Diaphragmatic plication
Anesthesia type General
Airway ETT with lung isolation
Lines and access PIV, Arterial Line
Monitors Standard, Arterial Line
Primary anesthetic considerations
Preoperative Possible hypoxia/hypercapnia, baseline atelectasis with possible dyspnea while supine
Intraoperative - Lung isolation required

- Lateral decubitus positioning

- Ensure optimal respiratory mechanics prior to extubation
Postoperative - Consider ICU given possibility of respiratory decompensation


Plication of the diaphragm is a surgical procedure indicated for the treatment of diaphragmatic paralysis. The diaphragm is the primary muscle of inspiration, but 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.[1]

Causes of diaphragmatic paralysis[2]:

  • Phrenic nerve injury due to stretching or cooling during cardiac surgery
  • Herpes zoster, poliomyelitis and other viral infections
  • Cervical spondylosis, cervical compressive tumors, blunt neck trauma, neck surgery, pneumonia, and iatrogenic embolization
  • Motor neuron disease, myopathy, inflammatory myositis
  • Malignancy
  • Idiopathic


Diaphragmatic paralysis has many clinical implications including[1]:

  • respiratory derangements (hypercapnia, hypoxia)
  • reduced energy levels
  • sleep disordered breathing during REM
  • inability to fully expand lungs resulting in higher risk of pleural effusions, pneumonia, atelectasis
  • with unilateral diaphragmatic paralysis patients are usually asymptomatic at rest, but may have exertional dyspnea and decreased exercise performance or when in lateral recumbent position with paralyzed side down
  • orthopnea sometimes occurs, especially in patients with bilateral diaphragmatic paralysis


The goal of diaphragm plication is to flatten the dome of the diaphragm, which increases the volume of expansion. The surgical technique for these procedures can be robotic, laparoscopic, VATS, or open with either transthoracic or transabdominal approaches described in the literature[1].

Preoperative management

Patient evaluation

System Considerations
Neurologic Sleep disturbances, possible cervical spine disease as etiology of diaphragmatic paralysis
Cardiovascular Possible transthoracic approach with standard intrathoracic considerations
Respiratory - PFTs: Diaphragmatic paralysis is usually associated with a mild-to-moderate restrictive deficit on spirometry testing, with a reduction in forced expiratory volume, forced vital capacity, and maximum voluntary ventilation.

- ABGs: these patients may present with chronic hypercapnia or hypoxia

- CXR: atelectasis, hemidiaphragm elevation may be present

- Risk of cor pulmonale and pulmonary hypertension in setting of chronic hypercapnia and/or hypoxia

Gastrointestinal Possible laparoscopic approach
Hematologic Possible polycythemia given chronic hypoxemia[3][4]
Renal
Endocrine
Other

Labs and studies

  • ABG
  • PFTs
  • CXR
  • CT scan
  • Depending on the degree and chronicity of hypoxia, may consider an echo for evaluation of pulmonary hypertension

Operating room setup

  • Lung isolation technique available: either DLT or SLT with bronchial blocker
  • Fiberoptic bronchoscope for lung isolation
  • Arterial line

Patient preparation and premedication

  • Consider pre-induction a-line on room air
  • Premedication with midazolam as needed, consider avoidance of opioids for premedication given possible tenuous respiratory status

Regional and neuraxial techniques

  • General anesthesia is required given the need for lung isolation, duration of the procedure, and invasiveness of the procedure
  • Consider epidural or ESP catheter for postoperative pain control due to chest tube placement

Intraoperative management

Monitoring and access

  • Standard monitors
  • Arterial line
  • 2 large bore IVs

Induction and airway management

  • Lung isolation technique available: either DLT or SLT with bronchial blocker[2][5]
  • Fiberoptic bronchoscope for lung isolation
  • Consider HOB 30° induction to optimize FRC
  • Higher risk of atelectasis and mucus plug, consider early recruitment and frequent suctioning

Positioning

  • Lateral decubitus with paralyzed diaphragm up[6]

