DIAPHRAGM EVENTRATION

DIAPHRAGM EVENTRATION

Professor İrfan Yalçınkaya, MD

Health Sciences University, Istanbul Hamidiye Faculty of Medicine, Department of Chest Surgery, Sureyyapasa Chest Diseases and Chest Surgery Health and Application Research Center, Chest Surgery Clinic

E-mail: profdrirfanyalcinkaya@gmail.com

Summary: In symptomatic patients with diaphragmatic eventration, minimally invasive plication is the primary option.

 

Keywords: Diaphragmatic Eventration, Plication, Video-Assisted Thoracoscopic Surgery, Minimally Invasive Surgery

 

Definition & History & Etiology

Diaphragmatic eventration is the permanent elevation of all or part of the diaphragm leaf, provided that the costal parts and organ connections are not disrupted. Another definition is the permanent elevation of the hemidiaphragm without any defect in the muscle attachments of the diaphragm and without disruption of the integrity between the pleural and peritoneal cavities. The terms eventration and paralysis are often confused. Paralysis describes the muscular degeneration resulting from denervation and is one of the pathologies that initiate eventration. However, eventration does not always occur together with paralysis. Despite this, eventration is used simultaneously to describe both paralysis and elevation of the diaphragm.

Diaphragm height was first defined by Jean Louis Petit and published in 1760. The term “diaphragm eventration” was first used by Beclard in 1829.

While it is not possible to reveal the etiological cause in the majority of patients (idiopathic diaphragmatic eventration), malignancy, trauma, infections, iatrogenic causes (mediastinal and cardiac surgery) and neuromuscular diseases are important etiological causes. Although the cause cannot always be fully explained, congenital and acquired diaphragmatic eventration are divided into two groups: those related to phrenic nerve paralysis and those not. It is one of the rare pathologies that is often detected incidentally after trauma or during the investigation of dyspnea etiology.¹ Although the cause can be revealed in many patients, the cause cannot be fully revealed in some patients. The underlying cause in these patients is thought to be viral infections.²

            The main cause of congenital diaphragm eventration is a congenital developmental defect of the diaphragm muscle, characterized by a decrease in the amount of muscle fibers. Acquired diaphragm elevation can be divided into two categories: paralytic and non-paralytic. The main cause of paralytic diaphragm eventration is the failure of the phrenic nerve to function after trauma, tumor, or surgery. In cases of phrenic nerve damage, diaphragm elevation is observed on the affected side (Table 1).

Table 1. Other factors causing diaphragm elevation other than eventration

 

Diagnosis

Diaphragmatic eventration, although rare, is more common in men and is usually predominantly left-sided. The most common symptom of acquired diaphragmatic eventration in adult patients is respiratory problems. Since the diaphragm is the primary respiratory muscle, the majority of patients complain of increased dyspnea, especially with exertion and when lying supine. Less frequently, cough, retrosternal or epigastric pain may also be a symptom. Respiratory insufficiency symptoms may also occur due to underlying lung disease or decreased lung reserve. In addition, nausea, vomiting, abdominal gas-bloating, belching or abnormally increased bowel sounds may be present as symptoms. It may also be associated with sleep disorders. Therefore, polysomnography should be performed in patients with diaphragmatic eventration/paralysis who show symptoms and who also have sleep disorders. Patients diagnosed with obstructive sleep apnea syndrome may benefit from surgery, and symptoms may completely improve or be alleviated. In this way, long-term comorbidities of sleep disorders can also be prevented.^3,4

Diagnosis is often made incidentally, most of the time, with posteroanterior (PA) or lateral chest radiography. While an elevation of the diaphragm on plain radiography may not indicate diaphragmatic paralysis, paralysis can be excluded if an elevated diaphragm is not seen. Thoracic Computed Tomography (CT) and, when necessary, Ultrasonography are also valuable methods in demonstrating the underlying pathology (Figure 1). However, these methods have limited ability to distinguish diaphragmatic eventration and hernias. Magnetic Resonance Imaging can also be used when necessary.

