Understanding central tendon fixation for diaphragm paralysis and eventration
Leading consultant thoracic surgeon Dr Ahmed Habib has put together a patient-friendly description of central tendon fixation, a procedure done to treat diaphragm paralysis and eventration - and to potentially lead to reduced symptoms such as improved breathing and lung function.
What is the diaphragm?
The diaphragm is a large, dome-shaped muscle. It separates the chest from the abdomen. It plays a key role in breathing by moving up and down with each breath.
What is diaphragm paralysis or eventration?
- Diaphragm paralysis means one side of the diaphragm is not moving properly, often due to nerve injury.
- Diaphragm eventration refers to a thinning or weakening of the diaphragm muscle, causing it to balloon upwards abnormally.
- In both conditions, the affected diaphragm doesn't contract properly, which can make breathing difficult and reduce lung function.
Symptoms may include:
- Shortness of breath, especially when lying down or exerting yourself
- Recurrent chest infections
- Fatigue
- Reduced exercise tolerance
- Difficulty sleeping due to breathlessness
What is central tendon fixation?
Central tendon fixation, is an award-winning minimally invasive surgical procedure performed using robotic technology. It is designed to allow the normally functioning opposite half of the diaphragm to compensate for the paralysed/eventrated side. This is done by fixing the central tendon to the ribs, bypassing the diseased side.
MMCTS video publication of the novel technique
Video prize for the Society of Cardiothoracic Surgeon of Great Britain and Northern Ireland 2021
- https://m.youtube.com/watch?v=Kgj_uacRAOo
- https://scts.org/professionals/education/scts_education_operative_video.aspx
Patient testimonial - Lynne Evans:
How is it done?
- The surgery is performed under general anaesthesia.
- Using tiny incisions, a robotic-assisted technique is used to carefully fold and stitch (plicate) the floppy or raised diaphragm.
- The central tendon — the strongest part of the diaphragm — is precisely fixed to the ribs so the normal opposite side can compensate for the diseased side of the diaphragm.
- No large cuts are needed, and most patients go home within one to three days.
What are the benefits?
- Improved breathing and lung function
- Better posture and core support
- Reduced symptoms and improved energy levels
- Quick recovery due to keyhole approach
Are there any risks?
Like any surgery, there are potential risks, including:
- Fluid collection: The body normally produces larger amounts of fluid around the sutures. Initially this large amount may compress lung. To avoid this, the drain is left in place till the pleural fluid collection is minimal, usually one to two weeks. During this period the patient is sent home with a mobile flutter bag. Weekly outpatient appointments are organised till the drain is removed.
- Irregular heartbeat: usually settles with time. May need tablets to help the heart beats return to normal.
- Bleeding: rare
- Infection
- Pain or nerve irritation
- Very rare risk of lung/bowel injury. However, these are uncommon, especially with experienced surgical teams.
Why robotic surgery?
- Enhanced precision and control
- Smaller incisions and faster healing
- Reduced pain and better cosmetic outcome
What results can I expect?
Most patients report:
- Significant improvement in breathing
- Ability to return to normal daily activities and exercise
- Fewer infections and better sleep
Your surgeon will guide you through expected outcomes based on your individual case.
The following table depicts the benefits of central tendon fixation (CTF) compared to plication and nerve transplantation
Long term outcomes for CTF:
- Comparison of quality of life pre- and post- central tendon fixation
- Patient reported outcomes using the diaphragm paralysis questionnaire (DPQ) quality of life assessment
- Cumulative mean score values compared pre- and post-op over two and a half years
Questionnaire:
Kosse NJ, Windisch W, Koryllos A, Lopez-Pastorini A, Piras D, Schroiff HW, Straßmann SE, Stoelben E, Schwarz SB
Development of the Diaphragmatic Paralysis Questionnaire: a simple tool for patient relevant outcome. Interact Cardiovasc Thorac Surg. 2021 Jan 22;32(2):244-249, doi: 10,1093/jcyta/ivaa.PMID:33221909;PMCID:PMC8906767.