Diaphragmatic Plication: Managing Complications and Postoperative Care

Overview

Diaphragmatic plication is a surgical procedure performed to address diaphragmatic paralysis or eventration, conditions that lead to impaired respiratory function due to the elevation and poor movement of the diaphragm. This procedure involves folding and suturing the diaphragm to reduce its size and restore its proper function. As a result, diaphragmatic plication is instrumental in improving respiratory mechanics and patient quality of life, particularly in cases where conservative treatments have failed.

Indications for Diaphragmatic Plication

The primary indication for diaphragmatic plication is diaphragmatic paralysis or eventration, which can result from various conditions, including:

1. Phrenic Nerve Injury: Damage to the phrenic nerve, which innervates the diaphragm, can lead to paralysis or paresis of the diaphragm. This injury can occur due to trauma, surgery (e.g., cardiac surgery), or diseases like poliomyelitis.
2. Congenital Diaphragmatic Eventration: A congenital defect where the diaphragm is abnormally elevated due to incomplete muscular development, leading to respiratory distress.
3. Chronic Obstructive Pulmonary Disease (COPD): In severe cases of COPD, the diaphragm can become flattened and dysfunctional, necessitating plication to restore normal breathing mechanics.
4. Post-thoracic Surgery: Diaphragmatic dysfunction following thoracic surgeries, such as lung resection, may require plication to improve postoperative respiratory function.
5. Idiopathic Diaphragmatic Paralysis: In some cases, diaphragmatic paralysis occurs without an identifiable cause, and plication may be indicated to alleviate symptoms.

Preoperative Evaluation

A thorough preoperative evaluation is crucial to determine the suitability of diaphragmatic plication and to plan the surgical approach. This evaluation typically includes:

1. Pulmonary Function Tests (PFTs): PFTs assess the extent of respiratory impairment. A significant reduction in vital capacity and inspiratory capacity may indicate the need for plication.
2. Imaging Studies: Chest X-rays and computed tomography (CT) scans are used to visualize the position and movement of the diaphragm. An elevated, immobile diaphragm on imaging strongly suggests diaphragmatic paralysis or eventration.
3. Fluoroscopy: Fluoroscopic examination during a "sniff test" can confirm diaphragmatic paralysis by showing paradoxical upward movement of the affected hemidiaphragm during inspiration.
4. Electromyography (EMG): EMG of the diaphragm can help assess the function of the phrenic nerve and the extent of diaphragmatic dysfunction.
5. Cardiopulmonary Exercise Testing: This test can evaluate the impact of diaphragmatic dysfunction on exercise capacity and help predict the potential benefits of plication.
6. Consultation with a Pulmonologist: A multidisciplinary approach, including consultation with a pulmonologist, is often beneficial in assessing the overall respiratory status and planning perioperative care.

Contraindications

While diaphragmatic plication is generally safe, certain contraindications should be considered:

1. Poor Pulmonary Reserve: Patients with severely compromised pulmonary function may not tolerate the procedure well, as it involves manipulating the diaphragm, which could further impair respiratory function.
2. Coexisting Cardiac Conditions: Patients with significant cardiac conditions, such as heart failure, may be at higher risk for complications during and after surgery.
3. Severe Obesity: Obesity can complicate both the surgical procedure and postoperative recovery, increasing the risk of complications.
4. Advanced Age: While age alone is not a contraindication, elderly patients with multiple comorbidities may have an increased risk of adverse outcomes.

Surgical Techniques and Steps

Diaphragmatic plication can be performed using various surgical approaches, with the choice of technique depending on the patient's condition, surgeon's expertise, and available resources.

1. Open Diaphragmatic Plication:
   • Patient Positioning: The patient is placed in a supine or lateral decubitus position, depending on the location of the diaphragmatic dysfunction.
   • Incision: A thoracotomy or laparotomy incision is made to access the diaphragm. The choice of incision depends on the side and extent of the plication required.
   • Plication: The surgeon identifies the elevated portion of the diaphragm and folds it over itself, securing it with non-absorbable sutures. The goal is to reduce the size of the diaphragm and restore its tension, allowing it to function more effectively during respiration.
   • Closure: The incision is closed in layers, and a chest tube may be placed to drain any residual air or fluid from the pleural cavity.
2. Minimally Invasive Diaphragmatic Plication:
   • Patient Positioning: Similar to the open approach, the patient is positioned to allow optimal access to the diaphragm.
   • Port Placement: Several small incisions are made to introduce trocars for a thoracoscope and surgical instruments.
   • Plication: Under thoracoscopic guidance, the surgeon performs the plication using sutures or staplers. This approach minimizes trauma and may result in faster recovery times.
   • Closure: The small incisions are closed, and a chest tube is typically placed.
3. Robotic-Assisted Diaphragmatic Plication:
   • Patient Positioning and Port Placement: The patient is positioned similarly to the thoracoscopic approach, with ports placed for the robotic instruments.
   • Robotic Plication: The surgeon uses robotic instruments to perform precise plication of the diaphragm, with enhanced visualization and dexterity provided by the robotic system.
   • Closure: As with other minimally invasive techniques, the incisions are closed, and a chest tube is placed.

