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Summary
Cardiophrenic and costophrenic lymphadenectomy is part of the maximal cytoreductive effort in advanced ovarian cancer and, in selected cases, could significantly improve Progression Free Survival (PFS) and Overall Survival (OS).1 If complete intra-abdominal cytoreduction is achievable, cardiophrenic lymph nodes with short-axis diameter over 1 cm may be considered for resection.2 Traditionally, the procedure was performed via a trans-diaphragmatic approach3 with a trans-xiphoid variation presented recently.4
The aim of this video is to present the PS technique - a simplified prediaphragmatic subxiphoid approach to cardiophrenic and costophrenic lymphadenectomy.
A fit patient in her late 60 s with no important co-morbidities was diagnosed in our cancer center with International Federation of Gynecology and Obstetrics (FIGO) stage 4B low-grade serous ovarian carcinoma. Her staging images showed bilateral ovarian cystic and solid masses, omental caking, diaphragmatic disease, and three prominent cardiophrenic and costophrenic lymphatic masses. The distribution of her disease was considered resectable and made her a good candidate for upfront surgery. Patient underwent a midline laparotomy from symphysis pubis to xiphisternum and complete intra-abdominal cytoreduction with removal of the uterus and bilateral ovarian masses, excision of the pouch of Douglas, excision of metastatic deposits from the falciform and round the ligament of the liver, from both diaphragms, and complete omentectomy. The lower anterior mediastinum was approached through the loose subxiphoid prediaphragmatic attachments situated between the two foramens of Morgagni, and thus preserving the integrity of the diaphragmatic muscle. The large cardiophrenic and costophrenic lymphatic masses were removed as described in the video. The right parietal pleura was closed en bloc with the diaphragm over the xiphoid and costal margin after suction of all the fluid and gas. Chest draining was deemed unnecessary. The patient experienced a good recovery and was discharged after 6 days.
The PS technique is avoiding the classic transection of the diaphragm for access to the lower anterior mediastinum and allows the surgeon to approach the cardiophrenic lymphatic basin and also the costophrenic nodes through a less traumatic approach. In our experience this technique has smaller complication rates and is associated with faster recovery. A prospective series to fully assess the outcomes will follow.
Cardiophrenic and costophrenic lymphadenectomy by prediaphragmatic subxiphoid approach: PS technique.
Data availability statement
All data relevant to the study are included in the article.
Ethics statements
Patient consent for publication
Ethics approval
This study involves human participants but our study would not be considered research by the NHS, which exempted it from ethics approval. Participants gave informed consent to participate in the study before taking part.
Acknowledgments
I would like to thank Dr Radhika Vikram and Dr Evangelos Tselos for video recording.
Footnotes
Contributors PS performed the surgery, edited the video article, and wrote the final draft. PS is the guarantor for the overall content.
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.