Laparoscopic phrenectomy for a diaphragmatic neurilemmoma
A 46-year-old man was referred to Sir Run Run Shaw Hospital (Hangzhou, China) in April 2009 with a perihepatic mass found during a medical checkup requiring further investigation. A plain chest X-ray revealed a local right diaphragmatic eventration []; abdominal ultrasonography demonstrated a 30 mm hypoechoic mass between the liver capsule and the diaphragm; a computed tomography [CT, Figure –] scan revealed a 30-32 mm tumor under the diaphragm; and enhanced magnetic resonance imaging [MRI, Figure and ] suggested a benign tumor, which was likely a diaphragmatic neurilemmoma at the same location. Simultaneously, a secondary diagnosis of asymptomatic cholecystolithiasis was confirmed. Given his absence of any discomfort and his inability to suspend his work, patient refused surgery and agreed to attend regular follow-up appointments instead.\nUnfortunately, his gallstones became symptomatic during the 16th month of follow-up with two attacks of cholecystalgia per month, although these attacks were relieved using antibiotics and antispasmodics while under the care of community hospitals. We encountered the patient again in November 2010, and he consented to a simultaneous laparoscopic cholecystectomy and diaphragmatic tumorectomy. At the time of his admission, all of the regular laboratory tests were normal, including carcinoembryonic antigen, α-fetoprotein, and neuron-specific enolase. The imaging findings were comparable to those 19 months earlier. In addition, the patient had a 4-year history of essential hypertension, which was satisfactorily controlled. Thus, he underwent laparoscopy under general anesthesia on November 9, 2010.\nPatient was placed in the prone position and four trocars were employed in accordance with our previous report:[] An umbilical trocar of 10 mm for the camera, a sub-xiphoid trocar of 12 mm as the main port, and two 5 mm trocars at the right midclavicular line for the assistant. A thorough exploration was undertaken, and a 3 cm mass underneath the right diaphragm was identified. At that time, an anti-Trendelenburg position was introduced, and the anesthesiologists turned down the tidal volume accordingly. While, the assistant fixed the diaphragm 2 cm away from the tumor, the surgeon performed a partial phrenectomy with our Laparoscopic Peng's Multifunctional Operative Dissector.[] Afterward, the diaphragm was continuously sutured with 2-0 Vicryl sutures [Ethicon Inc.; ]. The anesthesiologists were asked to manually expand the lungs using a breathing bag before the last suture was knotted in order to extrude the carbon dioxide from the thoracic cavity. Subsequently, the right subphrenic space was infused with water to perform an air test in the Trendelenburg position to identify any remaining diaphragmatic defects []; in addition, water was used to rule out an ongoing hemorrhage. Finally, a normal tidal volume and the anti-Trendelenburg position were resumed, and laparoscopic cholecystectomy was performed. The specimens were packed in a plastic bag and extracted via the 12 mm port []. A gross section of the mass revealed a multilobulated, yellowish, solid tumor with cystic parts [], and the intraoperative frozen section pathological diagnosis was a diaphragmatic neurilemmoma.\nThe entire skin-to-skin time was 65 min, and the artificial pneumothorax lasted 21 min. The intraoperative blood loss was less than 50 ml. No intraoperative blood transfusions or thoracic/abdominal drainage was needed. The intraoperative vital signs were stable, and no tension pneumothorax occurred. Post-operatively, the patient initiated oral intake and bedside activities 6 h later. No analgesics were used, and no complications occurred. He was discharged on the 3rd post-operative day, and the final pathology results confirmed the diagnosis of a diaphragmatic neurilemmoma by immunohistochemistry []. Patient has been observed for more than 2 years with no recurrence or symptoms.