Surgical Techniques

PLICATION OF THE DIAPHRAGM

chapter

119

Jrme Mouroux
Nicolas Venissac
Francesco Leo
Daniel Pop
Marco Alifano

Key Points
Eventration and permanent phrenic nerve injury are indications for

diaphragmatic plication in symptomatic patients.

Thoracotomy, laparotomy, and minimally invasive approaches

have all been described and successfully used.

Flag, accordion, and invagination techniques using nonabsorbable

suture have been described.

Timing of surgery must allow recovery of reversible phrenic nerve

injury.
Unfortunately, outcomes and related measures can be only anec-

dotally described.

The goal of diaphragmatic plication is tightening and lowering

of the diaphragm. It is a corrective surgery from a both morphologic and a functional point of view and may be applied
to the treatment of diaphragmatic eventration and paralysis.
The indications and the possible functional benefits have
been described by many surgical teams. The procedure is
widely performed in pediatric patients and, in particular, in
newborns with congenital eventration or acquired diaphragmatic paralysis. On the other hand, some confusion exists in
the classification of diseases causing diaphragmatic elevation
in adults that might suitable for surgical treatment. Furthermore, the use of thoracotomy (which has become the preferred approach in recent years) for a functional surgery is a
deterrent to both patients and physicians. Nevertheless, the
possibility of performing the procedure by video-assisted thoracic surgery (VATS), with the obvious adaptation of the
methods of plication to this approach, unquestionably has led
to a new interest in these pathologies and their surgical treatment. This chapter provides an overview of the diseases
involved (classification, epidemiology, etiology, and anatomicoclinical consequences), as well as surgical techniques, indications, and results of diaphragmatic plication.

HISTORICAL NOTE
Wood1 is classically credited with having introduced in 1916
the idea of wrinkling the diaphragm in order to reduce the
dimensions of the cupola. In 1923, Morrison2 performed the
first successful repair of an eventration, and he described
the surgical principles that are still used. He plicated the
diaphragm of a 10-year-old girl with immediate relief of

symptoms. In 1947, Bisgard3 described precisely the technique of plication employed to treat a 6-week-old baby. Since
these first publications, many studies were devoted to this
subject in both France (Quenu and Herlemont,4 Perrotin and
Moreaux,5 Dor and colleagues6) and the United States
(Michelson,7 McNamara and associates8). These studies
allowed evaluation of the various surgical techniques (plication by a thoracic or an abdominal approach, with excision
followed by suturing), as well as the indications for surgery.
The more recent works by Revillon and Fekete,9 DonzeauGouche and colleagues,10 Wright and colleagues,11 Graham
and colleagues,12 and Ribet and Linder13 confirmed the
improvement of respiratory functions with surgical treatment. Plication by the transthoracic approach has gradually
replaced the abdominal approach. Since the appearance of
video-assisted technology, several authors have reported their
experience on plication using this tool. We initially described
a technique of VATS in 1996 (Mouroux et al, 1996).14 More
recently, Httl and associates15 reported a technique of plication by video-assisted laparoscopy (Httl et al, 2004).
HISTORICAL READINGS
Bisgard JD: Congenital eventration of the diaphragm. J Thorac Surg
16:484-491, 1947.
Donzeau-Gouche, Personne CL, Lechien J, et al: Eventrations diaphragmatiques de ladultes: A propos de vingt cas. Ann Chir Thor Cardiovasc 36:87-90, 1982.
Dor J, Richelme H, Aubert J, Boyer R: Lventration diaphragmatique.
J Chir 97:399-432, 1969.
Graham DR, Kaplan D, Evans CC, et al: Diaphragm plication for
unilateral diaphragmatic paralysis: A 10-year experience. Ann Thorac
Surg 49:248-252, 1990.
Httl TP, Wichmann MW, Reichart B, et al: Laparoscopic diaphragmatic
plication. Surg Endosc 18:547-551, 2004.
McNamara JJ, Paulson DL, Urschel HC, Razzuk MA: Eventration of
diaphragm. Surgery 64:1013-1021, 1968.
Michelson E: Eventration of the diaphragm. Surgery 49:410-420, 1961.
Morrison JMW: Eventration of diaphragm due to unilateral phrenic
nerve paralysis. Arch Radiol Electrother 28:72-75, 1923.
Mouroux J, Padovani B, Poirier NC, et al: Technique for the repair of
diaphragmatic eventration. Ann Thorac Surg 62:905-907, 1996.
Perrotin J, Moreaux J: Chirurgie du Diaphragme VIII. Les ventrations.
Paris, Masson, 1965, pp 221-262.
Quenu J, Herlemont P: Du traitement chirurgical de lventration diaphragmatique. J Chir 69:101-121, 1953.
Revillon Y, Fekete CN: Eventration diaphragmatique chez lenfant. Ann
Chir 36:71-74, 1982.
1431

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1432

Section 6 Diaphragm

There are no radiologic boundaries allowing differentiation

between a slight or insignificant diaphragmatic elevation and
a relevant one. Nevertheless, an extreme elevation is manifestly pathologic, especially if an abnormal mediastinal shift
is present (Fig. 119-1).
The incidence of both eventration and paralysis is difficult
to estimate. Among newborns, the reported incidence ranges
from 1 in 1400 to 1 in 13,000 cases, but elevation of a hemidiaphragm is 10 times more frequently related to phrenic
paralysis than to a true congenital eventration.8,19 In adults,
the study of Christensen,20 published in 1959, retrieved 38
cases among 107,778 examined persons. No further study
was performed to allow actualization of these data. The male
predominance of the condition (60%-80% of cases) and the
preferential involvement of the left side are well-established
characteristics.17,18

Ribet M, Linder JL: Plication of the diaphragm for unilateral eventration

or paralysis. Eur J Cardiothorac Surg 6:357-360, 1992.
Wood HG: Eventration of the diaphragm. Surg Gynecol Obstet 23:344,
1916.
Wright CD, Williams JG, Ogilvie CM, Donnelly RJ: Results of the
diaphragm plication for unilateral diaphragmatic paralysis. J Thorac
Cardiovasc Surg 90:195-198, 1985.

