YGYNO-976185; No. of pages: 3; 4C: Gynecologic Oncology xxx (2016) xxx–xxx
Contents lists available at ScienceDirect
Gynecologic Oncology journal homepage: www.elsevier.com/locate/ygyno
Surgical Film
Cytoreduction of diaphragmatic metastasis from ovarian cancer with involvement of the liver using a ventral liver mobilization technique Kazuyoshi Kato ⁎, Takahiro Katsuda, Nobuhiro Takeshima Department of Gynecology, Cancer Institute Hospital, 3-8-31 Ariake, Koutou-ku, Tokyo 135-8550, Japan
H I G H L I G H T S • We present a ventral liver mobilization technique for the resection of diaphragmatic metastatic tumors from ovarian cancer. • Diaphragmatic tumors with involvement of the liver were safely removed using a ventral liver mobilization technique. • This surgical technique can be adopted for the management of bulky diaphragmatic tumors in select patients.
a r t i c l e
i n f o
Article history: Received 29 October 2015 Received in revised form 14 January 2016 Accepted 18 January 2016 Available online xxxx Keywords: Ovarian cancer Cytoreduction Diaphragm resection Liver mobilization
a b s t r a c t Objective. Upper abdominal spreading of advanced-stage ovarian cancer often involves the diaphragm. In addition, bulky diaphragmatic tumors occasionally infiltrate the liver. Here, we describe our early experiences with a ventral liver mobilization technique to remove diaphragmatic tumors with liver involvement. Methods. Two patients with primary ovarian cancer and 1 patient with recurrent ovarian cancer underwent en bloc resections of a diaphragmatic tumor together with the full-thickness diaphragm and the liver tissue using a ventral liver mobilization technique. The surgical technique involved a full-thickness division of the diaphragm at the central tendon and a ventral mobilization of the right lobe of the liver, with entry into the pleural cavity. During the parenchymal transection of the liver, the posterior area of the right lobe of the liver was pressed using the surgeon's hand to reduce bleeding from the resection surface. After the completion of the en bloc resection, the diaphragmatic opening was closed using running sutures. Results. All the diaphragmatic tumors were completely removed without severe bleeding in the current series. No intraoperative or postoperative complications occurred. Conclusion. Diaphragmatic tumors with involvement of the liver can be safely and effectively removed using a ventral liver mobilization technique. This surgical procedure may be suitable for the management of bulky diaphragmatic tumors in select patients. © 2016 Elsevier Inc. All rights reserved.
1. Introduction
2. Methods
Patients with advanced-stage ovarian cancer often have diseases that have invaded the upper abdomen, most commonly, the diaphragm [1]. Reportedly, as many as 40% of patients with advanced-stage ovarian cancer have a bulky tumor on the diaphragm [2]. The right side of the diaphragm is more likely to be involved than the left side. In particular, bulky diaphragmatic tumors are frequently identified in the area where the diaphragmatic peritoneum is reflected onto the capsule of the posterior aspect of the right lobe of the liver. These tumors occasionally involve both the diaphragm and the liver. In the present report, we present a ventral liver mobilization technique for removing such bulky diaphragmatic metastases from ovarian cancer.
Recently at our institution, 2 patients with primary ovarian cancer and 1 patient with recurrent ovarian cancer underwent en bloc resections of diaphragmatic tumors together with the full-thickness diaphragm and liver tissue using a ventral liver mobilization technique. The surgical procedures for the cytoreduction of diaphragmatic tumors with involvement of the liver using a ventral liver mobilization technique were performed as follows. The falciform ligament was divided to visualize the dome and the posterior aspect of the right lobe of the liver. The coronary ligament was not divided at this time because the bulky tumor was located on the line of division. In a similar, previously reported method, a diaphragm peritonectomy was initiated at the anterior edge of the tumor spreading [1,2]. Approaching the central tendon of the diaphragm, a full-thickness division of the diaphragm surrounding the lateral edge of the bulky tumor was performed. After entry into the pleural cavity, the right lobe of the liver was mobilized
⁎ Corresponding author. E-mail address: [email protected] (K. Kato).
http://dx.doi.org/10.1016/j.ygyno.2016.01.017 0090-8258/© 2016 Elsevier Inc. All rights reserved.
