Diaphragmatic Eventration

Introduction

Diaphragmatic eventration is an abnormal elevation of one or both hemidiaphragms. It is the result of congenital developmental defect of the diaphragmatic muscular portion or the result of diaphragmatic or phrenic nerve injury. An abnormal myoblast migration to the septum transversum and the pleuroperitoneal membrane is responsible of muscle developmental defect [1]. Indeed, phrenic nerve injuries may be related to nerve traction during a difficult birth or surgical dissection or electrocautery during cardiac or thoracic surgery. It can be unilateral or bilateral (it usually involves the left hemidiaphragm) or partial, localized to a part of the hemidiaphragm (anterior, posterolateral, medial) or complete, affecting the whole hemidiaphragm.

During the stretching of the diaphragm upwards, the gap between the diaphragm and the abdominal organs is decreased laterally and the contact surface between the inferior diaphragmatic lateral face and the abdominal organs is increased. This situation increases the risk of inadvertent abdominal injuries. In our technique, with a very small thoracotomy access (8 cm) and with the aim of a simple thoracoscope, we have a direct view of the abdominal organs during the suture creation, through a 1 cm trans diaphragmatic incision, subsequently closed by a purse-string suture. In addition, we perform a double muscular diaphragmatic layer with a double row of full layers interrupted sutures. The first row, holding the diaphragm stretched upwards and putting a clamp at his base, more laterally; the second row, after reversal of diaphragmatic flap on itself, is more medially, in the cardio phrenic angle. This double row of interrupted sutures, that constitutes a “waistcoat”suture, is performed for strengthening the diaphragmatic plication. With a very small thoracotomy approach, without a real costal divarication, we can directly control the peritoneal cavity, in order to avoid abdominal organs injuries. In addiction, the full layers interrupted sutures’ double row provides to a real diaphragmatic