Plication of the Diaphragm
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Plication of the diaphragm is a surgical procedure that has been performed since the 1920s for the treatment of diaphragmatic paralysis. [1] Diaphragmatic paralysis is a serious problem for individuals suffering from the respiratory abnormalities, reduced energy levels, and sleep disturbances that are commonly associated with the disorder. The inability of the lung to expand fully in patients with diaphragmatic paralysis also makes these individuals more susceptible to pleural effusions, pneumonia, and atelectasis.
The goal of diaphragm plication is to flatten the dome of the diaphragm, providing the lung with greater volume for expansion. Since its original description, diaphragm plication has been performed with numerous modifications, including the minimally invasive video-assisted thoracic surgery (VATS) approach. [2, 3] Diaphragm plication surgery has been reported in both children and adults using both transabdominal and transthoracic approaches.
Alternatives to diaphragm plication for the successful treatment of diaphragmatic paralysis include diaphragm pacing and phrenic nerve grafting. [4] Recently, there has been progress in the area of phrenic nerve surgery, which repairs injuries to the phrenic nerve using nerve grafts or nerve transfers. [5] Alternatively, patients with bilateral diaphragmatic paralysis from spinal cord injury may be better served with a diaphragm pacemaker to restore function to the diaphragm. Patients with diaphragmatic paralysis now have options for treatment, including both phrenic nerve grafting and diaphragm plication.
Diaphragm plication is appropriate for pediatric and adult patients with symptomatic diaphragmatic paralysis who have failed conservative management and have not exhibited spontaneous signs of improvement. There are instances when diaphragmatic paralysis is temporary; over the course of weeks to months, the injury may reverse itself, ultimately resulting in a return of normal diaphragm function. However, if there are no signs of spontaneous improvement over a 6- to 12-month period, then the injury is likely permanent.
A proper assessment of the muscle paralysis will determine if diaphragm plication is the most appropriate treatment option. Typically, this applies to patients with severe neuromuscular injuries who demonstrate complete loss of diaphragm motor units, making reinnervation difficult or impossible. Furthermore, complete loss of diaphragmatic innervation from the phrenic nerve will prevent successful diaphragm pacing. A comprehensive electrodiagnostic assessment of the phrenic nerve and diaphragm will usually provide the necessary information.
Patients with diaphragmatic paralysis are not candidates for diaphragm plication surgery if the injury is thought to be temporary or they are exhibiting signs of spontaneous improvement. Furthermore, diaphragm plication is contraindicated if the individual has significant comorbidities that would increase risk. Active or recurrent pulmonary infections, chronic lung disorders, and severe heart disease could be associated also be associated with unacceptable risks if diaphragm plication surgery was attempted.
Relevant Anatomy
The relevant anatomy consists of the right and left phrenic nerve and respective hemidiaphragm on both sides of the body. Each phrenic nerve leaves the spinal cord at the cervical level in the neck (C3-5), runs down the neck on the scalene muscle, and dives under the clavicle into the chest cavity.
In the chest cavity, each nerve runs between the heart and lung, entering the diaphragm towards the medial aspect of the muscle and dividing into several branches to provide nerve impulses to the various parts of the muscle. The intramuscular phrenic nerve has some variability; however, it is generally described as having several large branches that innervate segments of the diaphragm with an overlapping “net” of smaller nerve fibers.
The diaphragm is a broad flat muscle that effectively acts as both the barrier between the thoracic and abdominal cavities, and the primary muscle of inspiration. When the diaphragm muscle contracts, it descends, permitting the lungs to expand passively.
The vital role of the diaphragm in respiration is obvious, though its contribution varies based on position and sleep. The diaphragm is responsible for 56% of the tidal volume in the awake, supine patient and up to 81% during periods of deep sleep.
Outcomes are generally favorable with good long-term prognosis. In a study of 17 patients, Graham et al demonstrated that transthoracic plication resulted in improvement in symptoms and pulmonary function tests. [6] Specifically, the forced vital capacity improved up to 18%. In a study of 15 patients with an average follow-up of 10 years, Higgs et al also demonstrated durable improvements in dyspnea scores, patient satisfaction, and pulmonary function tests. [7] Specifically, forced expiratory volume improved 15.4%. In a study of 41 patients using thoracoscopic techniques, Freeman et al demonstrated improvement in forced vital capacity of 17% and forced expiratory volume of 21%. [8]
Leo F, Girotti P, Tavecchio L, Conti B, Delledonne V, Pastorino U. Anterior diaphragmatic plication in mediastinal surgery: the “reefing the mainsail” technique. Ann Thorac Surg. 2010 Dec. 90(6):2065-7. [Medline].
