Approach to Robotic, Transabdominal, Left Hemi-Diaphragm Plication

Impaired contractility of the diaphragm can occur secondary to diaphragm paralysis. Signs and symptoms of diaphragm paralysis vary among patients. Some may be asymptomatic and present incidentally, while others experience dyspnea secondary to impaired ventilation. Patients who are symptomatic from diaphragm paralysis may benefit from surgical intervention with diaphragm plication. Many surgical approaches are available for diaphragm plication, including open, thoracoscopic, laparoscopic, and robotic-assisted procedures. In this paper, we discuss our step-by-step approach to a robotic, transabdominal diaphragm plication. This was performed in a 60-year-old female presenting with dyspnea secondary to left hemidiaphragm paralysis. The technique includes inducing an iatrogenic pneumothorax to create a pressure equilibrium between the thoracic and peritoneal spaces. Subsequently, a diaphragm plication is performed in a 2-layer approach, using an initial running suture and subsequent reinforcing interrupted sutures in two separate axes, namely the posterior and anterior axes. Lastly, the plication repair is verified through the use of a thoracic port, which is subsequently used for tube thoracostomy placement.