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J Thorac Cardiovasc Surg 2006;132:187-189
© 2006 The American Association for Thoracic Surgery
Brief Communication |
Dipartimento di Chirurgia "Pietro Valdoni," Università degli Studi di Roma "La Sapienza," Rome, Italy
Received for publication January 18, 2006; accepted for publication February 13, 2006. * Address for reprints: Angelo Di Giorgio, MD, Università degli Studi di Roma "La Sapienza," Dipartimento di Chirurgia "Pietro Valdoni," Policlinico Umberto I, Via Lancisi 2-00161, Roma, Italy. (Email: angelo.digiorgio{at}uniroma1.it).
Total eventration of a hemidiaphragm is a rare anomaly in adults. This condition could be subsequent to primary or acquired phrenic nerve palsy, but often it presents as a pure degenerative muscular disease without evident signs of denervation. Surgical repair is indicated only in cases of progressive exertional dyspnea, recurrent respiratory infections, or both. Routine surgical techniques counted are plication or incision, followed by double-breast suturing performed through a low posterolateral thoracotomy or minimally invasive access. We report a case of left major eventration in a 58-year-old woman in which the vanishing of most of the diaphragmatic tissue represented an extreme condition incompatible with the performance of a standard procedure.
Clinical Summary
A 58-year-old, female heavy smoker was admitted to our department for a 6-month history of progressive exertional dyspnea and left-sided chest pain. Ten years previously, the patient had a blunt chest trauma caused by a road accident without particular complications and with complete recovery after 5 days of hospitalization. Clinical examination revealed auscultatory bruising over the lower anterolateral quadrants of the left hemithorax; other clinical signs were absent, and laboratory parameters were within normal ranges. A standard radiograph of the chest showed a high displacement of the left hemidiaphragm with contralateral mediastinal shift. A computed tomographic scan of the chest showed a major eventration of the left hemidiaphragm with compressive atelectasis of the anterior segment of the lower lobe and appearance of some bilateral apical subpleural bullae. Completion computed tomographic scanning of the brain, neck, mediastinum, and whole abdomen yielded negative findings and did not show any central or peripheral nervous lesions accounting for a phrenic nerve palsy. Static and dynamic ventilatory function parameters demonstrated a mild restrictive pattern: forced expiratory volume in 1 second of 1.63 (54%), forced vital capacity of 1.85 (44%), total lung capacity of 3.08 (56%), expiratory reserve volume of 0.42 (46%), and functional residual capacity of 1.37 (47%). Ventilatory scintigraphy did not reveal ventilated parenchyma in the basal segments in the lower lobe of the left lung; the right lung was totally ventilated. Bronchoscopic results were negative, and cardiac function was proved to be normal. Five days later, the patient underwent a left posterolateral thoracotomy at the seventh intercostal space with selective thracheobronchial intubation. The stomach was drained with a nasogastric tube. The intraoperative finding was a large eventration of the whole left hemidiaphragm invading about 2 thirds of the pleural cavity. The central part of the phrenic dome was reduced to a thin transparent film constituted only by pleura and peritoneum through the left colic angle, and the great omentum was visible. At first, the apex of the phrenic dome was opened through a transversal incision, and the left colon, with the great omentum, was pushed down into the abdomen. A first suture line of single stitches was performed between the 2 thicker and fleshy borders of the muscle. This resulted in 2 residual flaps of muscle, and the posterior thinner flap was excised. A dual mesh was tailored to fit the shape of the anterior flap and fixed with single stitches on the first suture line as reinforcement. The anterior flap was turned over and fixed around the borders of the diaphragm, including the mesh as the stuffing of the "sandwich," restoring the integrity and strength of the apex of the dome (Figures 1 and 2).
At the end of the procedure, a 28F chest tube was inserted. The postoperative course was uneventful, and the patient was discharged on the seventh postoperative day. She is doing well 24 months after the operation, with complete functional recovery.
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Total diaphragmatic eventration is an uncommon condition. Generally, the disease is a true congenital defect acquired during the fetal period associated with hypoplasia of the lung on the involved side, with appearance of severe cardiorespiratory symptoms at birth.
1,2
Eventration that occurs in adults is thought to be caused by acquired complete or incomplete palsy of a diaphragmatic leaf, often after head and neck operations or cardiovascular procedures. Other causes reported are trauma, motoneuron diseases, and neoplastic infiltration. Commonly, this condition is free of symptoms, and therefore any treatment is required. Some cases are associated with exertional dyspnea, respiratory failure, and/or recurrent pulmonary infections; however, their frequency is increased in heavy smokers and in patients with other primary or acquired respiratory diseases.
1,2
Right eventration with protrusion of the liver through the defect is often localized and asymptomatic and does not require any treatment. Surgical repair is reserved for patients with major left eventration with severe respiratory symptoms. Apart from access and technique, surgical correction is settled to remove lung compression and make the thoracic base and mediastinum more steady, restoring a satisfactory ventilation.
3-5
In our case an extreme condition of vanishing of the muscular support of the hemidiaphragm forced us to perform an alternative technique with optimal functional results.
The aim of this technique was as follows: (1) tailoring a plastic correction with a prosthetic mesh with a greater pressure-proof guarantee compared with that seen in the traditional surgical techniques; (2) creating an area of thickness corresponding to a new durable central tendon able to resist the constant abdominal pressure exerted by the viscera; and (3) avoiding a direct contact between the prosthesis and the lung parenchyma.
Optimal functional results and complete anatomic integration led us to believe that this technique could be worthy of consideration in the treatment of major diaphragmatic eventration.
References
This article has been cited by other articles:
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  J. M. Havens, E. Kelly, and V. Patel A 78-Year-Old Man With an Elevated Hemidiaphragm Following Trauma Chest, December 1, 2008; 134(6): 1336 - 1339. [Full Text] [PDF]
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