Plication surgery diaphragm

Plication surgery diaphragm DEFAULT



Associated congenital defects


Many candidates for the procedure due to eventration have other congenital disorder such as:

  • Undescended testicle
  • Abdominal visceral transposition
  • Cleft lip and palate
  • Hypoplastic arch disorder
  • Patent ductus arteriosus
  • Ventricular septal defect (VSD)
  • Coarctation of the aorta
  • Gastric volvulus
  • Horseshoe kidney


The operation can be performed either open or thoracoscopically.

For open plication of the diaphragm, the patient is placed lying on their side. A thoracotomy is performed below the eighth rib. The lung is deflated and retracted upward. Any adhesions found are freed. The weakened area of the diaphragm is then grasped with a clamp and elevated to determine the location of suture line. Layers of sutures, sometimes reinforced with Teflon pads, are sewn in rows at the edge of the diaphragm along the patient's rib cage encircling the inside of their chest wall.

After plication, the height of diaphragm is lowered by one or two ribs, helping the lungs inflate properly and prevent abdominal contents from pushing into the chest.

Chest tubes are placed to drain fluid or air that accumulates.

A thoracoscopic diaphragm plication is similar to the open technique.

Two or three small incisions are made and ports are placed, in addition a small five cm thoracotomy may be made. The diaphragm is depressed into the abdomen, and two rows of sutures are sewn into either side of the edge of diaphragm where it meets the chest wall. The suture is tied in place, creating a crease in the diaphragm, tightening and lowering the diaphragm into the abdomen.


Sugarbaker DJ, Bueno R, Krasna MJ, Mentzer SJ, Zellos L (eds). Adult Chest Surgery. New York: The McGraw-Hill Company, 2009.

Wood H. Eventration of the diaphragm. Surg Gynecol Obstet .23:344–8, 1916.

Graham DR, Kaplan D, Evans CC, et al. Diaphragmatic plication for unilateral diaphragmatic paralysis: A 10-year experience. Ann Thorac Surg. 49:248–51; discussion 252, 1990.

Leo F, Venissac N, Morales F, et al. Plication for diaphragmatic eventration: A simple technique, not a simple problem. Chest. 125:1170–1, 2004.


Laparoscopic Diaphragmatic Plication

Laparoscopic diaphragmatic plication is a safe and effective operation in carefully selected patients.  Laparoscopic diaphragm plication was first reported by Hüttl et al in three patients (1). The authors’ previously published experience demonstrated significant improvement in dyspnea, quality of life, and pulmonary function tests in patients with unilateral diaphragm paralysis or eventration (2).

The approach for hemidiaphragm plication should be individualized by patient anatomy, comorbidities, and surgeon experience. Regardless of approach, proper patient selection, safety, and a tight imbrication of the entire hemidiaphragm are essential.  


Prospective candidates for diaphragmatic plication must have dyspnea that cannot be solely attributed to another process (i.e., poorly controlled primary lung or heart disease), and must have an elevated hemidiaphragm on a PA/LAT chest x-ray. Since the only goal of diaphragm plication is to treat dyspnea, operative intervention is indicated exclusively for symptomatic patients. An elevated hemidiaphragm or paradoxical motion per se does not merit surgery in the absence of significant dyspnea.

Contraindications and Complications

Relative contraindications to a laparoscopic approach to diaphragm plication include: previous extensive abdominal surgery, BMI greater than 35, and comorbidities that may worsen with pneumoperitoneum (e.g., chronic renal failure, history of deep venous thrombosis). Morbidly obese patients pose particular technical challenges due to hepatomegaly from steatosis, or excessive omental fat in the left upper quadrant.  

Preoperative Planning

The diagnosis of symptomatic hemidiaphragm paralysis or eventration is primarily clinical, and relies mostly on history, chest x-ray, and the physician’s clinical acuity. Preoperative pulmonary function tests (PFTs) provide relative objectivity to the assessment of dyspneic patients with an elevated hemidiaphragm.  However, PFTs are imprecise and do not correlate well with severity of dyspnea, or response to plication. Diaphragm dysfunction reduces the compliance of the chest wall. Hence, a restrictive pattern (i.e., low forced vital capacity [FVC] and low forced expiratory volume in one second [FEV1]) is the norm.


On a standard full-inspiratory postero-anterior and lateral (PA/LAT) chest x-ray, the right hemidiaphragm is normally 1-2 cm higher than the left.

Sniff Test:
During fluoroscopy, patients are instructed to sniff, and diaphragmatic excursion is evaluated. Normally, the diaphragm moves caudally, but in patients with hemidiaphragmatic paralysis, the diaphragm may (paradoxically) move cranially. Patients with diaphragmatic eventration, however, may also exhibit passive upward movement of the diaphragm when sniffing.

CT Scan:
The main utility of CT scans is to rule out the presence of a cervical or intrathoracic tumor as the cause of phrenic nerve paralysis. CT scans may also be used to evaluate the possibility of an infra- or supradiaphragmatic process as the cause of hemidiaphragm elevation.

Surgical Technique

The procedure is performed under general anesthesia, with a single-lumen endotracheal tube. Selective ventilation is not necessary.

The patient is placed in the supine position with arms abducted. The abdomen and lower lateral chest wall are prepared and draped to allow access for chest tube placement. A foot board is essential for steep Trendelenburg positioning.