Figure 1: Left diaphragm eventration (PA chest X-ray, Left lateral chest X-ray), left diaphragm eventration in thorax CT

 

If the phrenic nerve is affected, diaphragm movements are reduced or absent on fluoroscopy, or paradoxical movements of the diaphragm can be seen. In patients who are suddenly inspired during fluoroscopy, the normal diaphragm moves downwards, while the paralyzed diaphragm moves upwards. Fluoroscopy or ultrasonography should definitely be performed, especially in cases with right diaphragm eventration. Today, fluoroscopy has almost completely given way to ultrasonography. Diaphragm thickness can be easily measured and diaphragm movements can be evaluated with thoracic ultrasonography. It should not be forgotten that pathologies under the diaphragm (such as hepatomegaly, subphrenic abscess, intra-abdominal pathologies) can cause right diaphragm elevation, and pleural effusion and pericardial cysts can also mimic diaphragm eventration.

Pulmonary Function Tests (PFTs) can be helpful in the evaluation of dyspneic patients with diaphragmatic eventration, and these patients often have decreased FEV1 and FVC values. Since the dysfunctional diaphragm cannot retract sufficiently, there is a decrease in lung volumes and compliance. This is reflected in spirometric values, and FVC and FEV1 values ​​are decreased. Although PFT values ​​are usually abnormal in symptomatic patients with diaphragmatic eventration/paralysis, these values ​​are often not related to the severity of dyspnea. PFTs are the most objective criteria used to exclude other factors in the differential diagnosis of dyspnea, in preoperative evaluation in eventration, in postoperative follow-up, and in response to surgery.

In the differential diagnosis, the causes of exertional dyspnea and increase in dyspnea, such as Chronic Obstructive Pulmonary Disease, congestive heart failure, and morbid obesity, should be carefully examined.

 

Treatment

In the presence of symptomatic diaphragmatic eventration & paralysis, treatment is surgical. Regardless of etiology, plication is the basic surgical method.^2,5

The aim of surgical plication is to stabilize the atrophic, thin, flaccid and elevated diaphragm, preventing the abdominal organs from moving to the evanescent side during inspiration, and to prevent the development of parenchymal linear atelectasis due to the compression of the mediastinal shift and elevated diaphragm. In addition, the elevation in the diaphragm is reduced to the normal position by plication, and the intrathoracic negative pressure required for the expansion of the contralateral lung is re-regulated, thus improving exercise performance.^2,6

In asymptomatic cases and secondary eventrations caused by neoplasm, even if eventration is detected on chest X-ray, there is no indication for surgery unless it is symptomatic and necessary. (Figure 2)

Figure 2. A case without surgical indication

 

Surgery is indicated when respiratory symptoms (usually dyspnea, especially dyspnea on exertion or orthopnea, less frequently cough) or when gastrointestinal findings (dyspepsia, meteorism) are at a level that will affect the patient's life. After neoplasia is excluded, surgery can be decided by considering the patient's clinical severity and duration of symptoms. If the cause of eventration is paralysis and the symptoms are new, it can be waited for 6-12 months for the picture to become clear in these patients, and in cases other than paralysis, we believe that there is no need to wait for surgery in patients with clinical symptoms (dyspnea on exertion) and radiologically demonstrated eventration. Spontaneous resolution is possible, albeit rarely, in eventrations that occur in the early postoperative period. Asymptomatic cases should be monitored and surgical treatment should be considered in case of symptoms or deterioration of respiratory functions. In addition, when phrenic nerve injury develops in patients undergoing thoracic surgery (especially in pneumonectomy), prophylactic diaphragm plication can be performed at the same session to reduce future respiratory complications.⁷ For patients on ventilator support, plication is not contraindicated if indicated.

Wood first proposed the idea that the diaphragm could be reduced in size by wrinkling it in 1916. In 1923, Morrison performed the first successful eventration surgery and defined the surgical principle that is still used.

Many methods have been defined in diaphragmatic eventration surgery and have been used throughout history. The traditional method for patients with symptomatic diaphragmatic eventration is open transthoracic or transabdominal plication. This method can provide significant improvement in patients' symptoms and considerable improvement in respiratory functions. However, open surgery is invasive and can also cause certain morbidity and even mortality. It is not a good option, especially in patients with multiple comorbidities and poor lung capacity. In addition, no matter how small the incision used in this surgery, which is performed to reduce and eliminate respiratory distress, it can have a restrictive effect on both pain and respiratory functions in the postoperative period, thus reducing the success of the expected outcome of the surgery.²

