When should intervention be considered for an elevated hemidiaphragm (half of the diaphragm)?

Intervention for Elevated Hemidiaphragm

Surgical intervention for elevated hemidiaphragm should be performed when patients have disabling dyspnea, lung compression, or significant functional limitations despite optimal conservative management.

Diagnosis and Evaluation

• Differentiation between causes:

  • Eventration: Congenital or acquired thinning of diaphragm muscle with elevation but no paradoxical motion
  • Paralysis: Phrenic nerve dysfunction with paradoxical motion during respiration
  • Hiatal hernia: Abnormal protrusion of abdominal contents through diaphragm

• Diagnostic tests:

  • Chest radiography: First-line imaging (sensitivity 2-60% for left-sided, 17-33% for right-sided) 1
  • Fluoroscopy: Critical for distinguishing paralysis (paradoxical motion) from eventration (no paradoxical motion) 2
  • CT scan: Better anatomical detail (sensitivity 14-82%, specificity 87%) 1

Indications for Intervention

Primary Indications (Absolute)

1. Disabling dyspnea that persists despite optimal conservative management 3, 4
2. Significant lung compression with mediastinal shift 3
3. Recurrent pneumonia due to inadequate ventilation 5
4. Failure to thrive (particularly in pediatric patients) 5

Secondary Indications (Relative)

1. Positional dyspnea (symptoms worsen when supine) 4
2. Cardiac or digestive symptoms due to compression 4
3. Chronic pain related to diaphragmatic elevation 4
4. Exercise intolerance attributable to diaphragmatic dysfunction 2

Treatment Options

1. Conservative Management

• Indicated for asymptomatic or mildly symptomatic patients
• Includes respiratory therapy and pulmonary rehabilitation
• Regular follow-up to monitor for symptom progression

2. Surgical Intervention: Diaphragmatic Plication

• Technique: Flattening and tightening of the elevated diaphragm using non-absorbable sutures
• Approaches:
  • Thoracoscopic (VATS): Preferred minimally invasive approach with excellent outcomes 2, 6
  • Thoracotomy: Traditional open approach, may be necessary for complex cases 3
  • Laparoscopic: Alternative approach from abdominal side 2

3. Special Considerations

• For diaphragmatic hernia: Surgical repair with mesh reinforcement for defects that cannot be closed with direct suture 7
• For bilateral dysfunction: Bilateral plication has been reported in select cases 4
• For central paralysis: Phrenic nerve pacing may be considered for ventilator-dependent patients 4

Expected Outcomes

• Immediate symptom improvement in most patients 5
• Progressive improvement over 1 year in others 5
• Long-lasting functional benefit reported in approximately 90% of appropriately selected patients 4
• Low morbidity and mortality when performed at centers with expertise 4

Post-Intervention Follow-up

• Regular chest radiography to assess diaphragm position
• Fluoroscopic evaluation to assess diaphragmatic motion when indicated
• Pulmonary function testing to document functional improvement
• Symptom assessment at regular intervals

Potential Complications

• Surgical site infection
• Bleeding
• Respiratory failure
• Recurrence of elevation (rare)
• Inadequate plication leading to persistent symptoms

Conclusion

The decision to intervene for an elevated hemidiaphragm should be based primarily on symptom severity, functional limitation, and objective evidence of pulmonary compromise. Diaphragmatic plication offers excellent outcomes in appropriately selected symptomatic patients, with high rates of symptom resolution and improved quality of life.