1. Anterior Diaphragmatic Plication in Mediastinal Surgery: The “Reefing the Mainsail” Technique 
Francesco Leo, MD, PhD, Paolo Girotti, MD, Luca Tavecchio, MD, Barbara Conti, MD, Vincenzo Delledonne, MD, Ugo Pastorino, MD 
The Annals of Thoracic Surgery 
Volume 90, Issue 6, Pages (December 2010)
DOI: /j.athoracsur
Copyright © 2010 The Society of Thoracic Surgeons Terms and Conditions

2. Fig 1
Redundant diaphragm is elevated by two forceps, and two Satinsky clamps are placed along the desired suture line creating the diaphragmatic fold. Two or three stitches are passed at the base of the fold and knotted on the posterior side.
The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur )
Copyright © 2010 The Society of Thoracic Surgeons Terms and Conditions

3. Fig 2
The fold is fixed, passing each stitch through the apex of the fold and then through the anterior dome of the diaphragm, maintaining a suture line parallel to the base of the fold.
The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur )
Copyright © 2010 The Society of Thoracic Surgeons Terms and Conditions

4. Fig 3
Stitches are knotted and the fold is blocked anteriorly, maintaining needles on the threads. Then each stitch is passed around the anterolateral portion of the sixth rib (arrow).
The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur )
Copyright © 2010 The Society of Thoracic Surgeons Terms and Conditions

5. Fig 4
The procedure is completed pulling the plicated diaphragm against the costal arch by knotting all stitches.
The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur )
Copyright © 2010 The Society of Thoracic Surgeons Terms and Conditions