Plication of the Diaphragm Technique

For a long time, diaphragm plication surgery was the only definitive treatment for symptomatic diaphragm paralysis. Because the paralyzed diaphragm muscle remains in an elevated position and prevents normal expansion of the lung with inspiration, the plication procedure flattens the dome of the muscle in an attempt to recreate its normal inspiratory position. ^[11] In doing so, the lung may be able to expand more readily, thereby improving ventilatory capabilities and alleviating some or all of the respiratory symptoms. Although this procedure does not result in physiological movement of the diaphragm and is instead a "static" repair leading to functional benefits, a successful plication does reverse paradoxical motion that is associated with the most severe cases of paralysis.

Patients receive general anesthesia and are then positioned for the procedure depending on the approach (ie, transsternal, transthoracic, transabdominal). The video-assisted thoracoscopic approach is less invasive, using small incisions placed in specific locations to visualize the diaphragm with a camera. The most common approach is a muscle-sparing minithoracotomy through the 6th or 7th intercostal space on the side of the paralyzed diaphragm. Video-assisted mini-thoracotomy has been reported to decrease recovery time, shorten hospital stays and significantly improve forced expiratory volume. ^[12] A plication may also be performed using a laparoscopic approach from a subdiaphragmatic orientation.

Thoracoscopic surgery usually requires three or more port wounds to complete the procedure. Some institutions, however, perform most thoracic surgical procedures with a two-port or single-port technique. Single-port thoracoscopic approach has been shown to be feasible and safe. ^[13] Uniportal thoracoscopic procedures seem to offer substantial benefit in terms of postoperative pain and cosmesis with similar outcomes as other surgical techniques. ^{[14, 15]}

The critical components of the procedure are as follows:

• The redundant diaphragm is manipulated in order to eliminate billowing and pulmonary crowding.
• The pleated portion of the diaphragm is folded and may be anchored to the diaphragm anteriorly for sturdy fixation.
• The plicated diaphragm is anchored to the costal arch of the 6th rib to prevent loosening.
• The diaphragm is accessed through one of the planned techniques and several (4-6) nonabsorbable monofilament sutures are woven or pleated in the sagittal plane to effectively reduce redundancy and flatten the diaphragm.
• Excess in the center can be folded back and sutured to the costal margin if necessary. A technique using a stapler has also been described for this plication. The pleated diaphragm becomes taut and fixed.
• A chest tube is placed and the incision is closed.

Complications are rare but can occur as with any thoracic procedure. Care must be taken not to injure the intraabdominal organs while placing the plication sutures through the diaphragm. ^[13] Any injury thus incurred may manifest immediately with bleeding (spleen, liver) or by delayed presentation of peritonitis due to injury to the stomach or bowel. Wound infection is rare.

Complications specific to plication surgery in the chest include the following:

• Injury to the pericardium/heart
• Bleeding
• Injury to intraabdominal organs, including stomach, spleen, and liver
• Injury to the pulmonary parenchyma

General complications to thoracic incision and thoracotomy may include chronic thoracotomy pain, atelectasis, pneumonia, pulmonary embolism, pleural effusion, empyema, chest wall infection, deep venous thrombosis, urinary tract infection, myocardial infarction, and any complication of general anesthesia (eg, mental status changes, stroke, myocardial infarction).

Another potential long term complication is relapse of the elevated diaphragm and/or paradoxical movement due to loosening of the sutures. When this occurs, patients will report a recurrence of the exertional dyspnea and difficulties with physical functioning that were associated with the original onset of the paralysis.