Diaphragm Plication using VATS to Hemi-diaphragmatic Paralysis because of Phrenic Nerve Injury: A Case Report

A 73-year-old woman experienced sudden dorsal thoracic pain on October 28,2004. Acute aortic dissection was diagnosed with the aid of chest computed tomography, and ascending aorta replacement was performed on the same day in the Department of Cardiovascular Surgery at our hospital. The endotracheal tube was removed on the 2nd postoperative day (POD) but was re-inserted due to respiratory failure attributable to hypoventilation. Chest X-ray showed marked elevation of the right hemidiaphragm, which was diagnosed as paralysis of the right hemi-diaphragm due to phrenic nerve injury during surgery. The patient was hemodynamically stable, but positive pressure ventilation was required, and refractory pneumonia was present. Diaphragm plication was performed in the Department of Respiratory Surgery at our hospital on November 29 to treat the paralyzed hemi-diaphragm; the diaphragm was relaxed and then plicated under thoracoscopic assistance with knifeless endostaplers. The diaphragm was markedly lowered, hypoventilation was improved after the operation, and the endotracheal tube was removed on the 3rd POD. The inflammation decreased, the clinical course was uneventful, and the patient was discharged on the 10th POD. Diaphragm plication using VATS is a minimally invasive, effective procedure that can be used when a patient cannot be weaned from ventilatory support because of unilateral diaphragmatic paralysis, as in the present case.