Diaphragmatic Attachments Research Articles

Surgical anatomy of minimally invasive lateral approaches to the thoracolumbar junction.

The thoracolumbar (TL) junction spanning T11 to L2 is difficult to access because of the convergence of multiple anatomical structures and tissue planes. Earlier studies have described different approaches and anatomical structures relevant to the TL junction. This anatomical study aims to build a conceptual framework for selecting and executing a minimally invasive lateral approach to the spine for interbody fusion at any level of the TL junction with appropriate adjustments for local anatomical variations. The authors reviewed anatomical dissections from 9 fresh-frozen cadaveric specimens as well as clinical case examples to denote key anatomical relationships and considerations for approach selection. The retroperitoneal and retropleural spaces reside within the same extracoelomic cavity and are separated from each other by the lateral attachments of the diaphragm to the rib and the L1 transverse process. If the lateral diaphragmatic attachments are dissected and the diaphragm is retracted anteriorly, the retroperitoneal and retropleural spaces will be in direct continuity, allowing full access to the TL junction. The T12-L2 disc spaces can be reached by a conventional lateral retroperitoneal exposure with the rostral displacement of the 11th and 12th ribs. With caudally displaced ribs, or to expose T12-L1 disc spaces, the diaphragm can be freed from its lateral attachments to perform a retrodiaphragmatic approach. The T11-12 disc space can be accessed purely through a retropleural approach without significant mobilization of the diaphragm. The entirety of the TL junction can be accessed through a minimally invasive extracoelomic approach, with or without manipulation of the diaphragm. Approach selection is determined by the region of interest, degree of diaphragmatic mobilization required, and rib anatomy.

Cardiophrenic and costophrenic lymph node resection via subxiphoid approach only

When enlarged cardiophrenic lymph nodes (CPLN) are resected the impact on survival is still uncertain, but resection 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 used 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. However, the transdiaphragmatic approach necessitates diaphragm opening and, in most cases, liver mobilization. Costophrenic nodes can be resected through the subxiphoid route in appropriate patients without opening the diaphragm. Thus, the subxiphoid approach may be preferred to remove the costophrenic lymph nodes, in cases in whom 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 using only the subxiphoid approach in a case of advanced ovarian cancer. 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 identifying any enlarged costophrenic nodes by palpation, the sternal and costal diaphragmatic attachments were incised and the right latero-cardiac space was extended. When the single enlarged node was reached, it was grasped and pulled with curved-ring forceps and ultimately resected.

Cardiophrenic and costophrenic lymph node resection via subxiphoid approach only

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.

TRAUMATIC CHEST WALL INJURY WITH DIAPHRAGMATIC RUPTURE AND LUNG HERNIATION

TOPIC: Cardiothoracic Surgery TYPE: Medical Student/Resident Case Reports INTRODUCTION: Traumatic diaphragmatic injuries are a rare injury that can occur after chest wall trauma. Injury to the diaphragm and its surrounding structures can easily be missed as the patients often have polytrauma. We present a case of a penetrating injury with blunt traumatic chest wall injury with diaphragm rupture and herniation of the left lung through the chest wall after a motorcycle collision. CASE PRESENTATION: A 24-year-old male presented to the hospital as a trauma alert after a motorcycle crash. The patient was found to have a large open chest wound with exposed lung and diaphragm. He was taken for CT imaging and found to have a left apical pneumothorax, left lung contusion, left rib fractures 2-10, and a grade 2 spleen laceration. The patient was taken for emergent exploration of his left chest wound. The patient was found to have disruption of his left chest wall and diaphragmatic attachments with rupture of the lateral aspect of his diaphragm at the level of rib 5-6. The wound was explored with evidence of injury to the left inferior lateral lobe of his lung. The lung did not require any resection. The entire left diaphragm was examined with the central tendon of the left diaphragm found to be intact, the diaphragm was repaired along the lateral edge and reattached to the costal cartilage laterally along the chest wall. The left chest was washed out and a chest tube was placed. The patients remaining hospital course was uneventful, and his chest tube was removed with no signs of air leaks. DISCUSSION: There are no specific signs of diaphragmatic injury or rupture on physical exam. Missed diaphragmatic injuries can result in major morbidity or mortality for the patient. All diaphragmatic injuries should be examined along with all surrounding structures at the time of diagnosis. Most diaphragmatic injuries occur on the left side as the right side is protected by the liver. We highly recommend CT imaging to examine the upper abdomen and chest. In the case of our patient which is rare, we were able to visualize his chest wall injury with his diaphragmatic injury on physical exam. When diagnosed early we recommend repair through the abdomen, but if found late repair through the chest is a better approach. In our case we were able to re-approximate the diaphragm to the chest wall. CONCLUSIONS: Traumatic injuries to the diaphragm can be tough to diagnose at times when there is not obvious injury noted to the diaphragm. We recommend full exposure of the diaphragmatic surface and examination of the surrounding organs and structures to rule out further injury that is not obvious on first examination. The diaphragm should be repaired and then reattached to the chest wall along its costal cartilage laterally. Complete repair with reattachment will allow the patient to avoid morbidity and mortality of a chronic diaphragmatic injury that could lead to impaired respiratory or chest wall function. REFERENCE #1: DeBarros, M., Martin, M.J. Penetrating Traumatic Diaphragm Injuries. Curr Trauma Rep 1, 91-101 DISCLOSURES: No relevant relationships by Michael Bishop, source=Web Response No relevant relationships by Alyssa Ritchie, source=Web Response

