Background: Thoracic surgeons should assess patients with raised hemi-diaphragms, as they might benefit from diaphragm plication (DP).
 
Objectives: We aim to review our DP practice over the years, assess causes, techniques and outcomes to decide if this is an effective treatment.
 
Methodology: This is a retrospective study. All patients who underwent DP between 2007 and 2022 were included. Pre and post-operative clinic letters, physiological studies and x-rays were reviewed.
 
Results: 42 patients had DP, 28 males and 14 females with mean age of 57 and mean BMI of 31.2. Commonest symptoms were dyspnoea (90%) and cough (19%). Patients had symptoms for 25 months, on average. 2 had bilateral diaphragmatic elevation. 55% occurred on the left. Commonest causes were idiopathic (52%) and iatrogenic (19%). 3 were on preoperative NIV. 45% never smoked. Mean ASA was 2. 78.5% of DP were done in the last 5 years, with more use of VATS and robotic surgery (61.9%). Robotic DP had hospital stay of 2.9 days, VATS 7.9 and Thoracotomy 6.5. Compared to VATS and robotic, thoracotomy had higher complications (25%), readmissions (18.7%) and return to theatre (12.5%). 2 patients (4.7%) needed redo-plication. There was no 30-day-mortality. On day one, mean radiological improvement was 5.1cm. On 1st follow-up clinic, this was 3.8cm. On longer-term follow-up, 26% had partial elevation of the diaphragm. 71.4% reported improvement in their symptoms and all 3 NIV users reduced or halted NIV use. 50% of those who felt no benefit had thoracotomy.
 
Conclusion: DP helps most patients with diaphragmatic paralysis. Minimally invasive techniques have reduced complications and robotic approaches have reduced hospital stay.