Operative Technique:

  1. Ports: The authors use four 12 mm ports. Two assistant ports are placed 2 cm parallel to the midline on the opposite site of the elevated hemidiaphragm.  The two working ports are placed in the ipsilateral upper quadrant (Figure 1). The abdomen is insufflated with CO2 to a pressure of 15 mmHg.
  2. Exposure: Steep reverse Trendelenburg positioning helps optimize exposure of the posterior portion of the hemidiaphragm. For a right-sided plication, transection of the falciform ligament is useful for appropriate access to the diaphragm. The thinned-out hemidiaphragm is taut and displaced cranially as a result of pneumoperitoneum (Figure 2A).  A small perforation is made at the dome of the diaphragm with electrocautery (Figure 2B).   The resulting pneumothorax releases the tension on the hemidiaphragm, and allows the surgeon to easily pull the hemidiaphragm into the abdominal cavity for suturing (Figures 2C, 2D).  At this point, the authors often place a 19 Blake pleural drain through an incision in the anterolateral chest wall to vent the pneumothorax as needed.
  3. Stitching: The authors use pledgeted U-stitches (#2 non-absorbable, braided suture, 31 mm curved needle).  The first stitch is placed centrally and as far posteriorly as possible (Figure 3A).  Traction on the first stitch facilitates exposure for two or three subsequent deeper stitches to plicate the posterior portion of the hemidiaphragm in an anteroposterior direction (Figures 3B, 3C, 3D).  To plicate the anterior portion of the hemidiaphragm, two to three weaving stitches are placed (Figure 4). The diaphragm must be taut at the end of the procedure. Closure of the initial perforation at the dome occurs with the plication.
  4. Tube Thoracostomy: The authors leave the pleural drain in place upon completion of the procedure, and verify that it has not been caught in a stitch.
  5. Intraoperative Management of Lower Lobe Atelectasis: Upon completion of the plication, the authors ask the anesthesia team to ventilate the patient with high tidal volumes and a PEEP of 10 cm H2O until extubation, with the intention of re-expanding the lower lobe. If respiratory secretions are copious after recruitment, flexible bronchoscopy should be performed.

Figure 1: Port placement for left-sided hemidiaphragm

Figure 2: Technique for diaphragmatic exposure. 

Figure 3: Technique for suture placement and antero-
posterior plication. 

Figure 4: Weaving stitches. 

Post-procedure Care

Postoperatively, patients participate in intense pulmonary toilet to re-expand the lower lobe of the ipsilateral lung. The chest drain remains in place until output is less than 200 mL/day. Occasionally patients need to be discharged with the chest tube in place. Premature removal of the chest drain can lead to symptomatic pleural effusion with recurrent lower-lobe atelectasis. The immediate postoperative chest x-ray should show that the plicated side is lower than the opposite side, with an acute costophrenic angle, and that the opposite side is actually elevated in comparison to the preoperative chest x-ray (Figure 5). Patients are monitored with the St. George’s Respiratory Questionnaire (SGRQ), PA/LAT chest x-ray, and PFTs at one month after discharge and yearly thereafter.

Figure 5: Post-operative CXR. 


Complications of laparoscopic plication include: prolonged chest tube drainage of greater than seven days (8%), respiratory failure (4%), gastrointestinal hemorrhage (4%), splenic laceration requiring splenectomy (4%), stroke (4%), and atrial fibrillation (4%) (3). The severity of some of these complications is probably also a reflection of the severity of comorbidities in this patient population.


  1. Hüttl TP, Wichmann MW, Reichart B, Geiger TK, Schildberg FW, Meyer G. Laparoscopic diaphragmatic plication: long-term results of a novel surgical technique for postoperative phrenic nerve palsy. Surgical endoscopy. 2004;18:547-51.
  2. Groth SS, Rueth NM, Kast T, D'Cunha J, Kelly RF, Maddaus MA, et al. Laparoscopic diaphragmatic plication for diaphragmatic paralysis and eventration: an objective evaluation of short-term and midterm results. The Journal of thoracic and cardiovascular surgery. 2010;139:1452-6.
  3. Groth SS, Andrade RS. Diaphragm plication for eventration or paralysis: a review of the literature. The Annals of thoracic surgery. 2010;89:S2146-50.
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Diaphragm plication in adult patients with diaphragm paralysis leads to long-term improvement of pulmonary function and level of dyspnea


Objective: There is still controversy about the feasibility and long-term outcome of surgical treatment of acquired diaphragm paralysis. We analyzed the long-term effects on pulmonary function and level of dyspnea after unilateral or bilateral diaphragm plication. Methods: Between December 1996 and January 2006, 22 consecutive patients underwent diaphragm plication. Before surgery, spirometry in both seated and supine positions and a Baseline Dyspnea Index were assessed. The uncut diaphragm was plicated as tight as possible through a limited lateral thoracotomy. Patients with a follow-up exceeding 1 year (n = 17) were invited for repeat spirometry and assessment of changes in dyspnea level using the Transition Dyspnea Index (TDI). Results: Mean follow-up was 4.9 years (range 1.2–8.7). All spirometry variables showed significant improvement. Mean vital capacity (VC) in seated position improved from 70% (of predicted value) to 79% (p ≪ 00.03), and in supine position from 54% to 73% (p = 0.03). Forced expiratory volume in 1 s (FEV1) in supine position improved from 45% to 63% (p = 0.02). Before surgery the mean decline in VC changing from seated to supine position was 32%. At follow-up this had improved to 9% (p = 0.004). For FEV1 these values were 35% and 17%, respectively (p ≪ 0.02). TDI showed remarkable improvement of dyspnea (mean + 5.69 points on a scale of −9 to +9). Conclusion: Diaphragm plication for single- or double-sided diaphragm paralysis provides excellent long-term results. Most patients were severely disabled before surgery but could return to a more or less normal way of life afterwards.

Diaphragm plication, Diaphragm paralysis, Phrenic nerve dysfunction, Surgical treatment of dyspnea

1 Introduction

Diaphragm paralysis results from an acquired dysfunction of the phrenic nerve and is rather uncommon in adults. It should not be confused with eventration of the diaphragm, a congenital disorder with permanently raised parts of the abnormally thin hemi-diaphragm. The exact incidence of diaphragm paralysis is not known since generally it is not recognized. Patients usually present with dyspnea on exertion; however, the severe and progressive dyspnea when bending over or changing to supine position is often even more disabling and almost pathognomonic for this disease. Patients eventually have to sleep in an upright position and have to stop working. The progression of dyspnea is caused by a decline in lung volumes, i.e. vital capacity (VC) and forced expiratory volume in 1 s (FEV1). The degree of decline is variable [1]. Also, immersion in water (taking a bath or swimming) causes deterioration of dyspnea by the increased pressure on the abdomen. Although it might be conceivable that long-lasting diaphragm paralysis leads to a cor pulmonale, there is no evidence for this statement.

