Thoracoscopic diaphragmatic eventration repair in children: about 10 cases

Background and Aim

Recent reports in literature have emphasized the clinical perception of reduced pain, postoperative morbidity, and dysfunction associated with thoracoscopic approach compared with standard thoracotomy.The authors describe a thoracoscopic approach and technical details for diaphragmatic eventration repair in children.

Patients and Methods

Ten patients, 4 girls and 6 boys, 1 teenager (14 years old) and 9 children (age range, 6-41 months; average, 17 months), were operated for a diaphragmatic eventration in 3 different pediatric surgery teams, according to the same technique. Symptoms were recurrent infection (7 cases), dyspnea on exertion (2 cases), and a rib deformity (1 case). An elective thoracoscopy was performed, patient in a lateral decubitus. A low carbon dioxide insufflation allowed a lung collapse. Reduction of the eventration was made progressively when folding and plicating the diaphragm. Plication of the diaphragm was done with an interrupted suture (6 cases) or a running suture (4 cases). The procedure finished either with an exsufflation (4 cases) or a drain (6 cases).

Results

A conversion was necessary in 2 cases: 1 insufflation was not tolerated and 1 diaphragm, higher than the fifth space, reduced too much the operative field. Patients recovered between 2 and 4 days. Dyspnea disappeared immediately. Mean follow-up of 16 months could assess the clinical improvement in every patient.

Discussion

Thoracoscopic conditions are quite different between a diaphragmatic hernia repair previously reported and an eventration. Concerning diaphragmatic hernias, reduction is easy, giving a large operative space for suturing the diaphragm. Concerning diaphragmatic eventrations, the lack of space remains important at the beginning of the procedure despite the insufflation into the pleural cavity. The operative ports must be high enough in the chest to allow a good mobility of the instruments. Chest drainage seems to be unnecessary.

Conclusion

Diaphragmatic eventration repair by thoracoscopy is feasible, safe, and efficient in children. Above all, it avoids a thoracotomy. It improves the immediate postoperative results with a good respiratory function.     

Incarcerated diaphragmatic hernia secondary to plication for eventration of diaphragm

Diaphragmatic plication is the procedure of choice for congenital diaphragmatic eventration. In the absence of complications, most newborns with eventration do well after plication and have normal long-term respiratory functions. However complications are rare. Recurrence, ipsilateral pneumothorax and rupture of the diaphragm have been reported in literature. We report a case of incarcerated diaphragmatic hernia in a two-yearold child who had undergone plication for eventration of the diaphragm at six months of age     

Left main bronchus foreign body masquerading as diaphragmatic hernia in an adult patient

OBJECTIVEForeign body aspiration is quite uncommon in the adults. It can be a life-threatening situation and it often requires a high index of suspicion, because the diagnosis can be obscure.PRESENTATION OF CASEWe present a case of food aspiration by a 31-year old female patient, masquerading as diaphragmatic hernia, for the first time in the literature.DISCUSSIONForeign body aspiration may escape diagnosis, especially if there is no recollection of the episode.CONCLUSIONThe thoracic surgeon may be suspicious of this condition, even if the patient history and imaging obscure the clinical picture.     

Eventration of the diaphragm due to phrenic nerve injury caused by intercostal drainage.

Acquired eventration of the diaphragm is caused by injury to the phrenic nerve with resultant paralysis and elevation of the entire diaphragm. In this reported case, damage to the phrenic nerve was caused by an intercostal drain. This has not been previously reported.     

