Laparoscopic Diaphragm Plicationaz9194.vo.msecnd.net/pdfs/120401/16.11.pdf · 2012. 5. 25. ·...

Division of Thoracic and Foregut Surgery

Laparoscopic Diaphragm

Plication

Jonathan D’Cunha, MD PhD

Assistant Professor of Surgery

University of Minnesota

No Disclosures

Diaphragmatic Plication

Eventration - congenital

Paralysis - acquired

Symptomatic

Dyspnea

Orthopnea

Traditional Approach:

Open Transthoracic Plication

Open Plication Results

Improved PFTs

Improved quality-of-life

Durable

Graham Ann Thorac Surg 1990

Higgs Eur J Cardiothorac Surg 2002

Simansky Thorax 2002

Verseegth Eur J Cardiothorac Surg 2007

Problems with Open Plication

Invasive

Post-thoracotomy pain

Single-lung ventilation

Alternatives to Thoracotomy?

Gharagozloo Surg Endosc 1995

VATS Plication

FVC +17.0%

FEV1 +21.4%

TLC +16.1%

Dyspnea Score

n = 22

Follow-up = 6 mo

Freeman, Ann Thorac Surg 2006

Problems with VATS

Requires single-lung ventilation

Limited space

Alternative?

Laparoscopic Plication

2005: The Real Story

2005: Setting the Record Straight

Laparoscopic Plication

3 patients

Follow-up: 40-84 months

PFTs improved

Symptom-free

Huttl, Surg Endosc 2004

Advantages

No intercostal nerve pain

Avoid single-lung ventilation

Better visualization

Ample working space

Technical Details

Surgical Technique

• Single lumen ET

• Both arms out

• Steep reverse

Trendelenberg

• Foot board

Surgical Technique

• T-shaped plication

#2 Ticron U-stitches

Pledgets, 31mm needle

• Posterior-Anterior

• Medial-Lateral

• Chest drain

Groth et al, JTCVS 2010

12 mm Port Placement

Right-Sided Plication

Umbilicus

Xyphoid

Diaphragmatic Hole

Chest Tube

Diaphragmatic Retraction

Groth et al, JTCVS 2010

Posterior to Anterior Plication

Plication Tip #1

If it is not hard to place the

posterior stitch, you are not

posterior enough!

#2 Ticron, 31 mm Needle

Load Pledget

Seat Pledget

Square Knot

Seat Square Knot

Intracorporeal Tie

Intracorporeal Tie (6-8 Knots)

Plication Tip #2

After your first posterior

suture you need to place 2 or

3 more

Medial to Lateral Plication

Completed Plication

Plication Tip #3

How tight is tight enough?

Post-op Plication Tip

Chest tube until output < 200 cc for 72 hrs

10% home with chest tube

No lifting > 20 lbs x 3 months

Left-Sided Plication

Pre-op Immediate

Post-op

1 month

Post-op

Left-Sided Plication

1 month

Post-op

12 months

Post-op

Pre-op Post-op 1 month

Post-op

Plication Tip #4

If BMI > 35, don’t try

laparoscopic approach

Plication Tip #5

Do the left side for your first

several cases

Purpose

Objective short- and mid-term evaluation

of laparoscopic plication

Groth, JTCVS 2010

Methods

Prospective cohort study

4/1/2005 - 8/31/2008

PFTs: preop, postop (1 mo and 12 mo)

SGRQ: preop, postop (1 mo and 12 mo)

Groth, JTCVS 2010

Inclusion Criteria

Dyspnea and/or orthopnea

Elevated hemidiaphragm

No alternative etiology

Groth, JTCVS 2010

Exclusion Criteria

Neuromuscular disorders

Groth, JTCVS 2010

Patients

25 patients

–16 left-sided

– 9 right-sided

Groth, JTCVS 2010

Morbidity and Mortality No deaths

Conversion (1)

Complications – Pleural effusions (2)

– Upper GI hemorrhage (1)

– CVA (1)

– UTI (1)

– A-fib (1)

– Reintubation (1)

Groth, JTCVS 2010

Results

Median Range

Chest Tube Duration

(Days)

0 to 20

(Days)

4 1 to 11

Groth, JTCVS 2010

Pre 1 mo 12 mo

p < 0.0001 p = 0.004

Groth, JTCVS 2010

FIFMAX

Pre 1 mo 12 mo

p = 0.003 p = 0.01

Groth, JTCVS 2010

SGRQ Symptom Score Perception of Respiratory Difficulties

Pre 1 mo 12 mo

p = 0.001 p = 0.009

Normal

Groth, JTCVS 2010

SGRQ Activity Score Disturbance of Daily Physical Activities

Pre 1 mo 12 mo

p = 0.003 p = 0.04

Normal

Groth, JTCVS 2010

SGRQ Impacts Score Disturbance of Psycho-Social Function

Pre 1 mo 12 mo

p < 0.001 p = 0.002

Normal

Groth, JTCVS 2010

SGRQ Total Score

Pre 1 mo 12 mo

p < 0.001 p = 0.002

Normal

Groth, JTCVS 2010

Conclusions

Laparoscopic diaphragmatic plication:

novel, minimally invasive, safe

Objective improvement:

– PFTs

– Respiratory quality-of-life

Circumvents disadvantages of transthoracic approaches

Laparoscopic Diaphragm Plicationaz9194.vo.msecnd.net/pdfs/120401/16.11.pdf · 2012. 5. 25. ·...

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