Phrenic nerve dysfunction can be caused by any disorder affecting nerve tissues, e.g. vasculitis, neuromuscular diseases like amyotrophic lateral sclerosis [2], and trauma. Thermal trauma or direct laceration during dissection of the internal mammary artery in coronary artery revascularization [3,4] and surgery for tumors involving the phrenic nerve should be mentioned especially. Diaphragm paralysis can also be part of a neuropathological entity called neuralgic amyotrophy [5–7]. These patients have a history of a viral infection like a common cold or influenza and sudden pain in the shoulder or neck region before the onset of progressive dyspnea [5,6]. They typically suffer from a weakness of the arm, which eventually recovers. Although some recovery of diaphragmatic strength has been described in neuralgic amyotrophy, both the extent and duration of recovery are highly variable [8]. If there is no sign of recovery at all after 1 year, chances of complete recovery of muscle strength are small [5]. Development of unilateral or bilateral (mono-) neuritis of the phrenic nerve (without any known cause) is sometimes considered a variety of neuralgic amyotrophy without the typical limb-muscle weakness [5–7,9,10].

Diaphragm paralysis can be suspected on a chest X-ray. Pulmonary function tests in upright and supine positions and a paradoxical diaphragm movement in a sniff-test using fluoroscopy or ultrasound confirm the diagnosis. Other suggested investigations [1,5,6,11] are not necessary and only add costs to the diagnostic route [1,12].

Surgical treatment by diaphragm plication has been described since 1985 in small series for unilateral paralysis [13–17] and in three patients with bilateral paralysis [18]. There is still controversy around this treatment, especially regarding its long-term outcome. We describe our experience in 22 patients of whom 5 had bilateral and 17 unilateral paralysis. We focus on both pulmonary function tests and dyspnea scores before surgery and at long-term follow-up.

2 Material and methods

2.1 Patient population

Between December 1996 and January 2006, 22 consecutive patients underwent surgical treatment for diaphragm paralysis. Since most patients had their paralysis for at least 1 year, the chance of recovery was small, which in combination with the symptoms, was the indication to consider surgical treatment. Mean age was 62 years (range 37–89 years) and half of them were male. Mean body mass index (BMI) in our patient group was 28.2 (range 22.0–34.4). Five patients had a bilateral paralysis. The initial findings from three patients have been reported previously [18]. The longest period of documented unilateral paralysis was 23 years and was present on the left side in a patient with a recent onset of right-sided paralysis. In three patients the cause of diaphragm paralysis was obviously iatrogenic (two after CABG, one after resection of a malignant thymoma), in one patient it was associated with a brachial plexus trauma, and six had neuralgic amyotrophy. Etiology was unknown in 12 patients. All patients suffered from dyspnea, aggravating when adopting a recumbent position. They all slept in upright position and three patients needed support with continuous positive airway pressure (CPAP). Patient data are presented in Table 1.

2.1.1 Diagnostic tests

Diaphragm paralysis was suspected when finding an elevated (hemi-) diaphragm on chest X-ray (Fig. 1A

Fig. 1

Patient with a left-sided diaphragm paralysis. (A) Typical preoperative chest X-ray of a patient with a left-sided diaphragm paralysis. (B) Postoperative chest X-ray of the same patient.

Fig. 1

Patient with a left-sided diaphragm paralysis. (A) Typical preoperative chest X-ray of a patient with a left-sided diaphragm paralysis. (B) Postoperative chest X-ray of the same patient.

) and confirmed by a sniff-test during fluoroscopy or ultrasound examination. Preoperatively, pulmonary function tests and dyspnea level assessment were performed (see below). In patients with long-lasting paralysis, a right-sided heart catheterization (n = 2) or an echocardiography (n = 5) was also performed to check for pulmonary hypertension. Two patients did have pulmonary hypertension, one of whom received sildenafil citrate (Viagra®).

2.1.2 Pulmonary function tests

VC and FEV1were both measured in upright and supine positions according to the guidelines of the European Respiratory Society (ERS) and expressed as a percentage of the predicted values. When patients were not able to lie completely flat, they were positioned individually as flat as possible. Baseline pulmonary function was compromised (Table 2). The typical deterioration when changing from upright to supine position was obvious, and is expressed both as an absolute value (Fig. 2

Fig. 2

Preoperative decline in FEV1 changing from seated to supine position expressed as percentage of predicted values.

Fig. 2

Preoperative decline in FEV1 changing from seated to supine position expressed as percentage of predicted values.

) and as a relative decline (Table 2) compared to the volumes in the upright position.

2.1.3 Dyspnea score

The level of dyspnea was assessed using the Baseline Dyspnea Index (BDI) and Transition Dyspnea Index (TDI) as proposed by Mahler et al. [19] (see  Appendix A). The BDI rates the patient’s functional impairment, the magnitude of task needed to evoke dyspnea, and the magnitude of effort associated with this task before treatment. In each of these three categories the patient’s condition is rated from 0 (severely impaired) to 4 (unimpaired). Ratings of the three categories are added, yielding the BDI score. The lower the total score, the worse the severity of dyspnea. To evaluate the result of treatment the TDI was used. Changes for all three categories are rated by the physician from −3 for major deterioration to +3 for major improvement. Adding these scores produces the total TDI score, which can thus range from −9 to +9.

2.2 Surgical procedure

A limited lateral thoracotomy is performed through the 8th intercostal space. The uncut diaphragm is shortened first in anteroposterior direction with a number of U-stitches (Mersilene®2; Ethicon®, Norderstedt, Germany), usually starting on the mediastinal side (Figs. 3 and 4

Fig. 3

Intra-operative photograph showing the extreme thinness of the diaphragm. The first layer of U-stitches is depicted here.

Fig. 3

Intra-operative photograph showing the extreme thinness of the diaphragm. The first layer of U-stitches is depicted here.

Fig. 4

Diaphragm plication. Drawing (A) illustrates the paralytic diaphragm. Drawing (B) shows the first row of U-stitches, starting on the mediastinal side. Drawing (C) shows the optional second layer, if the surgeon is not yet satisfied with the tightness. Drawings (D) and (E) are showing the radial U-stitch to complete the shortening, leaving redundant tissue in the middle of the operating field. Drawing (F) shows the running sutures to flatten the redundant tissue anteriorly and posteriorly to the plicature. Drawing (G) shows the final result.

