Transdiaphragmatic approach to the thorax using mini-invasive devices.

Operative management of synchronous abdominal and thoracic pathology has traditionally used 2 separate incisions. The introduction of laparoscopic devices has allowed the development of new techniques. The feasibility of a laparotomy and transdiaphragmatic access to the pleural cavity using mini-invasive instruments is presented. Three patients underwent combined thoracic and abdominal procedure through a laparotomy and transdiaphragmatic access using mini-invasive devices. The procedure was proposed for both elective and emergency procedures: the first to achieve histologic diagnosis and to perform resection of synchronous metastases, the latter in a trauma setting for control bleeding. The access was provided by a circumferential incision of 5 cm length at the periphery of the diaphragm, starting close to the esophageal hiatus and carried from behind forward 2.5 cm away from the lateral insertions of the diaphragm to the chest wall. After deflation of the lung a 30-degree-angled telescope, stapling instruments, and other devices were introduced through the diaphragm incision. We obtained good intraoperative view of the pleural cavity, safe removal of abdominal and pulmonary pathology at the same time, and early repair of the injured pleura with control of hemostasis. We had no associated mortality or postoperative complications. In the first 2 patients, histology confirmed complete removal of the lesion. No case of insufficient tissue for primary diaphragmatic closure was documented and none prosthetic material was required. The interesting aspect of this report lies in the combined management of abdominal and thoracic lesion through a laparotomy and transdiaphragm approach of the pleura using mini-invasive devices. Our series indicate that simultaneous thoracic and abdominal surgery is feasible and safe in selected patients. We feel that there is a considerable learning curve with this technique and future studies will have to prove the feasibility of this procedure.