Diaphragmatic relaxation: Pathophysiological [616902]

Diaphragmatic relaxation: Pathophysiological
alterations and current possibilitiesof surgical repair
Ann. Ital. Chir., 77, 2, 2006 131
Ann. Ital. Chir., 2006; 77: 131-136
Vassiliki Xenaki, Francesca Mitri, Gianni Sigismondi, Sonia Di Paolo, Nicola Picardi
Università degli studi “G. d’Annunzio” Chieti, Dipartimento di Scienze Chirurgiche Cliniche e Sperimentali, Presidio Ospedalier o
“SS. Annunziata” – I Divisione Clinicizzata di Chirurgica (Direttore: Prof. N. Picardi).
Introduction
The function of the diaphragm is central in the respi-
ratory dynamic. Every defect of its contractility com-promises the effectiveness of the respiratory exchangesdue to its deficient function as a pair of bellows. Except for the diaphragmatic lesions that can follow anopen or closed thoraco-abdominal trauma, there are otherpathological conditions which can make inefficient eitheran hemi-or the entire diaphragm .Nowadays surgery is advantaged by sophisticated dia-gnostic instruments and technological facilities whichpermit the restoration of any possible diaphragmaticdefect, when clinically evident and meaningful, besidesnaturally the thorough physiopathological knowledgeacquired thanks to the modern thoracic surgery.
Case report
A 63-year-old man was admitted in the 1stSurgical Clinic
of the University Hospital “SS. Annunziata” of Chieti in1995 hospitalized because of a respiratory failure crisis.The patient was affected by dyspnoea, polypnoea onlimited labor and presence of subcyanocis in the absen-ce of evident cardiopathy, which was thereafter excludedby the cardiologists.In the subsequent diagnostic process of the patient astatic x-ray of the thorax demonstrated a significantand permanent elevation of the right hemi-diaphragmwhich projected in P-A projection at the level of thefourth intercostal space. The fluoroscopic study
Pervenuto in Redazione Dicembre 2005. Accettato per la pubblicazio-
ne Febbraio 2006.For correspondence: Vassiliki Xenaki, MD, Odos Tompazi 1, 12243Egaleo (Athens), Greece ([anonimizat]).Diaphragmatic relaxation: Pathophysiological alterations and current possibility of surgical repair
Diaphragmatic relaxation is a pathology not frequently observed because it is generally oligosymptomatic.
The development of modern technology has induced an important contribution to the diagnosis and treatment of thedisease which can find a possibility of restoration in surgery. A 63-year-old patient with a light syndrome of respiration deficiency and an altered relaxed profile of the right cupolawas subjected to surgical treatment with the technique of diaphragmatic plicature without any adverse implication duringand after the operation. After a brief recovery, the patient was discharged and after 9 years he affirmed still absence ofdyspnoea from limited labor and absence of respiration problems. The selected surgical technique for the restoration ofthe altered muscle is the diaphragmatic plicature without incision or excision of the altered part of the muscle. The pre-ferable access way today is that of laparotomy which is devoid of problems of thoracotomy and generally it permits qui-teeasily the restoration of all diaphragmatic defects.
Diaphragmatic plicature is a simple, effective and long-lasting intervention but we cannot determine the complete reco-very of the normal contractile function of the muscle. There is no morbidity and mortality directly related to this tech-nique, the latter incidentally associated with complications of general anesthesia.
K
EY WORDS : Diaphragmatic relaxation, Plicate of the diaphragm.

demonstrated a clear symptom of Kienböck, while the
functional respiratory tests gave a Current Volume of450 cc, with respiratory frequency of 22/min, andreduced Inhaling and Expiratory volumes, and the-refore of the Vital Capacity. Therefore the diagnosisof diaphragmatic relaxation without apparent causebecome evident.The patient was informed of the benign nature of hispathology, the therapeutic potentials, the potential evo-lution of the disease without surgical procedure and thepossible complications connected to the treatment itself,recommending a reconstruction of at least the static func-tion of the hemi-diaphragm by means of a doubling ofit by folding. The patient accepted to proceed with thesurgical intervention proposed.
Surgical intervention:
Through a sub-costal, bilateral laparotomy, prevalentlyextended on the right side, the liver cupola was exposed,V. Xenaki et al
132 Ann. Ital. Chir., 77, 2, 2006
Fig. 1: Pre operative X-ray. Confronting inhalation and expiration both
the raising of the right diaphragmatic dome (A) and the exaggerated
widening of the right costo-phrenic sinus (B) become evidentel, without
equivalent lowering of the dome, lowering of the dome, that remainshigh located (C).
Fig. 2: The flail right hemi-diaphragmatic dome is grasped by a Babcock
forceps (A), and e series of pulling stitches is placed across all its free
margin, making a fold.
Fig. 3: At the base of the fold a series of U stitches are passed and knot-ted (A), to stabilize it. The anterior margin of the fold, is lifted and fixed
to the anterior costal insertion of the diaphragm (B, C). The fold is final-
ly fixed and at the lower aspect the U stitches are evident (D).
Fig. 4: View of the asymmetrical subcostal laparothomy.