Fig. 4

Diaphragm plication. Drawing (A) illustrates the paralytic diaphragm. Drawing (B) shows the first row of U-stitches, starting on the mediastinal side. Drawing (C) shows the optional second layer, if the surgeon is not yet satisfied with the tightness. Drawings (D) and (E) are showing the radial U-stitch to complete the shortening, leaving redundant tissue in the middle of the operating field. Drawing (F) shows the running sutures to flatten the redundant tissue anteriorly and posteriorly to the plicature. Drawing (G) shows the final result.

). No material to reinforce the sutures is used. It is very important to pass the needles with extreme care to avoid damaging the abdominal organs since the diaphragm is usually very thin (Fig. 3). These sutures are tied as tight as possible. A second layer below the first can be placed in case of insufficient tightness (at the discretion of the surgeon). Then, another radial U-stitch is used to complete the shortening in lateral direction. Redundant tissue is flattened both anteriorly and posteriorly to the plicature with running sutures (Ethibond®2-0, Ethicon®) (Figs. 4 and 5

Fig. 5

Final result. Intra-operative photograph showing the final result of the operative procedure: a tight and firm diaphragm.

Fig. 5

Final result. Intra-operative photograph showing the final result of the operative procedure: a tight and firm diaphragm.

). The result is a tense and firm diaphragm (Figs. 4G, 5, and 1B). Whenever feasible, patients are extubated in the operating theatre.

Three patients with bilateral paralysis underwent plication of both hemi-diaphragms in a single procedure. The other two patients had two separate procedures with an interval of 2 months.

2.3 Follow-up

All patients with a postoperative interval exceeding 1 year (n = 17) were invited for repeat spirometry and assessment of their actual dyspnea by TDI in our hospital. A chest X-ray was also performed.

2.4 Statistical analysis

Continuous data are expressed as mean values. Values of VC and FEV1 are expressed as percentage of that predicted. The rate of decline of both parameters changing from upright to supine position is expressed as percentage of the volume in upright position. Follow-up data are compared with preoperative values using Student’s t-test for paired and unpaired data when appropriate. The Pearson correlation coefficient (r) was calculated for pre- and postoperative function test data and for dyspnea indices. For all tests a p-value ≪ 0.05 (two-sided) was considered significant.

3 Results

Diaphragm plication could be achieved in all patients. There were no intra-operative complications.

3.1 In hospital

Three patients died in hospital. The first patient (patient #7, Table 1) had an uneventful procedure and postoperative course. The night before discharge she was found dead. Postmortem examination revealed acute myocardial infarction with two-vessel coronary artery disease. The second patient (patient #16) had long-lasting bilateral diaphragm paralysis associated with severe hypercapnia (pCO2 on room air: 6.8–11.8 kPa) and pulmonary hypertension. Postoperatively she developed renal insufficiency and died of right heart failure. The third patient (patient #19) had a family history of thrombosis. Although all routine tests for coagulopathies were normal, she received high-dose nadroparin prophylaxis starting the day before surgery. During the second postoperative night she sustained an electromechanical dissociation on the ward. Postmortem examination revealed massive pulmonary embolism in both lungs.

Mean postoperative hospital stay was 5.5 days (range 3–10). Starting this new program there was an intensive care unit (ICU) bed available for all patients, which was not used in seven cases. One patient (patient #16) stayed in the ICU for 5 days because of the above-mentioned complications. The other 14 stayed there just one night. Five patients who developed a paralytic ileus for 2 or 3 days recovered spontaneously. Almost all patients experienced a feeling of tightness in the lower chest/upper abdominal area after the procedure.

3.2 Long-term follow-up

There were no late deaths. At the time of follow-up 17 patients had a postoperative interval exceeding 1 year. Sixteen participated in our restudy including spirometry and assessment of TDI. Thirteen patients were assessed in our hospital; three underwent pulmonary function tests at their referring hospitals while TDI assessment was performed by telephone. The only patient who denied participation claimed that he was much improved. Mean follow-up was 4.9 years (range 1.2–8.7 years). There were no signs of recurrent elevation, ruptures, or tears of the plicated diaphragms as determined by chest X-ray. In one patient the diaphragm appeared to be slightly elevated 8 years after the operation compared to the immediate postoperative chest X-ray. All patients felt better after surgery but nine still experienced a feeling of tightness. Four complained of post-thoracotomy pain. All but one patient in the working age group resumed their work. All could sleep in supine position again. Three patients who needed CPAP support before the operation did no longer need it at follow-up.

3.3 Spirometry at follow-up

All spirometry variables showed significant improvement at follow-up compared to baseline (Table 2); mean VC in upright and supine and mean FEV1 in upright and supine position. The improvement becomes even more obvious calculating the decline in loss of VC and FEV1 changing positions (expressed as percentage loss compared to upright position) (p = 0.004) and TDI. A correlation was found between the preoperative VC in supine position and improvement of the same variable postoperatively (r = 0.73), and also with the improvement of the postoperative FEV1 in supine position (r = 0.71). The decline in preoperative VC changing from upright to supine position proved to be strongly correlated with the amount of decrease of these values at follow-up (r = 0.78) and the decline in FEV1 preoperatively with the amount of decrease of both the postoperative decline in FEV1 (r = 0.80) and VC (r = 0.78). To summarize, a worse pulmonary function test before surgery was correlated with a better test at follow-up.

3.4 Dyspnea level assessment

Mean (preoperative) BDI score in the study patients was 4.6 (range 0–11). Mean (postoperative) TDI score was +5.69 (range 0 to +9) on a scale from −9 to +9, indicating that no patient deteriorated and almost all improved remarkably. BDI was correlated with the extent of improvement at follow-up (r = 0.63). There was no correlation between TDI and improvement of pulmonary function at follow-up, and we could not determine a threshold of preoperative pulmonary function tests to predict the outcome in TDI.

In seven patients with both short-term and long-term follow-up data available, long-term and short-term results were similar, indicating that functional improvement after diaphragm plication occurs early and is sustained over time.

