Diaphragm plication is a surgical procedure that tightens and flattens a weakened or paralyzed diaphragm so the lungs have more room to expand. It’s primarily used when one side of the diaphragm no longer contracts properly, causing shortness of breath, poor sleep, and low energy. More than 70% of patients return to normal breathing after the procedure.
Why the Diaphragm Matters for Breathing
The diaphragm is a broad, flat muscle that separates your chest from your abdomen. It’s your primary breathing muscle. When it contracts, it pulls downward, creating a vacuum that draws air into your lungs. When one side of the diaphragm is paralyzed or abnormally elevated (a condition called eventration), it balloons upward into the chest cavity instead of pulling down. This compresses the lung on that side, reducing the volume of air you can inhale and making physical activity, eating, and sleeping significantly harder.
Plication essentially takes up the slack in the diaphragm by folding and suturing the excess tissue, pulling the muscle back into a flatter position. This stops it from pushing up into the chest and gives the lung underneath room to inflate fully again.
Conditions That Lead to Plication
The two main reasons people need this surgery are diaphragm paralysis and diaphragm eventration. Paralysis happens when the phrenic nerve, which controls the diaphragm, is damaged. This can result from cardiac surgery, trauma, viral infections, or neurological conditions. Eventration is a condition where part of the diaphragm is abnormally thin and rides higher than it should, sometimes present from birth.
Not everyone with a paralyzed or elevated diaphragm needs surgery. Many people compensate well enough with the other side of their diaphragm and their chest wall muscles. Plication is reserved for cases where conservative management isn’t enough. The specific situations that typically warrant surgery include:
- Persistent shortness of breath that isn’t explained by heart failure or lung disease
- Inability to come off a ventilator after an illness or surgery
- Recurrent or life-threatening pneumonia caused by the compressed lung
- Failure to thrive in infants, including poor feeding and inadequate weight gain
How the Surgery Works
Surgeons access the diaphragm through the chest. The traditional approach uses an open incision (thoracotomy) of about 8 to 10 centimeters between the ribs. The newer, minimally invasive approach uses video-assisted thoracoscopic surgery, or VATS, which requires only one to three small port incisions. Both methods achieve the same goal: the surgeon folds the stretched-out diaphragm tissue onto itself and stitches it in layers, typically using two rows of sutures (one interrupted, one running) to create a durable tuck.
The VATS approach has become increasingly popular because it offers better visibility of the elevated diaphragm, shorter operative times (roughly 50 minutes of surgical time compared to about 60 for open surgery), and less postoperative pain. A comparison study of the two techniques found that outcomes were equivalent regardless of approach. The type of surgical access doesn’t appear to affect whether breathing returns to normal.
What Recovery Looks Like
Hospital stays after diaphragm plication are short, typically up to two nights. Most people return to work and daily routines within two weeks. Full energy recovery takes longer, usually up to six weeks, as the chest wall heals and the lungs gradually re-expand to fill the space the surgery created.
The improvement in lung function is most dramatic around six months after surgery. On average, patients see a 26.8% increase in the total volume of air they can exhale in one breath, and a 24.3% increase in the volume they can push out in the first second of exhalation. These are meaningful gains that translate directly into less breathlessness during everyday activities like climbing stairs, walking, and lying flat to sleep. Previous research across multiple studies has consistently found improvements in the 17 to 30% range for these measures.
Risks and Long-Term Results
Diaphragm plication is a low-risk procedure. A large meta-analysis of surgical outcomes found that in-hospital mortality was 0.51%. Over longer follow-up (median of about 1.6 years), the recurrence rate was 1.64% per person per year, meaning the diaphragm re-elevated and symptoms returned in a small number of patients. Follow-up mortality from all causes was about 1% per person per year, which largely reflects the underlying conditions that led to paralysis in the first place rather than the surgery itself.
One interesting finding: patients with diabetes were actually more likely to return to normal breathing after plication. The reasons aren’t fully understood, but it suggests that diabetic nerve injury to the phrenic nerve may respond particularly well to the mechanical fix that plication provides.
Differences Between Children and Adults
In children, diaphragm plication is almost always performed because an infant or young child can’t be weaned off a ventilator. The paralysis is often related to birth trauma or cardiac surgery performed shortly after birth. When plication works in this group, the results are fast: children who responded were weaned from ventilatory support within a median of four days.
Adults present a broader range of situations. Some are ventilator-dependent, but more commonly they’re living at home with chronic shortness of breath that limits their daily life. Adults who underwent plication for chronic symptoms showed a 40% improvement above their baseline lung function and reported significant subjective improvement in their breathlessness, improving by two to three levels on a standard breathing difficulty scale. That’s the difference between getting winded walking on flat ground and being able to handle moderate hills or stairs comfortably.
Ventilator-dependent adults had less favorable outcomes than ventilator-dependent children in one comparative study, with only one of four adults successfully weaning off the ventilator. This likely reflects the fact that adults on ventilators tend to have more complex underlying medical conditions contributing to their breathing failure beyond the diaphragm alone.