https://orcid.org/0009-0007-9606-1260
Abstract
A 57-year-old woman with known metastatic thymoma who had recently undergone a thoracotomy with resection of a diaphragmatic nodule presented with a symptomatic para-esophageal diaphragmatic hernia. She was managed with an emergency laparoscopic diaphragm repair using a bovine pericardial patch. On visualizing the thoracic cavity through the hernia defect, sub-pneumonic pleural nodules were noted. Although not the primary goal of the surgery, these nodules were resected as re-accessing the thoracic cavity would have been challenging. This case presents a novel minimally invasive approach to the management of a diaphragmatic hernia and incidentally noted metastatic thymoma.
Introduction
Thymoma is an epithelial tumour of the anterior mediastinum [1, 2]. Although generally less aggressive than lung cancers, its clinical behaviour can be occasionally unpredictable. When metastasis and recurrence occur, it is often loco-regional involving pleural and mediastinal structures [3]. Surgical intervention with complete resection remains at the cornerstone of management of both primary thymoma and recurrent disease [2, 3]. This case represents a case of symptomatic diaphragmatic hernia after resection of the diaphragm via thoracotomy. During a minimally-invasive repair, trans-diaphragmatic resection of metastatic pleural thymoma was achieved.
Case presentation
A 57 year old woman with a history of stage II, WHO type B1 thymoma diagnosed 10 years prior and initially managed with a minimally invasive radical thymectomy and adjuvant radiotherapy, developed left pleural recurrence with enlarging costophrenic nodules noted on serial imaging (Fig. 1). She underwent a left-sided thoracotomy with resection of the involved diaphragm and a suture repair of the diaphragmatic defect. Four months later, she presented to the emergency department with a 1 week history of epigastric pain and a computed tomography (CT) scan demonstrating a diaphragmatic hernia containing stomach (Fig. 2a and b).
PET demonstrating FDG avid costophrenic nodules.
(a, b) CT scans demonstrating para-oesophageal hernia.
Given the patient’s symptoms, emergency surgery was recommended and she was taken to the operating room within 24 hours. Under standard general anaesthesia with a single lumen endotracheal tube, she was placed in a right lateral position in reverse Trendelenburg. A 12 mm optical port was inserted in the left upper abdomen. A further 12 mm port was placed under vision in the left abdomen alongside an additional four 5 mm working ports. Intra-abdominal adhesions were divided and spleen and pancreas tail mobilized from lateral to medial to expose the diaphragmatic defect. The short gastric vessels were divided to allow the stomach to be reduced from the thorax. Upon inspection of the pleural space, the patient was noted to have pleural nodules concerning for metastatic thymoma. Intra-operative cardiothoracic consult was sought with the decision made to resect these nodules. All visible nodules were resected using a trans-diaphragmatic technique through the existing defect. A chest drain was placed into the left pleural space and the diaphragmatic defect closed with Baxter Healthcare Peri Guard 10 × 16 cm bovine pericardium cut to size and secured with a continuous 15 cm 3–0 non-absorbable V-loc suture.
The patient’s post-operative recovery was uncomplicated. The chest drain was removed on post-operative Day 2 with discharge on post-operative Day 4. A CT at 1 month post-operatively showed no evidence of hernia recurrence (Fig. 3).
Post-operative CT scan with no evidence of hernia.
Discussion
Surgical resection remains the mainstay of management for primary and recurrent thymoma. In fact, resection is associated with prolonged disease-free and overall survival [1, 3]. Traditionally, thymectomy was performed by an open approach utilizing a median sternotomy, with re-sternotomy, hemi-clamshell or clamshell approaches utilized for local recurrence [4]. The adoption of video-associated thoracic surgery, and robotic-assisted thoracic surgery has allowed improved peri-operative recovery including lower rates of post-operative complications, shorter duration of hospitalization and faster improvement of lung function, without compromise of oncological outcomes [5–9]. However, minimally invasive approaches become more challenging after previous surgery, particularly if that surgery were open.
This case illustrates the opportunistic use of a trans-diaphragmatic technique as an alternative minimally-invasive approach to access subpneumonic thoracic pathology from the abdominal cavity. The technique has been described to complete a thymectomy for a mediastinal adenoma in a patient presenting with hypercalcaemia as well as for other operations including wedge resection, lobectomy, segmentectomy [10, 11]. Each of these cases required diaphragmatic incision to gain access to the thoracic cavity. Our case highlights a unique application of minimally invasive surgical technique where the trans-diaphragmatic approach was made through a pre-existing defect for the opportunistic resection of metastatic thymoma. A patch repair was performed for two reasons. First, the defect was at a site of previous suture repair, so suture closure alone had already failed. Second, the defect was close to, but not involving the esophageal hiatus, in a part of the diaphragm unable to adapt easily to tension. If tension induced by suture repair were to cause the defect to extend into the oesophageal hiatus, the complexity of repair would increase significantly. Although synthetic mesh is more commonly used, bovine pericardium was preferred for its resistance to infection and to avoid mesh erosion into visceral structures such as the stomach, oesophagus, and lung [12].
Conclusion
Thymoma has a predilection toward loco-regional metastasis, especially pleural. The progress of minimally invasive surgical techniques continues to expand the options we can provide patients. The importance of this case is in its illustration of techniques from multiple surgical disciplines that can be adapted and integrated to manage a rare clinical scenario, enabling treatment of both an acute presentation and an unforeseen oncological issue while minimizing patient morbidity.
Conflicts of interest
None declared.
Funding
None declared.