3.5 Unilateral or bilateral diaphragm paralysis and plication

Although there was a tendency of worse baseline spirometry values for patients with double-sided diaphragm paralysis, differences were not statistically significant with the exception of the loss of volumes when changing from upright to supine position (Table 3). BDI was not different in patients with unilateral or bilateral paralysis.

The fact that the extent of improvement of some spirometry values does not reach statistical significance comparing both groups is possibly due to the small number of patients with bilateral surgery. Although mean TDI score for patients after bilateral plication has a tendency to be less than after unilateral plication, this study proves there is still a major improvement.

4 Discussion

Surgical treatment of diaphragm paralysis by plication has been described since 1985 in small series for unilateral paralysis [13–17,20,21] and in three patients with bilateral paralysis [18]. Some studies only or mainly concern patients after cardiac surgery with problems at weaning from ventilation [16,22]. Follow-up in most studies is limited both in patient numbers and in time; Higgs et al. described a group of 19 patients with long-term follow-up in 15 [15]. In contrast to our results, they found only a limited effect of positional changes on pulmonary function, both before and after surgery. In fact, FEV1 changing to supine position even worsened after the procedure, both immediately and at long-term follow-up. In our study, the beneficial effect of the surgical procedure was obvious and significant, both for the loss of VC and for loss of FEV1. Freeman et al. described a series of unilateral diaphragm plications in 25 patients with improved spirometry values at follow-up [17]; however, this concerns only 6 months follow-up. The only article to date describing bilateral diaphragm plication comes from our own group [18]. The number of patients was small (three surgically treated patients and three controls), but follow-up (2 years) was complete.

Higgs was the first to use a dyspnea score to evaluate his patients. He used the score of the American Thoracic Society (ATS) and Medical Research Council (MRC), which was also used by Freeman. Mahler et al. showed the limitations of this score in 1984 by indicating that the MRC/ATS score primarily focuses on the magnitude of task that provokes dyspnea [19]. The magnitude of effort associated with this task is not considered. This is important because there is a large difference between climbing two flights of stairs at high speed or very slowly. Also the functional impairment resulting from the dyspnea is not considered in the MRC/ATS score. The impact of functional impairment is amongst others related to patient age and is strongly associated with quality of life. Mahler introduced a new score with assessment of functional impairment, magnitude of task provoking dyspnea, and the magnitude of effort associated with that task. All three categories are rated before (BDI) and after (TDI) treatment. This score has been validated in the United States [22] and in a number of other countries including The Netherlands [23]. Patterns of response to an effective pharmacological treatment in patients with COPD usually show a total TDI score of +1 or +2 points [22,24]. We believe that the huge TDI scores in our patients indicate the major functional impairment posed on these patients by their diaphragm paralysis.

Non-invasive ventilation techniques are described to relieve symptoms in patients with diaphragm paralysis and to prevent ventilatory failure [1] and can in selected cases be applied while waiting for the diaphragm to recover after iatrogenic trauma [12]. Several patients in our study used CPAP masks before surgery. Despite their benefits their negative impact on daily life is not to be underestimated. The fact that patients could stop CPAP treatment after surgery is a major clinical benefit.

Until 2006 only a few reports with very limited numbers of patients have been published using a laparoscopic or thoracoscopic technique for surgical plication [21]. Freeman et al. were the first to describe a patient group of substantial size treated with this technique [17]. One could wonder if these video-assisted techniques are the optimal choice. First, the advantages of a thoracoscopic technique are not obvious. Although the incisions are smaller, the incidence and intensity of post-thoracotomy pain does not seem to be very different [25]. Secondly, a paralyzed diaphragm can be very thin and extreme care has to be taken not to puncture the abdominal organs. Can this be performed safely for the patients with bilateral surgery using thoracoscopy? Furthermore it can be difficult to fully inspect the highly elevated dome of a paralyzed diaphragm. The third argument considers the tightness of the plication. We strongly believe that the diaphragm should be rendered as tense as possible (Figs. 1B and 4) and that this explains why the beneficial effects of the plication in our patients are sustained over time. We do not believe that such a tense diaphragm can be achieved with a video-assisted technique lacking full tactile feedback. Obviously, there are no head-to-head comparisons to date.

A limitation of this study is the lack of a control group. In our previous publication, however, we showed that all patients in the control group deteriorated during the study period in contrast to the treated patients [18]. The same was described by Freeman et al., despite all other treatment options offered to the patients who refused surgical treatment [17]. Although three patients in this study died in hospital, death was directly related to the surgical procedure in only one case. The improvement of the patients was found to be sustained at follow-up and there is no alternative treatment: in our opinion this justifies the use of surgical plication as soon as spontaneous recovery has become unlikely.

5 Conclusions

Diaphragm paralysis can be severely disabling. Surgical treatment by plication of the diaphragm can be done with excellent long-term results both in patients with unilateral or bilateral diaphragm paralysis, regardless of the etiology of phrenic nerve dysfunction. Follow-up examinations reveal not only significant improvement of pulmonary function test parameters but also a remarkable improvement of the level of dyspnea, resulting in the possibility for these patients to return to a more or less normal way of life. Although the magnitude of benefit of surgical treatment for patients with bilateral paralysis is less compared to that in patients with unilateral paralysis, results at long-term follow-up still suggest an important clinical benefit even in this difficult group of patients.

Appendix A

Baseline Dyspnea Index

Appendix B

Transition Dyspnea Index




Long-term results of diaphragmatic plication in adults with unilateral diaphragm paralysis

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Journal of Cardiothoracic Surgeryvolume 5, Article number: 111 (2010) Cite this article

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In this study we aimed to evaluate the long-term outcome of diaphragmatic plication for symptomatic unilateral diaphragm paralysis.


Thirteen patients who underwent unilateral diaphragmatic plication (2 patients had right, 11 left plication) between January 2003 and December 2006 were evaluated. One patient died postoperatively due to sepsis. The remaining 12 patients [9 males, 3 females; mean age 60 (36-66) years] were reevaluated with chest radiography, flouroscopy or ultrasonography, pulmonary function tests, computed tomography (CT) or magnetic resonance imaging (MRI), and the MRC/ATS dyspnea score at an average of 5.4 (4-7) years after diaphragmatic plication.