CLASSIFICATION AND EPIDEMIOLOGY

The radiologic finding of an elevated diaphragm has been
named in various ways, with subsequent confusion. The
medical debate has further contributed to these ambiguities,
since the initial description of diaphragmatic eventration by
Jean Louis Petit in 1774.16 Terms such as eventration, relaxation, paralysis, and hernia have been frequently used as
synonyms.7,17,18 Diaphragmatic eventration is an anomaly
defined by the long-lasting or permanent elevation of an
entire hemidiaphragm or a portion of it, without defects. The
muscular insertions are normal, the normal apertures are
sealed, and there is no interruption in the pleural or peritoneal layer. Eventration can be differentiated from hernia
(with or without sac) or from rupture because these other
conditions involve loss of continuity of one or more of the
layers constituting the diaphragm. According to most authors,
only congenital eventration needs to be considered as a
disease, whereas all other conditions need to be regarded as
a syndrome. On the other hand, the terms eventration and
paralysis are often confused because paralysis may be the
cause of an abnormal elevation of the diaphragm (with degenerative changes in the muscular layer), whereas pure eventration is not always associated with paralysis. In spite of several
differences, both eventration and paralysis carry the same
physiologic consequences and share most symptoms. Although
the management of these two conditions may be substantially
different, plication may constitute a treatment option in
both cases.

ETIOLOGY
Eventration and Paralysis in Children
In the newborn, diaphragmatic elevation may be related to
either a congenital eventration or an acquired diaphragmatic
paralysis. The latter is by far the most frequent cause of elevation in children. In the series by Huault and coworkers19
dealing with 202 pediatric patients with diaphragmatic elevation, a phrenic paralysis was observed in 190 cases, whereas
a true eventration accounted for only 12 cases.

Congenital Eventration
The diaphragm originates from the union of several components. Its development begins in the 4th week of gestation
and finishes during the third month. During the 4th week,
the septum transversum appears. It is represented by a thick
blade of mesoderm that is initially located on the level of
occipital and upper cervical somites but is subject to a pro-

FIGURE 119-1 A, Left diaphragmatic eventration with mediastinal contralateral shift. B, Same patient, 2 years after plication of the diaphragm.

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Chapter 119 Plication of the Diaphragm

gressive downward migration. During this descent, it is colonized by myogenous stem cells migrating from cervical
somites. There is progressive fusion of the septum transversum with the esophageal dorsal mesentery, which in turn
gives rise to the diaphragmatic crura. Communication
between the thoracic and the abdominal cavity persists up to
the 8th week because of the existence of the posterolaterally
located pleuroperitoneal ducts. Closure of this communication is achieved by the pleuroperitoneal membrane, which is
initially formed by apposition of the two serosal layers (pleura
cranially and peritoneum caudally) but secondarily is subject
to colonization from myoblasts originating from a lateral muscular burrowing. At the beginning of the 6th week of gestation, the initial structure of the diaphragm reaches the region
of thoracic somites, and at the end of the 8th week it can be
found at the level of the first lumbar vertebra (L1).
Congenital eventration occurs secondarily to an abnormal
myoblastic colonization of the diaphragm during fetal development. Macroscopically, the diaphragm has the appearance
of a translucid membrane. Microscopic examination shows
that the diaphragm consists of two serosal layers separated
by rare muscular fibers and fibrotic tissue. Peripheral insertions have a normal muscular aspect. Eventration may be
total (usually on the left side) or partial (more frequently
observed on the right). Partial eventrations are classified
into three different types: anterior, posterolateral, medial.
Congenital eventration may be associated with other
malformations.8,18,21

(obstetric, vertebral or neck surgery, central venous access,

locoregional analgesia, collapse therapy), and infection
(herpes virus). Nerve involvement at the mediastinal level is
caused by metastatic lymph nodes (especially from lung
cancers), mediastinal tumors, tuberculous adenitis, noniatrogenic trauma (penetrating and nonpenetrating), and iatrogenic trauma (lung and cardiac surgery).

Diaphragmatic Paralysis

ANATOMICOCLINICAL CONSEQUENCES

In the newborn, phrenic nerve injury is usually related to a

surgical trauma, in most cases occurring during the repair of
a congenital cardiovascular anomaly. In the series by Huault
and coworkers,19 this cause accounted for 68% of the cases.
The incidence of diaphragmatic paralysis after cardiac surgery
ranges from 0.3% to 12.8%.22 The second cause of phrenic
nerve injury in newborns is obstetric trauma (difficult delivery, use of forceps, intrauterine malposition). In these cases,
the identification of an associated nerve injury (brachial
plexus, recurrent laryngeal, sympathetic) may help in
diagnosis.9

Childhood

Diaphragmatic Elevation in Adults

The previously described forms may manifest in adulthood
and thus require consideration at the time of diagnostic
workup. Apart from these cases, the eventrations are classically divided into those with and without phrenic nerve
involvement.6,17,18,23

Eventrations With Phrenic Nerve Involvement

This group of eventrations can be classified according to
the level of involvement; such a classification allows a better
understanding of laboratory investigations useful in the
workup. The levels of involvement are spinal cord (amyotrophic lateral sclerosis, trauma, poliomyelitis), radicular
(vertebral disc diseases, osteophytosis), and nerve. Phrenic
nerve involvement at the cervical level is caused by noniatrogenic trauma (e.g., motor vehicle accident), iatrogenic trauma

Ch119-F06861.indd 1433

1433

Eventrations Without Phrenic Nerve Involvement

Eventrations without phrenic nerve involvement may result
from thoracoabdominal trauma, disease in neighboring tissues
(subphrenic abscess, atelectasis, pleural infection), or idiopathic causes.
Despite an exhaustive workup, the cause of diaphragmatic
elevation in adults often remains unexplained. In the study
of Pielher and colleagues,24 the cause of eventration could not
be found in 142 (57.5%) of 247 patients at initial workup,
and only in 6 further cases was the etiology identified during
the subsequent follow-up. Neoplasms and cervical or thoracic
surgery each accounted for 33% of causes among the 105
patients with a defined etiology of diaphragmatic elevation;
in the remaining cases, noniatrogenic trauma, infection, or
neurologic disease was responsible for the condition. At the
time this work was performed, several diagnostic tools were
not yet available; nevertheless, in spite of progress in imaging
technology, the cause of eventration still sometimes remains
uncertain.13

