Laparoscopic en bloc resection of intrahepatic cholangiocarcinoma with diaphragm

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Summary: A 59-year-old female visited our hospital for newly-developed tumor of the liver. She underwent laparoscopic right anterior sectionectomy with lymph node dissection for IHCCC at our hospital 8 months ago. The pathologic result revealed as 2.4cm sized T1 lesion without nodal involvement. After 8 months of primary surgery, 2 recurred tumors at S8 were found. She had chronic hepatitis B, history of pulmonary tuberculosis and three times of c-sec. We planned to perform laparoscopic resection of two IHCCCs. Initial laparoscopic view showed severe adhesion around the liver. After careful adhesiolysis, the contour of liver was identified and a tumor at S8 was found. But, the tumor invaded the diaphragm so we decided to perform en bloc resection of the tumor with diaphragm. During resection of the diaphragm and additional adhesiolysis of liver dome, another tumor was found at just beside of the primary tumor. The second tumor was also included in en bloc resection territory. After resection of diaphragm, liver parenchymal dissection was done using the Harmonic scalpel. Then reconstruction of defected diaphragm was done with polytetrafluoroethylene sheet. All these procedures were done by laparoscopically. The operation time was 336 minutes and the estimated intraoperative blood loss was __mL. Duting current operation, an intraoperative transfusion was not necessary. The postoperative pathologic report revealed that two mass-forming IHCCCs invading diaphragm (T4Nx) with negative resection margins. The patient was discharged on the fourth day after surgery without any complications. And after 3 months, there was no recurrence yet. This is the first reported Case of a laparoscopic en bloc resection of IHCCC with diaphragm and patch reconstruction of diaphragm. Laparoscopic approach can be adjusted in highly selected patients.