This is a case of a 6 month old boy who underwent a thoracoscopic right diaphragmatic plication and pleurodesis for recurrent pleural effusions associated with his peritoneal dialysis. This boy was born with autosomal recessive polycystic kidney disease. Due to his inability to be weaned from the ventilator, he underwent a bilateral nephrectomy and placement of a peritoneal dialysis catheter at one month of age. He initially did well, but was admitted to the hospital with a right pleural effusion at five months of age. Thoracentesis at that time revealed that the pleural fluid consisted of peritoneal dialysate. Despite reducing the volume of peritoneal dialysate, the boy was readmitted twice with right-sided recurrent pleural effusions. The decision was made to proceed with a right thoracoscopic diaphragmatic plication and pleurodesis. The patient was placed in the left lateral decubitus position after the induction of anesthesia. A single 5-mm port was placed in the mid-axillary line as superiorly as permitted by the anatomy. Upon inspection of the right hemi-thorax, a diaphragmatic eventration with a pleuroperitoneal communication was encountered. Two additional 4-mm ports were placed for needle drivers to be employed for the plication. After the first suture was placed, it was noted that the inability to use single lung ventilation due to the child's size would impede the ability to safely complete the procedure. Thus, a fourth port was placed to retract the lung medially. Interrupted silk sutures were used to complete the diaphragmatic plication all the way to the inferior pulmonary vein. At the conclusion of the procedure, talc poudrage was achieved through one of the working ports and a thoracostomy tube was placed. The patient tolerated the procedure without difficulty, and was extubated post-operative day number three. Low volume dialysis was initiated post-operative day number four without accumulation of fluid in the chest tube. The chest tube was removed and the patient was gradually increased to full volume dialysis without any recurrence of pleural effusion.