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 anecdotally 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.