What is the treatment for an elevated right diaphragm?

Treatment for Elevated Right Diaphragm

Surgical diaphragm plication is the definitive treatment for symptomatic patients with an elevated right hemidiaphragm, regardless of whether the cause is eventration or paralysis. 1

Diagnosis and Evaluation

Before initiating treatment, proper diagnosis is essential:

• CT scan is the gold standard for evaluating diaphragmatic abnormalities, with sensitivity and specificity of 14-82% and 87% respectively 2
• Fluoroscopic testing is crucial to differentiate between paralysis (shows paradoxical motion) and eventration (no paradoxical motion) 1, 3
• Chest X-ray is often the first imaging study that reveals an elevated hemidiaphragm but has limited sensitivity (17-33% for right-sided abnormalities) 2
• MRI or ultrasonography can also be used for functional assessment of diaphragmatic motion 3

Treatment Algorithm

For Asymptomatic Patients:

• Observation is appropriate for incidentally discovered elevated diaphragm 1
• Regular follow-up with chest imaging to monitor for changes 3

For Symptomatic Patients:

1. Surgical Plication is indicated for all symptomatic patients 1

   • Minimally invasive thoracoscopic approach (VATS) is preferred in hemodynamically stable patients 2, 4
   • Open surgical repair via thoracotomy or laparotomy is reserved for:
     • Hemodynamically unstable patients 2
     • Cases where laparoscopic equipment/skills are unavailable 2
     • Large defects requiring extensive repair 2

2. Surgical Technique Options:

   • Thoracoscopic plication (most common approach by thoracic surgeons) 1, 4
   • Uniportal or robotic approaches are emerging techniques 4
   • For large defects that cannot be closed with direct suture, mesh reinforcement is recommended 2

3. Mesh Selection (when needed):

   • Biosynthetic, biologic, or composite meshes are preferred due to:
     • Lower recurrence rates
     • Higher resistance to infections
     • Lower risk of displacement 2

Special Considerations

• For traumatic diaphragmatic hernia: Surgical repair is strongly recommended, preferably via laparoscopic approach in stable patients 2
• For large defects (>3cm): Primary repair may lead to excessive tension; mesh reinforcement is recommended to prevent recurrence 2
• For herniated abdominal contents: These must be reduced before diaphragmatic repair 2, 5

Expected Outcomes

Diaphragm plication has excellent outcomes with significant improvement in:

• Lung volumes
• Respiratory function
• Reduction of paradoxical diaphragm movement 1
• Relief of symptoms such as dyspnea and chest pain 4

Potential Complications

• Recurrence of diaphragmatic elevation (42% after primary repair without mesh) 2
• Respiratory complications
• Surgical site infections
• Mesh-related complications when used 2

Follow-up

Regular imaging follow-up is recommended to monitor for recurrence, especially in cases of traumatic etiology or when primary repair was performed without mesh reinforcement 2, 6.