Introduction/Background As a result of peritoneal fluid flow dynamics, one of the procedures frequently employed to reach the R0 aim is right diaphragmatic stripping. Generally, diaphragmatic peritoneum stripping or full-thickness resections necessitates complete liver mobilization. However, in cases of extensive tumor implants on or in the vicinity of the coronary ligament, an extra-peritoneal approach in which no direct touch to the tumoral implants on the intersection area of the diaphragm and liver can be a reasonable alternative.

Methodology The procedure was started with subperitoneal carbon dioxide gas insufflation. Then, sharp and blunt dissections of the right upper abdominal peritoneum were initiated and extended toward Morisson pouch inferiorly and diaphragmatic peritoneum superiorly. A roll-like folded towel was used and the course was markedly accelerated. Partial diaphragmatic resection was performed for full-thickness involvement. Thereafter, dissection of the peritoneum continued to reach behind the infiltrated hepato-diaphragmatic area. Then, the lateral parietal peritoneum was incised along the hepatic flexure to the duodenum medially and from the duodenum to the right anterior coronary and triangular ligaments infero-superiorly. At this point, care should be paid not to injure the major retroperitoneal and short hepatic veins, the adrenal gland itself, and its vein. Finally, the peritoneum was resected en-bloc with the involved Glissonian capsule in a retrograde fashion.

Results This approach does not disintegrate or cut through tumoral implants, which decreases bleeding due to liver lacerations and prevents tumoral implants from tearing into pieces during manipulation. In this video article, we present a right diaphragmatic peritonectomy procedure performed with ‘No Touch’ principle.

Abstract 2022-VA-1445-ESGO Figure 1

Conclusion A retroperitoneal approach with ‘No Touch Principle’ can be an alternative practice for cases of extensive hepato-diaphragmatic implants.