm.

Completely Thoracoscopic Diaphragmatic Plication.

Thoracoscopic diaphragmatic plication for diaphragmatic paralysis with consecutive eventration and respiratory compromise is a desirable alternative to standard thoracotomy. Since minimally invasive techniques usually involve suturing of the diaphragm, most surgeons use a video-assisted approach with a minithoracotomy. Herein we describe our completely thoracoscopic technique for diaphragmatic plication including outcome. We present our technique and experience for completely thoracoscopic diaphragmatic plication for the treatment of symptomatic diaphragmatic paralysis in six consecutive patients. The surgical technique basically consisted of stapling of the abundant diaphragm and reinforcement of the staple line using a self-locking thread. Primary outcome measure was the postoperative result (flattened diaphragm) and resolution of symptoms. Secondary outcome was improvement of lung function values 3months after surgery. Between June 2015 and March 2016, six patients have been operated for symptomatic diaphragmatic paralysis, with one of them suffering from additional transdiaphragmatic hernia. Flattening of the diaphragm was achieved in all 6 patients with resolution of their pre-existing symptoms within days after surgery and without any surgical complications. Lung function volumes measured 3months postoperative improved markedly with an increase in FEV1 as well as FVC of 540ml (SD±193ml) and 776ml (SD±121ml), respectively. In our experience, the presented technique is a safe and simple minimally invasive way to perform a completely thoracoscopic diaphragmatic plication with excellent results so far.

Unilateral Diaphragmatic Paralysis Resulting in Pulmonary Hypertension With Cor Pulmonale and Respiratory Failure

SESSION TITLE: Student/Resident Case Report Poster - Pulmonary Vascular Disease I SESSION TYPE: Student/Resident Case Report Poster PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM INTRODUCTION: Diaphragmatic paralysis is a condition commonly associated with trauma, neurologic compromise, or systemic disease. Unilateral diaphragmatic paralysis (UDP) uncommonly results in respiratory symptoms and is typically found incidentally on imaging. We present an unusual case of UDP causing pulmonary hypertension with cor pulmonale and respiratory failure. CASE PRESENTATION: A 67 year-old male presented to an outside facility with shortness of breath; he was found to be hypoxic to 60% for which he was intubated and thereafter transferred to our facility. His chest xray on admission indicated an elevated left hemidiaphragm with atelectasis. His renal function precluded obtaining a contrast CT scan to exclude pulmonary embolism (PE), so a bedside echocardiogram demonstrated dilation and regional wall motion abnormalities of the right ventricle concerning for sub-massive pulmonary embolism (PE). Interventional Radiology (IR) was consulted for direct thrombolysis of suspected PE but IR pulmonary angiogram found no evidence of PE. A CT Chest without contrast confirmed elevation of left hemidiaphragm with associated atelectasis of left lower lobe and rightward shift of mediastinal structures. A bubble echocardiography demonstrated no right to left shunt. Pulmonary artery catheter measured mean PA pressure of 46 (78/30), cardiac output of 6 l/min and central venous pressure of 14 cm. With no other obvious etiology of sustained respiratory failure, thoracic surgery was consulted for consideration of diaphragmatic plication. The patient underwent diaphragmatic plication with expansion of left lung, following which he was successfully weaned from mechanical ventilation in a few days. At a one month follow up, a six minute walk distance was 384 meters with a nadir of 90%. Total lung capacity was 4.56 L (70%) and DLCO was 15.3 (57%). DISCUSSION: We propose that the patient’s hypoxemic respiratory failure was due to UDP with decreased lung expansion leading to alteration of gas exchange1,2. This resulted in chronic hypoxemia that led to development of pulmonary hypertension (group 3.3) and cor pulmonale. This can occasionally lead to a right to left shunt via a patent foramen ovale, which was ruled out in our patient. Once pulmonary mechanics were improved through diaphragmatic plication, he was liberated from mechanical ventilation. CONCLUSIONS: This case underlies the importance of recognizing UDP as a cause of pulmonary hypertension and cor pulmonale resulting in acute respiratory failure. Reference #1: Elshafie, G., Acosta, J., Aliverti, A., Bradley, A., Kumar, P., Rajesh, P., & Naidu, B. (2016). Chest wall mechanics before and after diaphragm plication. J Cardiothorac Surg Journal of Cardiothoracic Surgery, 11(1). Reference #2: Freeman, R. K., Wozniak, T. C., & Fitzgerald, E. B. (2006). Functional and Physiologic Results of Video-Assisted Thoracoscopic Diaphragm Plication in Adult Patients With Unilateral Diaphragm Paralysis. The Annals of Thoracic Surgery, 81(5), 1853-1857. DISCLOSURE: The following authors have nothing to disclose: Kirill Lipatov, Tasnim Lat, Thomas Delmas, Shekhar Ghamande No Product/Research Disclosure Information

The usefulness of thoracoscopic diaphragmatic plication as a therapeutic procedure for hepatic hydrothorax due to the pluero-peritoneal communication

The usefulness of thoracoscopic diaphragmatic plication as a therapeutic procedure for hepatic hydrothorax due to the pluero-peritoneal communication

A simple thoracoscopic plication technique for diaphragmatic eventration in neonates and infants: technical details and initial results.

