Abstract
Diaphragmatic eventration is traditionally managed by plicating the area of the diaphragm which is either thinned (congenital defects) or weakened (acquired defects).
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Keywords
- Diaphragmatic Eventration
- Muscle-sparing Posterolateral Thoracotomy
- Phrenic Nerve
- Seventh Intercostal Space
- Transverse Fashion
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Diaphragmatic eventration is traditionally managed by plicating the area of the diaphragm which is either thinned (congenital defects) or weakened (acquired defects).
Operative Technique
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General anaesthetic with muscle relaxation is employed
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The patient’s position is supine.
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Isolated left-sided eventration is usually approached through a subcostal or transverse upper abdominal incision.
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Right-sided lesions may be approached using a posterolateral muscle-sparing thoracotomy through the sixth or seventh intercostal space to avoid the liver (Fig. 1).
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Bilateral eventration and cases with suspected or known concomitant abdominal pathology (i.e. malrotation) should be approached using an abdominal incision.
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The central area of muscle thinning or weakness is identified (Fig. 2), and the amount of diaphragm that must be included in the plication in order to achieve a taut closure determined.
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The diaphragm should initially aim to be lowered to a level of 1–2 intercostal spaces beyond that which is ultimately desired.
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In some cases the muscle is so thinned that it is nearly impossible to differentiate the eventration from a diaphragmatic hernia with a sac. In this circumstance, it may be necessary to remove the attenuated portion of diaphragm or sac with needle-point monopolar diathermy, thus creating a defect. This should only be done to avoid damage to the phrenic nerve.
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Multiple non-absorbable mattress sutures are then placed in the fashion demonstrated in Figs. 3 and 4. This has the effect of plicating the diaphragm and bringing the edges of the more muscular tissue together.
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Care must be taken to avoid the phrenic nerve, which divides into anterior and posterior branches in a medial to lateral orientation (Fig. 4). The phrenic nerve is easier to visualise using a thoracic approach.
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It is important to take bites of tissue that are adequate enough to avoid the suture cutting through without being deep enough to cause damage to any adjacent viscera.
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If a diaphragmatic defect has been created then it is closed in a transverse fashion in a similar manner.
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The result of the repair is that the muscularised diaphragm edges are brought together with an intervening portion of ‘gathered’ thin or weakened diaphragm (Fig. 5).
Tips
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Diaphragmatic eventration can be distinguished from diaphragmatic herniation by the presence of a smooth raised diaphragmatic outline on chest radiography.
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If diagnostic doubt persists then dynamic imaging using ultrasonography or fluoroscopy to demonstrate paradoxical diaphragmatic movement may be necessary.
Common Pitfalls
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Care should be taken with suture placement in order to avoid damage both to branches of the phrenic nerve and any adjacent viscera.
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Fixing the diaphragm to the thoracic wall can be at the expense of subsequent mobility.
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© 2013 Springer-Verlag Berlin Heidelberg
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Clarke, M., Carachi, R. (2013). E25 Diaphragmatic Eventration. In: Carachi, R., Agarwala, S., Bradnock, T.J., Lim Tan, H., Cascio, S. (eds) Basic Techniques in Pediatric Surgery. Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-3-642-20641-2_96
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DOI: https://doi.org/10.1007/978-3-642-20641-2_96
Publisher Name: Springer, Berlin, Heidelberg
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