Reconstructive techniques after diaphragm resection and use of the diaphragmatic flap in thoracic surgery

Although a rare occurrence, the need for diaphragmatic resection and reconstruction might be dictated by secondary invasion from different tumours, including lung cancer, mesothelioma, chest wall tumours, sarcomas and metastatic lesions. Additionally, the diaphragm plays an important role as structure for plastic or reconstructive surgery and its use as vascularised flap in thoracic surgery has been widely documented for the treatment of multiple conditions (i.e., reinforcement of spontaneous or iatrogenic oesophageal perforations, repair after extensive pericardial resection, prophylactic bronchial stump coverage or early closure of bronchopleural fistula). Some of the diaphragmatic resections can be repaired primarily, as long as there is adequate tissue that can be brought together without excessive tension. Larger defects or a completely resected diaphragm can be reconstructed only with synthetic or autologous tissue. The different techniques of resection and reconstruction are presented in a very detailed step-by-step format; the use of diaphragmatic flaps is widely discussed and a "tips and tricks" section is included in the final comments.