Thoracoscopic Diaphragm Plication

Thoracoscopic Diaphragm Plication

What is diaphragm?

The diaphragm is located below the lungs and separates the chest cavity from the abdominal cavity. It is the major muscle of respiration. It is a large, dome-shaped muscle that contracts rhythmically and continually, and most of the time, involuntarily. Upon inhalation, the diaphragm becomes flat and the chest cavity expands filling air with lungs. Upon exhalation, the diaphragm relaxes and returns to its dome like shape, evacuating air from lungs.

What are the indications for diaphragm plication?

The main indication to perform diaphragm plication is paralysis of the diaphragm. Paralysis of diaphragm can result from nerve injury or dysfunction of the nerve that activates diaphragm.

How is diaphragm plication performed ?

  • Open approach – thoracotomy
  • Keyhole approach – thoracoscopic or robotic

What is the difference between Thoracoscopic (VATS) and open approach?

Please click on this link : VATS approach v/s Thoracotomy

How is VATS diaphragm plication performed?

Surgery is performed under general anaesthesia. The lung on the side of the surgery is deflated by the anaesthetist with a special technique. This allows the space to be created for Dr Joshi to carry out surgery within the chest cavity using a telescope and instruments. He uses a telescope and carbon dioxide to visualise the diaphragm. Plication is like folding a cloth on its own multiple times to shorten it. This is performed by passing a series of sutures from one end of the diaphragm to the other end and then tying them tight to turn the dome shape diaphragm into a more flat diaphragm. Surgery takes under 2 hours . A small drain is placed at the end of surgery and the small incisions are closed with sutures. The patient is awake at the end of surgery. Typically, a nasogastric tube is inserted to keep your stomach empty for the first 24 hrs.

Hospital stay

After surgery the patient stays in the recovery room until the anaesthetic wears off. After that the patient is transferred to the ward. Typically, the stay after surgery is expected to be between 2-3 days. It takes about 2 weeks to become independent and get back to work. You should not drive for 2 weeks.

During your ward stay

Ward Stay

For First two days, the most important thing that patients have to deal with is pain from the operation and drains. Pain control methods includes oral tablets, intravenous infusions and infusions around spinal cord. Depending on the patients background history the anaesthetist decides the pain control method. Some of the methods include patient initiated analgesia regimen which may include infusion that patient can control or on demand tablets for pain control.


Figure: Patient controlled analgesia infusion system

While recuperating in ward patients are visited by physiotherapist. The patients are encouraged to participate in regular physiotherapy and mobilization. Apart from drains, patient is connected with infusion system to control pain. It is quite cumbersome to move in and out of bed while drains and infusions are connected. Nursing staff will provide you with assistance. The patient can also call for the staff if they want to move out of bed. Accidental disconnection of drain system or infusion can cause complications and its better avoided. Drains are usually removed next day.

Your drain site has dressing on it. Occasionally it can stain with blood-stained fluid. You need to inform your staff. This is due to fluid collected in chest leaking around the drainage pipe. Site of fluid leakage can be uncomfortable but this is not a complication. Nurses may need change dressing frequently and will discuss with Dr Joshi. Dr Joshi will advise further course of action.

Dr Joshi will visit you on alternate days and his practice nurse will also visit you while you are in ward. The staff stays in regular communication with Dr Joshi about your progress. Your recuperation plan is guided by Dr Joshi. He will discuss with you regarding your discharge plan. Prior to you being discharged you will be given discharge instruction that includes

  • Discharge letter
  • Instruction for removal of sutures and dressings
  • Advise regarding care of wounds and how to seek medical attention or advise in case of any potential complications.
  • Advise regarding making appointment with Dr Joshi, your referring specialist and GP

Complications

It is not uncommon to cough blood-stained phlegm for few days after surgery. You should inform your surgeon but generally it subsides on its own.

You may experience fever in first 48 hours and your blood counts are expected to rise. This is not a sign of infection. However, if fever persists then some additional tests may be carried out and treatment will be commenced if infection is suspected.

Nausea, vomiting and constipation are common side effects of pain medications and anaesthetic medications. Your staff will titrate the dose of pain medications for you to get optimum pain relief and to minimize side effects of pain medications. Pain does not completely disappear but the goal is to keep pain within the limit of tolerance and allowing for carrying out exercise and physiotherapy.

Infection of wounds and chest cavity can occur however, very uncommon unless specific risk factors are present in patient (e.g. Patients on steroids, immunosuppressants, Diabetes, advanced cancer etc.)

Life threatening complications are very rare but worth noting. Heart attack can occur in patients with risk factors. Major bleeding can occur during surgery which may require converting key hole surgery to open surgery to be able to control bleeding. Patients who have cancers are at risk of developing blood clots in legs which has a risk of migrating to heart. Patients are given injections of weak blood thinner to prevent the occurrence of clots in legs.

