Single port thoracoscopy for diaphragmatic disorders

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.

Port placement: 

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.

Example of sutured diaphragm - (view  from thoracotomy)  Photo courtesy of Dr. Ochoa, 2011.
Example of sutured diaphragm – (view from thoracotomy) Photo courtesy of Dr. Ochoa, 2012.

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.

Reference Article: 

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.

Resources for Additional Information

Eventration of the diaphragm at Learning Radiology

A. P. Kansal, Vishal Chopra, A. S. Chahal, Charanpreet S. Grover, Harpreet Singh, and Saurabh Kansal (2009).  Right-sided diaphragmatic eventration: A rare entityLung India. 2009 Apr-Jun; 26(2): 48–50.

Radhiana M Y H, Mubarak MY. (2011). A case of focal eventration of left hemidiaphragm with transthoracic left kidney confused with a traumatic diaphragmatic hernia.  Med J Malaysia. 2011 Mar;66(1):60-1.  Case report.

Visouli AN, Mpakas A, Zarogoulidis P, Machairiotis N, Stylianaki A, Katsikogiannis N, Tsakiridis K, Courcoutsakis N, Zarogoulidis K. (2012).  Video assisted thoracoscopic plication of the left hemidiaphragm in symptomatic eventration in adulthoodJ Thorac Dis. 2012 Nov;4(Suppl 1):6-16.  Three port VATS in an adult.

Dual port thoracoscopy for diaphragmatic plication with Dr. Edgard Gutierrez Puente

Talking with the energetic and innovative Colombian surgeon, Dr. Edgard Gutierrez Puentes.

Dr. Edgard Gutierrez Puente is a Colombian thoracic surgeon that I had the pleasure of interviewing in February of 2010.  He is a professor of Thoracic Surgery at the University of Cartagena.  As the only board certified thoracic surgeon in that city (of over 1 million people) – he currently operates in several facilities including: Hospital Naval de Cartagena, Clinica Universitaria San Juan de Dios, Hospital universitario del Caribe, Clinica Medihelp.

As part of a previous project on surgeons in Cartagena, I spent a considerable amount of time with Dr. Gutierrez, seeing patients in all of these facilities.  As a result, I have a deep and profound respect for his dedication to his patients and his work.  (As a matter of fact – I saw my first true* uni-port thoracoscopic surgery in Dr. Gutierrez’s operating room at Medi-help.)

I recently contacted Dr. Gutierrez on a return visit to Cartagena, and he was happy to tell me about some of his recent cases including a Diaphragmatic plication utilizing dual port thoracoscopy.  He is currently writing up the case for publication in surgery journals.  (This is more impressive than it may sound to many of us – traditionally Diaphragmatic plication requires open surgery or traditional VATS (with five ports). This is a big development in thoracic surgery, and I will be bringing you more information as soon as possible. (I don’t want to jeopardize his upcoming article – but still wanted to bring it to you first, here at Cirugia de Torax.)

* Often surgeons call a procedure with a small but 3 -5cm surgery a uni-port surgery, but this is actually more akin to a mini-thoracotomy.  A true uniport VATS procedure, is as the name implies – using an incision that is only large enough to accommodate a single port – and is then used with thoracoscopy equipment (not open surgery instrumentation).  This distinction is important because the amount of post-operative pain depends on the size of the incision and trauma to surrounding tissues and nerves.  (A small incision that is heavily stretched from the use of open surgery instrumentation may actually be more painful post-operatively that a sightly larger incision that is under less stress.)

More about Dr. Edgard Gutierrez Puente

Contact details:

Centro Medico Bocagrande
Consultorio 606
Bocagrande Calle 5  #6 -19
Telefonos: 6658300
Celular: 3114115130

Dr. Gutierrez is a specialty trained thoracic surgeon.  After completing medical school at the University of Cartagena, he completed his general surgery residency at the University of Costa Rica.  He returned to Colombia for his thoracic surgery fellowship at Universidad El Bosque.  He has been operating as a thoracic surgeon for over twenty years.

While his English is limited, his surgical skills aren’t.  In reviewing cases and spending time in the operating room with Dr. Gutierrez, I was very impressed by his extensive use of thoracoscopy for many of the cases that often remain in the realm of open surgery.  Having said that – I would like to clarify that Dr. Gutierrez is no ‘showboat’ – the decision to perform VATS in each of these cases was based on his skills, the patient’s anatomy and the ability to complete the surgery under safe and appropriate conditions via thoracoscopy  Had Dr. Gutierrez been unable to visualize the anatomy easily, or access structures during surgery (or encountered any other problems during the cases) he would have immediately converted to open thoracotomy (as is appropriate.)