Please cite this article as: K. Kato, et al., Cytoreduction of diaphragmatic metastasis from ovarian cancer with involvement of the liver using a ventral liver mobilization tec..., Gynecol Oncol (2016), http://dx.doi.org/10.1016/j.ygyno.2016.01.017
2
K. Kato et al. / Gynecologic Oncology xxx (2016) xxx–xxx
Table 1 Patient characteristics including operative data and complications. Patient
Age (years)
BMI (%)
Operative time (min)
Hemorrhage (mL)
Postoperative stay (days)
Tube thoracostomy
1 2 3
62 56 25
20.5 19.2 19.6
390 301 193
1091 780 40
16 17 7
Yes No No
BMI, body mass index.
ventrally. During stripping or resection of the medial side of the diaphragm, the right inferior phrenic vein was identified in view of the pleura. This vein was divided and ligated at a site before its conjugation with the inferior vena cava (IVC). As the position of the IVC was identified in the pleural cavity, injury to the IVC and the right hepatic vein was prevented during the resection of disease extending to the medial site of the diaphragm. Tumor involvement in the liver was verified by inspection and bimanual palpation. During the division of the hepatic parenchyma, the posterior area of the right lobe of the liver was pressed using the surgeon's hand to reduce bleeding from the resection surface. We used an electrocautery and a vessel-sealing system for the parenchymal division. The energy of the electrocautery device was increased to 80 W and saline drops applied with a syringe were used to avoid eschar buildup on the electrode. Small vessels and bile ducts visible on the hepatic surface of the resection were sealed or ligated. After the completion of the en bloc resection, the diaphragmatic opening was closed using a 2-0 non-absorbable continuous suture (Prolene®; Ethicon, USA). As we previously described, a prophylactic tube thoracostomy was thought to be unnecessary if the volume of the estimated blood loss was as usual or smaller [3]. Similar to a previously reported method, the suction catheter that was inserted into the pleural cavity was withdrawn as the final diaphragmatic suture was tied to evacuate the pneumothorax with the re-expansion of the lung [1,2]. 3. Results Data from all the cases utilizing this surgical technique are summarized in Table 1. No intraoperative or postoperative complications occurred in the current series. 4. Discussion In this preliminary report, we describe a surgical procedure for the cytoreduction of diaphragmatic tumors with involvement of the liver using a ventral liver mobilization technique. The characteristics of this surgical technique are the procedure to perform a full-thickness division
of the diaphragm surrounding the edge of the bulky tumor at the central tendon and the ability to mobilize the right lobe of the liver with entry into the pleural cavity. The site of the full-thickness division of the diaphragm depends on the site of tumor involvement in the liver. If the tumor has infiltrated the lateral edge of the liver, the site of the diaphragmatic division is made more laterally than in the case that is shown in the film. To evaluate the extent of tumor involvement in the liver, inspection and bimanual palpation using the surgeon's fingers is useful. Then, an en bloc resection of the diaphragmatic tumor together with the full-thickness diaphragm and the liver tissue can be performed with a safe margin from the tumor. During the hepatic parenchymal division, the resected surface of the liver was held in hand and pressed with the thumb on the hepatic dome and the other fingers on the pleura. Then, the hemorrhage from the liver was managed by the gynecologic oncologist's own hand to prevent increased blood loss. There is another merit in the ventral liver mobilization technique. If the diaphragmatic disease extends to the medial site of the diaphragm, diaphragm stripping or resection can be associated with injury to the right inferior phrenic vein. This vein drains into the inferior vena cava, and its injury often causes severe bleeding. The ventral mobilization of the right lobe of the liver with entry into the pleural cavity facilitates the identification of the right inferior phrenic vein in view of the pleura. To remove disease infiltrating the right side of the diaphragm radically and safely, the right-sided liver mobilization technique has been widely used [1,2]. This method is initiated by dividing the falciform ligament and the anterior and posterior layers of the right coronary ligament. The bare area of the liver is exposed, and the right hepatic vein and the IVC are visualized. Consequently, the right lobe of the liver is freed from the diaphragm and retracted medially away from the diaphragm. The diaphragm peritonectomy or resection can then be performed. During the mobilization of the right lobe of the liver from the diaphragm, care should be taken not to injure the distal right hepatic vein and the IVC lying just beneath the plane of dissection [2]. As the ventral liver mobilization technique does not require this procedure, it is associated with a lower risk of injury to these vessels. If the diaphragmatic disease extends to the medial site of the diaphragm, the position
Fig. 1. Appearance of the right diaphragmatic region during a cytoreduction using the ventral liver mobilization technique for a diaphragmatic tumor with involvement of the liver in an ovarian cancer patient.