In order to minimize the disadvantages of open transthoracic surgery, Gharagozloo et al. performed the first thoracoscopic diaphragm plication in a 72-year-old patient with left phrenic nerve involvement and left diaphragm paralysis due to thymic carcinoma in 1995. This procedure is technically no different from the classical transthoracic approach, except that it is performed with video assistance. In 1996, Mouroux et al. developed and published a thoracoscopic method that is technically more applicable than Gharagozloo's method.⁸

The first VATS applications were mostly in infants and children.⁹ In the literature, in the first series of publications on adults, cases where thoracotomy and VATS were applied are mostly together. Today, open surgical methods have given way to minimally invasive surgical methods. Open surgery is preferred only in patients where intubation with a double-lumen tube cannot be applied for VATS, or the patient cannot tolerate it, or in patients who cannot perform minimally invasive surgery due to advanced pleural/peritoneal adhesions due to previous diseases and surgeries. (Table 2)

Table 2. Surgical methods in diaphragm pathologies

 

In the VATS approach, the patient is positioned in the lateral decubitus position and 30 degrees reverse Trendelenburg, as in open surgery. The first port is opened from the 6th intercostal space (ICA) in the midaxillary line and the location of the other 2 ports is determined after diaphragm exploration, and some surgeons use CO2 to depress the diaphragm. During surgery, plication is performed using only thoracoscopic instruments (Endograsper, Endostitch, etc.). In the literature, the number of ports used for VATS varies between 2 and 4, and it is stated that this procedure can be performed with a single port.¹⁰ Although the endoscopic instruments used in the VATS procedure are suitable for diaphragm eventration in infants and children, it is relatively more difficult to perform a plication with sufficient tension with endoscopic instruments in adults because the diaphragm has both a larger surface area and a thicker thickness.

In diaphragm plication with RATS, the patient is in the lateral decubitus position, the head is in a 10-degree reverse Trendelenburg position. The first port is made from the place where the diaphragm is thought to be the highest, and CO2 is injected into the intrathoracic cavity. Then, the camera port is opened from the 4th ICA and after exploration, 2 more ports are opened for the robot arms and plication is applied. Although 3-dimensional image and no restriction of movement during plication seem to be among the advantages, the high cost of RATS, its not being easily accessible and widespread can be considered among the disadvantages of this method.

Another method is the hybrid method and is called video-assisted mini-thoracotomy. This method is a plication performed with 1 camera port and 1 utility thoracotomy. Thus, open surgical instruments can be used easily and the procedure can be performed with the comfort of open surgery. The intrathoracic area can be illuminated and when the diaphragm is grasped and pulled, the structures under the diaphragm can be easily seen with transillumination. It is not easy to suture the diaphragm with sufficient thickness and length with endostitch, which makes it difficult to create sufficient tension. Moreover, the 3-4 port sites used in VATS can reach a total utility incision. This method, which was first described by Lai and Paterson in 1999 and reported as a single case, was later modified by Rombolá et al. and applied in 18 cases.^10,11

We have successfully applied a modified version of these two methods with different characteristics in cases with diaphragmatic eventration.^12-16

In this method, the patient was intubated under general anesthesia with a double-lumen intubation tube according to the side. The patients were laid on the operating table in the lateral decubitus position with the operation side uppermost, with the head 30-45 degrees higher. In this way, the abdominal organs were taken down and the pressure of the abdominal organs on the diaphragm was reduced. The arm on the operating side was positioned in a way that would not hinder the movement of the endocamera. A nasogastric tube was inserted to provide stomach decompression and reduce abdominal distension. This procedure is especially important on the left side, thus allowing the diaphragm to descend more easily and reducing tension, allowing easier maneuverability for the surgeon. It may not be performed on the right side, but it can be. In these patients, an additional bowel cleansing is not necessary.

The surgeon who will perform the operation takes his/her place behind the patient if the eventration is on the right and in front of him/her if the eventration is on the left. First, a 10 mm (5 mm) port hole was opened for the endocamera from the 3rd or 4th ICA in the axillary line. The thoracic cavity and the eventrated diaphragm were evaluated using a zero-degree optic (30 degree). Unilateral ventilation was initiated and the lung on the side where the plication would be applied was deflated. The location where the thinned and eventrated diaphragm adhered to the chest wall was determined and a 3-4 cm utility thoracotomy was opened from the mid-axillary line two ribs above (usually the 7th or 8th ICA). In this way, both the level at which the diaphragm could be tense was determined (for this, a transthoracic syringe needle tip can be used if necessary) and a suitable and sufficient area was provided for working with the instruments used in open surgery (or preferably open instruments developed for thoracoscopy). In utility thoracotomy retraction, initially pediatric retractors and Weitlaner retractors were used, and later wound protection retractors (Alexis etc.) were used in all cases.

