a report from Dr. Chin Hao Chen and his colleagues at Mackay Memorial Hospital on 21 cases of diaphragmatic plication via single and dual port thoracoscopy.
Dr. Chen and his colleagues at Mackay Memorial Hospital in Taiwan published a new article on their experiences using single and dual port thoracoscopy for diaphragm plication.
The report follows 21 cases from July of 2008 to December of 2011. All 21 cases with left-sided eventrations. 11 were plicated using dual port thoracoscopy in the time period prior to January 2010. In January of 2010, single port thoracoscopy became routine practice at Mackay Memorial. The 10 subsequent cases were all performed by single-port thoracoscopy.
Surgical procedure: The average surgical time between dual port and single port varied by ten minutes with dual port surgery taking longer, averaging 92 minutes. ( see Table 1 of original article). 2.0 silk suture was used for plication of the diaphragm.
In cases using dual port thoracoscopy, the surgeons made the first port at the 7th ICS near the MCL with a second port at the 4th or 5th ICS along the anterior axillary line.
For single port cases, the sole port was 1.5 to 2.0 cm in length and was placed at the 6th ICS along the anterior axillary line.
At the conclusion of the VATS procedure for all patients, a single 24fr or 28fr chest tube was placed, and marcaine was administered as a intercostal block. Patients were extubated prior to leaving the operating room.
The chest tube was removed on the first or second post-operative day. Patients were discharged home following chest tube removal. Post-operative pain scores were minimal, and there was no operative mortality.
The authors discuss surgical technique, and port location for a significant portion of the article. Interested readers are advised to read the original for more details.
Interestingly, while much of the literature on diaphragmatic eventration focuses on early repairs of this condition (neonates and pediatric cases), all of the patients in this series were adults, with an average age of 54 – 55 years of age. Both genders were represented; 15 women and 6 men, with an almost equal distribution among single and dual port cases. (3 men in each group, 7 women in single port, 8 in dual port.)
Unlike traumatic diaphragmatic tear or rupture, diaphragmatic eventration is usually a congenital condition and may be asymptomatic. It is often discovered incidentally after patients undergo radiographic studies for other conditions. However, this condition may predispose patients to other conditions such as respiratory distress or dyspnea by compromising respiratory function on the affected side. In fact, the affected lung may appear tiny, and underdeveloped at the time of repair.
In Dr. Wu and Dr. Chen’s study, patients who underwent dual or single port thoracoscopy reported pain scores of four or less at 24 and 36 hours post-operatively. Post-operative hospitalization was short, with patients being discharged on the first or second post-operative day, with no recurrences or mortality.
Hsin-Hung Wu, Chih-Hao Chen, Ho Chang, Hung-Chang Liu, Tzu-Ti Hung and Shih-Yi Lee (2013). A preliminary report on the feasibility of single-port thoracoscopic surgery for diaphragm plication in the treatment of diaphragm eventration. Journal of Cardiothoracic Surgery 2013, 8:224. Provisional pdf of free full text article, with radiographs, color photographs.
Case report with video of SITS (single incision thoracoscopic surgery) repair of diaphragm defect in a case of hepatic hydrothorax resulting from liver cirrhosis with Dr. Chih-Hao Chen, MAckay Memorial Hospital, Taiwan
Case Report: Single incision thoracoscopic repair of diaphragmatic defect in a patient with hepatic hydrothorax
Dr. Chih-Hao Chen, Thoracic Surgeon MAckay Memorial Hospital, Taiwan
Patient is an elderly woman who was admitted after a motor-vehicle accident with a traumatic fracture of the humerus and femoral neck. She was brought to our ED immediately and was intubated due to acute respiratory failure.
Subsequent Chest radiograph showed diffuse opacity in right hemithorax and concomitant fracture in left side humerus and femoral neck. Attempt for tapping of the pleural effusion showed clear in nature.
According to previous medical records, she had no relevant history. She was admitted to ICU for further evaluation and management.
Fluid analysis in emergency department showed transudate.
LFTS: Total Bilirubin 2.7 mg/dL AST 116 ALT 68 Albumin 2.3 g/dL Direct Bilirubin H 1.1 mg/dL
Chem panel: BUN 83 mg/dL Creatinine 1.6 mg/dL K 3.2 mEq/LNa 144 mEq/L
Chest radiograph on admission showed a massive right-sided pleural effusion.
