Approach to Robotic, Transabdominal, Left Hemi-Diaphragm Plication

Summary

This manuscript reviews the surgical approach and the steps to perform a robotic, transabdominal left hemi-diaphragm plication.

Abstract

Impaired contractility of the diaphragm can occur secondary to diaphragm paralysis. Signs and symptoms of diaphragm paralysis vary among patients. Some may be asymptomatic and present incidentally, while others experience dyspnea secondary to impaired ventilation. Patients who are symptomatic from diaphragm paralysis may benefit from surgical intervention with diaphragm plication. Many surgical approaches are available for diaphragm plication, including open, thoracoscopic, laparoscopic, and robotic-assisted procedures. In this paper, we discuss our step-by-step approach to a robotic, transabdominal diaphragm plication. This was performed in a 60-year-old female presenting with dyspnea secondary to left hemidiaphragm paralysis. The technique includes inducing an iatrogenic pneumothorax to create a pressure equilibrium between the thoracic and peritoneal spaces. Subsequently, a diaphragm plication is performed in a 2-layer approach, using an initial running suture and subsequent reinforcing interrupted sutures in two separate axes, namely the posterior and anterior axes. Lastly, the plication repair is verified through the use of a thoracic port, which is subsequently used for tube thoracostomy placement.

Introduction

Diaphragm dysfunction can result from diaphragm paresis, paralysis, or, more rarely, eventration¹. Diaphragm paresis or paralysis refers to partial or complete loss of the diaphragm’s contractile ability, most commonly secondary to phrenic nerve damage, which may result in impaired ventilation and dyspnea. For symptomatic patients with persistent diaphragm paralysis, diaphragm plication is an effective surgical approach resulting in a significant decrease in dyspnea, notable improvement in pulmonary function tests (PFT), and better functional status^2,3.

Protocol

On the day of surgery, written informed consent was obtained from the patient for the procedure, and verbal consent was obtained to videotape the procedure and use this data for possible publication. Per the University of Minnesota institutional review board guidelines, this project is categorized as Not Human Subjects Research (NHSR). All data was presented in a completely anonymized and de-identified format, ensuring no direct or indirect tracking of human subjects. All ethical protocols for data handling and privacy were strictly observed.

1. Pre-operative Evaluation

1. Routine preoperative diagnostic evaluation....

Results

Post-operative course

The patient tolerated the procedure well and was brought to the general surgical floor for routine post-operative care following completion of surgery. They required oxygen supplementation through nasal cannula until post-operative day (POD) 1, but were weaned off following the use of incentive spirometry. Tube thoracostomy remained in place due to the presence of a small air leak and a small left-sided pleural effusion (Figure 9

Discussion

Diaphragm plication is an effective surgical treatment for diaphragm paralysis in symptomatic patients. Patients can experience impaired respiratory function as evidenced by decreased PFTs and decreased respiratory quality of life, both of which have been shown to improve with diaphragm plication. Thoracic surgeons have traditionally approached the diaphragm transthoracically, through both open and minimally invasive techniques such as video-assisted thoracoscopic surgery (VATS) or robotic-assisted thoracoscopic surgery .......

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
AirSeal Insufflator Trocar, bladeless, 12x120mm	ConMed	IAS12-120LP	Laparoscopic assistant port
Cadière Forceps, 8mm, Endowrist	Intuitive Surgical	471049
Chest drainage cannister - Suction Dry Chest Water Seal Drain Shore	Alleva Medical Ltd.	ST381-0001
da Vinci Xi Surgical System	Intuitive Surgical	Model Number IS4000
DaVinci Xi seal universal 5-12MM	Intuitive Surgical	470500
Endo Dissector Kittner Cigarette Roll	Carefree Surgical Specialties	15505/25
Endo Trocar First Entry KII FIOS Z-thread, 5x100mm	Applied Medical	CTF03	Thoracic assistant port
Insulated Blade Electrode	Medtronic	E1455	Electrocautery
Jackson Pratt Round Drain, 19 Fr	Cardinal Health	JP-HUR195
Laparoscopic bowel grasper forceps, 5mm	Stryker	250-080-084
Long Bipolar Grasper	Intuitive Surgical	471400
Mega SutureCut Needle Driver, 8mm	Intuitive Surgical	471309
Monocryl suture, 4-0, PS-2, undied	Ethicon	Y426H
Needle Insufflation, 13 GA, 150mm	Applied Medical	C2202
Pledgets, soft TFE polymer	Ethicon	D7044
Silk suture, #0, SH needle	Ethicon	K834H
Silk suture, #2-0, SH needle	Ethicon	K833H
Silk tie, #0	Ethicon	A306H
Surgical blade, #15	Bard-Parker	371115
Surgicel SNoW Absorbable Hemostat	Ethicon	2083
Ti-Cron suture, #2, GS-21 taper needle, braided, non-absorbable	Covidien	3146-81
Tip-Up Fenestrated Grasper, 8mm	Intuitive Surgical	470347
Tissue retrieval system, 12mm introducer trocar	ConMed	TRS-ROBO-12
Vicryl suture, #0, UR6 needle, VLT	Ethicon	VCP603H
Vicryl suture, #2-0, SH needle, undied	Ethicon	J417H
V-Loc suture, #0, GS-21 needle, 9 inches, Non-absorbable	Medtronic	VLOCM0346
Wayne Pneumothorax Tray, 29cm	Cook Medical	G56537	Thoracostomy catheter