Thoracoscopic diaphragm plication.

The diaphragm is grasped, and as much of the anterior diaphragm as possible is pulled into a retaining clamp. This maneuver is easier to perform for the right diaphragm than the left diaphragm, owing to the risk of incorporating viscera on the left. Upon initial placement of the clamp, it is evident that all of the diaphragm that would optimally be resected cannot occur in one application. This is precluded by three factors: the dome of the diaphragm, the length of the staple line, and the amount of diaphragm that would optimally be resected. Rather, the clamp is progressively advanced on the redundant diaphragm after each firing of the stapler resection is progressively regrasped after each staple load. A linear endostapling device (Covidien Endo GIATM and 45-mm Purple Reload with Tri-StapleTM) is placed under the clamp, and the diaphragm resection is begun at the most anterior aspect, with the intention to resect as much of the central portion of the diaphragm as possible. The diaphragm is then resected with subsequent staple loads, serially proceeding from anterior and medial on the diaphragm, diagonally in posterior and lateral direction.