Laparoscopic transdiaphragmatic chest surgery: Early experience

Objective: We describe laparoscopic transdiaphragmatic (LTD) chest surgery without intercostal incisions and focus on technique and safety. The goal of LTD is to minimize postoperative pain. Methods: We reviewed all patients undergoing LTD chest surgery (September 8, 2010-April 4, 2017). We place 4 abdominal ports with the patient in semilateral decubitus, make 2 diaphragmatic openings, and advance 2 ports into the chest. The intrathoracic operation is standard video-assisted thoracoscopic surgery (VATS), and diaphragmatic openings are closed at the end. We compared narcotic use (morphine equivalents) between patients undergoing LTD lung resection with historical controls undergoing conventional VATS. Results: We performed 28 LTD chest procedures (wedge, 19; lobectomy, 3; segmentectomy, 3; other, 3; right sided, 20). Indications were lung nodule (14), lung cancer (5), interstitial lung disease (6), and other (3). Median operative times were 138 minutes (96-240 minutes) for wedge resection and 296 minutes (255-356 minutes, including transcervical mediastinal lymphadenectomy) for anatomic resections. Respiratory complications occurred in 3 patients and other complications in 5 (total 8; 28.6%). Computed tomography in 22 patients (79%) at median 13 months (3-47 months) after surgery showed no diaphragmatic hernia. LTD chest surgery patients used less narcotics than conventional VATS without paravertebral block 24 to 48 hours postoperatively (P =.039). Conclusions: Early experience suggests that LTD chest surgery is feasible and safe on short- to midterm follow-up. The specific role of LTD chest surgery will require definition of patient selection criteria, further experience to reduce operative time, long-term follow-up, and prospective comparison with conventional VATS.