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International Society For Minimally Invasive Cardiothoracic Surgery

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Challenges Of A Diaphragmatic Robotic Plication
Georgios Geropoulos, Robert Nicolae, Sofoklis Mitsos, Martin Hayward, Nikolaos Panagiotopoulos.
Thoracic Surgery Department, University College London Hospitals, London, United Kingdom.

BACKGROUND: Plication of the diaphragm with the robotic approach is a challenging but rewarding procedure. Aim of this presentation is to highlight all the surgical difficulties of the procedure along with their management. METHODS: Patient positioned for typical robotic approach and the robot is approaching from the legs. The robotic arms utilised include an 8mm port 30-degree camera, 8mm port cadiere forceps, 8 mm port needle holder and a 12mm assistant port. The lung is isolated with double lumen endobronchial tube and CO2 insufflation with a pressure and a flow of eight applied. Assessment of the loose and flattened diaphragm is performed.
RESULTS: The type of suture, we use was ethibond 2.0, 15 cm in length with a knot on one side as an anchor. We begin in the middle of the diaphragm with multiple (8-10) posterior to anterior horizontal mattress sutures. Multiple pledget use can prevent diaphragmatic tear and possible bleeding. The length of the suture is important to keep the stitching process simple and to avoid unnecessary pulling and knot formation. The application of a metallic ligaclip in the end of each line is a useful trick to keep the tension we need and to avoid unnecessary pulling and suture break. CONCLUSIONS: The length of the stitch, utilisation of pledget, multiple horizontal suture lines and the application of the ligaclips have proven useful elements for a successful plication of the diaphragm.

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