There are four operations performed on the adult diaphragm, and the diagnosis decides which one applies. A paralysed or eventrated diaphragm that is causing breathlessness is treated by plication — the slack diaphragm is drawn down and stitched flat so the lung can expand again. A hole in the diaphragm is treated by hernia repair, with a patch where the defect is large. Endometriosis on the diaphragm is excised and the diaphragm repaired. A tumour involving the diaphragm is resected and reconstructed. Most are done robotically or by keyhole surgery. Dr Lawrence Okiror, Consultant Thoracic and Robotic Surgeon (GMC 6150382), operates at London Bridge Hospital and The Lister Hospital Chelsea. Appointments within 2–3 days. Self-referrals welcome. If you are still at the diagnosis stage, start with the raised diaphragm page →
Last reviewed: October 2026 · Dr Lawrence Okiror FRCS(CTh) FRCSEd(CTh) · GMC 6150382
A weak diaphragm is tightened. A hole in the diaphragm is closed. Telling those two apart on the imaging is the step that decides everything else, and it is not always as straightforward as a report makes it sound.
Plication is done robotically or by VATS through small incisions. Published series report lung function improving by roughly a fifth to a quarter, holding at follow-up averaging 5.4 years, with no patient needing the plication redone.
The right hemidiaphragm sits higher than the left in everyone. A phrenic nerve can recover in the first year. A small hernia containing only fat is usually left alone. A consultation that ends in no operation is a legitimate outcome.
Four different problems affect the adult diaphragm, and they need four different operations. The scan report will often name one of them, but the words used are not always precise, and the distinction between a diaphragm that is thin and slack and one that has an actual hole in it is the single most important thing to get right before anyone operates.
The phrenic nerve supplying one side of the diaphragm has stopped working, so that half no longer pulls down when you breathe in. It rides up into the chest and the lung above it cannot fully expand. Common causes are injury at cardiac or chest surgery, a viral illness, a tumour involving the nerve, or no identifiable cause at all.
The operation does not repair the nerve. It fixes the mechanics, by pulling the slack diaphragm down and holding it there.
The diaphragm is intact and continuous but abnormally thin and weak in one area, so it sits permanently high. Unlike paralysis this is usually present from birth and unchanging, which is why long-standing elevation on old films that has never altered points towards eventration rather than a new nerve injury. The operation is the same — the thin area is pleated and flattened — but the expectation is different, because there is no nerve here that might have recovered.
There is a genuine defect in the diaphragm and abdominal contents have passed through it into the chest. In adults this is most often a congenital defect that has gone unnoticed for decades — a Bochdalek hernia at the back or a Morgagni hernia at the front — or an old tear from a previous injury presenting years later.
Plicating a hernia would be the wrong operation. The defect has to be closed. Hernia repair in detail →
Endometriosis deposits on the diaphragm cause chest or right shoulder tip pain that tracks the menstrual cycle, and small holes in the diaphragm can allow air to pass into the chest and collapse the lung. The deposits are excised and the diaphragm repaired at the same operation. Thoracic endometriosis → · Cyclical chest symptoms →
Where a tumour involves the diaphragm, the affected part is removed and reconstructed as part of the cancer operation. Chest wall and diaphragm invasion → · Pulmonary metastasectomy →
Eventration and a true diaphragmatic hernia can look similar on a chest X-ray, and they can be reported differently by different readers looking at the same patient. A thin, intact but elevated diaphragm and a diaphragm with a defect in it produce a comparable shadow, and the report may describe an elevated hemidiaphragm with no visible defect when a defect is in fact present, or the reverse.
This is why Dr Okiror reviews the actual images rather than working from the report, and why older imaging is worth bringing — a diaphragm that has looked the same for ten years is telling you something that a single recent scan cannot.
Three things decide whether an operation is the right answer: what the diaphragm is actually doing, how much it is costing you functionally, and whether the symptoms you have fit the abnormality on the scan. An elevated diaphragm with no symptoms and normal numbers is not an operation, however striking the film looks.
Chest X-ray and CT, read alongside any previous films. The CT shows whether the diaphragm is continuous or has a defect, and what is sitting above it. What each scan shows →
A fluoroscopic screening test that watches both sides of the diaphragm move as you sniff. A paralysed side moves upwards instead of down — the paradoxical, see-saw movement that confirms the diagnosis. Reduced movement without paradox is a different and more equivocal result.
Measured sitting up and then lying flat. A substantial fall in vital capacity on lying down is the functional signature of a weak diaphragm, and it is the measurement most often left out when these tests are requested. Lung function explained →
A sleep study and a blood gas where breathlessness is severe, where sleep is disturbed, or where both sides may be affected — because a diaphragm that is weak during the day can be significantly more of a problem lying down at night.
Phrenic nerve conduction studies where the question is not whether the diaphragm is working but why, and whether the nerve might recover. These are arranged with neurophysiology colleagues and reviewed alongside everything else; they inform the timing of surgery more often than the decision itself.
