Laparoscopic Surgery Applying an Endostaple and Mesh for Adult Diaphragmatic Eventration

摘要

Diaphragmatic eventration, both congenital and acquired, is defined as abnormal elevation of the diaphragm. We report 2 cases of adult symptomatic diaphragmatic eventration successfully treated by laparoscopic diaphragmatic resection with an endostaple. These cases were observed for more than 1 year with no complications or recurrence after surgery. Diaphragmatic eventration, both congenital and acquired, is defined as abnormal elevation of the diaphragm. We report 2 cases of adult symptomatic diaphragmatic eventration successfully treated by laparoscopic diaphragmatic resection with an endostaple. These cases were observed for more than 1 year with no complications or recurrence after surgery. The Video can be viewed in the online version of this article [https://doi.org/10.1016/j.athoracsur.2020.05.115] on http://www.annalsthoracicsurgery.org. The Video can be viewed in the online version of this article [https://doi.org/10.1016/j.athoracsur.2020.05.115] on http://www.annalsthoracicsurgery.org. Diaphragmatic eventration (DE), both congenital and acquired, is an abnormal elevation of the diaphragm, and replacement of the diaphragm muscle with the defect, in part or whole, causes displacement of the hemidiaphragm by weakening the affected portion of the chest.1Deslauriers J. Eventration of the diaphragm.Chest Surg Clin N Am. 1998; 8: 315-330PubMed Google Scholar The incidence of DE is low (less than 0.05%), and it has been reported that DE is more common in males and more commonly affects the left hemidiaphragm. Open transthoracic plication is the traditional approach used to treat patients with symptomatic DE.2Efthimiou J. Butler J. Woodham C. Benson M.K. Westaby S. Diaphragm paralysis following cardiac surgery: role of phrenic nerve cold injury.Ann Thorac Surg. 1991; 52: 1005-1008Abstract Full Text PDF PubMed Scopus (95) Google Scholar Recently, minimally invasive surgery was attempted and thoracoscopic and laparoscopic plication was introduced.3Huttl T.P. Wichmann M.W. Reichart B. Geiger T.K. Schildberg F.W. Meyer G. Laparoscopic diaphragmatic plication: long-term results of a novel surgical technique for postoperative phrenic nerve palsy.Surg Endosc. 2004; 18: 547-551Crossref PubMed Scopus (38) Google Scholar There are no published reports on DE treated by an endostaple in symptomatic adults. We report 2 cases of symptomatic DE successfully treated by laparoscopic diaphragmatic resection with an endostaple. A 74-year-old woman described being out of breath for several years, and she experienced dyspnea over the past 8 months even when she ate half of her usual diet or walked short distances. She had pleuritis when she was approximately 10 years old. She showed dextrocardia on transthoracic echocardiography, but left ventricle systolic function was normal. She had restrictive ventilatory function on the pulmonary function test (forced vital capacity [FVC], forced expiratory volume in 1 second [FEV1], and FEV1/FVC of 1.07 L, 0.89 L, and 83.7%, respectively). We found abnormal elevation of the left diaphragm on the posteroanterior (PA) view of the chest x-ray (Figure 1A), but there were no specific findings except an elevated diaphragm in the abdominal computed tomography scan. We diagnosed the patient with idiopathic DE and decided to perform surgery because she experienced symptoms. A laparoscopic operation was performed in an inverted Y position. We inserted three 12-mm trocars (Medtronic, Minneapolis, MN) and two 5-mm trocars (Dalim, Seoul, South Korea) with chest tubes (20F, Medtronic). We tracked the distended diaphragm (Figure 1B, black arrow) and resected the distended left diaphragm with 4 laparoscopic linear staplers (EndoGIA 60-mm purple straight, SIGTRS60AMT, Medtronic) (Figure 1C, 1D, white, red, blue, and blue arrows). The whole staple line was reinforced with nonabsorbable V-Loc 3-0 sutures (polybutester nonabsorbable device) (Medtronic), and we applied mesh (Covidien Parietene Composite Mesh, Medtronic) with a