Elevation of the diaphragm reduces the lung volume. This

condition is precariously tolerated because of the weakness
of accessory muscles and the excessive mobility of the mediastinum, which shifts during inspiration, causing contralateral
lung compression. This situation is further worsened by the
dorsal decubitus position (with diaphragmatic compression
by abdominal viscera) and bronchial collapse caused by
inherent softness.
Clinical manifestations may appear very precociously:
acute respiratory distress, often necessitating a respiratory
assistance, is a frequent feature. The need of mechanical
ventilation varies between 13% and 72%, according to published series. It is more frequently necessary in children with
phrenic paralysis (40%-72%)13,25-27 than in patients with congenital eventration (13%-16%).9,25 In some cases, clinical
manifestations appear less precociously, and dyspnea, recurrent bronchitis or pneumonia, vomiting, postprandial suffocation crises, or failure to thrive may constitute the presenting
symptoms.
Occasionally, the elevation remains asymptomatic and is
discovered only in adulthood.

Adulthood
Elevation of the diaphragm is better tolerated in adults and
sometimes is discovered only when chest radiography is performed for other reasons. Consequences of diaphragmatic
elevation may be respiratory, digestive, or cardiac.6,17,18

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1434

Section 6 Diaphragm

firmed in the study by Graham and colleagues.12 Ridyard

and Stewart29 showed with ventilation-perfusion scanning
that both ventilation and perfusion of the ipsilateral lower
lobe are diminished in cases of unilateral diaphragmatic
paralysis (Fig. 119-2).

Respiratory: The elevation of the diaphragm causes a

decrease in lung volumes, which is responsible for a
restrictive syndrome and a moderate hypoxemia. Clague
and Hall28 showed that this syndrome was worsened by
placing the patient in the supine position. This was con-

B
244K

C
Anterior view

3/4 Posterior left

349K

FIGURE 119-2 Frontal (A) and lateral (B) radiographic views of an adult
with elevated hemidiaphragm. C, Computed tomographic scan of the
same patient. D, Ventilation-perfusion scan showing the absence of
ventilation in the inferior middle right lung.

Ch119-F06861.indd 1434

Posterior view

3/4 Anterior right

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Chapter 119 Plication of the Diaphragm

1435

TECHNIQUES OF DIAPHRAGMATIC PLICATION

Digestive: Elevation of the diaphragm is accompanied by

ascension of abdominal organs. On the right side, the liver
is primarily involved. In partial eventrations, it insinuates
itself into the deformation, giving rise to the classic
appearance of a bun on chest radiography. Sometimes,
liver can be accompanied by colon or gastric antrum. In
total eventration, the whole liver is pushed cranially,
inducing the ascension of the pylorus with the lower
portion of stomach. The right colic flexure and the median
portion of the transverse colon may become interposed
between the liver and the diaphragm, resulting in the
Chilaiditi syndrome (Fig. 119-3).30 On the left side, the
stomach is primarily involved, and it assumes a reversed-U
position, with the gastric fundus being pushed posterosuperiorly and the antrum anterosuperiorly. The median
portion, which has a horizontal position, is occupied by
a new air pocket with the potential for weakening the
lower esophageal sphincter, leading to the possibility of a
gastroesophageal reflux. Ascension of colon, spleen, and
kidney may be associated.
Cardiac: Cardiac symptoms are more frequent in leftsided eventration. In this case, cardiac shift (dextrocardia)
may be responsible for arrhythmias.

Principles
Plication of the diaphragm aims to provide a satisfactory
tension to an abnormally flask-shaped dome, while at the
same time lowering it. This procedure has obviously no
impact on the mobility of the diaphragm in cases of phrenic
paralysis. Nevertheless, in anticipation of restoring of phrenic
nerve function, the preservation of distal branches of the
nerve allows physiologic movement, in contrast to the excision-suture techniques that do not allow this kind of recovery.
Anatomic and histologic observations show that the central
portion of the dome is more or less slimmed, with various
degrees of atrophy or of rarefaction of the muscular fibers,
whereas the peripheral portion generally maintains a solid
texture. Stitches will find better support on this portion of
the diaphragm at the time of the plication.6 Lowering of the
cupola, while providing a more physiologic tension, allows
re-expansion of the adjacent lung, diminution of the adverse
effect of abdominal pressure, elimination of paradoxical
movements and of mediastinal shift, and improvement of the
actions of intercostal and accessory muscles.13

Conventional Procedures (Box 119-1)

Plication Through an Open Transthoracic Approach

As already stated, totally asymptomatic cases are possible.

Oligosymptomatic presentations are also possible, including
slight dyspnea, sometimes worsened by the supine position;
epigastric or upper quadrant pain (spontaneous or induced
by the flexion); regurgitation; and painful eructations.6,7,17,18,23
Exceptional presentations include acute respiratory failure31
and diaphragmatic rupture.32

Flag Plication. This is the reference technique (Fig.

119-4). It is carried out through a more or less large posterolateral thoracotomy. The location of the thoracotomy incision
is variable according to different authors experience (from
the 6th to 8th intercostal spaces). The lung and mediastinum

Ch119-F06861.indd 1435

FIGURE 119-3 A, Chilaiditi syndrome: barium swallow showing

interposition of the large bowel between the liver and the diaphragm.
B, Computed tomographic scan of the same patient.

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1436

Section 6 Diaphragm

are examined to exclude unsuspected disease. Two Babcock

forceps raise the slimmed cupola, creating a fold. The direction of the plication (anteroposterior or transverse) is determined by the grossly apparent axis of the eventration.
Generally, plication is performed according to a transverse
axis. The fold is fixed at its base by a series of U-shaped,
nonabsorbable stitches. The plicated area is subsequently
folded onto the portion of the diaphragm that appears more
weak and fixed close to the costal insertion of the diaphragm
by one or several rows of sutures. At the level of the weakened portion, the repaired diaphragm has thus a three-layer
thickness.
Mechanical stapling of the base of the fold has been proposed to replace the U-shaped stitches. Another variant is
represented by splitting of the plication after incision of the
apex of the fold. Each of the two aspects of the fold is subsequently folded onto a side of the axis of the plication. This
last technique unquestionably weakens the diaphragmatic
dome.