Maintenance and surgical considerations

  • GETA
  • Possible approaches: thorascopic, laparoscopic, robotically assisted thorascopic, open thoracotomy
  • Chest tube will be placed at the end of the procedure
  • Consider epidural or ESP catheter for chest tubes

Emergence

  • Ensure complete reversal of muscle relaxant
  • Would closely monitor tidal volumes during emergence given that this patient population is at high risk of respiratory compromise
  • Lower threshold to maintain the patient on the ventilator due to high risk of respiratory compromise

Postoperative management

Disposition

  • Floor or ICU depending if postoperative mechanical ventilation is required
    • In one study, mechanical ventilation was discontinued from 2 to 12 days after plication with dramatic improvement in respiratory mechanics [7][8]
  • The patients are generally discharged following chest tube removal. [5]
  • On follow-up, success is indicated by either the repositioning of the diaphragm caudally on radiograph and resolution or improvement in symptoms.[5]

Pain management

  • Consider epidural or ESP catheter for chest tubes

Potential complications

  • Respiratory failure in setting of no improvement in diaphragm
  • Pneumonia

Procedure variants

Variant 1 Variant 2
Unique considerations
Position
Surgical time
EBL
Postoperative disposition
Pain management
Potential complications

References

  1. 1.0 1.1 1.2 "Plication of the Diaphragm: Background, Indications, Contraindications". 2021-04-03. Cite journal requires |journal= (help)
  2. 2.0 2.1 "UpToDate". www.uptodate.com. Retrieved 2021-06-24.
  3. "Diaphragmatic plication for unilateral diaphragmatic paralysis: A 10-year experience". The Annals of Thoracic Surgery. 49 (2): 248–252. 1990-02-01. doi:10.1016/0003-4975(90)90146-W. ISSN 0003-4975.
  4. "Neuromuscular Disorders Affecting the Thorax: Diaphragm Paralysis". Pulmonology Advisor. 2019-01-23. Retrieved 2021-06-24.
  5. 5.0 5.1 5.2 Kara, H. Volkan; Roach, Michael J.; Balderson, Stafford S.; D’Amico, Thomas A. (2015-11). "Thoracoscopic diaphragm plication". Annals of Cardiothoracic Surgery. 4 (6): 573–575. doi:10.3978/j.issn.2225-319X.2015.08.11. ISSN 2225-319X. PMC 4669248. PMID 26693159. Check date values in: |date= (help)
  6. Kara, H. Volkan; Roach, Michael J.; Balderson, Stafford S.; D’Amico, Thomas A. (2015-11). "Thoracoscopic diaphragm plication". Annals of Cardiothoracic Surgery. 4 (6): 573–575. doi:10.3978/j.issn.2225-319X.2015.08.11. ISSN 2225-319X. PMC 4669248. PMID 26693159. Check date values in: |date= (help)
  7. Kuniyoshi, Yukio; Yamashiro, Satoshi; Miyagi, Kazufumi; Uezu, Toru; Arakaki, Katsuya; Koja, Kageharu (2004-06). "Diaphragmatic plication in adult patients with diaphragm paralysis after cardiac surgery". Annals of Thoracic and Cardiovascular Surgery: Official Journal of the Association of Thoracic and Cardiovascular Surgeons of Asia. 10 (3): 160–166. ISSN 1341-1098. PMID 15312011. Check date values in: |date= (help)
  8. Versteegh, Michel I. M.; Braun, Jerry; Voigt, Pieter G.; Bosman, Daniël B.; Stolk, Jan; Rabe, Klaus F.; Dion, Robert A. E. (2007-09). "Diaphragm plication in adult patients with diaphragm paralysis leads to long-term improvement of pulmonary function and level of dyspnea". European Journal of Cardio-Thoracic Surgery: Official Journal of the European Association for Cardio-Thoracic Surgery. 32 (3): 449–456. doi:10.1016/j.ejcts.2007.05.031. ISSN 1010-7940. PMID 17658265. Check date values in: |date= (help)