The etiology of paralysis was trauma (9 patients), cardiac by pass surgery (3 patients), and idiopathic (1 patient). The principle symptom was progressive dyspnea with a mean duration of 32.9 (22-60) months before surgery. All patients had an elevated hemidiaphragm and paradoxical movement radiologically prior to surgery. There were partial atelectasis and reccurent infection of the lower lobe in the affected side on CT in 9 patients. Atelectasis was completely improved in 9 patients after plication. Preoperative spirometry showed a clear restrictive pattern. Mean preoperative FVC was 56.7 ± 11.6% and FEV1 65.3 ± 8.7%. FVC and FEV1 improved by 43.6 ± 30.6% (p < 0.001) and 27.3 ± 10.9% (p < 0.001) at late follow-up. MRC/ATS dyspnea scores improved 3 points in 11 patients and 1 point in 1 patient at long-term (p < 0.0001). Eight patients had returned to work at 3 months after surgery.


Diaphragmatic plication for unilateral diaphragm paralysis decreases lung compression, ensures remission of symptoms, and improves quality of life in long-term period.

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Acquired diaphragm paralysis is characterized by the loss of muscle contractility that leads to progressive muscular atrophy and distension of the dome [1]. Diaphragm paralysis may deteoriate the function and efficiency of respiration. It may cause paradoxical motion of the affected diaphragm, atelectasis, and contralateral mediastinal shift. These changes can lead to chronic and progressive dyspnea particularly in adults [1]. Acquired diaphragm paralysis may be caused by trauma, cardiothoracic surgery, infection (e.g. herpes zoster, influenza) neoplastic diseases, or autoimmune pathologies directly involving the diaphragm or the phrenic nerve [1, 2]. The idiopathic form is considered the result of a subclinical viral infection. This form generally affects adults and presents more commonly with unilateral involvement.

Surgical correction of acquired unilateral diaphragm paralysis by plication as described by Wright (1985) and Graham (1990) is indicated in any case where there is evidence of respiratory compromise without resolution of the condition [3, 4]. The aim of surgical repair is to place the paralyzed diaphragm in a position of maximum inspiration which relieves compression on the lung parenchyma and allows its re-expansion [1].

The previous studies focused on the natural history and potential for recovery from diaphragmatic paralysis in adults. Potential benefits of diaphragmatic plication in adults is still uncertain, especially in long-term period. There is limited data on the long-term outcome of diaphragmatic plication in adults with unilateral diaphragm paralysis [4–8].

In this study we aimed to evaluate the long-term outcome of diaphragmatic plication in adults with symptomatic unilateral diaphragmatic paralysis for an average of 5 years.


Study population

This was a single-arm, long-term retrospective series study. Thirteen adult patients with symptomatic unilateral diaphragmatic paralysis who underwent diaphragmatic plication between January 2003 and December 2006 in Thoracic Surgery Department of the Siyami Ersek Cardiothoracic Training Hospital were included in the study. Patients with an upper motor neuron disease, malignant etiology, severe chronic obstructive pulmonary disease, bilateral diaphragm paralysis, chronic cardiac insufficiency, and mechanically ventilated patients were excluded from the study.

All patients gave written informed consent before study procedures. This study was approved by our Institutional Ethics Committe of the Siyami Ersek Cardiothoracic Training Hospital and conducted in accordance to the latest version of Helsinki Declaration and local requirements.

Surgical procedure

Diaphragmatic plication was performed through a posterolateral thoracotomy in the 6th or 7th intercostal space using controlateral single lung ventilation. The hemidiaphragm transsected approximately 5 cm initally to avoid intraabdominal organ injury, then plicated from medial to lateral with a series of six to eight parallel U sutures (2-0 polypropylene) until it became taut and flat. The use of larger sutures was avoided, since in the cases not diagnosed early, the diaphragm becomes very thin, causing ruptures at the suture line and preventing the tightening of the diaphragm. Pleural space was drained using single chest tube. Pain control was achieved with a thoracic epidural catheter using 0.5% bubivacaine for 48 hours. Patients were discharged 24 hours after their chest tubes were removed.

Study procedures

All patients received a standardized evaluation before plication operation that included medical history, physical examination, chest X-ray, flouroscopy or ultrasonography and thorax spiral computed tomography (CT) or magnetic resonance imaging (MRI), pulmonary function tests [forced vital capacity (FVC) and forced expiratory volume in 1 s (FEV1)], and assessment of dyspnea score using Medical Research Council (MRC)/American Thoracic Society (ATS) dyspnea grading system (Table 1) [9]. Patients were reevaluated at postoperative long-term period at an average of 5.4 (4-7) years after diaphragmatic plication. This evaluation included chest X-ray, flouroscopy or ultrasonography, thorax Spiral CT, pulmonary function tests, assessment of the MRC/ATS dyspnea score, and their ability to work.

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Statistical analysis

Study data was summarized using descriptive statistics (number, mean, range, and standard deviation). Wilcoxon signed rank test was used to compare categorical variables. Continuous variables were compared by Student's paired t-test. All tests were two-sided and statistical significance was set at p < 0.05.


Patients and preoperative findings

Among 13 patients included in the study, one died in postoperative period due to ventilatory dependency pneumonia and sepsis. This patient had moderate chronic obstructive pulmonary disease (FEV1 = 65% of predicted value) and body mass index was 30 m2/kg. The remaining 12 patients [9 males, 3 females; mean age 60 (36-66) years] were followed for long-term after diaphragmatic plication.

Patients' demographic and clinical characteristics are displayed in Table 2. The etiology of paralysis was trauma (9 patients), cardiac by pass surgery (3 patients), and idiopathic (1 patient). The principle symptom was progressive dyspnea on exertion with a mean duration of 32.9 (22-60) months before surgery. In addition to dyspnea, 9 patients had respiratory and digestive symptoms such as abdominal discomfort. All patients had an elevated hemidiaphragm in chest X-ray and CT or MRI (Figure 1) and paradoxical movement in ultrasound or flouroscopy and evaluation prior to surgery. There were partial atelectasis and reccurent infection of the lower lobe in the affected side on CT in 9 patients (Figure 2).