32例胎儿先天性膈膨升的产前超声及MRI诊断结果分析

目的分析产前超声(US)、磁共振成像(MRI)对胎儿先天性膈膨升(EOD)的诊断结果并探讨诊断价值。方法选取2016年4月至2019年4月我院产前检查疑似孕有EOD胎儿的52例孕妇的临床资料进行回顾性分析,均有完整的产前US及MRI影像资料及胎儿随访结果(产后胸片、手术或尸检病理结果)。以随访结果为"金标准",使用Kappa一致性检验评价产前US和MRI在EOD胎儿产前诊断中的应用价值。结果52例疑似EOD胎儿,经随访结果证实EOD 32例,疝囊型膈疝13例,胸骨后疝7例。产前US诊断EOD阳性46例,误诊16例,产前US诊断EOD与随访结果一致性差(Kappa=0.252),US诊断EOD的灵敏度、特异度和准确度分别为96.88%、25.00%和69.23%;产前MRI诊断EOD阳性34例,误诊2例,MRI诊断EOD与随访结果一致性较好(Kappa=0.917),MRI诊断EOD的灵敏度、特异度和准确度分别为100.00%、90.00%和96.15%。22例单纯性EOD和EOD合并患侧肺不张胎儿出生后经保守治疗或手术治疗后预后良好。结论产前US诊断EOD灵敏度高,可作为筛查的首选,但US特异度较低,易造成误诊,对于US发现的异常情形,结合MRI检查评估膨出物范围及膈肌连续性有助于提高EOD产前诊断的准确性。     

Successful management of bilateral congenital eventration of the diaphragm

A case of bilateral congenital eventration of the diaphragm is reported. Antenatal ultrasonography indicated the presence of a left diaphragmatic hernia; severe respiratory distress was present immediately following birth, and with the patient at the age of 7 h plication of the membranous left hemidiaphragm was performed. Postoperatively, respiratory distress persisted; X-ray films revealed an elevated right hemidiaphragm, which was plicated on the 11th day of life.     

产前超声诊断先天性膈膨升及漏误诊分析

目的:探讨超声诊断胎儿先天性膈膨升的声像图特征并对漏诊、误诊进行分析.方法:分析2014年1月—2018年12月产前超声诊断先天性膈膨升的10例胎儿病例资料及随访结果,总结其胸腔横切面、冠状面、矢状面的产前超声图像特征,观察双侧膈肌的矛盾运动,并与产前MRI、产后胸片、解剖结果对比分析.结果:10例胎儿膈膨升中右侧6例...     

Three-dimensional mesh for ventral hernias: a new technique for an old problem

The morbidity/mortality associated with ventral hernias continues to be a serious medical problem due to high rates of recurrence. Meshes offer a simple and effective solution and, bearing this in mind, we describe a new protocol developed in our department, which consists of dissecting the hernia to free the peritoneal space, in which the three-dimensional mesh (PHS) is lodged. From July 1999–November 2002, this technique was used in 32 adult and elderly patients: four eventrations caused by trocars, seven eventrations from laparotomy, 14 umbilical hernias, five epigastric hernias, and two spigelian hernias. The size of the hernial ring was 10 cm or less in all cases. All patients underwent surgery under spinal anaesthesia and with antibiotic prophylaxis. No patient required readmission, experienced infection of the mesh or recurrence, or required more oral analgesia than prescribed on discharge. The mean hospital stay was 30±15 h, and only five of 32 patients required more than 1 day of stay. No deaths occurred. Therefore, we think that the use of the PHS mesh in ventral hernia is a safe, effective, and simple technique.     

Treatment of abdominal wall eventrations associated with abdominoplasty techniques

An experimental and clinical study using alloplastic materials (Marlex and Prolene mesh) for repairing large defects of the abdominal wall is reported. A defect was created in the experimental model to simulate an anatomical disarrangement of the musculo-aponeurotic-fascial complex of the abdominal wall and the surgical correction of this deformity. Macroscopic and microscopic observations of the operated area were done to demonstrate the good integration of the surrounding tissues with the mesh.In a clinical study, 16 patients, presenting large eventrations of the abdominal wall, were surgically treated using Marlex or Prolene mesh to reinforce the abdominal wall. Two techniques of abdominoplasty, vertical and horizontal, were performed on these patients, according to the location of previous scars. The advantages of using alloplastic materials to reinforce the abdominal wall and the cosmetic results of both abdominoplasty techniques are discussed.