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Right diaphragmatic peritonectomy in extensive involvement of the coronary area: no touch principle
  1. Ghanim Khatib1,
  2. Mesut Misirlioglu1,
  3. Murat Varli2,
  4. Umran Kucukgoz Gulec1,
  5. Ahmet Baris Güzel1 and
  6. Mehmet Ali Vardar1
  1. 1 Department of Gynecologic Oncology, Cukurova University Faculty of Medicine, Adana, Turkey
  2. 2 Department of Obstetrics and Gynecology, Cukurova University Faculty of Medicine, Adana, Turkey
  1. Correspondence to Dr Ghanim Khatib, Gynecologic Oncology, Cukurova University Faculty of Medicine, Adana 1380, Turkey; ghanim.khatib{at}

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The right diaphragm peritoneum and its adjacent anatomical structures are commonly involved in advanced ovarian cancer. The most affected area and characteristic fluid dynamics of peritoneal fluid circulation form the substance of this presentation. In the past, right diaphragmatic involvement was one of major obstacles to achieving no macroscopic residual disease. Currently, it is well known that diaphragmatic procedures in advanced ovarian cancer are safe and feasible and do not increase long-term morbidity.1 2

On that basis surgeons performing advanced operations for ovarian cancer may contribute to better surgical and oncological outcomes if they have solid anatomic knowledge and competency in the diaphragmatic surgical procedures applied in ovarian cancer surgery.

Not every patient presents with a similiar extent of diaphragmatic involvement. In some patients tumorous implants may obliterate the hepatico-phrenic sulcus and spread extensively to adjacent structures, such as the Glissonian capsule. Typically, liver mobilization is performed through dissection of the hepatico-phrenic sulcus adjacent to the liver parenchyma. Obliteration and agglutination of the sulcus may cause more bleeding, disruption of tumor integrity, and scattering of tumor cells while the classic liver mobilization approach is tried.

By approaching retroperitoneally,3 without disturbing the hepatico-phrenic sulcus and Glissonian implants, the diaphragm can be stripped and resected with no physical contact through tumoral incision (Figure 1). In addition, bleeding and tumorous scattering can be minimized, and Glissonian implants can be eradicated retrogradely.

Figure 1

In cases of obliteration and/or agglutination of the hepatico-phrenic sulcus with tumorous implants, the right coronary ligament and Glissonian capsule can be approached retroperitoneally and retrpgradely, respectively, without disrupting tumorous integrity.

Subperitoneal carbon dioxide insufflation and towel-aided dissection may facilitate and accelerate the procedure.4

For a case of glissonectomy, we present some tips and anatomical landmarks for extraperitoneal diaphragmatic stripping and partial resection (Video 1).

Video 1 Right diaphragmatic peritonectomy in extensive involvement of the coronary involvement; no touch principle.

Data availability statement

Data are available upon request.

Ethics statements

Patient consent for publication

Ethics approval

This study involves human participants but did not require approval as cytoreductive procedures (various peritonectomies) are performed regularly in our department. As routine, written consent is obtained from every patient for using part or parts of surgical procedures for educational purposes. Participants gave informed consent to participate in the study before taking part.



  • Contributors GK, MM, MV performed the surgery and recorded the video. GK edited the video. MM narrated it. GK, MM wrote the draft. UKG, ABG, MAV reviewed the draft. MAV reviewed and supervised the final video. All authors approved the final edition. GK is the author responsible for the overall content as the guarantor.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.