Box 119-1 Surgical Techniques

Plication is carried out by the transthoracic approach in the absence
of indication for an abdominal approach (bilateral or associated intraabdominal disease).
Plication is technically feasible by VATS: the operation is bloodless
and rapid, and the desired tension can be applied to the plicated
diaphragm.

Accordion Plication. Other techniques of plication have

been described. In particular, the technique by Schwartz and
Filler33 is often employed by pediatric surgeons. In this technique (Fig. 119-5), the redundant diaphragm is pulled in a
radial direction, and pleats are created by the placement of
full-thickness horizontal mattress nonabsorbable sutures in
the anteromedial to posteromedial direction while avoiding
injury to branches of the phrenic nerve. This type of plication
gives the diaphragm an accordion appearance. In this
manner, the diaphragm can be plicated with as many rows of
sutures as necessary to tighten it. Some authors have also
suggested buttressing the final layers of the sutures with
polytetrafluoroethylene pledgets to prevent tearing out of the
sutures.12,34

Plication Through an Open

Transabdominal Approach
Plication by the abdominal approach (Fig. 119-6) is based on
the same principles. It is performed through a median or
transverse laparotomy.4,5,17 The diaphragm is grasped with
two Babcock forceps, and a large fold is drawn downward.
Transfixing stitches are applied at the base of the fold, which
is subsequently folded over and fixed to the anterior portion
of the hemidiaphragm. Inadvertent lung puncture with pneumothorax may complicate this technique. Pleuropulmonary
adhesions may render the technique unsuitable and even
dangerous. The abdominal approach is currently rarely
employed. It can be useful in cases of associated abdominal
disease or bilateral eventration.

FIGURE 119-4 Flag plication. A, The pleat is created and fixed with mattress sutures at the base. B, The pleat is folded down and fixed at its
top.

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Chapter 119 Plication of the Diaphragm

1437

FIGURE 119-5 Accordion plication. A, Mattress sutures are placed carefully to avoid major nerve fibers and entry into the abdominal cavity.
B, Completed repair.

Plication by Minimally Invasive Surgery

Plication by Video-Assisted Thoracic Surgery

FIGURE 119-6 Diaphragm plication by the abdominal approach. The

pleat is created with mattress sutures at the base; then it is folded
frontally and fixed at the anterior circumference.

Ch119-F06861.indd 1437

The previously described techniques of plication, and in particular the flag plication, require a wide surgical approach
to allow creation and handling of the diaphragmatic fold.
These methods are not compatible with a video-assisted
approach. One of us (JM) developed a technique,14 inspired
by the Bisgard operation,3 that has the advantage of being
compatible with VATS. The diaphragm is invaginated and
then stitched, using two superimposed layers of sutures.
Technique. The intervention is performed with the use of
general anesthesia and selective tracheobronchial intubation
to allow single-lung ventilation. Gastric decompression is
achieved by placement of a nasogastric tube. The patient is
placed in lateral decubitus position as for standard posterolateral thoracotomy, with the surgeon standing behind. The
operating table is positioned with the head raised to decrease
the abdominal pressure on the diaphragm. Two thoracoports
(10 mm or 5 mm) are introduced (Fig. 119-7). The first one
is placed in the fifth intercostal space on the posterior axillary
line for the introduction of the 0-degree scope (port 1). The
second one is inserted in fifth intercostal space on the anterior axillary line (port 2). After exploration of the lung and
mediastinum, a 4- to 5-cm thoracotomy is carried out at the
level of the eighth or ninth intercostal space on the posterior
axillary line. A retractor is not usually necessary. This minithoracotomy allows the introduction of conventional instruments (needle holder, forceps). An endoscopic Duval forceps,
introduced through port 2, is used to grasp and push the apex

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1438

Section 6 Diaphragm

FIGURE 119-7 A, Position of the two thoracoscopic ports. A minithoracotomy is made over the ninth intercostal space (ICS) for suturing of the
diaphragm. B, With the use of Duval forceps, the apex of the eventration is pushed down toward the abdomen. C, The newly created transverse
fold of diaphragm is sutured with nonabsorbable material. D, Completed operation. (FROM MOUROUX J, PADOVANI B, POIRIER NC, ET AL: TECHNIQUE
FOR THE REPAIR OF DIAPHRAGMATIC EVENTRATION. ANN THORAC SURG 62:905, 1996.)

of the eventration down into the abdomen. The invagination

creates a transverse fold from the minithoracotomy to the
cardiophrenic angle behind the phrenic nerve. This fold is
closed by a first suture line of nonabsorbable material (Surgipro 3.5, Tyco Healthcare, France), beginning at the periphery of the diaphragm closest to the minithoracotomy. The
first stitch is knotted, with the free end held with a forceps.
A superficial continuous suture is performed to avoid injury
to the subdiaphragmatic organs. Once at the cardiophrenic
angle, the sutures are drawn tight while the Duval forceps
used to push the diaphragm downward is removed. A row of
return stitches is made along the same axis, and the suture
is tied with the free end of the first knot. During placement
of the return stitches, the suture is followed by the assistant
using a gained forceps (to avoid injury to the stitch) introduced through port 2. The tension applied in this manner
facilitates grasping of the edges of the fold to be sutured. This

Ch119-F06861.indd 1438

first back-and-forth series of continuous suture places the

excess diaphragm in the abdomen, and care is taken to avoid
applying tension to the first series of sutures.
A second back-and-forth series of continuous suture is
carried out similarly, thus burying the first series of suture
lines: stitches are inserted through a more peripheral portion
of diaphragm to obtain the desired tension of the diaphragmatic dome.
At the end of the procedure, a chest tube is inserted
through port 2 and connected to an underwater suction
drainage system. The nasogastric tube is removed the next
day. The chest tube is removed 3 to 5 days postoperatively.
Breathing exercises are started on the first postoperative day
and continued for 1 month.
Comments. As for conventional surgery, video-assisted diaphragmatic plication carries the risk of late recurrence, thus
justifying long-term follow-up. In our opinion, two technical

