Plication of the Diaphragm

Plication of the diaphragm is a surgery aimed at providing relief from breathing difficulties (including shortness of breath) in individuals with diaphragm paralysis.

Diaphragm is a thin sheet of muscle that is present at the base of the chest cavity. It separates the chest and the abdominal cavities and plays an essential part in the breathing process. In the relaxed state, the diaphragm is in the shape of a dome with the convex surface facing the chest cavity and the concave surface facing the abdominal cavity. During inhalation, diaphragm contracts and pushes itself into the abdominal cavity. This increases the space within the chest cavity and allows the lungs to expand and fill themselves with air. On exhalation, diaphragm reverts to its original position and helps push the air out of lungs.

Diaphragm paralysis is an uncommon condition that affects one or both sides of the diaphragm. It reduces the air-retaining capacity of the lungs. Various causes can be attributed to this condition, such as cancer of lung/lymph node, damage to the nerve that controls the contraction and relaxation of the diaphragm, spinal cord disorders, and unintentional surgical trauma.

If diaphragm paralysis does not present any symptoms or is not severe, then it is managed using non-surgical measures such as oxygen supplementation and physical therapy and rehabilitation (related to breathing exercises). Surgery is recommended when diaphragm paralysis causes considerable trouble in breathing. During the surgery, the weakened or paralysed section of the diaphragm is lowered and stitched to the chest wall. This results in an increased space in the chest cavity, thereby increasing the expanding capacity of lungs.

This surgery is recommended when diaphragm paralysis causes any of the following symptoms:

• Respiratory distress that is not responding favourably towards non-surgical measures
• Recurring or life-threatening pneumonia
• Dependency on external oxygen supply
• Infants with unmet nutritional needs or failure to thrive

This surgery is not recommended in individuals who have diaphragm paralysis but no dyspnoea. Some contraindications of this procedure include:

• Morbid obesity
• History of deep venous thrombosis
• Chronic failure in the kidneys
• Dyspnoea caused by a condition other than diaphragm paralysis, e.g., heart problems and lung diseases

You will be making a few visits to the hospital before the surgery for a preoperative assessment, wherein you will be asked to share the following details with the doctor:

• Medical conditions (past and current)
• Allergies
• History of anaesthesia
• List of medicines that you take, including herbs and over-the-counter drugs

Women should inform the doctor if they are pregnant or think they might be.

Additionally, you will need to undergo several tests to confirm the diagnosis and ensure that you are medically fit for the surgery:

• Blood tests
• Urine tests
• Pregnancy test
• Chest x-ray
• Sniff test
• Computed tomography scan

You will be provided with the following instructions to prepare for the surgery:

• Discontinue the use of aspirin, warfarin, ibuprofen or other blood-thinning medicines a few days prior to the surgery.
• Fast from the midnight before the surgery to prevent vomiting (a risk of general anaesthesia) during the surgery.
• Quit smoking and drinking.
• Take a shower and remove all the nail polish, body piercings and make-up before you arrive at the hospital on the scheduled day of the surgery.
• Arrange for a friend, family member or a responsible adult to drive you home post-discharge from the hospital.
• Inform the surgeon if you have flu, cold or fever on the days leading to the surgery. In such a case, the surgeon may either cancel or postpone the surgery.

All the information regarding the procedure and risks associated with the surgery will be shared with you. If you understand the details and agree to undergo this surgery, then the hospital staff will ask you to sign a consent form for your formal approval.

After you arrive at the hospital, you will be asked to change into a hospital gown. After you are taken into the operation room/theatre, the surgeon or his/her team will start an intravenous line (IV) in your arm or leg for the supply of medicines and fluids during the surgery. Thereafter, the surgery will be done either by open or laparoscopic technique.