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Preoperative chest X-ray of a 45-year-old female patient with diabetes who had dyspnea for 22 months shows that left diaphragm ascended up to infrahiler level.

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Spiral CT of the patient in Fig. 1 shows the atelectasis in left lower lobe, and relocation and retraction of mesenteric adipose tissue and colon loops towards diaphragm.

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Postoperative findings

Eleven patients including the patient who died in postoperative period had left, and 2 patients had right diaphragmatic plication. Mean lenght of hospital stay was 7 days. Two patients (15.3%) experienced a superficial wound infection. None of the patients died at long-term follow-up.

Radiological findings

In eleven patients, position of the diaphragm was normal after plication, but the diaphragm was elevated without symptoms in one patient at the end of postoperative 12th month. Flouroscopy showed that surgically plicated diaphragm was immobile and still elevated without any symptom, and there was no paradoxical motion. Atelectasis, which was found in 9 patients preoperatively, completely improved in X-ray (Figure 3) and CT scan after plication (Figure 4).

Chest X-ray of the patient in Fig. 1 at the end of postoperative 3rd year shows that left diaphragm is in normal position and lung is fully expanded.

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Three-dimensional multislice reconstruction of the patient in Fig. 1 at the end of postoperative 3rd year. Plicated left diaphragm is entirely in normal position.

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Pulmonary function tests

Preoperative pulmonary function tests showed a clear restrictive patern. Mean preoperative FVC was 56.7 ± 11.6% and FEV1 65.3 ± 8.7% in spirometry. FVC and FEV1 improved by 43.6 ± 30.6% (p < 0.001) and 27.3 ± 10.9% (p < 0.001) at late follow-up (Table 3).

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MRC/ATS dyspnea score

Preoperative MRC/ATS dyspnea score improved from 3 to 0 (3 points) for 11 patients and from 4 to 3 (1 point) in 1 patient at long-term follow-up after plication (p < 0.0001) (Table 4).

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Working history

Eight patients who had left their jobs because of dyspnea had returned to work within 6 months after surgery. The other 4 patients were retired. None of the patients treated with subsequent hospital admission related to pulmonary or digestive complaints and required re-plication.


In this long-term follow-up study, we evaluated an average of 5.4 (4-7) years outcome of diaphragmatic plication in adults with symptomatic unilateral diaphragmatic paralysis. We found that diaphragmatic plication for unilateral diaphragm paralysis reexpands the atelectatic lung, improves respiratory and digestive symptoms, and quality of life in long-term period.

Symptomatic unilateral diaphragmatic paralysis in adult patients is an uncommon but severely disabling clinical problem. The diagnosis of diaphragm paralysis is suggested when the chest X-ray shows a raised diaphgram and is confirmed by fluoroscopy, ultrasonography, Spiral CT, thorax MRI, and most definitively by electromyogram (EMG) stimulation. For differantial diagnosis, spiral CT is used to eliminate particularly thorax malignancies and fiberoptic bronchoscopy is used to define endobronchial patologies due to atelectasis. Particularly multislice CT is a valuable tool for evaluating subdiaphragmatic area, and diaphragm rupture and/or herniation associated with postraumatic diaphragm paralysis [10]. The diagnosis of unilateral diaphragm paralysis may be missed in older patients and postoperative cases. Moreover, the diagnosis is often delayed, unless it follows trauma or cardiothoracic surgery. Nowadays, ultrasound evaluation of diaphragm function is a sensitive, safe, and non-invasive method without radiation exposure and has replaced the use of radioscopy and EMG [11]. The etiology of diaphragm paralysis is usually defined based on the history and previous chest X-ray of the patients.

Careful evaluation of the disease is obligatory prior to surgical correction to differantiate other possible reasons that may lead to respiratory symptoms. Following diagnosis of diaphragm paralysis, surgical treatment is indicated after excluding paranchymal lung disease, chronic heart failure, and neoplastic etiology; and if pulmonary symptoms still persist in spite of treatment of lung infection, physical therapy, and body weight control. Patients should be selected properly for plication surgery to prevent unnecessary operations. Exertional dyspnea severe enough to impair simple daily activity is the most common indication for surgery.(1) However, timing of surgery is still debated. Some authors recommend plication after a period of 3-6 months [1], while others recommend a longer waiting period anticipating the potential spontaneous recovery especially in diaphragm paralysis due to cardiac surgery [12]. Summerhill et al. reported that 11 of 16 patients (69%) functionally recovered from diaphragmatic paralysis and the time for spontaneous recovery ranged from 5 to 25 months (mean 14.9 ± 6.1 months) [11]. Mouroux et al. suggested to wait 18-24 months before the plication surgery for diaphragm paralysis and eventration which is not an objective criteria [13].

The mean time to plication was 32.9 months in our series. This relatively long duration was due to the late diagnosis and late referral of most patients to our clinic rather than long waiting period for surgery.

According to our clinical experience, the waiting period should be at least 12 months depending on the etiology of paralysis.

Plication through standard thoracotomy is the most frequently used surgical technique in diaphragm paralysis. It carries low morbidity and no mortality. Graham et al. treated 17 patients using thoracotomy, and showed that functional improvement was present even at long-term follow-up [4]. Higgs et al. also reported that diaphragmatic plication is an effective treatment for long-term in unilateral diaphragmatic paralysis and showed improvement of spirometry findings at long-term period up to 14 years [5]. Similar results were also reported by Ribet and Linder [6].

The surgical technique preferred in the current study has several advantages. The paralyzed diaphragm is almost always thin, thus it's difficult to avoid injury of abdominal organs just below this thin structure. This surgical technique also gives extratightness and tense to diaphragm by strongly suturing the lowest border of flaccid diaphragm. The standard thoracotomy enables the surgeon to control the diaphragm completely by touching and feeling. Following the incision of the diaphragm and the examination of the underlying organs, the suturing procedure becomes easier with a tightened diaphragm. Strong and tense plication of paralyzed diaphragm is the most important factor for providing favorable long-term surgical outcome. Our experience showed that the only limitation of this technique is long duration of serosanguineous drainage and removal of chest tube at day 3 (2-9) on average. This situation may be due to trauma caused by incision of diaphragm and impaired lymphatic circulation. The incision area of diaphragm should be avascular with no neurons, which may be easily recognized with thinest atrophic structure.

