Video-assisted thoracoscopic diaphragmatic plication in a ventilator-dependent patient with an elevated and dysfunctional hemidiaphragm

Abstract

Unilateral hemidiaphragm dysfunction can reduce ventilatory reserve, but its contribution to weaning failure is difficult to isolate in a critically ill patient. A 61-year-old woman with asthma and a chronically elevated left hemidiaphragm developed severe pneumonia and acute hypercapnic respiratory failure, with an arterial partial pressure of carbon dioxide (PaCO₂) of 164.9 millimeters of mercury (mmHg), followed by recurrent extubation failure and tracheostomy. Pulmonary embolism was excluded. Bronchoscopy, microbiological treatment, nutritional support, and treatment for suspected autoimmune disease improved several reversible problems, yet hypercapnia recurred during ventilator reduction. Prior imaging showed that the elevation predated the acute illness. Formal fluoroscopic sniff testing, diaphragm ultrasound, phrenic nerve studies, and complete ventilator-setting records were unavailable; the condition is therefore described cautiously as an elevated and dysfunctional hemidiaphragm, most consistent clinically with acquired paralysis rather than a true hernia. After multidisciplinary reassessment, three-port left video-assisted thoracoscopic diaphragmatic plication was performed under low-pressure capnothorax. The diaphragm was flattened with six rows of continuous nonabsorbable braided polyester suture, using repeated mattress-type bites reinforced with polytetrafluoroethylene pledgets. Operative time was 180 minutes. PaCO₂ was 36.0 mmHg on postoperative day 1. Spontaneous-breathing trials began on postoperative day 2, and sustained side-arm oxygen through the tracheostomy began on postoperative day 7. Hypercapnic acidosis recurred on postoperative days 11–12 during ongoing pulmonary infection. She was transferred for rehabilitation off the ventilator on postoperative day 15 and remained off ventilatory support at last contact, with the tracheostomy still in place. This case does not establish that plication alone produced ventilator liberation. It shows how a familiar operation may be used after cautious selection to remove one potentially reversible mechanical burden in multifactorial weaning failure.

Highlight box.

Surgical highlights

• A three-port video-assisted thoracoscopic approach was used to flatten a markedly elevated left hemidiaphragm in a patient with multifactorial weaning failure.

• Six continuous imbricating rows were fashioned with repeated mattress-type bites using 2-0 nonabsorbable braided polyester suture and polytetrafluoroethylene pledgets.

• The central judgment was timing: surgery was deferred while infection, gastrointestinal bleeding, nutrition, and anesthetic risk were unstable, then reconsidered when persistent hypercapnia remained during ventilator reduction.

What is conventional and what is novel/modified?

• Thoracoscopic diaphragmatic plication and plication for ventilator-dependent adults have both been reported. Neither the access nor the intensive care unit (ICU) setting is presented as novel.

• The case adds an explicit account of selection under uncertainty: the diaphragm was not accepted as the sole cause of respiratory failure, the first surgical assessment was conservative, and the eventual outcome remained confounded by infection and critical-illness deconditioning.

What is the implication, and what should change now?

• In a patient with an elevated hemidiaphragm and failed weaning, plication should be considered only after other reversible causes have been treated and after the team has agreed that removing a mechanical disadvantage is worth the perioperative risk.

Introduction

An elevated intact hemidiaphragm is a radiographic description, not a complete diagnosis. Congenital eventration reflects deficient muscular development, whereas acquired paralysis usually reflects phrenic nerve or diaphragmatic muscle dysfunction. The terms overlap in parts of the surgical literature, but both are distinct from diaphragmatic hernia, in which continuity of the diaphragm is disrupted (1-3). Plication does not restore contractility. It lowers and stabilizes the dome, increases space for the compressed lung, and reduces paradoxical displacement.

Most adult plication series involve ambulatory patients with dyspnea or orthopnea. Recent cohort and pooled data support durable improvement in symptoms and pulmonary function in selected patients, but they do not answer the harder question of whether plication will help an infected, deconditioned patient already dependent on ventilation (4,5). A thoracoscopic operation may correct the anatomy while leaving the biology of critical illness largely unchanged.