severing the sickle-shaped ligament up to the point whe-
re it joints to the sub-diaphragmatic inferior vena cava.The right diaphragmatic cupola, become thinner, is gra-sped by Babcock forceps, drawn downwards, paying atten-tion not to include the overlying pleura and lung paren-chyma. Naturally for the same purpose the applied trac-tion was progressive and moderate. A series of successi-ve, non-absorbable stitches are passed through the mar-gin of diaphragmatic folding for all its length, pullingfinally on the stitches, to elevate it from the basal dome(Fig. 2B). Thus, a series of U-shaped stitches is appliedright at the basal margin of the diaphragmatic elevation,transfixed on both surfaces of the stretched fold, makingstable and autonomous the diaphragmatic fold as regardof the remaining diaphragm (Fig. 3A). For this suturenon-absorbable stitches of 1/0 or 2/0 caliber were used,with knots tightened on the lower, abdominal, side ofthe fold. It war thereafter bend forwards to duplicate thelower anterior diaphragmatic surface, and fixed by sutu-re with the previous marginal non absorbable stitches, tothe front costal insertions of the diaphragm fibers witha series of X-shaped knots (Fig. 3C-D).Results
Postoperatively all the clinical and laboratory tests neces-sary for the evaluation of the outcome were carried out.Already a few days after the operation, the patient affir-med absence of dyspnoea and the Current Volume wasincreased to about 530 cc. The patient’s follow up con-tinues until today and the respiration conditions remaingood after 9 years.From the clinical point of view, lack of dyspnoea andabsence of subcyanosis were constantly reconfirmed.The respiratory functional tests demonstrate a perma-nent improvement of the Current Volume, with aTiffenau index of 74%, however without a return tothe normal values. In the fluoroscopic study, a sati-sfactory post-operational mobility of the right side ofthe muscle was demonstrated and particularly a lack ofparadox movements. Therefore a stabilization of theright diaphragm was obtained. The Spirometric exami-nation showed that the vital capacity (VC) as well asthe force of exhaled volume of air in 1 sec (FEV 1)was within the normal range.
Discussion
Under normal conditions the down movement of thediaphragmatic dome of 1,5 cm during the inhalationphase causes an augmentation of approximately 270 ccin the thoracic volume, whereas the exhalation – fun-damentally passive and caused prevalently by muscularcontraction of the abdominal wall – provokes a decrea-se of the same measure. Therefore, a decrease of 3 cmof the profound inhalation acts corresponds to anincrease of over 700 cc of the thoracic capacity
1. The
air volume during normal respiration ranges between+270 cc and –270 cc for a complete 3 cm up anddown movements of the diaphragma, moving a normalCurrent Volume of 540 cc, which is the one utilizedin normal respiration. The diaphragmatic relaxation ischaracterized by a global lack of respiration movementof the affected part, and thus a defective CurrentVolume for every respiration act. The paradox move-ments of the Kienböck phenomenon make worse therespiratory defect, with effects analogous to those ofthe “flail chest”. The parameters of normal respirationphysiology are therefore deeply altered, not only becau-se of Current Volume reduction, but also because ofthe lack of functional movements in the airways. Mustbe underlined however that the clinical defective respi-ratory presentation of the hemi-diaphragmatic relaxa-tion is not absolutely well correlated to the extent ofmuscular defect. Patients with serious forms of thedisease on a morphological and fluoroscopic level, maybe asymptomatic, whereas patients with a limited extentof the disease may manifest symptoms. It is evidentthat this variety of clinical pictures makes the selection
Ann. Ital. Chir., 77, 2, 2006 133Diaphragmatic relaxation: Pathophysiological alterations and current possibilities of surgical repair
Fig. 5: Control of diaphragmatic motility after the consolidated healing.
A, B: mild lowering of the right hemi-diaphragmatic dome, with lowe-ring of the left one during inhalation. B: reduction of the costo-phre-
nic sinus at rest.

