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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

  • General anaesthetic with muscle relaxation is employed

  • The patient’s position is supine.

  • Isolated left-sided eventration is usually approached through a subcostal or transverse upper abdominal incision.

  • 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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Fig. 1

  • Bilateral eventration and cases with suspected or known concomitant abdominal pathology (i.e. malrotation) should be approached using an abdominal incision.

  • 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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Fig. 2

  • The diaphragm should initially aim to be lowered to a level of 1–2 intercostal spaces beyond that which is ultimately desired.

  • 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.

  • 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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Fig. 3

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Fig. 4

  • 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.

  • 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.

  • If a diaphragmatic defect has been created then it is closed in a transverse fashion in a similar manner.

  • 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).

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Fig. 5

Tips

  • Diaphragmatic eventration can be distinguished from diaphragmatic herniation by the presence of a smooth raised diaphragmatic outline on chest radiography.

  • If diagnostic doubt persists then dynamic imaging using ultrasonography or fluoroscopy to demonstrate paradoxical diaphragmatic movement may be necessary.

Common Pitfalls

  • Care should be taken with suture placement in order to avoid damage both to branches of the phrenic nerve and any adjacent viscera.

  • Fixing the diaphragm to the thoracic wall can be at the expense of subsequent mobility.