We report the operative technique and perioperative course of a ventilator-dependent patient with an elevated and dysfunctional left hemidiaphragm. The procedure itself was conventional. The educational value lies in diagnostic restraint, timing, and interpretation of a delayed and incomplete clinical response. We present this article in accordance with the SUPER reporting checklist (6) (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-1455/rc).

Preoperative preparations and requirements

Ethical statement

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written consent for publication of the de-identified clinical details, accompanying images, and operative video was obtained from the patient.

Clinical presentation

A 61-year-old woman developed chest pain, dyspnea, orthopnea, and leg edema on January 13, 2026. She had seasonal asthma diagnosed in 2012 and no history of hypertension or diabetes. She had fallen in 2020, and later imaging showed an old rib fracture. A chest computed tomography (CT) scan obtained for cough in 2025 had already shown left lower-lobe volume loss and an elevated left hemidiaphragm, then reported locally as a diaphragmatic hernia. Her baseline function before the acute illness was reasonable; she could climb four flights of stairs.

On January 21, 2026, she became encephalopathic, with an arterial partial pressure of oxygen (PaO₂) of 71.6 mmHg and an arterial partial pressure of carbon dioxide (PaCO₂) of 164.9 mmHg, and was intubated. An extubation on January 27 was followed by recurrent carbon dioxide (CO₂) retention despite noninvasive support. At a second hospital, she was reintubated for severe pneumonia, type II respiratory failure, and gastrointestinal bleeding. A further extubation on February 5 failed within two hours. She reached our emergency department on February 6 and was admitted to the emergency intensive care unit (EICU) on February 9. Admission pH was 7.27 and PaCO₂ was 75.4 mmHg. The chest radiograph showed marked elevation of the left hemidiaphragm and left basal volume loss (Figure 1).

Figure 1.

Preoperative portable chest radiograph showing marked elevation of the left hemidiaphragm with left basal volume loss.

Work-up, optimization, and surgical selection

CT pulmonary angiography on February 10 excluded pulmonary embolism. Bronchoscopy and bronchoalveolar lavage were performed, and tracheostomy was placed on February 11 because early extubation was unlikely. Pulmonary and bloodstream infections were treated according to serial microbiological results. Positive autoimmune serology raised concern for an autoimmune process or antiphospholipid syndrome, and glucocorticoid plus intravenous immunoglobulin treatment was given by the intensive care unit (ICU) team. Stool occult blood was initially strongly positive; parenteral nutrition was used before enteral feeding was restarted after the bleeding settled.

Thoracic surgery was requested on hospital day 15. The first assessment was deliberately conservative because infection and overall reserve remained poor. A senior review on February 28 noted that the hemidiaphragm had been elevated on prior imaging, that the patient had previously tolerated daily activity, and that the diaphragm was unlikely to be the only or principal explanation for the acute deterioration. Plication was considered technically feasible but with uncertain respiratory benefit and a real risk of worsening pulmonary infection. Surgery was reconsidered only after relative clinical stabilization and recurrent hypercapnia during ventilator reduction. Key events and arterial blood gases are summarized in Table 1.

Table 1. Clinical and respiratory timeline.

Date	Clinical point	pH	PaCO2 (mmHg)	PaO2 (mmHg)	Respiratory status/event
Jan 21, 2026	Before first intubation	Not recorded	164.9	71.6	Encephalopathy; emergency intubation
Feb 6, 2026	Arrival at our emergency department	7.27	75.4	67.7	Invasive ventilation; bilateral pneumonia and left basal volume loss
Feb 19, 2026	Preoperative weaning period	7.28	66.5	Not retrievable	Recurrent hypercapnic acidosis
Mar 2, 2026	Two days before plication	7.36	55.0	83.9	Tracheostomy; persistent hypercapnia
Mar 4, 2026	Operation	–	–	–	VATS plication, 11:30–14:30; operative time 180 min
Mar 5, 2026 (POD 1)	Early postoperative period	7.42	36.0	83.9	Ventilatory support still in use
Mar 11, 2026 (POD 7)	Sustained side-arm oxygen	7.38	49.0	208	Spontaneous breathing through tracheostomy
Mar 15, 2026 (POD 11)	Ongoing pulmonary infection	7.28	69.1	88.1	Recurrent hypercapnic acidosis
Mar 16, 2026 (POD 12)	Ongoing pulmonary infection	7.29	69.9	89.7	Bronchoscopy and airway clearance
Mar 17, 2026 (POD 13)	Side-arm oxygen	7.35	49.4	133.5	Improved PaCO2
Mar 19, 2026 (POD 15)	Transfer for rehabilitation	Not sampled	Not sampled	Not sampled	Off ventilator; side-arm oxygen; tracheostomy retained
Apr 12, 2026	Physician follow-up	Not available	Not available	Not available	Remained off ventilator; tracheostomy retained; rehabilitation ongoing