of patients to undergo the surgical operation difficult.
In fact, it is generally accepted that surgical treatmentis indicated only in cases of evident simptomatology,especially if involving the thoracic organs or the abdo-minal ones, which are probably implicated in thispathologic condition. In the case of a symptomatologywhich lasts less than a year and is of neurological orinfectious nature, a wait and see approach may be adop-ted, hoping for a nervous revitalization and re-inner-vation of the dome area. An 8-12 month interval isnecessary for the recovery; this interval may reach orexceed 18 months
2.
The possible surgical methods for repairing the diaph-ragmatic defect may be of two kinds: the diaphragma-tic doubling by folding and the incision followed by asuture of the type “double breasted”
2. What must always
precede is a complete liberation of the “relaxed” diaph-ragmatic cupola in all its extent except for the coronaryarea of the liver in cases of right diaphragmatic relaxa-tion. The phrenic center in contact with the pericardiummust be detached only when the selected access route isthe thoracic one
2. Among the possible surgical methods,
the one selected in our experience was the method ofdiaphragmatic doubling by folding. Particularly impor-tant for the surgical intervention of the diaphragmaticrelaxation restoration is to ensure the integrity of thephrenic nerve, a caution which is superfluous if the sta-ble deficiency of the nerve is the real cause of the patho-logy. The preferable access route is the abdominal one.The thoracic route is unavailable if the liver itself is her-niated in the thorax or if the relaxation concerns alsothe rear part of the dome.Our choice was for the diaphragmatic doubling foldingby means of a laparotomic access, which is devoid ofthe postoperative problems of thoracotomy. However, itpermits quite easily the restoration of all diaphragmaticdefects and, if needed, it permits also an inspection ofthe abdominal internal organs.The direction of the diaphragmatic folding is selectedaccording to the longer axis of the relaxation. The folding,therefore, may be transverse or front-rear, but the bestresults are accomplished with the transverse plicature.In the application of stitches in U shape at the base ofthe plicature, we must warn against the possible perfo-ration of pleura, which could be drawn down pullingthe margin of the plicature itself as described. For thisreason, a good coordination with the anesthetist candraw timely the attention to a possible provoked pneu-mothorax. To avoid this, it is necessary that the stit-ches should not tear the diaphragmatic plane, shouldbe close one to another and taken with moderate thick-ness of the tissues.If we are not certain of the diaphragmatic solidity, it ispossible to reinforce it with a sheet of prosthetic mate-rial (a net of polyglactic or polyglycolic acid or poly-propylene) or autoplastic tissues (fascia lata tendon). Theheteroplastic materials less preferred are polypropylenenets because they create adhesions with adjacent tissuesthey come in contact with, in favour of the sheets oftetrafluoroethylene (permanent material) or absorbablepolymer nets as polyglactic or polyglycolic acid, predi-sposed to hydrolytic destruction.The rigidity attained in the right semi-diaphragm throu-gh plicature renders the paradox respiration movementfar less effective, with reduction of the flail diaphragmand creating a strong supportive point for a better effec-tiveness of all the respiratory muscles, and naturally ofthose of the healthy hemi-diaphragm. The pulmonaryvolume during the last inhalation phase increases becau-se the pressure applied on the lung by the abdominalcontent is inhibited
3.
The diaphragmatic plicature, in our experience, is a sim-ple and quick surgical technique which can be appliedwithout risks during operation even on infants and withfavorable and long-lasting results
4.
This technique proved to be without morbidity or mor-tality and with a brief post-operational rehabilitation.Therefore, it’s a safe, well-tolerated technique and per-mits a reduction in pulmonary compression of the affec-ted side, a stabilization of the thoracic base and themesothorax and a reinforcement of the respiration actionof intercostal muscles and of the abdominal ones
5,
through a rehabilitation of their tension state.
Conclusions
The purpose of surgical correction of the diaphragmaticrelaxation is not that to improve the mobility of theaffected diaphragm, but to reinforce and make stiff thediaphragmatic plane. Generally it retains limited mobi-lity but the convexity is permanently reduced, thusimproving the respiration function, eliminating the flailpassive movements. In fact, even if it is not possible torecreate movement, which depends mainly on the pre-sence of innerved muscles, there is an augmentation ofthe thickness and stiffness of the diaphragmatic layerwhich, this way, partly loses its passive retreat in themuscular abdominal thrusts, reducing the symptom ofKienböck.
Riassunto
La relaxatio diaframmatica è una patologia di non fre-quente osservazione anche perché in genere oligosinto-matica. Lo sviluppo della tecnologia moderna ha appor-tato un’importante contributo alla diagnosi e al tratta-mento della patologia, che quindi ha nella chirurgia unapossibilitá di riparazione.Un paziente di 63 anni con sindrome di lieve isuffi-cienza respiratoria e con un profilo diaframmatico dellacupola destra alterato viene sottoposto al trattamento chi-
rurgico con la tecnica della plicatura diaframmatica sen-V. Xenaki et al
134 Ann. Ital. Chir., 77, 2, 2006

za complicanze intra e post-operatorie. Il paziente, dimes-
so dopo breve convalescenza, dichiara a nove anni didistanza assenza di dispnea da sforzo e di problemi ditipo respiratorio.La tecnica chirurgica elettiva di riparazione del muscoloalterato è la plicatura del diaframma senza incisione oescisione della parte alterata del muscolo. La via di acces-so oggi preferibile è la via laparotomica che è esente daiproblemi della toracotomia e in genere consente abba-stanza agevolmente la riparazione di tutti i difetti dia-frammatici.La plicatura del diaframma è un intervento semplice,efficace e duraturo senza peró poter determinare la com-pleta ripresa funzionale normale del muscolo. La mor-bilitá e la mortalitá legata a questa tecnica è nulla omolto bassa, quest’ultima associata alle complicazionidell’anestesia generale.References
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Ann. Ital. Chir., 77, 2, 2006 135Diaphragmatic relaxation: Pathophysiological alterations and current possibilities of surgical repair