Key Points

• Surgery involving the diaphragm can be required for a number of diaphragmatic and nondiaphragmatic abnormalities.
• It entails thoracic, abdominal, and combined thoracoabdominal approaches.
• Minimally invasive video-assisted thoracoscopic and laparoscopic approaches with or without robotic assistance are increasingly being employed.
• The diaphragm can be widely incised with no functional compromise, provided that major branches of the phrenic nerves are respected.
• Most of transdiaphragmatic surgical procedures can be optimally performed through a circumferential peripheral phrenotomy.

The diaphragm is a musculotendinous structure that provides an anatomic barrier separating the pleural cavities and pericardium from the abdomen. A competent surgeon needs to be confident using all of the available surgical modalities, which, aside from the classic thoracic, abdominal, and combined thoracoabdominal open approaches, include minimally invasive thoracoscopic and laparoscopic approaches with or without robotic assistance.