Arterial blood-gas values are shown only when retrievable. kPa values were converted to mmHg by multiplying by 7.5006. Detailed ventilator settings were unavailable. mmHg, millimeters of mercury; PaCO₂, arterial partial pressure of carbon dioxide; PaO₂, arterial partial pressure of oxygen; POD, postoperative day; VATS, video-assisted thoracoscopic surgery.

No fluoroscopic sniff test, quantitative diaphragm ultrasound, phrenic nerve conduction study, transdiaphragmatic pressure measurement, or supine pulmonary function test could be retrieved. The available evidence supported a chronically elevated, intact, and poorly functioning left hemidiaphragm, probably related to acquired phrenic dysfunction after trauma. We therefore avoid claiming definite congenital eventration or proving that unilateral dysfunction was the main cause of ventilator dependence. The operation was offered as a means of removing one potentially correctable mechanical burden within a multifactorial weaning problem.

Operative requirements

Preparation included review of recent CT imaging, availability of lung isolation or bronchial blockade, a plan for postoperative ventilation through the existing tracheostomy, and immediate EICU support. Nonabsorbable braided polyester sutures and polytetrafluoroethylene (PTFE) pledgets were prepared because the diaphragm was expected to be thin. The family was told that anatomical correction might not lead to immediate or permanent ventilator independence.

Step-by-step description

Position and access

Under general anesthesia, the patient was placed in the right lateral decubitus position with the left hemithorax elevated. A three-port left video-assisted thoracoscopic surgery (VATS) approach was used: a 10-mm camera port in the seventh intercostal space at the midaxillary line, a 10-mm anterior working port in the fifth intercostal space, and a 5-mm posterior working port in the eighth intercostal space. This geometry provided a tangential view of the diaphragm and separated the two needle-working angles (Figure 2).

Figure 2.

Schematic port placement for left three-port VATS diaphragmatic plication: 10-mm camera port in the seventh intercostal space at the midaxillary line, 10-mm anterior working port in the fifth intercostal space, and 5-mm posterior working port in the eighth intercostal space. AAL, anterior axillary line; ICS, intercostal space; MAL, midaxillary line; PAL, posterior axillary line; VATS, video-assisted thoracoscopic surgery.

Exposure and low-pressure capnothorax

CO₂ insufflation was established at 8 mmHg. The anesthesiology team monitored gas exchange and end-tidal CO₂ continuously; insufflation could be reduced or interrupted if hypercapnia worsened. Complete intraoperative capnography and arterial blood-gas traces were not retained in the retrospective record. Pleural adhesions between the lung and diaphragm were divided, and the inferior pulmonary ligament was released until the redundant dome could be seen from the posterolateral to the cardiophrenic region.

Planning the plication

The plication axis was planned to distribute the redundant surface over broad folds rather than one tight ridge. On the left, the medial bites were kept away from the pericardium. When the diaphragm was thin, the assistant lifted the intended bite gently and maintained traction until the needle tip reappeared. This kept the needle shallow and visible and reduced the risk of entering the abdomen.

Continuous pledgeted plication

Plication was performed with 2-0 nonabsorbable braided polyester suture (Ti-Cron, Covidien) and PTFE pledgets. Six continuous imbricating rows were placed from the posterolateral diaphragm toward the anteromedial portion. Within each running row, repeated broad mattress-type bites incorporated the redundant diaphragm. The assistant maintained gentle counter-traction while each pass was completed under direct vision. Pledgets distributed tension across attenuated tissue. The rows were tightened sequentially until the dome was flattened without creating a narrow high-tension ridge. Figure 3 shows the repair, and Video 1 demonstrates the operative sequence.