Robotic-assisted left lower-lobe pulmonary lobectomy: Eleven steps.

Robotic-assisted left lower-lobe pulmonary lobectomy: Eleven steps.

Surgical resection of locally advanced paravisceral neuroganglioma

Background: Neurogangliomas are rare, benign tumors of neural crest origin most commonly seen in the mediastinum/retroperitoneum and can involve critical vasculature. They are indolent and slow-growing tumors that present with symptoms based on mass effect and location. A 29-year old male presented with 2 months of worsening abdominal pain, early satiety, and diarrhea. Initial outside imaging revealed an indeterminate abdominal mass with EUS biopsy consistent with neuroganglioma. Triple phase CT revealed a large (10 x 7 x 9 cm) abdominal mass that appeared to arise from the right diaphragmatic crus and involving the paravisceral arteries of the abdominal aorta. Methods: The mass spared the left gastric artery but circumferentially encased the common hepatic artery with extension to the proper hepatic/gastroduodenal artery bifurcation, and circumferential encasement of the proximal splenic artery and superior mesenteric artery origin from the aorta extending down to the middle colic artery take-off with sparing of distal superior mesenteric root branches. The mass abutted the body/tail of the pancreas and anteriorly displaced the main portal, splenic vein and distal superior mesenteric vein with narrowing and there was encasement of the coronary vein. The left renal vein was involved and two right renal arteries were abutted but left renal artery uninvolved. After multidisciplinary discussion with no other viable treatment options in a highly symptomatic patient with a paravisceral ganglioneuroma, surgical resection was recommended Results: The patient was taken to the operating room for attempted vascular-sparing resection with plan for en bloc multi-arterial resection and reconstruction. A midline laparotomy was performed, the left lateral bisector was mobilized from its diaphragmatic attachments and reflected medially. The omentum was taken off transverse mesocolon, lesser sac entered and gastro-hepatic ligament divided. The right and left colon were mobilized and full Kocher maneuver performed. The medial wall of IVC and left renal vein and right renal arteries were dissected from the mass arising from the right diaphragmatic crus. The distal CHA at the proper hepatic/gastroduodenal bifurcation was dissected free and GDA was ligated. The omentum was divided close to the spleen and short gastric vessels ligated. The spleen and distal pancreas were dissected,mobilized in a retrograde fashion along left kidney/adrenal gland andIMV was ligated. The left diaphragmatic crus was divided and left renal artery preserved. Dissection was carried onto the aorta and the origins of the variant visceral vessels were isolated The splenic artery required ligation at its origin but the CHA and SMA origins preserved. Splenectomy was performed preserving the distal pancreas.The distal uninvolved SMA from the mesenteric root was dissected identifying the middle colic artery. The tumor was divided over the course of the SMA distally to its origin from the aorta circumferentially dissecting it from the encased SMA ligating several lateral pancreaticoduodenal branches going to the uncinate of the pancreas preserving distal jejunal mesenteric branches. Similarly the mass was dissected where it was encasing the common hepatic from the proper hepatic to the CHA origin with circumferential dissection of the vessel. Tumor was adherent to the portal vein and pancreas. Conclusion: Ligation of various venous tributaries including coronary vein was performed and tumor was carefully dissected off the uncinate and the specimen removed en bloc. Despite ligation of short gastric arteries and GDA there was still adequate arterial gastric inflow via the preserved right and left gastric arcade and this was confirmed with intraoperative Doppler signals and ICG injection under SPY device revealing good perfusion. Ganglioneuromas are rare, benign tumors that can arise in challenging anatomic locations with no other effective options other than resection. In our case pathology revealed benign paravisceral ganglioneuroma. Tumors involving visceral aortic branches require careful preoperative planning, experience with advanced resection and anatomical dissection, and attention to anatomical variants that can assist with R0 resection with minimal morbidity.