Versteegh MI, Braun J, Voigt PG, et al. Diaphragm plication in adult patients with diaphragm paralysis leads to long-term improvement of pulmonary function and level of dyspnea. Eur J Cardiothorac Surg. 2007 Sep. 32(3):449-56. [Medline].
Freeman RK, Wozniak TC, Fitzgerald EB. Functional and physiologic results of video-assisted thoracoscopic diaphragm plication in adult patients with unilateral diaphragm paralysis. Ann Thorac Surg. 2006 May. 81(5):1853-7; discussion 1857. [Medline].
Merav AD, Attai LA, Condit DD. Successful repair of a transected phrenic nerve with restoration of diaphragmatic function. Chest. 1983 Nov. 84(5):642-4. [Medline].
Kaufman MR, Elkwood AI, Rose MI, et al. Reinnervation of the paralyzed diaphragm: application of nerve surgery techniques following unilateral phrenic nerve injury. Chest. 2011 Jul. 140(1):191-7. [Medline].
Graham DR, Kaplan D, Evans CC, Hind CR, Donnelly RJ. Diaphragmatic plication for unilateral diaphragmatic paralysis: a 10-year experience. Ann Thorac Surg. 1990 Feb. 49(2):248-51; discussion 252. [Medline].
Higgs SM, Hussain A, Jackson M, Donnelly RJ, Berrisford RG. Long term results of diaphragmatic plication for unilateral diaphragm paralysis. Eur J Cardiothorac Surg. 2002 Feb. 21(2):294-7. [Medline].
Freeman RK, Van Woerkom J, Vyverberg A, Ascioti AJ. Long-term follow-up of the functional and physiologic results of diaphragm plication in adults with unilateral diaphragm paralysis. Ann Thorac Surg. 2009 Oct. 88(4):1112-7. [Medline].
Groth SS, Andrade RS. Diaphragm plication for eventration or paralysis: a review of the literature. Ann Thorac Surg. 2010 Jun. 89(6):S2146-50. [Medline].
Matthew R Kaufman, MD, FACS Partner, The Institute for Advanced Reconstruction at the Plastic Surgery Center
Matthew R Kaufman, MD, FACS is a member of the following medical societies: Alpha Omega Alpha, American Academy of Otolaryngology-Head and Neck Surgery, American Society of Plastic Surgeons, Phi Beta Kappa
Disclosure: Nothing to disclose.
Lourens J Willekes, II, MD Consulting Surgeon, Eastern Thoracic Surgical Associates; Section Chief of Thoracic Surgery, Monmouth Medical Center; Consulting Surgeon, Bayshore Medical Center and Riverview Medical Center
Lourens J Willekes, II, MD is a member of the following medical societies: American College of Surgeons, Society of Thoracic Surgeons
Disclosure: Nothing to disclose.
Andrew I Elkwood, MD, MBA, FACS Founder and Medical Director, Institute of Advanced Reconstruction; Medical Director, Center for the Treatment of Paralysis and Reconstructive Nerve Surgery, Jersey Shore Medical Center; Director, Institute for Advanced Hernia Repair, Monmouth Medical Center; Assistant Clinical Instructor, Drexel University College of Medicine
Andrew I Elkwood, MD, MBA, FACS is a member of the following medical societies: American College of Surgeons, American Society for Aesthetic Plastic Surgery, American Society of Plastic Surgeons, Northeastern Society of Plastic Surgeons
Disclosure: Nothing to disclose.
Dale K Mueller, MD Co-Medical Director of Thoracic Center of Excellence, Chairman, Department of Cardiovascular Medicine and Surgery, OSF Saint Francis Medical Center; Cardiovascular and Thoracic Surgeon, HeartCare Midwest, Ltd, A Subsidiary of OSF Saint Francis Medical Center; Section Chief, Department of Surgery, University of Illinois at Peoria College of Medicine
Dale K Mueller, MD is a member of the following medical societies: American College of Chest Physicians, American College of Surgeons, American Medical Association, Chicago Medical Society, Illinois State Medical Society, International Society for Heart and Lung Transplantation, Society of Thoracic Surgeons, Rush Surgical Society
Disclosure: Received consulting fee from Provation Medical for writing.
Plication of the Diaphragm
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