title: Intentional resection of the diaphragm during cytoreductive laparoscopic radical nephrectomy.
abstract: OBJECTIVE
  Laparoscopic radical nephrectomy is being performed more commonly. To our knowledge intentional resection of the diaphragm during laparoscopic radical nephrectomy for large renal tumors has not yet been described. We detail the laparoscopic management of diaphragmatic resection.
  
  
  METHODS
  From March 1996 to February 2001, 36 patients underwent cytoreductive laparoscopic radical nephrectomy at our institution in preparation for systemic immunotherapy. Charts and operative tapes were reviewed and cases were identified in which diaphragmatic resection was performed for locally invasive tumors.
  
  
  RESULTS
  In 3 patients a portion of the diaphragm was dissected via laparoscopy during debulking nephrectomy. All patients had renal cell carcinoma with documented metastatic disease. The diaphragm was repaired laparoscopically using intracorporeal suturing techniques in 2 of the 3 patients and a chest tube was placed in all 3. Transient systolic hypotension and hypercarbia in 1 case resolved with manual ventilation. The chest tube was removed on postoperative days 2 to 4. There were no complications and no ipsilateral pleural metastasis was identified at an average of 6 weeks (range 2 to 23) of followup.
  
  
  CONCLUSIONS
  A portion of the diaphragm may be intentionally resected during laparoscopic radical nephrectomy. This maneuver may be successfully managed without conversion to an open procedure. In cases of a large diaphragmatic defect or the potential for coagulopathy postoperatively a chest tube should be inserted. Potential invasion of the diaphragm by large tumors should not be considered a contraindication to cytoreductive laparoscopic radical nephrectomy.
authors.affiliation: Urologic Oncology and Surgery Branches, National Cancer Institute and Department of Anesthesiology, Warren G. Magnuson Clinical Center, National Institutes of Health, Bethesda, MD, USA.
authors.forename: Stephen E
authors.initials: SE
authors.lastname: Pautler
authors.forename: Colletta
authors.initials: C
authors.lastname: Richards
authors.forename: Steven K
authors.initials: SK
authors.lastname: Libutti
authors.forename: W Marston
authors.initials: WM
authors.lastname: Linehan
authors.forename: McClellan M
authors.initials: MM
authors.lastname: Walther
mesh_terms: D000328:Adult; D002292:Carcinoma, Renal Cell / Q000601:surgery*; D003964:Diaphragm / Q000601:surgery*; D005260:Female; D006801:Humans; D007440:Intubation; D007680:Kidney Neoplasms / Q000601:surgery*; D010535:Laparoscopy / Q000379:methods*; D008297:Male; D009392:Nephrectomy / Q000379:methods*