Diaphragmatic plication by video-asissted thoracoscopic surgery (VATS) has been reported by Freeman et al. in a study that showed that all patients who underwent plication of hemidiaphragm through VATS improved in dyspnea and spirometric values at long-term period [7]. However, there is still limited data on the advantages and disadvantages of VATS technique. In the present study, we did not perform plication with VATS. Our recent experience with VATS indicated the difficulty of obtaining a sufficiently tense diaphragm with VATS technique. On the other hand, diaphragm must not be over-tightened because that will restrain the lower chest wall from expanding to prevent limiting inspiration.

The incidence of phrenic nerve dysfunction in adults after coronary artery by pass grafting reported to be 10% to 60% [14–16]. Katz et al. showed that 80% of patients spontaneously recovered in 1 year [17]. However, Kuniyoshi et al. suggested that one of the indications of plication for patients with diaphragm paralysis due to coronary artery by pass surgery is difficult to wean from mechanical ventilation [12]. Kuniyoshi et al. also reported that plication is an effective and safe technique for diaphragm paralysis due to open cardiac surgery in adults as in children [12]. In our study, plication was performed in 3 patients with diaphragm paralysis due to coronary artery by pass surgery. In these 3 patients, the internal mammary artery had been used for by pass surgery and duration of dyspnea was over 15 months.

Diaphragmatic paralysis after coronary artery by pass grafting in adult patients is commonly attributed to topical cooling [16, 17]. However, topical cooling is not currently used, which decreased the frequency of diaphragm paralysis. One of the possible causes of diaphragm paralysis after coronary artery by pass grafting is harvest of internal mammary artery. It was shown that phrenic nerve crosses over internal mammary artery in anterior thoracic wall in 54% of patients and in posterior thoracic wall in 14% of patients [18]. Furthermore, pericardiophrenic artery originates from internal mammary artery in 89% of cases [19, 20]. In case of thermal injury of internal mammary artery by electroknife, phrenic nerve may become ischemic. In addition to surgical technique, diabetes and older age have been considered as potential risk factors for diaphragm paralysis [20, 21].

In the present study, MRC/ATS dyspnea scale was used to evaluate the subjective effect of diaphragm plication on symptoms. Dyspnea score was first used for assessment of shortness of breath by Higgs et al. MRC and ATS dyspnea scoring systems are currently the most commonly used dyspnea evaluation tools [5]. These systems are based on the assessment of apparent dyspnea by 5 different severity statements. While Simansky et al. used ATS dyspnea scoring system, Freeman et al. used MRC system; and both studies reported that dyspnea was improved in long-term after plication surgery and majority of patients returned to their work [22, 7]. Versteegh et al. performed lateral thoracotomy in 15 patients with unilateral diaphragm paralysis and found that all patients showed subjective and objective improvement [22]. However, they used baseline dyspnea index in preoperative period and transition dyspnea in postoperative period as described by Witek and Mahler [23]. These indexes evaluates the magnitude of functional impairement for task provoking dyspnea and the magnitude of the effort associated with that task. But these indexes are not easy to understand and the application of them is more difficult, thus they are not practical to use in routine.

One patient in our series died in postoperative 60th day due to sepsis and multiorgan failure as a result of ventilatory pneumonia after prolonged entubation. This patient had moderate chronic obstructive lung disease, and body mass index was 30 m2/kg. Diaphragm paralysis patients with chronic obstructive lung disease and obesity have high risk for morbidity and mortality. This experience has taught us that plication must not be applied in the patients with an ejection fraction below 40, in the patients with moderate to severe chronic obstructive lung disease and to the patients with a body-mass index of 30 m2/kg or above. Even though plication was performed in these patients, long-term intense bronchodilator treatment and respiration physiotherapy should be applied, and patients should be encouraged to lose weight. Versteegh et al. reported preoperative 3 deaths among series of 22 patients who underwent plication. Deaths were due to heart attack, massive pulmonary embolism, and renal failure and right heart failure [8]. Pathak and Page reported splenic injury due to plication for which they suggested the incision of diaphragm to control the underneath tissues [24]. Phadnis et al. reported abdominal compartment syndrome after right plication surgery [25]. They speculate that their patient had abdominal compartment syndrome develop as a consequence of downward hepatic shift and reduced intra-abdominal volume. Mortality related to surgical procedure has not yet been reported.


As a conclusion, diaphragm paralysis patients showed both objective and subjective improvement in long-term period after plication. Hence, it ensures remission of symptoms, and improves quality of life in long-term period.


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Two-year long-term follow-up results of this study was presented in 15th European Conference on General Thoracic Surgery in 2007 as an oral presentation (Celik S, Celik M. Long term results of diaphragmatic plication in adult patients with unilateral diaphragmatic paralysis. Oral Presentation No. 046-O. 15th European Conference On General Thoracic Surgery. 3-6 June 2007, Leuven, Belgium.)

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  1. Thoracic Surgery Department, Siyami Ersek Cardiothoracic Training Hospital, Istanbul, Turkey

    Sezai Celik, Muharrem Celik, Bulent Aydemir, Cemalettin Tunckaya, Tamer Okay & Ilgaz Dogusoy

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Correspondence to Sezai Celik.

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The authors declare that they have no competing interests.

Authors' contributions

SC: study design and writing all sections of the manuscript. MC: development of methodology. BA: collection of data. CT: analysis and interpretation of data. TO: supervision. ID: supervision.

All authors read and approved the final manuscript.

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Celik, S., Celik, M., Aydemir, B. et al. Long-term results of diaphragmatic plication in adults with unilateral diaphragm paralysis. J Cardiothorac Surg5, 111 (2010).

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  • Force Vital Capacity
  • Phrenic Nerve
  • Abdominal Compartment Syndrome
  • Internal Mammary Artery
  • Diaphragmatic Paralysis

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