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Chapter 119 Plication of the Diaphragm

aspects of this technique would prevent recurrence: the first

back-and forth running suture allows for maintenance of the
excess diaphragm within the abdomen while achieving a
favorable distribution of tension, whereas the second running
suture involves more peripheral portions of the diaphragm,
with more resistant tissues, and provides the desired tension
on the diaphragmatic dome. For this reason, care needs to be
taken to avoid applying tension to the first series of sutures.
In our opinion, there are two contraindications to this
technique: the existence of extended pleuropulmonary adhesions and the need to reinforce the diaphragm with synthetic
material. These situation are rarely predictable preoperatively. The level and extent of the thoracotomy incision and
the optimal technical aspects of diaphragmatic repair can be
decided only after exploration through port 1 and, if necessary, port 2.
Variations. Since our initial work, several authors have
reported their experience with both adults and children and
suggested technical variations.35-42 Hwang and associates35
performed the diaphragmatic plication by a four-port thoracoscopic approach: an 11.5-mm port for a 0-degree 10-mm
rigid thoracoscope is placed in the fifth intercostal space in
the midaxillary line; two 5-mm ports are inserted in the
eighth and ninth intercostal spaces in the posterior axillary
line; and an 11.5-mm port is placed in the sixth intercostal
space in the anterior axillary line. On the other hand, Lai and
Paterson36 used a 7-cm anterior thoracotomy at the level of
the xyphoid cartilage and a posterior thoracoscopic port
introduced in the auscultatory triangle. Moon and associates37
used four thoracoports and carry out plication with the use
of endoscopic linear staplers.
Since the first successful correction of eventration by
video-assisted thoracoscopy in a baby weighing 3 kg,39 the
technique has gained popularity among pediatric surgeons.
Various authors have described modifications to the technique, concerning either the caliber of the thoracoports or
the method employed to fix the plication (Hines, 2003).40-42
These limited surgical series testify to the interest in the
technique and the possibility of its implementation in
children.

Laparoscopic Diaphragmatic Plication

Httl and associates15 have recently reported a laparoscopic
technique of diaphragmatic plication. They treated three
patients who had a left-sided diaphragmatic paralysis secondary to cardiovascular surgery. In their technique, the plication
is done with the patient in a 30-degree reversed Trendelenburg position under general anesthesia after single-lumen
endotracheal intubation. The surgeon is positioned between
the legs of the patients, and the two assistants are placed one
at each side of the patient. Through a paraumbilical incision,
a 30- to 45-degree angle laparoscope is introduced via a 10mm port. Three additional working ports (two of 10 mm and
one of 5 mm) are placed in a semicircle in the right or left
middle and upper abdomen under visual control. The left
hepatic lobe is mobilized along the left triangular ligament.
Subsequently, three retention stitches are placed transcutaneously. By application of extracorporeal traction on these

Ch119-F06861.indd 1439

1439

sutures, the diaphragmatic dome is reduced and an intraabdominal fold is created. This fold is used for the laparoscopic diaphragmatic plication with 12 to 15 nonabsorbable
U-type sutures that are than tied extracorporally and placed
inside the abdomen using the knot pusher. The line of the
plication runs from the left dorsal portion of the diaphragm
to the ventral medial portion. In the experience of the
authors, two minimal splenic injuries occurred, neither
requiring splenectomy. No pneumothorax was noted, and
satisfactory results were observed on long-term follow-up
(at 40, 72, and 84 months).

INDICATIONS FOR PLICATION (Box 119-2)

Childhood
Congenital Eventration
Knowledge about treatment of congenital eventration in children is mainly derived from case reports and relatively small
retrospective series.13,17,25 Patients were usually symptomatic,
and in most cases they presented with respiratory distress.
There are no data comparing surgical treatment to conservative management, and the timing of operation with respect
to the onset of symptoms is usually not stated. In these
patients, if there is no evidence of phrenic nerve injury, spontaneous recovery is unlikely; therefore, surgical indication is
probably indicated in every symptomatic patient. These
babies are often severely ill because of the frequently associated comorbidities, and diaphragm repositioning may help
restore partial function in a hypoplastic lung.13,17,25 Little is
known about the management of eventration with few or no
symptoms. Although conservative management is probably
sufficient, some authors advocate routine plication to maximize development of the ipsilateral lung.25

Phrenic Nerve Injury

Management of phrenic nerve injury in children (postpartum
or postsurgical) has been much more extensively studied
than management of congenital eventration. The condition is
usually suspected because of respiratory distress, failure to
thrive, or, in operated patients, difficulty in weaning from
mechanical ventilation. If nerve injury is suspected, confirmation is obtained by chest radiography, fluoroscopy, and/or
ultrasonography of the chest.13,22,25,26,41,43-45

Box 119-2 Indications

Childhood
Indication for plication exists in every symptomatic child with congenital eventration.
In asymptomatic patients with congenital eventration, there are
insufficient data to provide a level of evidence or grade of recommendation as to whether plication is indicated.
Adulthood
Plication is indicated in adults with long-lasting, symptomatic diaphragmatic elevation.

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1440

Section 6 Diaphragm

The policies at various centers differ in terms of the indications for and timing of surgery. In the retrospective surgical
series by Tsugawa and associates,25 including 50 patients aged
4 days to 7 years with diaphragmatic elevation of miscellaneous origin (but secondary to phrenic nerve injury in most
cases), respiratory distress was the indication for surgery.
Ventilatory support was necessary in 10 of their patients for
2 to 6 weeks before plication. The number of cases managed
conservatively during the time frame of the study (19711996) is not stated. This information can be derived from the
retrospective experience (1996-2000) of Joho-Arreola and
colleagues,22 who reported on 43 pediatric patients with diaphragmatic paralysis complicating cardiac surgery. Twentynine patients underwent plication because of failure to wean
from mechanical ventilation or respiratory distress. Among
the 14 patients treated conservatively, the mean assisted
ventilation time after cardiac surgery was relatively short (5
days), but some patients were mechanically ventilated for
several weeks (up to 49 days). Patients ultimately treated by
plication received mechanical ventilation for a longer period
(mean, 13 days) before the decision for plication was made.
Similarly, in the retrospective series by deVries Reilingh and
coworkers,26 18 consecutive patients with obstetric injury to
the phrenic nerve were evaluated between 1986 and 1997.
All required resuscitation immediately after birth, and 14 of
them received intubation and mechanical ventilation. Thirteen of the 18 patients were ultimately treated by plication
(at an average of 100 days postpartum), and in the remaining
5 patients, spontaneous clinical and radiologic recovery was
observed within 1 month.
Generally, in the published reports, conservative management is always attempted before surgery is contemplated in
children with phrenic nerve injury. There is general agreement that surgery must be performed after stabilization of
the clinical condition by gastric decompression, administration of supplemental oxygen, and, if necessary, mechanical
ventilation, but the optimal timing of plication is not known.
In fact, conservative treatment would permit restoration of
diaphragmatic function if the phrenic nerve is not transected,
but the time required may be very long (weeks or months),
exposing patients to the unacceptable risks associated with
prolonged mechanical ventilation. Most authors have proposed that observation and ventilation not be prolonged
beyond a period of 2 weeks,13,43 so as to allow extubation and
improved ventilation, with diaphragm plication being of
course indicated only if there is no other primary cause of
respiratory distress. If phrenic nerve injury is recognized
during the initial cardiac or mediastinal surgery, immediate
plication must be performed (Simansky et al, 2002).44

