Thoracoscopic diaphragm plication.

Diaphragm plication is a relatively common operation in thoracic surgery and can be a major benefit to patients who have suffered phrenic nerve injury and who are left short of breath as a result [1]. With the advent of video-assisted thoracoscopic surgery (VATS) many surgeons have attempted diaphragm plication endoscopically. Barriers to implementation of VATS diaphragm plication include concerns regarding initial port entry with such a high diaphragm, the technical ability to suture by VATS and concern regarding the placement of sutures to a thin diaphragm draped tightly over a spleen, liver or large intestine. We present a simple way to overcome these barriers using carbon dioxide to increase the size of the hemithorax and relax the tension on the diaphragm, an Endostitch device that makes pledgeted suturing straightforward and a novel endograsper that allows a wide range of angles to be achieved when handling the diaphragm.