Diaphragmatic Plication With the Versius Robotic System

This video presents a robotic diaphragm plication procedure using the Versius robotic surgical system. The patient is a fifty-eight-year-old man with a history of mitral valve regurgitation who underwent mitral valve repair surgery in June 2022. Following surgery, he experienced progressive dyspnea on exertion and imaging revealed an elevated left hemidiaphragm. Evaluation included a transthoracic echocardiogram showing normal mitral valve function, adequate biventricular systolic function with an ejection fraction of 62 percent, and pulmonary function tests indicating an FEV1 of 80 percent and DLCO of 57 percent. Due to his worsening dyspnea, elevated hemidiaphragm from phrenic nerve paralysis, and no clear cardiopulmonary cause, he was recommended for robotic diaphragm plication.

The surgery was performed via the left hemithorax with the patient in a right lateral decubitus position. Given the patient's recent history of median sternotomy, abdominal access was considered in case of significant adhesions. The console was positioned to allow for visualization of the arms for the surgeon, with the assistant's screen at the patient's feet on the opposite side.

Under general anesthesia with double-lumen intubation, a 10 mm, zero-degree camera port was placed in the posterior mediastinum, approximately in the fifth intercostal space, just posterior to the scapula. Another 5 mm port was placed in the same space anterior to the scapula for the needle holder. In the posterior aspect, a 5 mm port was placed at the seventh intercostal space for the grasper. An additional 5 mm port was added to the anterior aspect of the left hemithorax, in the fifth or sixth intercostal space, for the assistant.

CO2 insufflation ranging between 8 and 10 mmHg facilitated visualization of a redundant diaphragm. Diaphragmatic plication was then performed using parallel lines encompassing the entire tendinous and redundant center of the diaphragm. 0-Ethibon sutures with a single needle were used, with the suture ends supported on a small Teflon patch. Knot tying was performed by the assistant, who slid the knots using an Ethibon suture knot pusher. Care was taken not to position the ports too low, and any bleeding from the diaphragm was typically self-limiting.

Following completion of the parallel sutures, CO2 insufflation was stopped to confirm the diaphragm remained in its anatomical position. A 24 Ch drainage tube was placed, and both lungs were ventilated again.

The postoperative period progressed well, with IV analgesia using acetaminophen and dexketoprofen providing adequate pain control. An X-ray on the first postoperative day showed the diaphragm in an appropriate anatomical position, allowing removal of the pleural drainage tube and discharge home.

At the outpatient clinic visit after 30 days, X-ray findings were similar to the immediate postoperative period, with minimal pain not requiring analgesia and significant improvement in dyspnea. At the two-month follow up, the patient remained stable. Continued thoracic surgery follow ups were planned.

References

1. Groth SS, Andrade RS (2018) Diaphragm plication for eventration or paralysis: a review of the literature. Ann Thorac Surg 89(6):S2146–S2150. https:// doi. org/ 10. 1016/j. athor acsur. 2010.03. 021
2. Aresu G, Dunning J, Routledge T, Bagan P, Slack M. Preclinical evaluation of Versius, an innovative device for use in robot-assisted thoracic surgery. Eur J Cardiothorac Surg 2022; doi:10.1093/ejcts/ezac178.
3. Marmor HN, Xiao D, Godfrey CM, Nesbitt JC, Gillaspie EA, Lambright ES, Bacchetta M, Moe DM, Deppen SA, Grogan EL. Short-term outcomes of robotic-assisted transthoracic diaphragmatic plication. J Thorac Dis 2023;15(4):1605-1613. doi: 10.21037/jtd-22-442
4. Lampridis S. Raising the bar, lowering the diaphragm: a new era in diaphragmatic plication. J Thorac Dis 2023;15(7):3529-3532. doi: 10.21037/jtd-23-716

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