A paralysed diaphragm is not tight. It is slack, and with every breath in, the negative pressure in the chest pulls it further upwards instead of allowing it to descend. Plication removes the slack. The diaphragm is drawn down, pleated in on itself and stitched flat, so that it becomes a taut sheet that cannot balloon up into the chest. The lung above it has room to expand, and the paradoxical movement stops.
It is keyhole surgery. The operation is performed through small incisions between the ribs, robotically or by video-assisted thoracoscopic surgery (VATS), under a general anaesthetic. The chest is not opened. Robotic instruments articulate, which matters for suturing at the back and the outer edges of the diaphragm where the angles are awkward.
A chest drain is placed at the end and is normally removed the following day. Most people are in hospital for around two to four days. The breathing improvement is usually noticed in the first weeks rather than immediately, because the chest wall and the new diaphragm position take a little time to settle, and the measured improvement in lung function is documented at follow-up.
Open surgery through a thoracotomy remains the right choice in a minority of cases — a very large or scarred diaphragm, or previous surgery that has left adhesions. Where that applies it is discussed in advance rather than discovered afterwards.
Risks are discussed individually and in full before any operation: injury to structures beneath the diaphragm, bleeding, infection, air leak, and chest wall numbness or discomfort along the incisions, which is common in the first weeks and settles in most people. General recovery guidance is on the recovery page, and pain control on the pain relief page.
The commonest question asked about this operation is whether the benefit wears off after a few years. The published follow-up does not support that fear.
5.4
Years mean follow-up, range 4 to 7, with the improvement maintained
Celik 2010
None
Patients in that series required the plication to be redone
Celik 2010
4.5
Days in hospital after keyhole plication, against 7 after open surgery
Beshay 2023, 134 patients
2%
Long-term chest wall pain after keyhole plication, against 13% after open
Beshay 2023
Lung function. In a series of 134 patients undergoing plication for unilateral diaphragmatic paralysis, forced vital capacity improved by up to 25% and FEV1 by up to 20% between the pre-operative tests and those at six to twenty-four months. There were no deaths in either the keyhole or the open group (Beshay M, Abdel Bary M, Kösek V, et al. Journal of Clinical Medicine 2023;12:5301).
Durability. In a smaller series followed for a mean of 5.4 years, with a range of 4 to 7 years, forced vital capacity was improved by 43.6% and FEV1 by 27.3% from a pre-operative baseline of 56.7% and 65.3% predicted respectively. The MRC breathlessness score improved in every patient, by three grades in eleven of the twelve followed up. No patient required the plication to be redone, and eight had returned to work within six months (Celik S, Celik M, Aydemir B, et al. Journal of Cardiothoracic Surgery 2010;5:111).
How to read these numbers. These are single-centre series, not randomised trials, and the patients in them were selected for surgery in the first place. They are consistent with one another and with the wider published literature, but the honest position is that diaphragm plication rests on consistent observational evidence rather than trial evidence. That is worth knowing before you are quoted a percentage, and it is the reason the assessment before surgery matters as much as the operation itself.
A diaphragmatic hernia is a genuine defect through which abdominal contents pass into the chest. In adults there are three routes to one: a congenital defect present since birth that has simply never been found — a Bochdalek hernia at the back of the diaphragm or a Morgagni hernia at the front; an old traumatic tear from an injury years or even decades earlier, presenting late; and, less commonly, a defect acquired around previous surgery.
Many are found by chance, on a scan arranged for something else entirely — a CT coronary angiogram for chest pain is a recurring example. Others cause symptoms that took years to be connected to the diaphragm: chest or upper abdominal pain, discomfort that comes on after a large meal or after alcohol, a feeling of fullness, or breathlessness. Pain that arrives hours after eating or drinking and then settles on its own fits contents intermittently catching in the defect.
A minority present as an emergency, when what is inside the hernia becomes trapped. That is the situation everything else is designed to avoid.
Two things drive the decision: symptoms, and what is inside the hernia. A hernia that is causing symptoms is repaired. A hernia found by chance is judged on its contents and its size — because the argument for operating on a symptom-free hernia is entirely about preventing something worse later.
Small defects containing only fat are common incidental findings and are usually left alone. In the largest CT series, incidental Bochdalek hernias were identified in 0.17% of 13,138 abdominal CT scans, 73% contained only fat or omentum, and none of those patients were symptomatic (Mullins ME, Stein J, Saini SS, et al. American Journal of Roentgenology 2001;177:363–6).
Where the stomach, bowel, spleen or kidney has passed through the defect, the calculation changes. Those contents can become trapped and lose their blood supply, and an emergency operation for a trapped hernia is a larger undertaking with more risk than a planned repair of the same defect. That, rather than the symptoms, is usually the reason a symptom-free hernia of that kind is still repaired.
The evidence here is worth being straight about. Adult diaphragmatic hernia is rare enough that there are no randomised trials and no formal guidelines. The most complete review of adult right-sided Bochdalek hernia found 44 cases across 41 published studies and judged the available evidence to be of moderate to low methodological quality (Ramspott JP, Jäger T, Lechner M, et al. Hernia 2021;26:47–59). Conservative management and repair are both defensible in a symptom-free patient, and the decision belongs to the individual case rather than to a rule.