Adulthood
Experience with surgical treatment of eventration in adulthood is much more limited. Most of the experience is derived
from case reports, a small number of retrospective series, and
a few prospective studies.11-14,46-49 Controversies exist about
indications and the optimal timing of surgery; in this context,
consideration of the natural history of diaphragmatic elevation is of paramount importance.

Ch119-F06861.indd 1440

Information about spontaneous evolution of nontraumatic

diaphragmatic paralysis can be derived from the large retrospective study by Pielher and colleagues24 involving 247
patients. The cause of paralysis could be identified at initial
evaluation in 105 patients but remained obscure in the
remaining 142 subjects, who were followed-up for a mean of
8.7 years with no attempt at surgical repair. The cause of
paralysis became evident in only 6 of these patients during
the follow-up. In the remaining 136 cases, the leading
symptom (exertional dyspnea) improved in only 34%;
improvement in the other manifestations, cough and chest
wall pain, was observed in 78% and 82% of cases, respectively. On chest radiography, the diaphragm returned to a
normal position in only 12 of 131 patients who had this
examination available.
Efthimiou and colleagues47 studied the evolution of postsurgical diaphragmatic paralysis. In a prospective observational study enrolling 100 consecutive patients over a 6-month
period, they reported a 32% incidence of unilateral paralysis
among patients receiving ice/slush topical hypothermia during
cardiac surgery, compared with 2% among those not receiving
topical hypothermia. All of these patients could be treated
conservatively, and paralysis regressed within 1, 6, and 12
months in 25%, 56%, and 69% of cases, respectively. At
2-year follow-up, the paralysis had regressed in all but one
patient. Electromyography showed the absence of nervous
conduction in all patients within 1 week after cardiac surgery
but progressive reappearance of conduction in those patients
who experienced restoration of diaphragmatic function.
Obviously, in these patients, the phrenic nerve had suffered
a thermal injury but had not been transected.
In the experience of Deng and associates,48 derived from
a retrospective analysis of a prospectively collected database
of patients undergoing high free right internal mammary
artery harvesting, the incidence of right-sided diaphragmatic
paralysis was 4%. In this setting, the phrenic nerve can be
either thermally injured (by the proximity of electrocautery
dissection) or completely transected. Management included
immediate diaphragmatic plication (i.e., during the sternotomy for cardiac surgery), if phrenic nerve transection was
identified intraoperatively, or a middle-term observation for
postoperatively evidenced paralysis. Conservative management was adopted for the first 3 months after cardiac surgery,
after which plication was recommended in the absence
of spontaneous regression of paralysis (apparently without
regard to the presence of symptoms). Among the 26 patients
with postoperative diaphragmatic paralysis, spontaneous
regression was observed in 14 cases, and the remaining 12
patients were finally operated on.
Information about indications for plication can be derived
from some retrospective surgical series evaluating the
outcome of adult patients with diaphragmatic eventration
treated by surgery.11-13,43,46,49 All of these studies included
patients with diaphragmatic paralysis secondary to various
conditions and idiopathic forms. In almost all instances, the
indication for surgery was the presence of respiratory symptoms (mainly dyspnea or orthopnea, but also cough and chest
wall pain) or, less commonly, digestive symptoms (dyspepsia
or meteorism) that interfered with patients normal activi-

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Chapter 119 Plication of the Diaphragm

ties. The mere presence of an elevated diaphragm on chest

radiography was not considered an indication for operation
(with some exceptions). Because of the retrospective character of these surgical series, conservative management was
not evaluated, and the number (and relative proportion) of
patients treated by a nonoperative approach in the same time
frames in the various institutions was not stated.
It is generally believed that there is no indication for surgical treatment of diaphragmatic eventration if the condition
is secondary to a neoplastic disease or if there are no symptoms. In our opinion, if a neoplastic origin is excluded on
clinical and radiologic grounds, surgery must be considered
on the basis of the clinical presentation and the timing of
onset of symptoms. If the patient is symptomatic and the
diaphragmatic eventration is long-lasting (>2 years), surgery
is usually indicated; the operation is planned after clinical
conditions have been optimized (e.g., treatment of respiratory infections, appropriate weight loss). If the patient is
symptomatic but the diaphragmatic eventration is recent, a
period of observation (18-24 months) before surgery is advocated. During this period, physiotherapy is performed and
possible issues of excessive weight addressed. In these
patients, serial diaphragmatic electromyographies may be
suggested to determine possible recovery of phrenic nerve
function.50,51 It is noteworthy that spontaneous resolution of
a recent eventration is possible.
If the patient has no or few symptoms, strict follow-up is
performed, so that surgery may be promptly if even slight
deterioration of respiratory function occurs. If significant
respiratory impairment is already present, a modest chest
trauma or a pulmonary infection could precipitate adverse
clinical conditions and necessitate mechanical ventilation.49
Finally, diaphragmatic plication is not contraindicated in
patients with ventilatory support. In fact, experience has
shown that plication done under these circumstances

1441

can wean the patient from mechanical ventilation if the

causes of respiratory distress are identified and treated
(Fig. 119-8).31,43,49
Recently, Smyrniotis and colleagues proposed, in order to
decrease the risks of respiratory complications, to perform
simultaneous prophylactic diaphragmatic plication during a
major abdominal operation in patients with phrenic nerve
palsy.52

RESULTS (Box 119-3)

Childhood
Postoperative Outcome
Several studies have evaluated the outcome of pediatric
patients treated by diaphragmatic plication, usually for
phrenic nerve injury. They are summarized in Table 119-1.

