Management of Left Hemidiaphragm Eventration
Surgical plication is indicated for symptomatic eventration of the left hemidiaphragm, with minimally invasive thoracoscopic plication being the preferred approach, while asymptomatic cases can be managed conservatively with observation. 1, 2, 3
Clinical Decision Algorithm
Step 1: Assess Symptom Severity
Symptomatic patients require surgical intervention, specifically those experiencing: 1, 4
- Effort or positional dyspnea
- Recurrent pneumonia or respiratory distress
- Cardiac symptoms from mediastinal shift
- Digestive symptoms from visceral compression
- Persistent pain
- Failure to thrive (in pediatric cases)
Asymptomatic patients discovered incidentally on imaging should be observed, as eventration without functional impairment does not require surgical treatment. 1, 5
Step 2: Confirm Diagnosis and Optimize Medical Management
Before proceeding to surgery, ensure: 1, 4
- Chest radiograph confirms hemidiaphragm elevation
- Fluoroscopy differentiates eventration (no paradoxical motion) from paralysis (paradoxical motion present) 3
- Optimal conservative management has been attempted and failed in symptomatic cases 1, 5
- Complete morphological and functional investigation of neuromuscular and respiratory components has been performed 1
Step 3: Surgical Approach Selection
Minimally invasive video-thoracoscopic plication is the gold standard approach for left hemidiaphragm eventration. 2, 3 This technique offers:
- Significant improvement in dyspnea and quality of life 2
- Excellent safety profile with low morbidity and mortality 1
- Long-lasting functional benefit approaching 100% 1
Alternative approach includes lateral thoracotomy, though this is less preferred given the advantages of minimally invasive techniques. 1
Step 4: Surgical Technique
The goal of plication is to: 4, 3
- Restore normal pulmonary parenchymal volume by replacing the diaphragm in its normal anatomical location
- Improve lung volumes and decrease paradoxical elevation
- Prevent compression of the ipsilateral lung by abdominal organs
Use interrupted non-absorbable sutures (2-0 or 1-0 monofilament) to plicate the elevated diaphragm, creating multiple rows of sutures to flatten and stabilize the hemidiaphragm. 6, 1
Expected Outcomes
Immediate clinical improvement occurs in most patients, with: 1, 4
- Remission of respiratory symptoms in the majority
- Normal diaphragm position restored postoperatively
- Immobile but non-paradoxical diaphragm on follow-up fluoroscopy 4
Critical Caveats
Be aware that some patients may experience gradual diaphragmatic rise or relapse of symptoms after repair, particularly in adults. 5 In one series, 5 of 7 adult patients had gradual diaphragmatic elevation or symptom relapse despite initial good results. 5
Success depends on rigorous preoperative patient selection, specifically ensuring that symptoms are truly attributable to the eventration and not other cardiopulmonary pathology. 1
Morbidity and mortality are mainly associated with comorbid factors rather than the procedure itself, making preoperative optimization essential. 1
Surgery should only be performed for distress stemming from the eventration that is unresponsive to medical therapy, as the procedure is symptomatic and non-curative. 1, 5