The stitches were first placed with a needle and forceps, starting from the closest point where the diaphragm adheres to the chest wall, from lateral to medial, and starting from the point where the pericardium sits on the diaphragm, using a needled number 1 silk suture in a continuous single row. The first sutures can be placed directly by seeing the diaphragm directly from the retractor and applying a sling with the help of the sutures, while the final sutures can be placed easily by looking at the monitor. The diaphragm was lifted with forceps or clamps and plication was applied without damaging the abdominal organs with the help of the camera light and the transillumination method. When the plication process was most medial, the plication line was tightened like a spring from both suture ends with the help of a finger and a knot was tied at the closest point to the utility thoracotomy, and a knot pusher was used when necessary. With this first row of sutures, other plication lines became apparent, and subsequent procedures became easier. Then, in the same way, two rows of stitches were sewn on both sides of this first row of stitches to provide sufficient tension in the diaphragm, and the diaphragm was lowered to its normal position.

If the patient's diaphragm is extremely thin and it is thought that the sutures may tear, a pledget suture may be used. During plication, care was taken not to try to pass the needle through the folds formed when the diaphragm, which is loose and loose, was held with forceps and not to insert the needle either superficially or too deeply. In this way, the diaphragm was plicated very strongly and a possible complication related to the structures under the diaphragm was prevented. After checking the diaphragm tension with a finger or a tool, the entire field was reviewed with the help of a camera. Care should be taken not to over-tension the diaphragm as a result of plication. Because the sutures placed may tear in cases where intra-abdominal pressure increases.

A chest tube of size 24 or 28 was inserted into the pleural space through a utility thoracotomy and placed in the pleural cavity with its tip at the apex. The incision should be closed very well, otherwise lung herniation may occur, and I believe that a single intercostal suture may be placed if deemed necessary. Postoperative PA chest radiographs were taken for all patients to see the diaphragm levels in the early period. Nasogastric tube was terminated with the onset of bowel movements on the first postoperative day and all patients were started on a soft diet. If there is no drainage & air leak and the lung is expanded on the PA chest radiograph, the drain can usually be removed at the end of the first or second postoperative day. The patient whose drain has been removed can be discharged after a follow-up chest radiograph. After discharge, the patient is advised not to be constipated for a while and not to lift heavy objects.

Many methods are described in the literature for diaphragm plication; hand-tied U sutures, matrix sutures, continuous sutures with or without pledgets or staples, methods with or without mesh, resection of a portion of the diaphragm and bringing the remaining portion end to end with overlapping sutures.^8,14

Although there is no study comparing VATS and plication methods, a study by Evman et al. compared plication techniques performed via thoracotomy. In a series of 42 cases, accordion plication and laparoscopic plication techniques were compared and increases in spirometric values ​​were found to be similar between the two groups. It was emphasized that there was an increase in spirometric tests regardless of the technique.¹⁷ The choice of plication method depends on the surgeon's expertise, training, and preference. Improvement in dyspnea is the most important measure of clinical success.

We apply and prefer accordion plication with non-absorbable continuous interrupted sutures such as silk. However, prolene and polyester sutures can also be used as suture materials. We also used pledget sutures in a few cases where the diaphragm was extremely thinned and we thought it would rupture with the sutures. We do not prefer staples due to concerns that the staples may break as a result of the tension created in the diaphragm, and we also do not prefer diaphragm resection due to the need for sufficiently thick tissue, even if it is thinned. We do not recommend mesh and think that it can only be used in recurrent cases.

In cases of right-sided diaphragmatic eventration, one must be very careful and meticulous. The cause of eventration must be investigated thoroughly, and if possible, fluoroscopy must be performed. Since fluoroscopy is no longer widely used, in recent years we have preferred diaphragmatic ultrasonography. Thus, the movement and thickness of the diaphragm can be easily measured. The patient's symptoms and respiratory function values ​​should be carefully examined in terms of COPD, obesity and heart failure. While no indication for surgery was given in four cases with right diaphragmatic eventration, in two cases the diaphragm was found to be normal during surgery and plication was abandoned.

