VATS-пластика купола діафрагми внаслідок її паралічу в цивільних осіб та військовиків: досвід клініки

The plication of the diaphragm is aimed at returning the contents of the abdominal cavity to its normal position and ensuring a greater expansion of the lungs due to the reduction of the large surface of the diaphragm. Traditionally, the plication of the diaphragm was performed through a thoracotomy. Access to the diaphragm through a large incision is traumatic, and the indications for surgery are limited to patients who can actually tolerate such an invasive approach and associated morbidities. Objective — to report our own experience of video-assisted thoracoscopic (VATS) plication of the diaphragm at our institution between 2015 and 2025 in civilians and military personnel. Materials and methods. Patients underwent VATS plication of the diaphragm using a 3-port technique without CO2 insufflation. During 2015—2025, 90 plications of the diaphragm were performed in our clinic. There were 55 men (61 %), 35 women (39 %). The age of the patients ranged from 27 to 78 years, with an average of 55.3 years. The average body mass index was 32.1 (range = 22.2—45.4). Among 90 patients, 10 (11 %) patients were military personnel, in whom paralysis of the diaphragm occurred as a result of combat trauma: thoracoabdominal penetrating trauma — in 4 observations, neck injury — in 3, landmine injury — in 3. One military man underwent repeated plication of the diaphragm in our clinic, as a result of ineffective plication in another medical institution. Two patients underwent cardiac surgery in the past. The main complaints expres­sed by the patients were: shortness of breath, cough, general weakness, pain or discomfort in the chest. Paralysis was idiopathic in 76 (84 %), post-traumatic in 12 (13 %), after mediastinal tumour removal in 2 (2 %). The duration of the disease was from 1 to 108 months, with an average of 12.4 months. The average volume of forced exhalation in the supine position for the first second was 62.5 % (49.5—87.4 %) of the predicted value. There were no conversions to thoracotomy. Drains from the pleural cavity were removed if the exudation was 100 ml or less per day. Patients were observed for 6 weeks in the clinic, and were also consulted by telephone 6—12 months after surgery. Data on postoperative complications, postoperative pain, symptomatic impro­vement, and change in quality of life after surgery were collected. Results and discussion. In the postoperative period, 69 (76 %) patients had no complications. Twenty-one (24 %) patients had complications: long-term discharge of exudate through the drains — 13 (14 %) patients, long-term discharge of air through the drain — 3 (3 %), infection around the drains — 2 (2 %), hypersensitivity pneumo­nitis — 1 (1 %), exacerbation of COPD — 1 (1 %), acute cerebrovascular accident (the patient also had such a complication in the anamnesis) — 1 (1 %). All these complications did not require active surgical interventions.The average duration of pleural cavity drainage (and, accordingly, hospital stay) ranged from 6 to 33 days (11 days on average). At the same time, the number of patients with drainage for more than 15 days was 12 (13 %) observations. There were no deaths, 30-day rehospitalisations, and prolonged neuralgia in the observation group. The average reduction in the Medical Research Council dyspnoea score per patient was 2.2 points. 72 patients (80 %) reported significant symptomatic improvement leading to improved quality of life, and 96.6 % (n = 87) were satisfied with the surgical outcome. Conclusions. VATS plication of the diaphragm is a safe procedure that ensures a quick postoperative recovery. It is effective in reducing debilitating shortness of breath and improving quality of life.