Two-port Video-Assisted Thoracoscopic Plication Using Porous Nitinol Pledgets for Diaphragmatic Paralysis

BackgroundDiaphragmatic plication is a standard treatment for symptomatic unilateral diaphragmatic paralysis, but the best minimally invasive technique and reinforcement material remain debated. We evaluated a two-port VATS plication technique using porous Nitinol pledgets.MethodsThis retrospective single-center study included 30 consecutive adults with symptomatic unilateral diaphragmatic paralysis who underwent two-port VATS plication between 2018 and 2024. All procedures were performed using porous NiTi pledgets (7 × 5 × 3 mm) and non-absorbable sutures. Perioperative outcomes included operative time, blood loss, extubation, ICU use, chest tube duration, pain scores, complications, and length of stay. Functional outcomes comprised spirometry (FVC, FEV1), MRC dyspnea scores, and radiographic hemidiaphragm elevation at 1, 6, and 12 months.ResultsMean age was 61.3 ± 10.3 years; 66.7% of patients were female. Mean operative time was 123.1 ± 29.0 min and blood loss 20.3 ± 20.8 mL. Immediate extubation occurred in 86.7%; 40% required brief ICU monitoring. Chest tube duration and hospital stay were 2.2 ± 1.3 and 5.5 ± 2.9 days. Complications occurred in 13.3%, all grade I-II. At 12 months, FVC increased from 60.2 ± 12.2% to 82.1 ± 10.6%, FEV1 from 60.2 ± 14.5% to 81.1 ± 11.8%, MRC score improved from 3.8 ± 0.4 to 0.5 ± 0.6, diaphragm elevation decreased by ∼34%, and 90% of patients reported symptomatic improvement.ConclusionsTwo-port VATS diaphragmatic plication reinforced with porous NiTi pledgets demonstrates feasibility, safety, and reproducibility with sustained functional and symptomatic improvement and low morbidity. The absence of a control group precludes claims of material superiority; observed benefits primarily reflect the mechanical restoration achieved by plication itself, with porous NiTi serving as a biocompatible alternative to standard PTFE pledgets.