title: Laparoscopic diaphragmatic plication: long-term results of a novel surgical technique for postoperative phrenic nerve palsy.
abstract: BACKGROUND
  Paralysis of the diaphragm is a severe complication of cardiothoracic surgery carrying significant morbidity and mortality. This study demonstrates a novel minimally invasive technique for treatment of phrenic nerve injuries presenting with symptomatic eventration of the diaphragm. It also presents long-term results of three patients treated with this operation.
  
  
  METHODS
  Chest x-ray proved eventration of the left diaphragm in all patients. Two patients required treatment due to prolonged respirator therapy/assisted ventilation for 4 weeks after cardiac surgery. One patient suffered from progressive dyspnea caused by increasing left-sided diaphragmatic elevation and underwent surgery 2 years after cardiac surgery. In all cases, a minimally invasive abdominal approach was chosen. During surgery the dome of the diaphragm was pulled down via three percutaneously inserted retention stitches. This resulted in two or three folds of the diaphragm located within the abdomen. These diaphragmatic folds were subsequently tightened using 12 to 15 unresorbable sutures with extracorporally prepared knots. Surgical as well as long-term follow-up results are presented of all patients and a review of the current literature is provided.
  
  
  RESULTS
  Mean operating time was 203 min; mean intraoperative blood loss was 130 ml. No major complications occurred during surgery or the postoperative period. At a median follow-up of 72 months no recurrence was observed.
  
  
  CONCLUSIONS
  Laparoscopic diaphragmatic plication provides excellent relief of symptoms caused by diaphragmatic paralysis. There is no perioperative morbidity, and hospital stay is short. The laparoscopic approach, therefore, is an attractive surgical alternative for the treatment of phrenic nerve palsy and should be considered in all suitable patients.
authors.affiliation: Department of Surgery, Klinikum Grosshadern, University of Munich, Marchioninistrasse 15, 81377 Munich, Germany. thomas.huettl@med.uni-muenchen.de
authors.forename: T P
authors.initials: TP
authors.lastname: Hüttl
authors.forename: M W
authors.initials: MW
authors.lastname: Wichmann
authors.forename: B
authors.initials: B
authors.lastname: Reichart
authors.forename: T K
authors.initials: TK
authors.lastname: Geiger
authors.forename: F W
authors.initials: FW
authors.lastname: Schildberg
authors.forename: G
authors.initials: G
authors.lastname: Meyer
mesh_terms: D000368:Aged; D001026:Coronary Artery Bypass; D003964:Diaphragm / Q000601:surgery*; D004417:Dyspnea / Q000209:etiology; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007431:Intraoperative Complications / Q000601:surgery*; D010535:Laparoscopy / Q000379:methods*; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures; D010523:Peripheral Nervous System Diseases / Q000209:etiology / Q000601:surgery*; D010791:Phrenic Nerve / Q000293:injuries*; D012121:Respiration, Artificial; D012133:Respiratory Paralysis / Q000209:etiology / Q000601:surgery*; D016896:Treatment Outcome