Four-Port Robotic Diaphragm Plication

Idiopathic diaphragmatic relaxation is a rare condition characterized by the abnormal elevation of one hemidiaphragm within the thoracic cavity without any evidence of abdominal visceral herniation. This anatomical displacement can lead to symptoms such as dyspnea, dysphagia, and tachycardia. While many cases are secondary to phrenic nerve injury—either post-traumatic or post-surgical—a subset of patients presents without any identifiable cause, thus classified as idiopathic. Diaphragm plication is a surgical technique that involves folding and suturing the diaphragm to stabilize it in a lower anatomical position. This approach improves the expansion of the lower lung lobe, optimizes cardiac positioning, and restores normal abdominal organ orientation. Traditionally performed using thoracoscopic methods, the robotic transthoracic approach has recently gained popularity, offering enhanced visualization, precision suturing, and favorable clinical outcomes.  

The authors present a case of idiopathic diaphragmatic relaxation treated with robotic diaphragm plication using the da Vinci Xi platform through a four-port technique. Three robotic ports were utilized (camera, Cadiere forceps, and needle holder), along with one assistant port for the introduction and retrieval of sutures and pledgets. CO₂ insufflation provided adequate lung retraction, obviating the need for a fourth robotic arm. Intraoperatively, the diaphragm appeared thinned without visible evidence of phrenic nerve injury. Plication was performed using multiple running sutures with 2-0 polydioxanone barbed sutures, reinforced with polytetrafluoroethylene (PTFE) pledgets. Careful attention was paid to avoid injury to subdiaphragmatic organs. The postoperative course was uneventful, and the patient was discharged safely on postoperative day three. At the 30-day follow-up, the patient reported significant improvement in dysphagia and a reduction in dyspnea. 

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