CHAPTER

19

Diaphragmatic Eventration
and Paralysis
Li Guang Hu, Liu Wei, and Jean Deslauriers

Diaphragmatic eventration (Box 19-1) is an anomaly that can be defined as a permanent elevation
of part or of an entire hemidiaphragm without loss in the continuity in the pleuroperitoneal
layers. It is characterized by normal peripheral muscular insertions of the diaphragm but marked
decrease in muscular fibers in the eventrated part, which has the appearance of a thin, translucent membrane. It is generally thought that diaphragmatic eventration is a congenital anomaly
resulting from an incomplete migration of myoblasts during the fourth week of embryologic
development. It has a marked left-sided predominance and does not generally result in paradoxical diaphragmatic motion.
Diaphragmatic paralysis is usually an acquired disorder in which the diaphragm, even if
somewhat atrophic, is still muscular. It may manifest in childhood or adulthood and can be
associated with phrenic nerve involvement. In many cases, especially in the adult, the exact
cause of diaphragmatic paralysis will remain unexplained despite extensive investigation and
follow-up.
Diaphragmatic herniation, with or without a hernia sac, involves the loss of continuity in one
or more of the layers constituting the diaphragm.

Step 1. Surgical Anatomy

The mature diaphragm is a dome-shaped muscle that is anchored to the bony structures of
the thorax and is considered the most important inspiratory muscle. When it contracts, the
dome moves inferiorly and becomes flattened, thus decreasing the intrathoracic pressure and
allowing air to be taken into the lungs. The muscular parts that originate from the lower six
ribs bilaterally, the posterior aspect of the xiphoid, and the external and internal arcuate ligaments unite at the central tendon. As such, the diaphragm should be viewed as a single
muscular unit with two halves.
The diaphragm receives its motor supply through the phrenic nerves, which are formed at
the lateral border of the anterior scalenus muscles, chiefly from the C4 nerve roots but with
contributions from the C3 and C5 nerve roots. From there, the phrenic nerves enter the
superior mediastinum between the ipsilateral subclavian artery and innominate vein and pass
anterior to the pulmonary hilum along the pericardium. It is at that level that they are most
susceptible to surgical injury, which may result in complete paralysis and eventual muscular
200

Chapter 19 Diaphragmatic Eventration and Paralysis 201

BOX 19-1. Terminology

Eventration
Congenital in origin
Can be total or partial (anterior, posterolateral, medial)
Characterized by normal muscular insertions and thin membranous abnormal eventrated
area
Predominantly left-sided
Paralysis
Nearly always acquired
Characterized by atrophic muscle
Can occur with or without phrenic nerve involvement
Hernia
Involves loss of continuity of one or more of the layers constituting the diaphragm

atrophy of the corresponding half of the diaphragm. The right phrenic nerve reaches the
diaphragm lateral to the inferior vena cava, and the left phrenic nerve joins the diaphragm
lateral to the left border of the heart. They both divide into several terminal branches whose
anatomy delineates safe areas in the diaphragm where incisions can be made without creating
loss of diaphragmatic function.
Arterial supply to the diaphragm is through the pericardiophrenic and intercostal arteries;
venous drainage is through the right and left inferior phrenic veins, which drain medially
into the inferior vena cava.

202 Section II Thoracic Benign

Step 2. Preoperative Considerations

In the adult population, symptoms related to an elevated diaphragm are predominantly

respiratory, mainly dyspnea, cough, and retrosternal discomfort. The diagnosis can usually
be made on standard posteroanterior chest films (Fig. 19-1A) which show a diaphragm in
higher position than normal, forming a round, unbroken line arching from the mediastinum
to the costal arch laterally. Often the mediastinum will be shifted toward the unaffected side.
If there is diaphragmatic paralysis, paradoxical motion can be observed on fluoroscopic
examination. Although seldom done, diagnostic pneumoperitoneum might be useful to distinguish between an elevated diaphragm and frank herniation (see Fig. 19-1B). Computed
tomography (CT) scanning and ultrasonography are not particularly helpful in differentiating
between an elevated diaphragm and true herniation, but magnetic resonance imaging (MRI)
allows one to acquire high-quality images in several planes, which provides a better evaluation of the entire diaphragm.
The most important preoperative considerations (Box 19-2) in patients with an elevated
hemidiaphragm are to rule out a diaphragmatic hernia or thoracic (pulmonary or mediastinal)
malignancy affecting the phrenic nerve, to document by pulmonary function studies and
exercise testing the respiratory consequences of the elevated diaphragm, and finally to establish clearly the indication for surgery. This should be done with the understanding that most
cases of eventration diagnosed in adults should be treated conservatively unless severe
dyspnea that interferes with normal activities, orthopnea, or gastrointestinal symptoms are
clearly related to the high position of the diaphragm. Indications for surgery in adults are
thus uncommon, and the surgeon must be cautious before recommending plication for
respiratory or digestive symptoms thought to be secondary to an elevation of the
diaphragm.