Box 119-3 Results

Childhood
Diaphragmatic elevation secondary to phrenic nerve injury in children
may be satisfactorily managed by plication; in almost all instances,
weaning from respiratory support is possible, often with only a short
delay.
Mortality is generally related to the underlying disease and not to
the operation itself.
Long-term outcome is determined by the associated comorbidities
because the operation allows a permanent improvement in respiratory
function.
Adulthood
Diaphragmatic plication in nonventilated adult patients carries a low
morbidity and very low, if any, mortality. Functional results are fully
satisfactory in almost all cases.

FIGURE 119-8 A, Radiograph of a 59-year-old woman who experienced right-sided eventration secondary to a blunt chest trauma apparently
received 10 years previously. A second blunt trauma (fall down stairs) caused rib fractures and precipitated respiratory failure requiring mechanical
ventilation. Tracheostomy was performed to facilitate weaning, but it was complicated by a tracheoesophageal fistula. Staged diaphragmatic
plication to allow weaning and repair of the fistula was planned. B, Radiograph of same patient 4 years after the plication of the diaphragm.

Ch119-F06861.indd 1441

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1442

Section 6 Diaphragm

TABLE 119-1 Outcome of Plication in Children

Author
Tonz et al45

Operative
Deaths*

Follow-up
(Yr)

Weaning From
Respiratory
Support

Radiologic
Improvement

Clinical
Improvement

Retrospective

11

3.2 (mean)

11/11

10/11

9/9

Study
Period

Design

1983-1992
25

Tzugawa et al

1971-1996

Retrospective

25

1-25

20/20

20/20

deVries Reilingh
et al26

1986-1997

Retrospective

14

9/9

14/14

deLeeuw et al44

1985-1997

Retrospective

68

49/50

Simansky et al43

1988-2000

Retrospective

10

7/7

Retrospective

2/2

5/5

5/5

1996-2000

Retrospective

29

13/21

Hines

41

Joho-Arreola
et al22

*No deaths were related to plication.

Not taking into account operative mortality.

From Alifano M: Plication for eventration. In Ferguson M (ed): Difficult Decisions in Thoracic Surgery. New York, Springer, 2007, pp 356-364.

These studies aimed to evaluate operative mortality, impact

of the procedure on weaning the patient from respiratory
support, and, in some cases, improvement in clinical and/or
radiologic presentation. In the retrospective series by Tsugawa
and associates25 dealing with 25 children with phrenic nerve
injury treated by thoracotomy plication, weaning from respiratory support (mechanical ventilation or supplemental
oxygen) was possible with only a short delay (0-6 days) in 15
of 17 patients; the other 2 patients underwent repeat plication, which was successful in one instance. In the same study,
25 additional patients underwent plication for congenital
eventration, including 4 who were mechanically ventilated
before the operation. Weaning was possible in all 25 cases, 1
to 61 days postoperatively.
Similar results were reported in the retrospective study by
Simansky and colleagues.43 Among the 10 children with postsurgical phrenic nerve injury causing respiratory failure who
underwent open plication, 7 could be weaned from mechanical ventilation (within 8 days in 6 cases), but the remaining
3 died despite a radiologically successful plication, mainly
because of intractable underlying cardiac disease. No deaths
were reported in the series by Tonz and coworkers,45 who
operated on 11 of 25 patients with postsurgical phrenic nerve
injury because of failure to wean from mechanical ventilation
or respiratory distress after extubation. The remaining
patients could be managed conservatively. Weaning was possible in all the cases (within 1 week in all but two cases), and
respiratory distress was managed successfully.
A more consistent experience, albeit retrospective, can be
drawn from the study by deLeeuw and colleagues,44 also
dealing with postsurgical phrenic nerve paralysis. In their
experience, 40% of 170 children with this condition underwent open plication. Respiratory insufficiency was the indication in almost all cases, with most patients being mechanically
ventilated at the time of plication. The median time to final
extubation after plication was 4 days, with a range of 1 to 65
days. Multivariate analysis showed that the independent
factors associated with a longer time to extubation were

Ch119-F06861.indd 1442

bilateral paralysis and a longer interval from the initial operation to diagnosis. There were four in-hospital deaths, but
none of these was considered related to the procedure. As in
all of the pediatric series described here, all of the deaths
were considered secondary to the underlying disease.
Further evidence that the plication per se is not associated
with mortality or major morbidity was provided by the experience of deVries Reillingh and associates,26 who performed
the operation by open approach in 13 patients with phrenic
nerve injury resulting, in almost all cases, from an obstetric
trauma (with no associated cardiac or pulmonary malformations). Respiratory distress necessitating mechanical ventilation was present in most cases. Dramatic improvement was
observed in all of the patients, with discontinuation of
mechanical ventilation within a few days and return of arterial gas values to normal in all cases.
A small series of diaphragmatic plication in children by
VATS was recently published.41 The authors reported on five
children, weighing 3.2 to 13.2 kg, with congenital or postsurgical diaphragmatic eventration causing respiratory insufficiency or recurrent respiratory infections. Satisfactory clinical
and radiologic results were observed in all of the cases. In
particular, weaning from mechanical ventilation could be
achieved within 3 days in both of the patients who underwent
surgery for this indication.

