Continuous double-layer suturing technique for uniportal thoracoscopic diaphragmatic plication after phrenic nerve resection of thymoma: a technical case report

Introduction: Sutured diaphragmatic plication by uniportal video-assisted thoracoscopic surgery (VATS) is technically demanding and involves a risk of abdominal organ injury. Here, we present a novel, safe, and simple sutured diaphragmatic plication technique, namely a double-layer sutured plication technique. Case presentation: We describe a 66-year-old woman who underwent multiportal VATS extended thymectomy for a 53 × 48 × 39-mm anterior mediastinal thymoma with left phrenic nerve sacrifice; the defect exceeded 5 cm, precluding reconstruction. Preventive diaphragmatic plication was performed via a 4-cm uniportal incision using a simple double-layer continuous suturing technique. First, continuous 2-0 braided non-absorbable sutures were used to create two ridges along the central tendon to elevate the diaphragm away from abdominal organs. Second, continuous 2-0 monofilament non-absorbable sutures were applied to reinforce the plication, with pledgets and clips securing terminal knots. The postoperative course was uneventful. Elevation of the left diaphragm was not observed on a chest roentgenogram after surgery. Discussion: The first-layer continuous sutures create ridges that elevate the diaphragm toward the thoracic cavity, thereby reducing the risk of inadvertent suturing into abdominal organs during the second layer. Second-layer suturing ensures secure reinforcement. Conclusion: The double-layer continuous suturing technique presented in this report is a simple, reproducible, and safe method for uniportal diaphragmatic plication and may be a clinically useful stapler-free option, particularly for prophylactic plication after phrenic nerve resection.