Laparoscopic ligation of cisterna chyli for refractory chylothorax: A case series and review of the literature.

OBJECTIVES: We describe an alternative surgical technique for the treatment of chylothorax in patients who have had failure of or are not candidates for transthoracic ligation or embolization by interventional radiology. METHODS: We describe our experience with laparoscopic ligation of the cisterna chyli in 3 such patients and compare our results with published literature. We used a 5-port approach as for foregut surgery. We retracted the liver, transected the gastrohepatic ligament, and retracted the stomach to the left. We exposed the right lateral aspect of the aorta at the level of the celiac trunk and clipped fatty tissue between the aorta and the right crus. We skeletonized the right crus and dissected from the right crus to the inferior vena cava. We then retracted the inferior vena cava laterally, exposed all soft tissue posteriorly, and identified the cisterna chyli posteromedially to the inferior vena cava. Finally, we ligated and clipped all fatty tissue between the right crus and the inferior vena cava. RESULTS: Success rate was 67%; 1 patient with idiopathic chylothorax did not have resolution and eventually died of multisystem organ failure. There were no procedure-related complications. CONCLUSIONS: Laparoscopic ligation of cisterna chyli is an available therapeutic option for patients with chylothorax unresponsive to medical management, embolization, and transthoracic ligation of the thoracic duct. Our series is comparable with other reports of transabdominal approach to chylothorax.

Laparoscopic transdiaphragmatic chest surgery: Early experience.

OBJECTIVE: We describe laparoscopic transdiaphragmatic (LTD) chest surgery without intercostal incisions and focus on technique and safety. The goal of LTD is to minimize postoperative pain. METHODS: We reviewed all patients undergoing LTD chest surgery (September 8, 2010-April 4, 2017). We place 4 abdominal ports with the patient in semilateral decubitus, make 2 diaphragmatic openings, and advance 2 ports into the chest. The intrathoracic operation is standard video-assisted thoracoscopic surgery (VATS), and diaphragmatic openings are closed at the end. We compared narcotic use (morphine equivalents) between patients undergoing LTD lung resection with historical controls undergoing conventional VATS. RESULTS: We performed 28 LTD chest procedures (wedge, 19; lobectomy, 3; segmentectomy, 3; other, 3; right sided, 20). Indications were lung nodule (14), lung cancer (5), interstitial lung disease (6), and other (3). Median operative times were 138 minutes (96-240 minutes) for wedge resection and 296 minutes (255-356 minutes, including transcervical mediastinal lymphadenectomy) for anatomic resections. Respiratory complications occurred in 3 patients and other complications in 5 (total 8; 28.6%). Computed tomography in 22 patients (79%) at median 13 months (3-47 months) after surgery showed no diaphragmatic hernia. LTD chest surgery patients used less narcotics than conventional VATS without paravertebral block 24 to 48 hours postoperatively (P = .039). CONCLUSIONS: Early experience suggests that LTD chest surgery is feasible and safe on short- to midterm follow-up. The specific role of LTD chest surgery will require definition of patient selection criteria, further experience to reduce operative time, long-term follow-up, and prospective comparison with conventional VATS.

To Sink the Lifted: Selection, Technique, and Result of Laparoscopic Diaphragmatic Plication for Paralysis or Eventration.

Introduction Diaphragmatic eventration is a congenital defect of the muscular portion of a hemidiaphragm that eventually leads to hemidiaphragmatic elevation and dysfunction. The clinical diagnosis of diaphragmatic eventration or diaphragmatic paralysis may be indistinguishable and diaphragmatic plication is the treatment of choice for both conditions. Discussion We review the indications, patient selection, and surgical techniques for diaphragmatic plication. We explain our preferred technique and guide the reader step by step on our approach. Conclusion Minimally invasive diaphragm plication techniques are effective alternatives to open transthoracic plication and result in significant improvement in dyspnea and quality of life in adequately selected patients.