Open thoracotomy and plication of eventration of diaphragm leads to hyppoventilation due to pain and lung contusion due to retraction. We present two cases, 8 month and 4 years old; in whom plication was done thoracoscopically. Both had smooth recovery, early extubation and excellent cosmetic result.

Key words: Eventration, thoracoscopic plication.

Eventration of diaphragm is usually repaired by open thoracotomy. Thoracoscopic plication of diaphragm has been reported in adult patients(1,2). We report two cases of thoracoscopic plication of diaphragm in congenital eventration in children.

Case 1: An eight-month-old male child presented with severe pneumonia. Child had past history of recurrent respiratory tract infections. x-ray revealed eventration of right diaphragm with consolidation of right upper zone. Child was taken up for surgery five days later following antibiotic therapy.

A 5 mm, 30-degree telescope was used. Camera port was sited at the third inter costal space just anterior to the mid axillary line to avoid injury to the high rising diaphragm. Two 3 mm working ports were introduced along the fifth intercostal space in the anterior and posterior axillary lines. Diaphragm was pushed down using a 3 mm grasper through the working port and a fourth port of 5 mm was inserted at the seventh intercostal space just anterior to the mid axillary line. A fan retractor was introduced through this and the diaphragm was pushed down to the desired level. Plication was done with 1 ‘0’ silk interrupted sutures placed in an anterolateral to posteromedial direction. Five to six pleats were taken with each suture. Plication was started at the dome in the middle and then advanced medially and laterally. This modification allowed us to tie each suture before proceeding to the next one. Carbon dioxide pressure was kept at 5 mm initially but there was an increase in ET CO2 level, so CO2 insufflation was stopped and surgery was continued at atmospheric pressure. This reverted the ET CO2 to normal levels. Inter costal tube was introduced through the 5 mm port used for traction and its tip was positioned anteriorly under vision. Inter costal tube was kept clamped post operatively to prevent rapid expansion of the lung and interstitial emphysema due to high transpulmonary gradient. Duration of surgery was 150 minutes. Child was extubated after five hours and discharged on the fifth post operative day. Repeat x-ray after five months showed the diaphragm in good position.

Case 2: Four-year-old male child presented with recurrent respiratory tract infection and dyspnea. x-ray chest revealed even tratin of right diaphragm. Child was stabilized and thoracoscopic plication of the diaphragm was done as described in the Case 1. Duration of surgery was 180 minutes. Child was extubated after sixteen hours. Repeat x-ray after five months showed the diaphragm in good position.

Traditional way of repair of eventration is by thoracotomy and plication of the diaphragm. Thoracoscopic surgery avoids the problems of open surgery. Its safety is well documented in children(3). Both our patients had smooth postoperative recovery and were extubated early. The usual difficulty with thoracoscopic surgery in children is the problem of space inside the chest cavity. However, we found that because of the collapsed and hypoplastic lung there was enough space near the diaphragm for performing the repair even without single lung anesthesia. In contrast to laparoscopic surgery there is no need to keep high pressures of insufllation in thoracoscopy since the rib cage keeps the chest wall from collapsing. We kept the chest cavity filled with carbon dioxide at atmospheric pressures to prevent the theoretical possibility of air embolism. In open surgery sutures are placed first and tied later. This is difficult in thoracoscopic plication because of the chances for entanglement of the sutures. Our modification of placing the first suture in the middle of the dome allows the suture to be tied before placing the next one. Since the diaphragm is kept pushed down to the desired level by the fan retractor, tying the suture does not put excessive tension on the suture line. Fan retractor is closed and removed after most of the sutures are placed and tied. Although Mouroux, et al.(2) described a technique using two layers of continuous sutures we could do the repair with one layer of interrupted sutures as in open surgery, Interrupted sutures are better in preventing recurrence due to suture line break down.

Authors are thankful to our pediatric anesthetists Dr. Laksmi Kumar and Dr. Rekha Varghese for their expert help in management of the patients. We also acknowledge the encouragement and administrative help provided by Dr. Prem Nair, our Medical Director and Mr. Ron Gottsegen our Administrative Director.

Contributors: MKA operated on the case and prepared the manuscript. SSM and BPS assisted in the surgery and were involved in the management of case and drafting the paper.

Funding: None.

Competing interests: None stated.

1. Moon SW, Wang YP, Kim YW, Shim SB, Jin W. Thoracoscopic plication of diaphragmatic eventration using endostaplers. Ann Thorac Surg 2000; 70: 299-300.

2. Mouroux J, Padovani B, Poirier NC, Benchimol D, Bourgeon A, Deslauriers J, et al. Technique for the repair of diaphragmatic eventration. Ann Thorac Surg 1996; 62: 905-907.

3. Shah AA, Shah AV, Shah RC, Shah PR. Thoracoscopy in management of empyema thoracis in children. Indian Pediatr 2002; 39: 957-961.