Please cite this article as: K. Kato, et al., Cytoreduction of diaphragmatic metastasis from ovarian cancer with involvement of the liver using a ventral liver mobilization tec..., Gynecol Oncol (2016), http://dx.doi.org/10.1016/j.ygyno.2016.01.017
K. Kato et al. / Gynecologic Oncology xxx (2016) xxx–xxx
of the IVC in the pleural cavity should be identified but the IVC should not be exposed. Such identification can prevent injury to the IVC and the right hepatic vein during the resection of disease extending to a medial site of the diaphragm. In cases with diaphragmatic disease but without involvement of the liver, right-sided liver mobilization followed by a diaphragm peritonectomy or resection seems to be a preferable procedure. Gynecologic oncologists may select this procedure for the resection of diaphragmatic disease depending on the situation. This preliminary report shows that a ventral liver mobilization technique for the cytoreduction of diaphragmatic tumors with involvement of the liver is feasible and safe. This surgical procedure can be adopted for the management of bulky diaphragmatic tumors in select patients (Fig. 1). Conflict of interest statement
3
Appendix A. Supplementary data Supplementary data to this article can be found online at http://dx. doi.org/10.1016/j.ygyno.2016.01.017.
References [1] S. Bashir, M.A. Gerardi, R.L.2nd. Giuntoli, T.P. Montes, R.E. Bristow, Surgical technique of diaphragm full-thickness resection and trans-diaphragmatic decompression of pneumothorax during cytoreductive surgery for ovarian cancer, Gynecol. Oncol. 119 (2010) 255–258. [2] E.L. Eisenhauer, D.S. Chi, Liver mobilization and diaphragm peritonectomy/resection, Gynecol. Oncol. 104 (2 Suppl 1) (2007) 25–28. [3] K. Kato, S. Tate, K. Nishikimi, M. Shozu, Assessment of intraoperative tube thoracostomy after diaphragmatic resection as part of debulking surgery for primary advanced-stage Müllerian cancer, Gynecol. Oncol. 131 (2013) 32–35.
The authors declare that there are no conflicts of interest.
Please cite this article as: K. Kato, et al., Cytoreduction of diaphragmatic metastasis from ovarian cancer with involvement of the liver using a ventral liver mobilization tec..., Gynecol Oncol (2016), http://dx.doi.org/10.1016/j.ygyno.2016.01.017
Contents lists available at ScienceDirect
Gynecologic Oncology journal homepage: www.elsevier.com/locate/ygyno
Surgical Film
Cytoreduction of diaphragmatic metastasis from ovarian cancer with involvement of the liver using a ventral liver mobilization technique Kazuyoshi Kato ⁎, Takahiro Katsuda, Nobuhiro Takeshima Department of Gynecology, Cancer Institute Hospital, 3-8-31 Ariake, Koutou-ku, Tokyo 135-8550, Japan
H I G H L I G H T S • We present a ventral liver mobilization technique for the resection of diaphragmatic metastatic tumors from ovarian cancer. • Diaphragmatic tumors with involvement of the liver were safely removed using a ventral liver mobilization technique. • This surgical technique can be adopted for the management of bulky diaphragmatic tumors in select patients.
a r t i c l e
i n f o
Article history: Received 29 October 2015 Received in revised form 14 January 2016 Accepted 18 January 2016 Available online xxxx Keywords: Ovarian cancer Cytoreduction Diaphragm resection Liver mobilization
a b s t r a c t Objective. Upper abdominal spreading of advanced-stage ovarian cancer often involves the diaphragm. In addition, bulky diaphragmatic tumors occasionally infiltrate the liver. Here, we describe our early experiences with a ventral liver mobilization technique to remove diaphragmatic tumors with liver involvement. Methods. Two patients with primary ovarian cancer and 1 patient with recurrent ovarian cancer underwent en bloc resections of a diaphragmatic tumor together with the full-thickness diaphragm and the liver tissue using a ventral liver mobilization technique. The surgical technique involved a full-thickness division of the diaphragm at the central tendon and a ventral mobilization of the right lobe of the liver, with entry into the pleural cavity. During the parenchymal transection of the liver, the posterior area of the right lobe of the liver was pressed using the surgeon's hand to reduce bleeding from the resection surface. After the completion of the en bloc resection, the diaphragmatic opening was closed using running sutures. Results. All the diaphragmatic tumors were completely removed without severe bleeding in the current series. No intraoperative or postoperative complications occurred. Conclusion. Diaphragmatic tumors with involvement of the liver can be safely and effectively removed using a ventral liver mobilization technique. This surgical procedure may be suitable for the management of bulky diaphragmatic tumors in select patients. © 2016 Elsevier Inc. All rights reserved.