Even in cases with a history of trauma, when thoracotomy is performed, it is possible to encounter eventration instead of rupture in the diaphragm. In fact, different pathologies such as diaphragmatic hernia and pericardial cyst can be encountered. Therefore, even if there is a history of trauma, we recommend starting all diaphragmatic pathologies with VATS. Because in closed surgery, if desired and necessary, it is possible to convert to open surgery at any time, but in open surgery, it is not possible to convert to closed surgery.

In the Chest Surgery Clinic of the Health Sciences University, Istanbul Sureyyapasa Chest Diseases and Chest Surgery Health Application and Research Center, between December 2009 and May 2025, 106 cases with symptoms of exertional dyspnea and diagnosed with diaphragm paralysis & eventration underwent minimally invasive surgery with diaphragm plication. In all cases, clinical complaints improved completely or largely in the postoperative period. No mortality was observed, and more than ten cases developed minimal complications (lung herniation in one case), and recurrence was seen in one case, and follow-up was sufficient. (Figure 3)

Figure 3. Our 106th case with VATS plication

 

In the doctoral thesis study of 50 cases titled “The effect of minimally invasive surgery on respiratory functions in diaphragmatic eventration” conducted in 2017 by Deniz Gürer MD and for which I was the thesis advisor at the same institution; when the preoperative and postoperative FEV1 (% and lt) values ​​of the patients were compared, a statistically significant increase was found in both parameters (p<0.001). There was an average increase of 12.1% in FEV1 (lt) values. Similarly, when the preoperative and postoperative FVC (% and lt) values ​​were compared, a statistically significant increase was found in both parameters (p<0.001). There was a postoperative increase of 11.5% in FVC (lt) values. Recurrence was detected in one patient during long-term follow-ups; this patient did not accept surgery and was followed up.

Surgery is indicated in symptomatic cases with diaphragmatic eventration and effort dyspnea, especially on the left. Today, diaphragmatic plication with minimally invasive surgery is an easy, fast and highly effective method in diaphragmatic pathologies, especially in diaphragmatic eventration, as in other thoracic structures. In this surgical method, where the instruments used in open surgery can be used, sufficient diaphragmatic tension similar to that in open surgery can be achieved and statistically significant improvements can be achieved in spirometric tests. At the same time, as in other surgeries performed with minimally invasive surgery, postoperative pain and morbidity are less, patient comfort increases, the recovery process is accelerated and the patient is discharged quickly.^18-21

We would like to underline once again that plication with minimally invasive surgery is the primary option in symptomatic patients with diaphragmatic eventration.

 

*Viewing Recommendation: Minimally Invasive Surgery in Diaphragmatic Eventration, https://www.youtube.com/watch?v=GKqM4OX37Xs

 

*Viewing Recommendation: Prof. Dr. İrfan Yalçınkaya, Minimally Invasive Surgery in Diaphragmatic Eventration & Paralysis, School of Thoracic Surgery, 2024,

https://www.youtube.com/watch?v=3DOxq0VrRRU&t=245s

 

References:

1.      Yalçınkaya İ. Dispne etyolojisinin araştırılması sırasında saptanan nadir bir patoloji: Diyafram evantrasyonu [A rare pathology detected during the investigation of dyspnea etiology: Diaphragm eventration]. Akciğer Bülteni 2019;5(2):51-5.

2.      Yalçınkaya İ. Diyafram paralizisi ve evantrasyonu [Diaphragm paralysis and eventration]. Yalçınkaya İ, editör. Diyafram Hastalıkları. Toraks Cerrahisi Bülteni 2013;4(4):266-71.

3.      Oruc O, Sarac S, Afsar GC, Topcuoglu OB, Kanbur S, Yalcinkaya I, Tepetam FM, Kirbas G. Is polysomnographic examination necessary for subjects with diaphragm pathologies? Clinics 2016;71(9):506-10.

4.      Sarac S, Salturk C, Oruc O, Kanbur Metin S, Bayram S, Karakurt Z, Yalcınkaya I. Sleep-related breathing disorders in diaphragmatic pathologies. Sleep and Breathing 2021;26:959-963.

5.      Derdiyok O, Yalçınkaya İ. Diyafram patolojilerinde cerrahi yaklaşım [Surgical approach to diaphragm pathologies]. In: Göğüs Cerrahisi. Metin M, Cansever L, Sezen CB (eds). Akademisyen Yayınevi, Ankara, 2022, Sh.415-20.