Step 3. Operative Steps

The objective of the procedure of diaphragmatic plication is to immobilize the diaphragm in

a lower, relatively flat position (see Fig. 19-1C) to reduce lung and mediastinal compression.
This can be done through an open posterolateral approach, video-assisted techniques, or a
laparoscopic abdominal approach. For all these procedures, gastric decompression with a
nasogastric tube is mandatory.

Chapter 19 Diaphragmatic Eventration and Paralysis 203

Figure 19-1

BOX 19-2. Important Preoperative Considerations in Patients with

Diaphragmatic Eventration and Paralysis

Rule out a diaphragmatic hernia

Rule out a thoracic malignancy affecting the phrenic nerve
Document the respiratory consequences of the elevated diaphragm
Establish a clear indication for surgical repair

204 Section II Thoracic Benign

1. Open Posterolateral Approach

The operation is carried out through a seventh interspace posterolateral thoracotomy. The
lung and mediastinum are first examined to rule out unsuspected pathological processes,
and the diaphragm is then plicated in successive layers until it becomes taut. This should be
done with heavy interrupted silk sutures often reinforced with Teflon pledgets to prevent
tearing. The direction of the plication is determined by the axis of the eventration, which is
generally transverse rather than anteroposterior.
In the flag plication technique, two Babcock clamps are used to raise the eventrated diaphragm, and the created fold is fixed at its base with U-shaped heavy silk sutures (Fig.
19-2A). This plicated area is then folded and resutured close to the intercostal insertion of
the diaphragm by one or several rows of additional stitches (see Fig. 19-2B).
In the accordion plication technique, the eventrated diaphragm is pulled in a radial direction, and folds are created by placing full-thickness sutures in the anterolateral to posteromedial direction (Fig. 19-3A). In this manner, the diaphragm can be plicated with as many
rows of sutures as necessary to tighten it (see Fig. 19-3B).
Other techniques that can be carried out through an open thoracotomy include mechanical
stapling of the base of the eventration, incising the eventration and folding it onto one side,
or plicating the fold with U-shaped sutures placed over one or two right-angle clamps. With
this last technique, the created semilunar fold is laid down and sutured again to reinforce
the thinnest portion of the eventration, usually its anterior part.

Chapter 19 Diaphragmatic Eventration and Paralysis 205

A
Figure 19-2

A
Figure 19-3

206 Section II Thoracic Benign

2. Plication by Minimally Invasive Thoracoscopic Technique

This procedure, originally described by Mouroux, is carried out through two 5-mm thoracoports and a mini-thoracotomy made over the ninth intercostal space for the suturing of
the diaphragm (Fig. 19-4A). The eventrated diaphragm is first pushed down toward the
abdomen (see Fig. 19-4B), and the created transverse fold is closed with a back and forth
continuous suture beginning at the periphery of the diaphragm down to the cardiophrenic
angle (see Fig. 19-4C).This is followed by a second row of continuous suture burying the
first suture line (see Fig. 19-4D). It is to be noted that the presence of extended pleuropulmonary adhesions is generally considered a contraindication to videothoracoscopic
plication.

3. Laparoscopic Plication

This technique for left-sided eventrations, which was described by Httl, is done with the
patient in a 30-degree reverse Trendelenburg position where the surgeon is positioned
between the legs of the patient. The redundant diaphragm is pulled down and plicated with
12 to 15 U-type sutures inserted from the left dorsal portion of the diaphragm to its ventral
medial portion.

Chapter 19 Diaphragmatic Eventration and Paralysis 207

Port 1
5th ICS
Port 2
5th ICS

9th ICS

Figure 19-4

208 Section II Thoracic Benign

Step 4. Postoperative Care

The postoperative care of these patients is usually fairly straightforward with placement of
one chest tube, which is removed within 48 to 72 hours of the operation, and a nasogastric
tube, which is kept in place until abdominal peristalsis has resumed (normally within 24
hours).

Step 5. Pearls and Pitfalls

In adults, diaphragmatic eventration rarely requires surgical correction, except when respiratory or digestive symptoms are clearly related to the abnormality and other causes of elevated
hemidiaphragm have been ruled out. In selected patients, however, there is evidence that
diaphragmatic plication will provide substantial and long-lasting benefits in terms of improving symptoms and lung function. The possibility of performing these operations by less
invasive techniques, such as video-assisted thoracoscopy, may lead to new interests in these
disorders and their surgical treatment.

Chapter 19 Diaphragmatic Eventration and Paralysis 209

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Lai DTM, Paterson HS. Mini-thoracotomy for diaphragmatic plication with thoracoscopic assistance. Ann Thorac Surg
1999;68:2364-2365.
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Merendino KA, Johnson RJ, Skinner HH, et al. The intradiaphragmatic distribution of the phrenic nerve with particular reference to the
placement of diaphragmatic incisions and controlled segmental paralysis. Surgery 1956;39:189-198.
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