Robot-Assisted Plication of the Right Hemidiaphragm

Unilateral diaphragm paralysis results from spinal injury or disease near its cervical vertebra (C5) origin or from phrenic nerve injury (1). In addition, phrenic nerve injury can occur with all types of atrial fibrillation ablation, ranging in incidence from 1-5% (2, 3). Most patients are asymptomatic; however, for symptomatic patients, diaphragm plication for paralysis has been shown to improve symptoms of dyspnea, as well as pulmonary function tests with durability shown out to five years (4, 5). Previous studies have shown that thoracotomy, minimally invasive thoracoscopic repair, and even laparoscopic repair result in similar results, with no significant difference in morbidity, mortality, or improvement in symptoms between techniques (6, 7). Using this premise, robot-assisted plication may prove a valuable and arguably superior alternative over thoracoscopic or laparoscopic repair, given the improvement in visualization, orientation, and dexterity.

A 66-year-old woman with a one-year history of paroxysmal atrial fibrillation underwent a percutaneous radiofrequency ablative procedure that resulted in conversion to sinus rhythm, but was complicated by a paralyzed right hemidiaphragm. This was confirmed with a post-procedure computed tomography (CT) scan, as well as by a one-month follow-up chest x-ray and sniff test. Post-procedure, she developed pneumonia, requiring hospitalization, as well as new onset shortness of breath, both at rest and with activity.

She underwent robot-assisted right diaphragm plication. She was placed in a left lateral decubitus position. An 8 mm port was placed in the seventh intercostal space, just inferior and anterior to the tip of the scapula. Another 8 mm port was placed in the sixth intercostal space, anterior near the costal margin, and between these ports a 12 mm assistant port was placed. An additional 8 mm port was placed 8 cm posteriorly to the camera port and a fourth 8 mm port was placed as posteriorly as possible, staying lateral to the erector spinae muscle. Using interrupted figure of eight sutures with 2-0 braided sutures, the diaphragm was plicated posterior-laterally to anterior-medially using intracorporeal knot-tying techniques.

Postoperatively, she did well from the surgery, with drains removed on postoperative day one, and she showed immediate improvement on chest x-ray. Postoperatively, she developed atrial fibrillation and was discharged home on postoperative day nine. She had substantial improvement in her shortness of breath.

On return to clinic at one and three months postoperatively, her shortness of breath was gone and chest x-rays showed the right hemidiaphragm was down.

References

1. Graham DR, Kaplan D, Evans CC, Hind CRK, Donnelly RJ. Diaphragmatic plication for unilateral diaphragmatic paralysis: a 10-year experience. Ann Thorac Surg. 1990;49(2):248–52.
2. Calkins H, Kuck KH, Cappato R, Brugada J, Camm AJ, Chen S, et al. 2012 HRS/EHRA/ECAS expert consensus statement on catheter and surgical ablation for atrial fibrillation: recommendations for patient selection, procedural techniques, patient management and follow-up, definitions, endpoints, and research trial design. J Interven Card Electrophysiol. 2012;33(2):171-257.
3. Sacher F, Monaham KH, Thomas SP, Davidson N, Adragao P, Sanders P, et al. Phrenic nerve injury after atrial fibrillation catheter ablation: characterization and outcome in a multicenter study. J Am Coll Cardiol. 2006;47:2498-2503.
4. Freeman RK, Van Woerkom J, Vyverberg A, Ascioti AJ. Long-term follow-up of the functional and physiologic results of diaphragm plication in adults with unilateral diaphragm paralysis. Ann Thorac Surg. 2009;88(4):1112-1117.
5. Celik S, Celik M, Aydemir B, Tunckaya C, Okay T, Dogusoy I. Long-term results of diaphragmatic plication for unilateral diaphragm paralysis. J Cardiothorac Surg. 2010;5(1):111.
6. Evman S, Tezel C, Vayvada M, Kanbur S, Urek S, Baysungur V, et al. Comparison of mid-term clinical outcomes of different surgical approaches in symptomatic diaphragmatic eventration. Ann Thorac Cardiovasc Surg. 2016;22(4):224-229.
7. Groth SS, Rueth NM, Kast T, D’Cunha J, Kelly RF, Maddaus MA, et al. Laparoscopic diaphragmatic plication for diaphragmatic paralysis and eventration: an objective evaluation of short-term and midterm results. J Thorac Cardiovasc Surg. 2010;139(6):1452-1456.

G. Kimble Jett is a proctor and speaker for Intuitive Surgical, Inc.