Transdiaphragmatic Approach to the Thorax Using Mini-invasive Devices

Abstract

Operative management of synchronous abdominal and thoracic pathology has traditionally used 2 separate incisions. The introduction of laparoscopic devices has allowed the development of new techniques. The feasibility of a laparotomy and transdiaphragmatic access to the pleural cavity using mini-invasive instruments is presented. Three patients underwent combined thoracic and abdominal procedure through a laparotomy and transdiaphragmatic access using mini-invasive devices. The procedure was proposed for both elective and emergency procedures: the first to achieve histologic diagnosis and to perform resection of synchronous metastases, the latter in a trauma setting for control bleeding. The access was provided by a circumferential incision of 5 cm length at the periphery of the diaphragm, starting close to the esophageal hiatus and carried from behind forward 2.5 cm away from the lateral insertions of the diaphragm to the chest wall. After deflation of the lung a 30-degree-angled telescope, stapling instruments, and other devices were introduced through the diaphragm incision. We obtained good intraoperative view of the pleural cavity, safe removal of abdominal and pulmonary pathology at the same time, and early repair of the injured pleura with control of hemostasis. We had no associated mortality or postoperative complications. In the first 2 patients, histology confirmed complete removal of the lesion. No case of insufficient tissue for primary diaphragmatic closure was documented and none prosthetic material was required. The interesting aspect of this report lies in the combined management of abdominal and thoracic lesion through a laparotomy and transdiaphragm approach of the pleura using mini-invasive devices. Our series indicate that simultaneous thoracic and abdominal surgery is feasible and safe in selected patients. We feel that there is a considerable learning curve with this technique and future studies will have to prove the feasibility of this procedure.

Transdiaphragmatic Single-Port Video-Assisted Thoracoscopic Surgery; a Novel Approach for Pulmonary Metastasectomy through Laparotomy Incision – Case Series

“…were the rst to utilize the novel technique in thoracic surgery [11]. The rst reported case series of laparotomy trans-diaphragmatic approach (LTDA) for a combined procedure was by Dionigi et al in 2006 using a 5 cm incision around the diaphragmatic hiatus, which was utilized to access the thoracic cavity for pulmonary metastasectomy in two of the three reported cases [12].…”

“…A reverse trans-thoracic approach via thoracotomy incision, with intra-abdominal liver segment resection was described by Delis et al Authors reported 5 patients with metastatic colorectal cancer, two of which developed pleural effusion [16]. Possible contraindications for this approach include but are not limited to tenacious adhesions in the pleural space; inability to obtain or to tolerate mono-pulmonary ventilation; pulmonary hilar lesions; neoplastic in ltration of the thoracic wall and contaminated or infected abdominal entity [12].…”

Traumatic avulsion of kidney and spleen into the chest through a ruptured diaphragm in a young worker: a case report

“…The general contraindications refer above all to the state of haemodynamic instability of the patient and to seriously ill patients (ASA IV) [ 18 ]. In the absence of any specific contraindications for the specific laparoscopic procedure to be carried out, many abdominal traumas requiring immediate surgery exploration can now be diagnosed with the laparoscopic approach [ 19 ]. Indeed, both thoracoscopy and laparoscopy have been demonstrated as feasible and safe methods to confirm diaphragmatic disruptions in selected patients [ 3 , 14 , 20 ].…”