Existing minimal-access surgical approaches for correction of symptomatic diaphragmatic eventration may be technically difficult in neonates and infants. We report technical details and initial outcomes of a novel, simple thoracoscopic repair technique. The technique uses one 3-mm camera port, a 3-mm instrument incision without a port, and an 18-gauge spinal needle, which is passed through the chest wall into the pleural space. The excess diaphragm is first plicated over the needle, after which a non-absorbable suture is passed through the needle and tied extracorporeally. The needle is passed repeatedly until the desired degree of tension is achieved. A retrospective review was performed for all patients undergoing repair by this technique. Nine patients have undergone thoracoscopic plication at a median age of 3months (range 0.2-13.2 mos.) and a median weight of 4.5kg (range 2.3-8.2kg). No organ injuries or conversions to thoracotomy occurred. Median operative time was 60min. Patients repaired beyond the neonatal period were extubated in the operating room. There were two post-operative pneumothoraces. No recurrences have been seen at a mean follow-up of 17months. This technique of thoracoscopic diaphragm plication is safe, effective, and technically straightforward in neonates and infants.

Is video-assisted thoracoscopic diaphragmatic plication a widespread technique for diaphragmatic hernia in adults?: Review of the literature and results of a national survey

Diaphragmatic plication is the most accepted treatment for symptomatic diaphragmatic hernia in adults. The fact that this pathology is infrequent and this procedure not been widespread means that this is an exceptional technique in our field.To estimate its use in the literature, we carried out a review in English and Spanish, to which we added our series. We found only 6 series that contribute 59 video-assisted mini-thoractomy for diaphragmatic plications in adults, and none in Spanish. Our series will be the second largest with 18 cases.Finally, we conducted a survey in all the Spanish Thoracic Surgery units in Spain: none reported more than 10 cases operated by thoracoscopy in the last 8 years (except our series) and most continue employing thoracotomy as the main approach.We believe that many patients with symptomatic diaphragmatic hernia could benefit from the use of such techniques.

Robotic thoracoscopic plication for symptomatic diaphragm paralysis.

Diaphragmatic paralysis is an uncommon condition characterized by significant elevation of a hemidiaphragm, and can cause dyspnea. The goal of diaphragm plication is to improve dyspnea by correcting the dysfunctional movement of a diaphragm during inspiration. Minimally invasive thoracoscopic diaphragm plication has been widely used and has been reported to lead to significant improvements in dyspnea and postoperative pulmonary function. Advantages of thoracoscopic plication compared to open thoracotomy are less postoperative pain and shorter hospitalization, yet technical difficulties due to limited workspace afforded by the ribcage and the elevated hemidiaphragm have been a major drawback in using the thoracoscopic approach for this disorder. We describe our experience with robotic thoracoscopic plication for the treatment of diaphragmatic paralysis. This is, to our knowledge, the first report of this kind.

Thoracoscopic Diaphragmatic Plication Using Three 5 mm Ports

Background: Diaphragmatic plication through a thoracoscopic approach has been an effective modality to treat diaphragmatic enventration. However, the conventional technique for thoracoscopic plication has some disadvantages. We have developed an improved and simplified technique with utilizing the head up position, CO₂ insufflation and figure-of-eight sutures. Material and Method: Between October 2005 and September 2009, 9 patients with diaphragmatic paralysis underwent repair using our modified technique. The mean patient age was 38.5±53.0 years (range: 2~76 years). Result: The mean operation time was 46.7±15.9 min (range: 30~85 min). None of the patients died due to this procedure, but there was one case of prolonged air leakage, and a case of re-expansion pulmonary edema, which required 3 days of ventilator support after the procedure. The mean hospital stay was 6.22±2.04 days (range: 4~11 days). The mean follow-up duration was 27.2±11.6 months (range: 2~43 months). All the patients had their symptoms relieved and there was no recurrence of eventration except for one patient who developed more than 2 ㎝ elevation of the diaphragm compared to the immediate post-operation status. Conclusion: With our technique, thoracoscopic diaphragmatic plication was feasible via using only three 5 ㎜ ports and without a working window and the midterm results were favorable. Therefore, we advocate thoracoscopic diaphragmatic plication as a preferred technique to the conventional open plication technique.