The contents are returned to the abdomen and the defect is closed. A small defect is closed with non-absorbable sutures alone. A large one is reinforced with a patch — synthetic or biological — and in the published series mesh reinforcement is generally reserved for defects beyond about 10 cm, with direct suture used below that. Which applies to you is determined by the measurements on your scan and confirmed at operation.
The approach — through the chest or the abdomen, keyhole or open — is chosen case by case, and this is where the planning matters more than the closure. Getting bulky contents safely back down into the abdomen is frequently the hardest part of the operation, and it is the step that most often converts a planned keyhole repair into an open one. A defect sitting close to the aorta and the pericardium, on the left, adds to that difficulty, particularly where a patch will be needed. Long-standing hernias develop adhesions that make the contents harder to free. None of this makes the operation unsafe; it makes honest pre-operative planning, and an honest conversation about the likelihood of converting, part of the consent.
Where a large hernia carries much of the stomach, spleen, pancreas or colon into the chest, the operation is often best done through the abdomen and jointly with an upper gastrointestinal surgeon, with a thoracotomy added if the diaphragm cannot be closed from below. A joint operation of that kind carries a longer stay — usually around a week — and it is planned as a joint operation from the outset rather than improvised.
A good number of people who arrive on this page after reading a scan report do not need an operation, and saying so plainly is part of the assessment rather than a disappointing outcome of it.
The liver sits directly under the right hemidiaphragm and pushes it up, so in almost everyone the right side sits higher than the left. A report noting a raised right hemidiaphragm may be describing nothing more than that. What matters is the degree, whether it has changed from earlier films, and whether the symptoms fit.
A phrenic nerve injured rather than divided — after cardiac surgery, or following a viral illness — can regain function, and recovery may continue over the first year. Plicating a diaphragm that was going to recover is an avoidable operation. Where recovery is plausible, the sensible course is to confirm the diagnosis, wait with a plan, and repeat the measurements.
Plication is an operation for symptoms, not for an appearance on a film. Where the diaphragm is elevated but you are not limited, and the lung function upright and supine does not show a meaningful fall, the appropriate answer is to explain the finding and leave it alone. Equally, where the breathlessness is real but the diaphragm measurements are normal, the cause lies elsewhere and operating on the diaphragm would not help. The other causes of breathlessness →
Bilateral diaphragm weakness is assessed differently from one-sided paralysis. It is more likely to reflect an underlying neuromuscular condition, it causes breathlessness lying flat and disrupted sleep out of proportion to the daytime picture, and the mainstay of treatment is often ventilatory support rather than surgery. Where surgery has a role it is considered only after that assessment, not before it.
Bring the imaging itself rather than only the reports, and bring any older chest X-rays or scans you can get hold of, including ones done years ago for unrelated reasons. With the diaphragm, what has changed over time is frequently more informative than any single film. Bring any lung function results, sniff test report, or letters from cardiology, respiratory medicine or a previous surgeon.
Dr Okiror reviews the images personally before the consultation, goes through them with you, and sets out what the diaphragm is doing, whether an operation would help, which operation it would be, and what it would involve for you specifically. Where the answer is that surgery is not indicated, that is said plainly and the reasoning explained.
If you have been told nothing can be done, a second opinion is reasonable. Diaphragm conditions are uncommon enough that many clinicians will not have seen one operated on, and breathlessness from a paralysed diaphragm is regularly attributed to the heart, the lungs, anxiety or deconditioning for years before anyone tests the diaphragm itself. A second opinion gives you a straight answer either way, including if that answer is that surgery would not help you.
A guide price for a robotic diaphragm plication at London Bridge Hospital is £18,000–£22,000, covering hospital, surgeon and anaesthetist fees for an uncomplicated stay. Hospital charges are the largest part of the total. Diaphragmatic hernia repair is quoted individually after consultation. The hospital issues a written fixed quote after consultation and before treatment, and that quote is the figure that applies. All guide prices and how fees work →
Dr Okiror is recognised by AXA Health, Bupa, Aviva, Vitality, WPA and Cigna, and by most other UK and international insurers. If you have private medical insurance, Dr Okiror and the hospital bill your insurer directly, and insurers usually settle the hospital, surgeon and anaesthetist fees in full, less any excess written into your policy. Please confirm with your insurer that your policy covers treatment at London Bridge Hospital or The Lister before your first appointment. Self-paying patients are equally welcome.
How quickly treatment happens. Surgery is usually within a week of completing investigations. Patients who already have their tests can be booked for surgery within days of their consultation. Transfers from NHS hospitals are arranged by the HCA Medical Concierge team.
The questions patients ask most often about the diaphragm operations — what they involve, whether they last, and whether they are needed at all. See also the raised diaphragm page → and the breathlessness page →
Book a Consultation →Or call Jo Mitchelson:
020 7952 2882
Self-referrals welcome. Private appointments at London Bridge Hospital and The Lister Hospital Chelsea within 2–3 days, with outpatient clinics at Canary Wharf and the City of London. Bring your imaging, including anything old. Dr Okiror reviews the scans himself and tells you plainly whether an operation would help.
Jo Mitchelson, PA · 020 7952 2882 · pa@lungsurgeon.co.uk
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