Figure 3.

Thoracoscopic view during plication. Pledget-reinforced nonabsorbable sutures create broad imbricating folds in the redundant left hemidiaphragm. This image is published with the patient’s consent.

Video 1.

Download video file ^{(23.7MB, mp4)}

Left video-assisted thoracoscopic diaphragmatic plication. After exposure of the elevated left hemidiaphragm, six continuous imbricating rows are fashioned with repeated mattress-type bites using 2-0 nonabsorbable braided polyester suture and polytetrafluoroethylene pledgets. The video shows needle passage under traction, pledget reinforcement, sequential tensioning, flattening of the dome, and final thoracoscopic inspection. The operative sequence is displayed at 5.5× speed. Patient-identifying information has been removed. The opening card identifies the operator and operation date; the closing card confirms publication consent.

Completion

Capnothorax was released and the lung was reinflated under thoracoscopic vision. The repair was inspected for tension, bleeding, and pull-through; the adhesiolysis field was checked for air leak. The operation lasted 180 minutes (11:30–14:30). The patient returned to the EICU through the existing tracheostomy with ventilatory support.

Postoperative considerations and tasks

Postoperative radiography showed a lower left hemidiaphragm and increased left basal lung volume (Figure 4). PaCO₂ was 36.0 mmHg on postoperative day (POD) 1 while ventilatory support was still being used. Intermittent weaning trials began on POD 2, and the chart documents sustained side-arm oxygen through the tracheostomy from POD 7. The respiratory course remained unstable: pulmonary infection persisted, and hypercapnic acidosis recurred on POD 11 (pH 7.28; PaCO₂ 69.1 mmHg) and POD 12 (pH 7.29; PaCO₂ 69.9 mmHg). Hour-by-hour ventilator modes, pressure support, positive end-expiratory pressure, tidal volume, and minute ventilation could not be reconstructed; ventilatory support was resumed or made available as clinically required.

Figure 4.

Postoperative portable chest radiograph showing a lower left hemidiaphragm and increased left basal lung volume.

Bronchoscopy on POD 12 cleared secretions and confirmed patent left lower-lobe bronchi. PaCO₂ improved to 49.4 mmHg on POD 13. The patient was transferred to a rehabilitation facility on March 19, POD 15, breathing through the tracheostomy with side-arm oxygen; decannulation was considered unsafe. At physician follow-up on April 12, she was in a local hospital ICU, remained off the ventilator, was alert and participating in rehabilitation, and still had the tracheostomy. The precise date of final ventilator liberation after transfer could not be recovered, so no earlier or more specific date is claimed.

Tips and pearls

Practical lessons from this case are summarized in Table 2.

Table 2. Practical lessons from this ventilator-dependent case.

Step	Pearl	Pitfall to avoid
Diagnosis	Call the finding an elevated dysfunctional hemidiaphragm when dynamic testing is unavailable	Do not equate radiographic elevation with hernia, congenital eventration, or proven paralysis
Selection	Treat infection, bleeding, nutrition, airway access, and other reversible causes before attributing weaning failure to the diaphragm	Do not operate on the radiograph alone
Counseling	Explain that plication corrects mechanics but may not produce immediate ventilator liberation	Do not present an anatomic repair as a cure for multifactorial critical illness
Access	Use port geometry that provides separate needle angles toward the posterolateral and cardiophrenic diaphragm	Avoid an anterior port that forces every bite toward the pericardium
Capnothorax	Use the lowest pressure that provides exposure and monitor CO2 continuously	Do not allow exposure needs to override worsening hypercapnia
Needle passage	Lift the intended bite gently and keep the needle tip visible; use broad pledgeted bites in thin tissue	Avoid deep blind bites toward abdominal viscera
Tension	Flatten the dome progressively over several rows	Avoid one narrow high-tension ridge that can tear through
Postoperative care	Continue culture-directed treatment, airway clearance, nutrition, and rehabilitation while weaning	Do not judge success solely by the first spontaneous-breathing trial

CO₂, carbon dioxide.