For symptomatic control, the physician performed intermittent thoracentesis. Because the traumatic site is left aspect of the trunk ( fracture in left side humerus and left side femoral neck ) and right side effusion was very clear.
Hepatic hydrothorax was suspected. Later peritoneal scan confirmed the diagnosis.
The scan showed left side pleural space was sparring from radioisotope. Direct communication between right side pleural cavity and the abdomen. The diagnosis is confirmed with such findings.
CT scans are not diagnostic for this condition, and were not indicated for her other injuries. Therefore, we did not arrange CT scan of the chest / abdomen.
Abdominal ultrasound showed moderate to massive ascites. Along with hepatic encephalopathy, moderate to massive ascites, prolonged PT/PTT, low albumin, higher bilirubin, the extent of cirrhosis is Child’s class C.
Operative Procedure: Single incision thoracoscopic repair of a diaphragmatic defect. Theoretically, with SITS, the wound can be very tiny. However, in our experience (fifteen total cases to date), diaphragm surgery through single port may be a bit difficult because we did not know where the defect is. We have to inspect very carefully and to search for the defect where the fluid came out. In this case, we made one small wound around 2 cm in length at the 6th ICS along the anterior axillary line.
Repair of the diaphragmatic defect was performed using silk suture similar to that used to repair inguinal hernias. Intra-operatively, the defect was 2 -3 mm in diameter.
At the conclusion of the procedure, using the original incision, we placed one Fr.24 chest tube to monitor the drainage and may consider chemical pleurodesis if the drainage persists. The operative procedure was accomplished within 30 minutes.
Post-operative Chest Radiograph
Post-operative condition of the chest film showed near complete resolution of the effusion and lung re-expansion was complete.
Pathology/ Fluid Cytology: fluid analysis and peritoneal scan showed communication between peritoneal space and right side pleural space confirming pre-operative diagnosis. No tissue specimens were taken during this procedure.
Hepatic hydrothorax is the development of a pleural effusion in a patient with liver disease in the absence of cardiopulmonary pathology, making it a diagnosis of exclusion in many cases. It can occur in patients with and without ascites and may be the first presenting symptom in patients with undiagnosed liver disease. Similar to catamenial pneumothorax; hepatic hydrothorax is predominantly a right-sided disease. This is due to an anatomic gutter or diaphragmatic defect that occurs, and allows the passage of material or fluid from the abdominal cavity into the pleural space. This can be seen and identified on peritoneal studies(Peritoneal scan) like the study showed in our case study above. (Similar pathologies can occur in related conditions such as renal failure related hydrothorax due to this defect). Such defect is usually identified in the tendon part of the diaphragm. Peritoneal scan can confirm there is communication between the abdominal cavity and the pleural space. However, the definite location, size and number of defects can not been identified by the scan alone. Thoracoscopic inspection is the only method to search for such defect(s).
Video-assisted thoracoscopic surgery (VATS) has been shown to be a safe and effective method of treating this condition, by allowing surgeons to correct the defect, and thus prevent recurrence (Saito et al. 2012). The cure rate varied greatly in the literature. The key is whether the defect can be repaired. For one to two obvious defects, direct suture repair usually cured the disease. (the cure rate more than 80%) However, for some undetectable defects or defects with fenestration type, the cure rate is very low, ( around 30-50% ). Alternative strategies have to be considered in such condition, such as tissue glue, abrasion pleurodesis, mesh interposition and using sclerosing agents(OK432, bleomycin, Minocin, talc, etc). This is in distinct contrast to the numerous non-surgical drainage procedures such as thoracentesis, which removes accumulated fluid but does not correct the underlying pathology. However, the hallmark of this condition, liver failure predisposes patients to complications such as bleeding, infection and poor wound healing. These risks are one of the primary reasons treatment was often limited to drainage procedures prior to the popularization of lower risk VATS procedures. In the past, patients with Child’s class C liver cirrhosis are basically not proper surgical candidates because of extremely high mortality/morbidity rate. In recent experience of single-port approach, some patients with Child B and C are still safe with minimal postoperative complications. The advance of these minimally invasive technologies such as uni-port thoracoscopy permits fewer and more limited incisions which is believed to further reduce these risks while providing patients with definitive treatment options. More case studies such as this one, along with larger studies are needed to demonstrate the benefits of this technique for hepatic hydrothorax.