Cardiophrenic and costophrenic lymph node resection via subxiphoid approach only

Abstract

Even the resection's impact of enlarged cardiophrenic lymph nodes (CPLN) on survival still uncertain, it contributes to accurate staging and complete gross resection in advanced ovarian cancer. CPLN resection can be performed via video-assisted thoracic surgery or transabdominally through the subxiphoid or transdiaphragmatic routes. The subxiphoid approach is utilized to reach the prepericardiac nodes located in the anterior mediastinum. The transdiaphragmatic route is used to remove the costophrenic and supradiaphragmatic paracaval lymph nodes located in the middle and posterior mediastinum, respectively. Transdiaphragmatic approach necessitates diaphragm opening and, in most cases, liver mobilization. However, costophrenic nodes can be resected through the subxiphoid route in appropriate patients without opening the diaphragm. Thus, the subxiphoid approach can be firstly preferred to remove the costophrenic lymph nodes, in cases whose diaphragm resection is not anticipated, and especially when the resection procedure is planned to include the prepericardiac nodes. In this video article, we present the method of resecting both prepericardiac and costophrenic lymph nodes through the subxiphoid approach in an advanced ovarian cancer case. The subxiphoid virtual space between the pericardium and diaphragm was developed. The observed and palpated CPLNs were dissected and excised from the prepericardiac and right latero-cardiac spaces. Thereafter, diaphragm peritoneum beneath the right costophrenic nodes was dissected. After determining the enlarged costophrenic node by palpation, the sternal and costal diaphragmatic attachments were incised and the right latero-cardiac space was extended. When the node was reached, it was grasped and pulled with curved-ring forceps and ultimately resected.