Discussion

Diagnosis and causal restraint

Diagnostic terminology warrants particular restraint. The referring label of ‘diaphragmatic hernia’ was not supported by subsequent imaging or the operation: the diaphragm was intact, and there was no herniated viscus or strangulation. The distinction between eventration and paralysis was harder. Remote trauma, prior elevation, and the intraoperative appearance made acquired paralysis plausible, but formal dynamic or electrophysiological testing was unavailable. ‘Elevated and dysfunctional hemidiaphragm’ is therefore more accurate than a definitive etiologic label.

The respiratory failure was also not attributable to one structure. Severe pneumonia, airway disease, prolonged ventilation, nutritional depletion, possible autoimmune disease, and critical-illness respiratory-muscle weakness all reduced compensatory reserve (7,8). The February 28 surgical assessment explicitly judged the elevated hemidiaphragm unlikely to be the principal acute problem. The later decision did not reverse that conclusion; it reflected a narrower question: after treating several reversible factors, was it reasonable to remove a persistent mechanical disadvantage?

What the case adds

Plication in ventilated adults is not new. Simansky et al. reported successful weaning in only one of four ventilated adults, whereas Uchida et al. later reported withdrawal of mechanical ventilation in eight patients after cardiothoracic surgery (9,10). These contrasting results reinforce the importance of case selection and underlying lung disease. Recent studies describe elective three-port VATS with CO₂ insufflation and pledgets, and a two-port technique using porous nitinol pledgets, with favorable functional outcomes in stable symptomatic cohorts (11,12). This recent two-port report was published after the present operation but is relevant as contemporary technical context; we cite it without implying that its elective cohort or reinforcement material is directly comparable to this ICU case.

We retained the three-port approach because pleural adhesiolysis, needle angles near the left cardiophrenic region, and team familiarity favored controlled triangulation. Low-pressure capnothorax improved exposure, but CO₂ absorption was a legitimate concern in a patient with prior hypercapnia. A two-port or no-insufflation approach would also have been reasonable in experienced hands. In this case, pressure was limited to 8 mmHg, end-tidal CO₂ and gas exchange were monitored, and the option to reduce or stop insufflation was maintained. Because exact intraoperative traces were unavailable, no target value or unrecorded physiologic result is claimed.

Interpreting the outcome

The anatomical result was immediate; the clinical result was not. Early PaCO₂ normalized on support, but hypercapnia recurred during a period of persistent infection, and the patient still required prolonged airway care and rehabilitation. The operation may have increased ventilatory reserve by lowering the diaphragm and expanding the left base, but this single course cannot separate that effect from antimicrobial treatment, airway clearance, nutrition, and rehabilitation. Studies in less complex patients show that symptoms and pulmonary function can improve after plication, particularly when paradoxical motion is documented (5,13), but those observations should not be transferred uncritically to a ventilated ICU patient.

The report is limited by its single-patient design, retrospective records, absence of formal diaphragm ultrasound or sniff testing, and lack of complete pre- and postoperative ventilator settings, respiratory mechanics, pulmonary function tests, standardized quality-of-life measures, and cost or resource-use analysis. Follow-up was short, and the tracheostomy remained in place. We can conclude that VATS plication was technically feasible, produced anatomical correction, and was followed by transfer off the ventilator. We cannot conclude that plication alone caused ventilator liberation.

Conclusions

In a ventilator-dependent patient with multifactorial respiratory failure and an elevated dysfunctional hemidiaphragm, VATS plication can remove a potentially important mechanical disadvantage. In this case, it lowered the diaphragm, expanded the left lung base, and was followed by improved gas exchange and eventual off-ventilator transfer, although recurrent hypercapnia and ongoing infection prevented a simple causal interpretation. The practical lesson is to operate neither on the radiograph alone nor on the expectation of immediate weaning, but after multidisciplinary agreement that the anatomy is correctable and the remaining physiologic reserve justifies the risk.

Supplementary

The article’s supplementary files as

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written consent for publication of the de-identified clinical details, accompanying images, and operative video was obtained from the patient.