Plication is a surgical technique involving the folding, tucking, or pleating of tissue to modify its form or function. This method is utilized across various medical specialties to shorten, strengthen, or reduce the volume of a structure. By manipulating existing tissue rather than removing it, plication offers a versatile approach to altering the architecture of organs and muscle layers. The technique enables surgeons to achieve precise anatomical changes with minimal disruption to surrounding biological systems.
The Core Principle of Tissue Folding
The core principle of plication surgery centers on reducing the length or surface area of a target tissue using sutures. Unlike a resection, which involves cutting out and removing a portion of tissue, plication simply folds the material upon itself. The surgeon places a series of non-absorbable or long-lasting sutures through the tissue layers, cinching them together to create a permanent fold.
This deliberate folding action achieves two main physiological outcomes depending on the location of the procedure. When applied to a hollow organ, such as the stomach, the technique effectively decreases the internal volume. When used on a weakened or stretched muscle or fascial layer, the folding increases the density and thickness of the tissue, thereby restoring its structural integrity and strength.
Applications in Volume Reduction Surgery
Plication is used for reducing the internal capacity of hollow organs, most notably in bariatric procedures like gastric plication. This operation, also known as greater curvature plication, aims to shrink the stomach’s size without cutting or stapling any tissue. The procedure is typically performed laparoscopically, where the surgeon folds the greater curvature of the stomach inward, reducing its volume by an estimated 70 to 75 percent.
The stomach wall is secured in its new, folded position using multiple lines of permanent sutures. This creates a restrictive effect, making the patient feel full much faster after eating smaller amounts of food. Since the procedure does not involve re-routing the intestines or removing stomach tissue, it is a distinct option compared to other bariatric surgeries.
Beyond the stomach, the principle of volume reduction through folding has been applied to other internal structures. In some procedures for gastroesophageal reflux disease (GERD), plication techniques create a fold of tissue near the gastroesophageal junction to reinforce the barrier against acid reflux. Longitudinal plication has been employed in the management of complete rectal prolapse, where the redundant rectal wall is folded and sutured to shorten the tissue and prevent further protrusion.
Plication for Structural Reinforcement and Tightening
The folding technique is used to reinforce and tighten weakened muscle and fascial layers. A common application is the repair of diastasis recti, a condition where the rectus abdominis muscles separate, following pregnancy. During this procedure, known as rectus plication, the surgeon sutures the stretched tissue back together along the midline of the abdomen.
This surgical repair creates an “internal corset,” restoring the integrity of the abdominal wall and eliminating the characteristic bulge. By bringing the separated muscles closer together, the procedure offers both a functional benefit, such as improved posture and reduced back pain, and a cosmetic improvement.
Plication plays a role in hernia repair, where a layer of muscle fascia is folded and reinforced with sutures to strengthen the abdominal wall at the site of the defect. Additionally, in ophthalmology, plication is a technique used to correct strabismus, or eye misalignment. The surgeon shortens the eye muscle by folding it upon itself and suturing it in place, which strengthens the muscle’s pull without the need to detach and reattach it, a method that can spare the eye’s blood supply.