A Simple and Effective Technique for Diaphragm Plication

The patient in this case is a sixty-year-old woman with increasing shortness of breath, especially in a horizontal position. She was diagnosed with right-sided diaphragmatic paralysis. Surgeons suspected trauma or a viral infection to be the possible causes, but exact etiology was not clear. Observation did not result in any functional or radiological improvement and surgical repair was proposed. 

The patient underwent diaphragmatic plication via uniportal VATS approach. A single 3 cm incision was made at the level of the sixth intercostal space on the midaxillary line. The team’s instrument kit included a 10 mm 30 degree thoracoscope, endoscopic needle holder, curved suction, and lung grasper. A plastic wound retractor was inserted for better access and wound protection. We used 2-0 nonabsorbable, braided suture material to plicate the diaphragm with multiple horizontal mattress sutures. These sutures were reinforced with polymer pledgets on both sides. Suturing continued until sufficient tension and position of the diaphragm was achieved. 

A subpleural catheter was inserted for continuous infusion of local anesthetic and a single 20 Fr tube was used for postoperative fluid drainage. The patient experienced an uneventful postoperative period with relief of her symptoms. A chest x-ray and spirometry one month after surgery demonstrated significant improvement.

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