The bulk of disease is usually distributed among the pelvis, omentum, and right diaphragm. Diaphragm resection or stripping is often necessary to achieve optimal cytoreductive surgery. In a recent review of a single institution's experience, Aletti and associates20 identified 181 patients with tumor involving the diaphragm. Patients who underwent diaphragm surgery (stripping of the diaphragmatic peritoneum, full-or partial-thickness diaphragm resection, excision of nodules or Cavitron ultrasonic surgical aspirator) had improved 5-year survival relative to those who did not (53% versus 15%). Furthermore, in multivariate analysis of patients with diaphragm disease, both residual disease and performance of diaphragm surgery were independent predictors of outcome.
In most instances, the right hemidiaphragm bears the largest volume of disease. To gain access to the entire right diaphragm, the abdominal incision is extended to the xiphoid process. A liver mobilization should then be completed by first dividing and ligating the infrahepatic portion of the falciform ligament, which is then incised superiorly to detach the liver from its anterior attachments to the abdominal wall. The anterior right coronary and right triangular ligaments are cautiously divided, being careful not to injure the right hepatic vein and inferior vena cava. Small implants can be excised or fulgurated using electrocautery, the argon beam coagula-tor, or the ultrasonic surgical aspirator. Larger-volume disease often requires a peritoneal resection, which is carried out by first mobilizing the anterior or lateral free edge of the diaphragm peritoneum and then separating it from the underlying musculature using a combination of sharp and blunt dissection proceeding ventrocaudally or lateromedially, respectively (Figs. 7-11 and 7-12). The integrity of the diaphragm is then confirmed by filling the ipsilateral space with water and observing for air bubbles at end inspiration. The defect is repaired by placing a catheter through the hole and aspirating at maximum inspiration as the edges of the opening are reap-proximated using a purse string or a series of interrupted permanent sutures.
Figure 7-11. Diaphragm peritonectomy. (From Levine DA, Barakat RR, and Abu-Rustum NR: Atlas of Procedures in Gynecologic Oncology, 2nd ed. New York and London: Informa Healthcare, 2008. Reprinted courtesy of the authors.)
Figure 7-12. Peritonectomy completed. (From Levine DA, Barakat RR, and Abu-Rustum NR: Atlas of Procedures in Gynecologic Oncology, 2nd ed. New York and London: Informa Healthcare, 2008. Reprinted courtesy of the authors.)
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