One of the important long term side effects to note is nerve pain. With VATS surgery, the incidence of nerve pain is less likely however can occur. Nerves underneath each ribs are sensitive and delicate and can occasionally damaged while removing lung specimen. This will manifest as numbness over the front of chest or breast. Women may feel heaviness in breast. This side effects is likely to improve over period of time. Some patients may require pain killers.

Treatment after VATS diaphragm plication

Dr Joshi will arrange post operative review in his rooms between 3-4 weeks. This is to assess your wounds, chest x ray and discuss the results of examination of your lung specimen. After that he will discharge you to your referring doctor and GP.

You should avoid lifting heavy weight and avoid exertional work for 6 weeks.

Life after VATS diaphragm plication

After 6 weeks you should be able to return back to normal life. Sometimes despite good early results failure can occur. It depends on tissue quality and strain placed on repaired diaphragm after surgery.

After surgery the patient stays in the recovery room until the anaesthetic wears off. After that the patient is transferred to the ward. Typically, the stay after surgery is expected to be between 2-3 days. It takes about 2 weeks to become independent and get back to work. You should not drive for 2 weeks.

For the first two days, the most important thing that patients have to deal with is pain from the operation and drains. Pain control methods include oral tablets, intravenous infusions and infusions around the spinal cord. Depending on the patient’s background history the anaesthetist decides the pain control method. Some of the methods include a patient initiated analgesia regimen which may include infusion that patient can control, or on demand tablets for pain control.

Figure : Patient controlled analgesia infusion system

While recuperating in the ward patients are visited by a physiotherapist. Patients are encouraged to participate in regular physiotherapy and mobilization. Apart from drains, patients are connected to an infusion system to control pain. It is quite cumbersome to move in and out of bed while drains and infusions are connected. Nursing staff will provide you with assistance. The patient can also call for staff if they want to move out of bed. Accidental disconnection of the drain system or infusion can cause complications and it’s better avoided. Drains are usually removed the next day.

Your drain site has a dressing on it. Occasionally it can stain with blood-stained fluid. You need to inform your staff. This is due to fluid collected in the chest leaking around the drainage pipe. The site of fluid leakage can be uncomfortable but this is not a complication. Nurses may need to change dressings frequently and will discuss with Dr Joshi. Dr Joshi will advise on a further course of action.

Dr Joshi will visit you on alternate days and his practice nurse will also visit you while you are in the ward. The staff stay in regular communication with Dr Joshi about your progress. Your recuperation plan is guided by Dr Joshi. He will discuss with you regarding your discharge plan. Prior to you being discharged you will be given discharge instructions that include:

  • Discharge letter.
  • Instruction for removal of sutures and dressings.
  • Advice regarding care of wounds and how to seek medical attention or advice in case of any potential complications.
  • Advice regarding making an appointment with Dr Joshi, your referring specialist and GP.

It is not uncommon to cough blood-stained phlegm for a few days after surgery. You should inform your surgeon, but generally it subsides on its own.

You may experience a fever in the first 48 hours and your blood counts are expected to rise. This is not a sign of infection. However, if fever persists then some additional tests may be carried out and treatment will be commenced if infection is suspected.

Nausea, vomiting and constipation are common side effects of pain medications and anaesthetic medications. Your staff will titrate the dose of pain medications for you to get optimum pain relief and to minimize side effects of pain medications. Pain does not completely disappear but the goal is to keep pain within the limit of tolerance and allow for carrying out exercise and physiotherapy.

Infection of wounds and chest cavity can occur however, they are very uncommon unless specific risk factors are present in patient (e.g. Patients on steroids, immunosuppressants, Diabetes, advanced cancer etc)

Life threatening complications are very rare but worth noting. Heart attacks can occur in patients with risk factors. Major bleeding can occur during surgery which may require converting keyhole surgery to open surgery to be able to control bleeding. Patients who have cancers are at risk of developing blood clots in the legs which have a risk of migrating to the heart. Patients are given injections of weak blood thinner to prevent the occurrence of clots in legs.

One of the important long term side effects to note is nerve pain. With VATS surgery, the incidence of nerve pain is less likely however it can occur. Nerves underneath each rib are sensitive and delicate and can occasionally be damaged while removing lung specimens. This will manifest as numbness over the front of the chest or breast. Women may feel heaviness in their breasts. These side effects are likely to improve over a period of time. Some patients may require painkillers.

Dr Joshi will arrange a post operative review in his rooms between 3-4 weeks. This is to assess your wounds, chest x-ray, and discuss the results of examination of your lung specimen. After that he will discharge you to your referring doctor and GP

You should avoid lifting heavy weights and avoid exertional work for 6 weeks.

After 6 weeks you should be able to return back to normal life. Sometimes despite good early results failure can occur. It depends on tissue quality and strain placed on the repaired diaphragm after surgery.