The laparoscopic procedure is performed using a tube-like instrument fitted with a light source and camera (a laparoscope), which helps the surgeon to look inside your chest cavity through a monitor placed in the operating room or theatre. It involves the following steps:

• An anaesthetist will provide you with general anaesthesia via the IV line. You will be under deep sleep during the procedure and feel no pain.
• The surgeon will introduce two to four small cut/incisions in your chest and place small plastic tubes in the incision for the insertion of surgical instruments. 
• He/she will fill and expand your abdomen with carbon dioxide gas.
• Next, the surgeon will introduce a small hole in your diaphragm to release the tension on the paralysed diaphragm.
• He/she will grasp the paralysed part of your diaphragm and lower it by one or two ribs.
• The surgeon will stitch the edge of the lowered part of your diaphragm to your inner chest wall. In some cases, Teflon pads are used to reinforce the stitches.
• Thereafter, the surgeon will close the hole created in your diaphragm along with the stitches in your chest and place a dressing on the surgery site.
• Finally, he/she will place a drain in your chest to remove any excess air or fluids that may accumulate after surgery.

Open plication of the diaphragm is similar to the laparoscopic technique; however, open surgery involves a large incision instead of many small ones.

Compared to open surgery, the laparoscopic surgery provides several advantages, such as minimal postoperative pain, shorter hospital stays, faster recovery and reduced scarring.

You will need to continue your stay at the hospital for about one to seven days after the surgery and expect the following during your hospital stay:

• You will feel tired, restless or groggy after regaining consciousness post-surgery. Furthermore, you may also experience dry mouth and sore throat. These are side effects of general anaesthesia that usually fade within a few hours.
• A chest x-ray will be immediately done after the surgery to check whether the position of the diaphragm is appropriate.
• You will be given medicines to relieve postoperative pain and vomiting. The medicines will be given either through the IV line or orally.
• You will be initially started on a liquid diet. However, if you were on a ventilator before the surgery with a breathing tube inserted in the throat, then feeding through the oral route will be started only after removal of the tube.
• The chest drain will be connected to a bottle that collects the fluids. If you need to move around with the chest drain in place, then you should remember to carry the bottle along with you by holding it below the chest level. You should inform the hospital staff if you feel that the tube is coming out of your chest. The drain will be removed after one to two days of surgery.

The surgeon will provide you with some of the following instructions to care for yourself at home:

• You will be given medicines for pain-relief and laxatives or stool softeners, to be taken as directed.
• Make sure to keep the operated area clean and dry.
• Follow the instructions provided by the surgical staff to change the dressing. Wash your hands thoroughly before removing the old dressing. Gently clean the operated skin with mild soap or salt water and let the surface dry. If any ointments are prescribed, then you can apply them before you put on the new dressing.
• You will probably be allowed to resume your regular diet at home.
• Avoid lifting heavy objects and indulging in strenuous activities for four to six weeks after open surgery and for one to two weeks after laparoscopic surgery.

The surgery does not improve the function of the paralysed diaphragm; however, by lowering the diaphragm from its original location, it provides relief from difficulty in breathing and other symptoms. For individuals who were dependent on ventilator support, the surgery assists in coming off the external support.

When to see the doctor?

Immediately contact the surgeon/hospital if you experience any of the following symptoms post-discharge from the hospital:

• Vomiting
• Increased abdominal pain
• Increased chest pain
• Difficulty in breathing
• Redness at the surgical site
• Discharge from the operated area

The potential complications/risks associated with the surgery are as follows:

• Stroke
• Injury to the lung, heart or abdominal organs
• Prolonged drainage from the chest
• Failure of the respiratory system 
• Risks of general anaesthesia including confusion, lung infection, heart attack.

The medical staff/team will provide you with a schedule for follow-up appointments before discharging you from the hospital. Your surgeon may ask you to visit him/her two to four weeks after the surgery so he/she can assess the healing process in the surgical site.

Disclaimer: The above information is provided purely from an educational point of view and is in no way a substitute for medical advice by a qualified doctor.