6.      Işık AF, Yalçınkaya İ, Kurnaz M. Erişkinlerde diyafragma yükselmeleri; Cerrahi gerekli mi? [Diaphragmatic elevations in adults; Is surgery necessary?] Van Medical Journal 2002;9(1):33–7.

7.      Yalçınkaya İ,  Doğruyol MT. Prophylactic chest surgery procedures. In: Dilek ON, Uranues S,  Latifi R, eds. Prophylactic Surgery. 1 st ed. Switzerland: Springer; 2021. p. 371-8.

8.      Gürer D, Atinkaya C, Yalçınkaya İ. Diyafram eventrasyonu [Diaphragm eventration]. In: Eren TŞ, editor. Torasik Cerrahi. 1st ed. İstanbul: İstanbul Tıp Kitapevi 2019; p. 53–60.

9.      İrdem AK, Doyurgan O, Kılıç Y, Balık H. İnfantlarda konjenital kalp cerrahisi sonrasında gelişen diyafram felcinin cerrahi tedavisi [Surgical treatment of diaphragmatic paralysis developing after congenital heart surgery in infants]. Dicle Tıp Dergisi 2024;51(3):415-24.

10.  Rombolá C, Crespo MG, López PT, Martínez AH, Atance PL, Ramírez AT, et al. Video-assisted minithoracotomy diaphragmatic plication: respiratory effects in adults. Thorac Cardiovasc Surg. 2016;64(08):647–53.

11.  Lai DTM, Paterson HS. Mini-thoracotomy for diaphragmatic plication with thoracoscopic assistance. Ann Thorac Surg. 1999;68(6):2364–5.

12.  Yalçınkaya İ. Plikasyon [Plication]. In: Toker A, Batırel HF, editors. Çağdaş Videotorakoskopik Cerrahide Teknikler ve Sonuçlar. 1st ed. İstanbul: Nobel Tıp Kitabevi; 2014; p. 157–62.

13.  Yalcinkaya I, Evman S, Lacin T, Alpay L, Kupeli M, Ocakcioglu I. Video-assisted minimally invasive diaphragmatic plication: feasibility of a recognized procedure through an uncharacteristic hybrid approach. Surg Endosc. 2017;31(4):1772–7.

14.  Yalçınkaya İ, Atinkaya Baytemir C. Diyafram Eventrasyonu ve Paralizisi ]Diaphragm Eventration and Paralysis]. In: Yalçınkaya İ, editor. Diyafram Hastalıkları. 1st ed. Ankara: Türkiye Klinikleri Yayınevi, 2020; p. 38–44.

15.  Doğruyol MT, Yalçınkaya İ. Chapter 75: VATS plication of diaphragm. In: Advanced Thoracic Surgery; Balcı AE, Ersöz H, Yüksel M (editors), Ankara; Akademisyen Kitabevi, 2021;781-5.

16.  Yalçınkaya İ. VATS İle diyafram cerrahisi [Diaphragm surgery with VATS]. In: Minimal İnvazif Torasik Yaklaşımlar; Metin M, Sezen CB (editors), İstanbul; Medical Network, 2021;291-308.

17.  Evman S, Tezel C, Vayvada M, Kanbur S, Urek S, Baysungur V, Yalçınkaya I. Comparison of mid-term clinical outcomes of different surgical approaches in symptomatic diaphragmatic eventration. Ann Thorac Cardiovasc Surg. 2016;224-29.

18.  Nardini M, Jayakumar S, Migliore M, Nosotti M, Paul I, Dunning J. Minimally invasive plication of the diaphragm: A single-center prospective study. Innovations 2021;16(4):343-9.

19.  Gritsiuta AI, Gordon M, Bakhos CT, Abbas AE, Petrov RV. Minimally invasive diaphragm plication for acquired unilateral diaphragm paralysis: A systematic review. Innovations 2022;17(3):180-90.

20.  Gilbert A, Wei B. Diaphragmatic plication: current evidence and techniques in the management of the elevated hemidiaphragm. Video-Assisted Thoracic Surgery 2023;8.

21.  Balamurugan G, Bhandarwar A, Wagh A, Bakhshi G, Ansari K, Bhondve S, Dhimole N, Jawale H. Comparison of short-term outcomes of video-assisted thoracoscopic (VATS) plication of diaphragmatic eventration-a six-year prospective cohort study. Updates in Surgery 2024;76(1):279-88.