Postoperative Care

Postoperative management is crucial to ensure optimal outcomes and minimize complications. Key aspects of postoperative care include:

1. Pain Management: Adequate pain control is essential for effective respiratory function and to prevent complications such as atelectasis and pneumonia. This may involve the use of epidural analgesia, patient-controlled analgesia (PCA), or intercostal nerve blocks.
2. Respiratory Support: Some patients may require temporary respiratory support, such as mechanical ventilation or non-invasive ventilation, particularly in the immediate postoperative period.
3. Chest Tube Management: If a chest tube was placed, it should be carefully monitored for air leaks, drainage, and proper function. The chest tube is usually removed once the lung has fully expanded and there is minimal drainage.
4. Pulmonary Rehabilitation: Early mobilization and pulmonary rehabilitation exercises are essential to improve lung function and prevent complications such as deep vein thrombosis (DVT) and pulmonary embolism.
5. Monitoring for Complications: Patients should be closely monitored for potential complications, including respiratory distress, infection, and bleeding.
6. Follow-Up: Regular follow-up appointments are necessary to assess the patient's recovery, monitor lung function, and detect any late complications.

Possible Complications

While diaphragmatic plication is generally safe, like any surgical procedure, it carries the risk of complications:

1. Respiratory Complications: These may include atelectasis, pneumonia, or respiratory failure, particularly in patients with pre-existing pulmonary conditions.
2. Bleeding: Intraoperative or postoperative bleeding may occur, necessitating re-exploration or transfusion.
3. Infection: Surgical site infections or pleural infections, such as empyema, can complicate recovery.
4. Phrenic Nerve Injury: Although rare, injury to the phrenic nerve during surgery can lead to further diaphragmatic dysfunction.
5. Prolonged Air Leak: Persistent air leaks from the chest tube may occur, particularly in patients with underlying lung disease.
6. Recurrent Diaphragmatic Elevation: In some cases, the diaphragm may re-elevate over time, requiring further intervention.

Different Techniques

Diaphragmatic plication techniques have evolved, with various approaches tailored to the patient's needs:

1. Anterior vs. Posterior Plication: Depending on the location of the diaphragmatic dysfunction, the surgeon may choose to plicate the anterior or posterior portion of the diaphragm.
2. Single vs. Double Layer Plication: Some surgeons prefer a single-layer plication, while others advocate for a double-layer approach to increase the strength and durability of the repair.
3. Suture vs. Stapler Plication: While sutures are the traditional method for plication, some surgeons use staplers for a quicker and potentially more secure repair.
4. Use of Mesh: In cases of severe diaphragmatic thinning or eventration, the use of a synthetic or biological mesh may be considered to reinforce the plication.

Prognosis and Outcome

The prognosis following diaphragmatic plication is generally favorable, with most patients experiencing significant improvements in respiratory function and quality of life. Key factors influencing the outcome include:

1. Preoperative Pulmonary Function: Patients with better preoperative lung function tend to have better postoperative outcomes.
2. Severity of Diaphragmatic Dysfunction: The extent of diaphragmatic paralysis or eventration can impact the degree of improvement following plication.
3. Surgical Approach: Minimally invasive techniques may result in faster recovery and fewer complications compared to open surgery.
4. Patient Compliance: Adherence to postoperative rehabilitation and follow-up care is crucial for optimal recovery.

Alternative Options

In some cases, diaphragmatic plication may not be the best option, and alternative treatments should be considered:

1. Phrenic Nerve Stimulation: For patients with intact but non-functional phrenic nerves, electrical stimulation of the nerve may restore diaphragmatic function.
2. Diaphragmatic Muscle Training: Respiratory muscle training exercises, often combined with pulmonary rehabilitation, may improve diaphragmatic function in some patients without the need for surgery.
3. Watchful Waiting: In cases of mild diaphragmatic dysfunction, a conservative approach with regular monitoring may be appropriate, particularly in patients with significant comorbidities.
4. Diaphragm Pacemaker: For select patients with chronic respiratory insufficiency, a diaphragm pacemaker may be implanted to improve breathing.

Average Cost

The cost of diaphragmatic plication can vary widely depending on factors such as the surgical approach, hospital setting, and geographic location. On average, the cost ranges from $20,000 to $50,000 in the United States, including preoperative evaluation, surgery, and postoperative care. Minimally invasive techniques may be more expensive due to the use of specialized equipment, but they can also reduce overall costs by shortening hospital stays and recovery times.

Recent Advances

Recent advances in diaphragmatic plication have focused on improving surgical techniques and patient outcomes:

1. Robotic Surgery: The adoption of robotic-assisted plication has increased due to its precision, reduced trauma, and shorter recovery times.
2. Enhanced Recovery Protocols: The implementation of enhanced recovery after surgery (ERAS) protocols has improved postoperative outcomes, reducing complications and hospital stays.
3. Biological Meshes: The use of biologically derived meshes in cases of severe eventration has shown promise in providing a durable and flexible repair.
4. Long-Term Outcomes Research: Ongoing research into the long-term outcomes of diaphragmatic plication is helping to refine patient selection criteria and improve surgical techniques.

Conclusion

Diaphragmatic plication is a highly effective surgical procedure for restoring diaphragmatic function in patients with paralysis or eventration. With careful patient selection, meticulous surgical technique, and comprehensive postoperative care, most patients experience significant improvements in respiratory function and quality of life. As surgical techniques continue to evolve, diaphragmatic plication remains a cornerstone in the management of diaphragmatic dysfunction.