Introduction: Here we present a 60 year old female with iatrogenic paralysis of her left hemi-diaphragm. Due to paradoxical motion of the diaphragm she had profound positional difficulty of breathing and dyspnea on exertion. Robotic assisted thoracic surgery, or RATS diaphragm plication involves pleating the diaphragm with running sutures. This allows the diaphragm to remain fixed in a caudal position; therefore eliminating paradoxical motion and preventing lung and mediastinal compression.

Methods: Robotic diaphragm plication, utilizing a 4 arm robot is a minimally invasive alternative. We utilize four 8 mm ports, and a 5th non robotic assist port. For suture we use a non-absorbable wound closure suture that locks in place after cinching. The grasping forceps are placed in Arm 1, camera in arm 2, needle driver in Arm 3 and retractor in Arm 4 for this left sided approach. A series of running Lembert sutures are placed. Care is taken to grasp the diaphragm and lift up to ensure there is no bowel underneath, before placing the suture. The suture lines are performed posterior to anterior and medial to lateral. Care is taken to make a relatively tight plication, but not so tight the diaphragm is made ischemic, risking the possibility of tearing the diaphragm post-operatively.

Results: The patient was discharged to home on post-operative day #3. She had marked improvement of her symptoms with elimination of her dyspnea on exertion.

Conclusions: Robotic diaphragm plication is a viable minimally invasive approach to the palliation of hemi-diaphragm paralysis.