1. Introduction
2. Methods
Patients with advanced-stage ovarian cancer often have diseases that have invaded the upper abdomen, most commonly, the diaphragm [1]. Reportedly, as many as 40% of patients with advanced-stage ovarian cancer have a bulky tumor on the diaphragm [2]. The right side of the diaphragm is more likely to be involved than the left side. In particular, bulky diaphragmatic tumors are frequently identified in the area where the diaphragmatic peritoneum is reflected onto the capsule of the posterior aspect of the right lobe of the liver. These tumors occasionally involve both the diaphragm and the liver. In the present report, we present a ventral liver mobilization technique for removing such bulky diaphragmatic metastases from ovarian cancer.
Recently at our institution, 2 patients with primary ovarian cancer and 1 patient with recurrent ovarian cancer underwent en bloc resections of diaphragmatic tumors together with the full-thickness diaphragm and liver tissue using a ventral liver mobilization technique. The surgical procedures for the cytoreduction of diaphragmatic tumors with involvement of the liver using a ventral liver mobilization technique were performed as follows. The falciform ligament was divided to visualize the dome and the posterior aspect of the right lobe of the liver. The coronary ligament was not divided at this time because the bulky tumor was located on the line of division. In a similar, previously reported method, a diaphragm peritonectomy was initiated at the anterior edge of the tumor spreading [1,2]. Approaching the central tendon of the diaphragm, a full-thickness division of the diaphragm surrounding the lateral edge of the bulky tumor was performed. After entry into the pleural cavity, the right lobe of the liver was mobilized
⁎ Corresponding author. E-mail address: [email protected] (K. Kato).
http://dx.doi.org/10.1016/j.ygyno.2016.01.017 0090-8258/© 2016 Elsevier Inc. All rights reserved.
Please cite this article as: K. Kato, et al., Cytoreduction of diaphragmatic metastasis from ovarian cancer with involvement of the liver using a ventral liver mobilization tec..., Gynecol Oncol (2016), http://dx.doi.org/10.1016/j.ygyno.2016.01.017
2
K. Kato et al. / Gynecologic Oncology xxx (2016) xxx–xxx
Table 1 Patient characteristics including operative data and complications. Patient
Age (years)
BMI (%)
Operative time (min)
Hemorrhage (mL)
Postoperative stay (days)
Tube thoracostomy
1 2 3
62 56 25
20.5 19.2 19.6
390 301 193
1091 780 40
16 17 7
Yes No No
BMI, body mass index.
ventrally. During stripping or resection of the medial side of the diaphragm, the right inferior phrenic vein was identified in view of the pleura. This vein was divided and ligated at a site before its conjugation with the inferior vena cava (IVC). As the position of the IVC was identified in the pleural cavity, injury to the IVC and the right hepatic vein was prevented during the resection of disease extending to the medial site of the diaphragm. Tumor involvement in the liver was verified by inspection and bimanual palpation. During the division of the hepatic parenchyma, the posterior area of the right lobe of the liver was pressed using the surgeon's hand to reduce bleeding from the resection surface. We used an electrocautery and a vessel-sealing system for the parenchymal division. The energy of the electrocautery device was increased to 80 W and saline drops applied with a syringe were used to avoid eschar buildup on the electrode. Small vessels and bile ducts visible on the hepatic surface of the resection were sealed or ligated. After the completion of the en bloc resection, the diaphragmatic opening was closed using a 2-0 non-absorbable continuous suture (Prolene®; Ethicon, USA). As we previously described, a prophylactic tube thoracostomy was thought to be unnecessary if the volume of the estimated blood loss was as usual or smaller [3]. Similar to a previously reported method, the suction catheter that was inserted into the pleural cavity was withdrawn as the final diaphragmatic suture was tied to evacuate the pneumothorax with the re-expansion of the lung [1,2]. 3. Results Data from all the cases utilizing this surgical technique are summarized in Table 1. No intraoperative or postoperative complications occurred in the current series. 4. Discussion In this preliminary report, we describe a surgical procedure for the cytoreduction of diaphragmatic tumors with involvement of the liver using a ventral liver mobilization technique. The characteristics of this surgical technique are the procedure to perform a full-thickness division
