Background: Diaphragmatic eventration is a rare (incidence <0.05%)
congenital developmental defect of the muscular portion of the diaphragm,
which maintains its normal attachments (to dorsolumbar spine, ribs,
sternum). Eventration results in diaphragmatic elevation (cephalad
displacement). It can be unilateral or bilateral, partial or complete. It is more
common in males, and involves more often the left hemidiaphragm. Surgery
is indicated only in the presence of symptoms. The commonest symptom
is dyspnoea. We present a video assisted thoracoscopic plication of the left
hemidiaphragm in a symptomatic patient.
Patients and methods: A 47-year old woman presented with nonspecific
gastrointestinal symptoms (dyspnoea and bloating after small
meals, despite continuous gastrokinetic drug consumption), dyspnoea
on exertion, and limited physical activity since childhood. A known left
hemidiaphragm elevation (8 cm higher than the right) was confirmed
on chest radiography. Intraoperatively, the hemidiaphragm appeared
thin, fully deprived of muscular layer, with a cephalad displacement. A
3 port video assisted thoracoscopic postero-anterior plication of the left
hemidiaphragm was performed. The plicated area was further reinforced
by suturing of a bovine pericardial patch.
Results: The patient had an excellent postoperative recovery. She was
extubated in theatre, transferred to the ward without need of oxygen
supplementation, received liquid oral feeding 8 hours postoperatively,
underwent full mobilization and was discharged home on the 3rd postoperative
day. She discontinued gastrokinetic medication (8th postoperative day).
One month postoperatively the Forced Expiratory Volume in 1 second
was increased by 25% and the Forced Vital Capacity by 11% in comparison
to preoperative measurements. One year postoperatively she remains
well; reporting increased physical activity, and absence of dyspnoea and
gastrointestinal symptoms, while weight gain was noted.
Conclusions: Retrospective studies showed that minimally invasive
plication was equally effective to open techniques, being associated with
decreased morbidity, and functional improvement that is maintained for at
least 4 years. Disadvantages attributed to the method include requirement
of single lung ventilation and technical difficulty due to limited space by the
thoracic wall and the cephalad diaphragmatic displacement. In our opinion,
thoracoscopic hemidiaphragmatic plication is an excellent minimally
invasive alternative to open plication, providing good early and medium term results.