title: Total Transthoracic Approach Facilitates Laparoscopic Hepatic Resection in Patients with Significant Prior Abdominal Surgery.
abstract: BACKGROUND
  While the oncologic safety of minimally invasive hepatectomy for colorectal liver metastases (CLM) has been demonstrated, lesions in the postero-superior segments may be challenging.1-3 For these lesions, a transthoracic approach may be particularly helpful, especially in patients with a hostile/reoperative abdomen or morbid obesity.4,5 PATIENT: A 43-year-old man with a body mass index of 36.0 who had undergone rectosigmoid resection for primary cancer 5 years ago recurred with a solitary liver metastasis in SVIII. He had previously undergone the following resections for metachronous CLM: (i) partial resections of SV/VIII and SII/III; (ii) ablation for SVII; and (iii) left hepatectomy, common bile duct resection, and choledochojejunostomy. Following four cycles of FOLFIRI/panitumumab with good response, the patient was considered for his fourth abdominal cancer intervention via a thoracoscopic approach.
  
  
  METHODS
  In a modified French position with left-lung ventilation, access to the right thoracic cavity was gained. Following thoracic adhesiolysis, transdiaphragmatic intraoperative ultrasonography (IOUS) was performed. To ensure optimal margins, IOUS-guided transthoracic hepatic resection with partial resection of the diaphragm was conducted. The diaphragm was reconstructed and a chest tube placed. Operative time was 247 min, with an estimated blood loss of 100 mL. Postoperative recovery was uneventful; pathology demonstrated no viable tumor, with the closest margin 5 mm from the necrotic area.
  
  
  CONCLUSIONS
  Transthoracic hepatic resection of SVIII can optimize the port-target axis while minimizing morbidity. A systematic approach that includes precise port positioning, non-traumatic intrathoracic adhesiolysis, and meticulous transdiaphragmatic IOUS-guided parenchymal transection can optimize outcomes.
authors.affiliation: Department of Surgical Oncology, Hepato-Pancreato-Biliary Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
authors.forename: Suguru
authors.initials: S
authors.lastname: Yamashita
authors.affiliation: Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
authors.forename: Evelyne
authors.initials: E
authors.lastname: Loyer
authors.affiliation: Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
authors.forename: Hyunseon C
authors.initials: HC
authors.lastname: Kang
authors.affiliation: Department of Surgical Oncology, Hepato-Pancreato-Biliary Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
authors.forename: Thomas A
authors.initials: TA
authors.lastname: Aloia
authors.affiliation: Department of Surgical Oncology, Hepato-Pancreato-Biliary Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
authors.forename: Yun Shin
authors.initials: YS
authors.lastname: Chun
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
authors.forename: Reza J
authors.initials: RJ
authors.lastname: Mehran
authors.affiliation: Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
authors.forename: Cathy
authors.initials: C
authors.lastname: Eng
authors.affiliation: Department of Surgical Oncology, Hepato-Pancreato-Biliary Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
authors.forename: Jeffrey E
authors.initials: JE
authors.lastname: Lee
authors.affiliation: Department of Surgical Oncology, Hepato-Pancreato-Biliary Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
authors.forename: Jean-Nicolas
authors.initials: JN
authors.lastname: Vauthey
authors.affiliation: Department of Surgical Oncology, Hepato-Pancreato-Biliary Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA. cconrad1@mdanderson.org.
authors.forename: Claudius
authors.initials: C
authors.lastname: Conrad
mesh_terms: D000005:Abdomen / Q000601:surgery; D000328:Adult; D015179:Colorectal Neoplasms / Q000473:pathology* / Q000601:surgery; D006498:Hepatectomy / Q000379:methods*; D006801:Humans; D010535:Laparoscopy / Q000379:methods*; D008113:Liver Neoplasms / Q000556:secondary / Q000601:surgery*; D008297:Male; D012086:Reoperation; D013909:Thorax