Thoracoscopic diaphragmatic plication in small infants

Introduction: Diaphragmatic eventration often causes progressive dyspnea on exertion or respiratory infection in small children, especially those under 2 years of age. Diaphragmatic plication by minimally invasive surgery is evaluated for quick recovery and has been performed on small children. Methods: Nine patients ranging in age from 1 to 33 months and in weight from 3 to 12 kg were treated by thoracoscopic diaphragmatic plication. Six of them needed preoperative support from a respirator or nasal directional positive airway pressure. Three patients had congenital heart disease with right-to-left shunt. The operations were performed with three ports. We put the optical port at the sixth intercostal space and had enough view with artificial pneumothorax at 4 mmHg using carbon dioxide. Single-lung ventilation was never used. The redundant diaphragm was pulled and plicated with non-absorbable 3-0 sutures. Results: The thoracoscopic approach was successful in all nine patients. No conversion was needed. All patients were recovered well postoperatively, except for one patient with a pneumothorax. The patients who needed respiratory support before the operation no longer required it within 8 d of surgery. Conclusion: In conclusion, we showed the feasibility of performing the thoracoscopic plication procedures on small infants. In our series, six out of nine patients were <6 kg and four of them were as young as 1 month old. We placed the optical port near the diaphragm, and this may have been a major factor in helping the surgery succeed. In conclusion, early thoracoscopic plication should be considered even for the small infants with diaphragmatic eventration.

Functional and Physiologic Results of Video-Assisted Thoracoscopic Diaphragm Plication in Adult Patients With Unilateral Diaphragm Paralysis

Plication of the hemidiaphragm for unilateral diaphragm paralysis is infrequently performed in adults. Barriers to diaphragm plication have included the perceived need for thoracotomy and uncertainty of the potential benefits. The purpose of this investigation was to assess the effects of video-assisted thoracoscopic diaphragm plication in symptomatic adult patients with unilateral diaphragm paralysis. Patients with unilateral diaphragm paralysis underwent an evaluation that included a chest radiograph, fluoroscopic sniff test, pulmonary spirometry, and the Medical Research Council (MRC) dyspnea score. Patients with symptomatic unilateral diaphragm paralysis present for at least 6 months were offered video-assisted thoracoscopic diaphragm plication. Patients who underwent diaphragm plication as well as those who declined surgery were reassessed at 6 months with a chest radiograph, spirometry, and the MRC dyspnea score. Twenty-five patients underwent left (19) or right (6) diaphragm plication through video-assisted thoracoscopic diaphragm plication (22) or thoracotomy (3). There were no operative deaths. Mean hospital length of stay for diaphragm plication was 3.7 days for video-assisted thoracoscopic diaphragm plication and 5.4 days for thoracotomy. After diaphragm plication, mean forced vital capacity, forced expiratory volume at 1 second, functional residual capacity, and total lung capacity improved by 17%, 21.4%, 20.3%, and 16.1%, respectively (p < 005) at 6 months. Mean MRC dyspnea scores also significantly improved in the operative cohort (p < 0001). Seventeen patients in the surgical cohort had returned to work at 6 months. Seven patients treated without surgery displayed a trend toward more frequent hospitalizations and deteriorating pulmonary spirometry and MRC dyspnea scores during the follow-up period. Plication of the hemidiaphragm using minimally invasive techniques produced significant improvements in patients' functional status, pulmonary spirometry, and MRC dyspnea scores. Video-assisted thoracoscopic diaphragm plication should be considered appropriate therapy in symptomatic adult patients with unilateral diaphragm paralysis.

Thoracoscopic Diaphragm Plication in Children and Indications for Conversion to Open Thoracotomy

Thoracoscopic plication of the diaphragm has been recently described as an alternative treatment for eventration. It is considered to be much less traumatic than the conventional method. We attempted thoracoscopic diaphragm plication on three patients. Two patients were treated successfully by the minimally invasive technique and were discharged from hospital on the second postoperative day. In the third case, the presence of a mobile intrathoracic kidney due to previous diaphragmatic hernia repair necessitated conversion to open thoracotomy. This patient was discharged on postoperative day six following an uneventful recovery. All patients are well and asymptomatic on followup. We advocate thoracoscopic diaphragm plication in children as a safe procedure with less morbidity and excellent cosmetic results.