of the diaphragm surrounding the edge of the bulky tumor at the central tendon and the ability to mobilize the right lobe of the liver with entry into the pleural cavity. The site of the full-thickness division of the diaphragm depends on the site of tumor involvement in the liver. If the tumor has infiltrated the lateral edge of the liver, the site of the diaphragmatic division is made more laterally than in the case that is shown in the film. To evaluate the extent of tumor involvement in the liver, inspection and bimanual palpation using the surgeon's fingers is useful. Then, an en bloc resection of the diaphragmatic tumor together with the full-thickness diaphragm and the liver tissue can be performed with a safe margin from the tumor. During the hepatic parenchymal division, the resected surface of the liver was held in hand and pressed with the thumb on the hepatic dome and the other fingers on the pleura. Then, the hemorrhage from the liver was managed by the gynecologic oncologist's own hand to prevent increased blood loss. There is another merit in the ventral liver mobilization technique. If the diaphragmatic disease extends to the medial site of the diaphragm, diaphragm stripping or resection can be associated with injury to the right inferior phrenic vein. This vein drains into the inferior vena cava, and its injury often causes severe bleeding. The ventral mobilization of the right lobe of the liver with entry into the pleural cavity facilitates the identification of the right inferior phrenic vein in view of the pleura. To remove disease infiltrating the right side of the diaphragm radically and safely, the right-sided liver mobilization technique has been widely used [1,2]. This method is initiated by dividing the falciform ligament and the anterior and posterior layers of the right coronary ligament. The bare area of the liver is exposed, and the right hepatic vein and the IVC are visualized. Consequently, the right lobe of the liver is freed from the diaphragm and retracted medially away from the diaphragm. The diaphragm peritonectomy or resection can then be performed. During the mobilization of the right lobe of the liver from the diaphragm, care should be taken not to injure the distal right hepatic vein and the IVC lying just beneath the plane of dissection [2]. As the ventral liver mobilization technique does not require this procedure, it is associated with a lower risk of injury to these vessels. If the diaphragmatic disease extends to the medial site of the diaphragm, the position
Fig. 1. Appearance of the right diaphragmatic region during a cytoreduction using the ventral liver mobilization technique for a diaphragmatic tumor with involvement of the liver in an ovarian cancer patient.
Please cite this article as: K. Kato, et al., Cytoreduction of diaphragmatic metastasis from ovarian cancer with involvement of the liver using a ventral liver mobilization tec..., Gynecol Oncol (2016), http://dx.doi.org/10.1016/j.ygyno.2016.01.017
K. Kato et al. / Gynecologic Oncology xxx (2016) xxx–xxx
of the IVC in the pleural cavity should be identified but the IVC should not be exposed. Such identification can prevent injury to the IVC and the right hepatic vein during the resection of disease extending to a medial site of the diaphragm. In cases with diaphragmatic disease but without involvement of the liver, right-sided liver mobilization followed by a diaphragm peritonectomy or resection seems to be a preferable procedure. Gynecologic oncologists may select this procedure for the resection of diaphragmatic disease depending on the situation. This preliminary report shows that a ventral liver mobilization technique for the cytoreduction of diaphragmatic tumors with involvement of the liver is feasible and safe. This surgical procedure can be adopted for the management of bulky diaphragmatic tumors in select patients (Fig. 1). Conflict of interest statement
3
Appendix A. Supplementary data Supplementary data to this article can be found online at http://dx. doi.org/10.1016/j.ygyno.2016.01.017.
References [1] S. Bashir, M.A. Gerardi, R.L.2nd. Giuntoli, T.P. Montes, R.E. Bristow, Surgical technique of diaphragm full-thickness resection and trans-diaphragmatic decompression of pneumothorax during cytoreductive surgery for ovarian cancer, Gynecol. Oncol. 119 (2010) 255–258. [2] E.L. Eisenhauer, D.S. Chi, Liver mobilization and diaphragm peritonectomy/resection, Gynecol. Oncol. 104 (2 Suppl 1) (2007) 25–28. [3] K. Kato, S. Tate, K. Nishikimi, M. Shozu, Assessment of intraoperative tube thoracostomy after diaphragmatic resection as part of debulking surgery for primary advanced-stage Müllerian cancer, Gynecol. Oncol. 131 (2013) 32–35.
The authors declare that there are no conflicts of interest.
Please cite this article as: K. Kato, et al., Cytoreduction of diaphragmatic metastasis from ovarian cancer with involvement of the liver using a ventral liver mobilization tec..., Gynecol Oncol (2016), http://dx.doi.org/10.1016/j.ygyno.2016.01.017
