Thoracoscopic transdiaphragmatic approach for tumors located in postero-superior segments.

Tomojiro Ono, Dr, Shinichi Ikuta, MD, PhD, Takayoshi Nakajima, MD, Tukasa Aihara, MD, PhD, Naoki Yamanaka, MD, PhD. Meiwa Hospital

Background: Laparoscopic liver resections for tumors located in postero-superior segments are more difficult than those for antero-lateral segments. Some tumors located on the dome of the liver immediately beneath the diaphragm can be accessed easily from thoracic cavity than from abdominal cavity because the distance from skin incision to the tumor is much nearer thoracoscopically than laparoscopically. Here, we report our 4 cases of thoracoscopic transdiaphragmatic approach for postero-superior segments.

Methods: 4 patient underwent thoracoscopic transdiaphragmatic partial liver resection in our hospital. All patients had hepatocellular carcinoma, 2 with chronic hepatitis C and 2 with Non Alcoholic Steato-Hepatitis (NASH). 2 patients had previous hepatectomy with laparotomy. In all cases, tumors were located just beneath diaphragm in segment 8. Mean tumor diameter was 3.0 cm (SD 0.2 cm) and mean resected liver volume was 16.3 g (SD 12.4 g).

Results: In all cases, patients were placed in the left lateral decubitus position with the right arm suspended. Single-lung ventilation was initiated before trocar placement or first thoracotomy. Resection through mini-thracotomy with 3 thoracic port were done in all cases, in one of which we needed to extend the thoracotomy scar because of severe intrathoracic adhesion. Tumor location was confirmed via trans-diaphragmatic ultrasonography and diaphragm was cut open directly above the tumor. Parenchymal transection was done using Harmonic scarpel or clamp crushing method. Glissonean pedicules or venous branches were secured and cut between clips and small bleedings were arrested with irrigation monopolar cautery. Mean operative time was 280 min (SD 144 min) and mean blood loss was 343 g (SD 233). In 3 cases, post-operative pleural effusion was complicated and 1 patients needed extra drainage, while the other 2 treated with medication only. 1 patient had minor superficial SSI. There was no mortality.

Conclusion: Thoracoscopic transdiaphragm approach seems to be safe and feasible for tumors located in postero-superior segment immediately beneath the diaphragm. Post-operative pleural effusion seems the complication to watch for.

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