Long-Term Outcome
In some surgical series of pediatric patients, information
about long-term follow-up is available. Tonz and coworkers45
reported no late deaths related to diaphragmatic paralysis and
good radiologic results in 10 of 11 patients. No children had
respiratory symptoms at late follow-up. Similarly, Tsugawa
and colleagues25 observed fully satisfactory clinical and radiologic results in all of the patients who are available at followup after plication for either phrenic nerve injury or congenital
eventration. On the other hand, in the study by Joho-Arreola
and associates,22 6 of 21 patients had elevated diaphragm 1

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Chapter 119 Plication of the Diaphragm

1443

TABLE 119-2 Outcome of Plication in Adults (Nonventilated Patients)

Improvement
Author
Wright et al11
12

Study
Period

Design

Retrospective

N
7

Operative
Deaths

Follow-up
(Yr)

Clinical

Radiologic

Functional

0.3-4

7/7

7/7

7/7

Graham et al

1979-1989

Retrospective

17

5-7

6/6

6/6

6/6

Ribet and Linder13

1968-1988

Retrospective

11

8.5 (mean)

9/11

6/11

5/5

1988-2000

Retrospective

7.3 (mean)

7/7

7/7

7/7

Higgs et al

1983-1990

Retrospective

19

7-14 (n = 15)

14/15

14/15

15/15

Mouroux et al49*

1992-2003

Prospective

10

6.3 (mean)

10/10

10/10

10/10

43

Simansky et al
46

*Operated by video-assisted thoracic surgery.

From Alifano M: Plication for eventration. In Ferguson M (ed): Difficult Decisions in Thoracic Surgery. New York, Springer, 2007, pp 356-364.

year postoperatively; the percentage of patients with respiratory symptoms in that study is not stated.
Overall, diaphragmatic elevation secondary to phrenic
nerve injury in children may be satisfactorily managed by
plication; in almost all instances, weaning from respiratory
support is possible, often with only a short delay. Mortality
is generally related to underlying disease and not to the operation itself. Similarly, long-term outcome is determined by the
associated comorbidities because the operation allows a permanent improvement in respiratory function.

Adulthood
Because adults with unilateral diaphragmatic elevation usually
present with a mild respiratory insufficiency, weaning from
mechanical ventilation is a rare indication for plication. In the
recent prospective study by one of us (JM), plication by
VATS was performed for this indication in only two patients,
and both were successfully weaned within 1 week.49 On the
contrary, only one among the four mechanically ventilated
patients in the series by Simanski and colleagues43 involving
patients with phrenic nerve injury could be weaned.
When the operation is performed because of less severe
respiratory symptoms (or because of digestive problems),
satisfactory results are uniformly observed (Table 119-2). In
the aforementioned retrospective study by Simansky and
colleagues,43 all seven nonventilated patients experienced an
improvement in American Thoracic Society (ATS) dyspnea
score of 2 or 3 levels at 3-month re-evaluation. At long-term
follow-up (11-114 months), all seven were completely
asymptomatic from a respiratory point of view.
In the experience of Graham and coworkers12 dealing with
17 patients treated by plication via thoracotomy between
1979 and 1989, an improvement was observed in all patients
in both subjective (dyspnea score) and objective measurements. In particular, the operation resulted in significant
improvement in terms of postoperative forced vital capacity
(FVC), total lung capacity (TLC), diffusing capacity for
carbon monoxide (DLCO), partial pressure of oxygen (PO2),
and partial pressure of carbon dioxide (PCO2). These satisfactory results were still present in all of the six patients who
could be reassessed at long-term follow-up (>5 years).12 In
the retrospective study by Ribet and Linder,13 9 of 11 patients

Ch119-F06861.indd 1443

were persistently asymptomatic after the operation (followup of 3 months to 18 years), 1 patient was mildly dyspneic,
and 1 had persistent digestive symptoms. Of note, chest
radiographs showed a persistently elevated (though at a lesser
extent) diaphragm in 5 of these cases. In this study, only five
patients had both preoperative and postoperative functional
assessment, and an improvement in both FVC and forced
1-second expiratory volume (FEV1) was observed in all of
those cases.
In the prospective study at Nice University Hospital
dealing with 12 adult patients treated by video-assisted plication for diaphragmatic elevation of miscellaneous origin
(posttraumatic in most instances),49 all of the patients experienced a complete disappearance of symptoms shortly after
the operation, and no radiologic relapse was observed at a
follow-up of 64.4 46 months. A significant improvement in
both FEV1 and FVC was observed at late spirometry in all of
the cases.

SUMMARY
Plication of the diaphragm is a simple and feasible technique.
It is frequently employed in pediatric surgery. In the adult
population, the indications are still debated. The availability
of minimally invasive surgery can, in the future, increase
interest in the plication technique.

COMMENTS AND CONTROVERSIES

Restoration of size and contour of the diaphragm by plication is
simplistic in its appeal and performance. However, it is an uncommon operation, and reports of its approaches, techniques, indications, and outcomes are few and mostly anecdotal. In the extreme,
for the infant with congenital eventration or neonatal phrenic nerve
damage, this procedure is well described and very successful in
permitting weaning from ventilator support. In the asymptomatic
adult with phrenic paralysis or a large eventration, the role of plication has not been defined. In any patient, time must be allowed for
return of phrenic nerve and diaphragmatic function. All reversible
causes of restrictive and obstructive respiratory impairment must be
addressed (e.g., smoking, asthma, obesity). Only then plication is
considered.
T. W. R.

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1444

Section 6 Diaphragm

KEY REFERENCES
Dor J, Richelme H, Aubert J, Boyer R: Lventration diaphragmatique.
J Chir 97:399-432, 1969.
This article describes all techniques of plication.
Graham DR, Kaplan D, Evans CC, et al: Diaphragm plication for unilateral diaphragmatic paralysis: A 10-year experience. Ann Thorac
Surg 49:248-52, 1990.
This report confirms that diaphragmatic plication is a safe and effective procedure
for adult patients with dyspnea resulting from unilateral diaphragmatic paralysis.
Hines MH: Video-assisted diaphragm plication in children. Ann Thorac
Surg 76:234-236, 2003.
The first short series (five patients) of plication by VATS in children.

Ch119-F06861.indd 1444

Httl TP, Wichmann MW, Reichart B, et al: Laparoscopic diaphragmatic

plication. Surg Endosc 18:547-551, 2004.
Description (with very good photographs) and results of diaphragmatic plication by
laparoscopy.
Mouroux J, Padovani B, Poirier NC, et al: Technique for the repair of
diaphragmatic eventration. Ann Thorac Surg 62:905-907, 1996.
The first description (with schemas) of the plication by VATS.
Simansky DA, Paley M, Refaely Y, Yellin A: Diaphragm plication following phrenic nerve injury: A comparison of paediatric and adult
patients. Thorax 57:613-616, 2002.
Presents the results of diaphragmatic plication of ventilated versus nonventilated
pediatric and adult patients.

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