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Surgical Management of the Subdiaphragmatic Mass: A Sequential Combined Approach With Laparoscopy Followed by Posterior Thoracotomy
  1. Jorge P. Orezzoli, MD*,
  2. John C. Wain, MD and
  3. Arlan F. Fuller, MD
  1. * Vincent Memorial Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Massachusetts General Hospital and Harvard MedicalSchool, Boston, MA;
  2. Division of General Thoracic Surgery, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA; and
  3. Winchester Hospital, Cancer Care Center, Winchester, MA.
  1. Address correspondence and reprint requests to Arlan F. Fuller Jr, MD, Winchester Hospital, Cancer Care Center, 88 Montvale Ave, #1, Stoneham, MA, 02180. E-mail: afuller{at}


Recurrent ovarian cancer in the upper abdomen involving the liver parenchyma and diaphragmatic muscle traditionally requires a major abdominal surgical procedure; this involves pubis to xyphoid incision and complete mobilization of the liver. We present a strategy for evaluating 4 cases with apparently isolated recurrence to the diaphragm and liver approached by a sequential 2-phase procedure, involving diagnostic laparoscopy and subsequent posterior lateral thoracotomy. Preliminary diagnostic laparoscopy was performed to distinguish candidates for either definitive laparoscopic treatment or posterior thoracotomy. Two patients with disease confined to the diaphragm were successfully treated by laparoscopy alone, whereas full-thickness diaphragmatic resection and liver metastasis excision with cavitational ultrasonic surgical aspirator was performed in the other 2 patients. Argon beam coagulation was used to control local hemostasis and to fulgurate any possible residual tumor at the margin of resection. This is a multidisciplinary approach that is technically feasible and safe, requiring a short hospital stay.

  • Ovarian carcinoma
  • Thoracotomy
  • Diaphragm resection
  • Liver metastasis

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