Surgical anatomy of the diaphragm in the anterolateral approach to the spine: a cadaveric study.

Laboratory cadaveric study. To delineate the pertinent surgical anatomy of the diaphragm during access to the anterolateral thoracolumbar junction. The general anatomy of the thoracic diaphragm is well described. The specific surgical anatomy as it pertains to the lateral and thoracoabdominal approaches to the thoracolumbar junction is not well described. Dissections were performed on adult fresh cadaveric specimens. Special attention was paid to the diaphragmatic attachments to the lower rib cage and to the spinal thoracolumbar junction. The pertinent diaphragmatic attachments to the rib cage are at the 11th and 12th ribs. Whether the diaphragm is incised or mobilized ventrally, the pertinent spinal attachments are the lateral and medial arcuate ligaments. Identifying and sectioning these structures allows for direct access to the thoracolumbar junction, particularly the L1 vertebral body. An understanding of the diaphragmatic-costal and diaphragmatic-spinal attachments is key for the safe and effective implementation of diaphragm mobilization during the lateral and thoracoabdominal approaches to the spine.

Technical considerations for radical resection of a primary leiomyosarcoma of the vena cava

BackgroundRadical resection provides the best hope for cure in leiomyosarcoma of the inferior vena cava (IVC). Multi-visceral resection is often indicated by extensive tumour involvement. This report describes the technical challenges encountered during resection of a retrohepatic IVC leiomyosarcoma. MethodsComputed tomography showed an IVC leiomyosarcoma measuring 7.8 × 10.0 × 19.3cm in a 41-year-old patient. The tumour reached the confluence of the hepatic veins, displacing the caudate lobe anteriorly and extending towards the IVC bifurcation inferiorly. En bloc resection of the IVC tumour with a right hepatic and caudate lobectomy, and a right nephrectomy was performed. ResultsSubsequent to a Cattel manoeuvre, the operative procedures carried out can be broadly categorized in four major steps: (i) mobilization of the infrahepatic IVC and tumour; (ii) mobilization of the suprahepatic IVC from diaphragmatic attachments; (iii) right hepatectomy with complete caudate lobe resection, and (iv) en bloc resection of the IVC tumour. This approach allowed the entire length of tumour-bearing IVC to be freed from the retroperitoneum and avoided the risk for iatrogenic tumour rupture during dissection at the retrohepatic IVC. Reconstruction of the IVC was not performed in the presence of venous collaterals. ConclusionsExperience in liver resection and transplantation, and appreciation of the hepatocaval anatomy facilitate the safe and radical resection of retrohepatic IVC leiomyosarcoma.

Kerley pergamon lecture: The diaphragm. Radiologic correlations with anatomy and pathology

Anatomically, the diaphragm consists of muscular fibres which are attached to the periphery of the thoracic cage and converge into a central tendon. Physiologically, the diaphragm acts as if it were composed of two muscle aggregates, a costal portion attached to the ribs and a crural portion not attached to the ribs. Radiologically, the diaphragm can therefore be considered to have anterior (more accurately, anterolateral) and posterior attachments. In the ensuing discussion, several aspects of the anatomy and pathology of the diaphragmatic attachments will be considered. The subject of diaphragmatic injury will not be reviewed.

Regional variation in pericardial contact pressure in the canine ventricle.

We studied eight open-chest dogs to determine whether there is regional variation in pericardial contact pressure (PCP). Flat, air-filled balloons were used to measure PCP simultaneously over the lateral walls of the right and left ventricles while cardiac volume was varied by dextran infusion. End-diastolic and mean PCP were significantly higher over the left than right ventricle at high (20.3 +/- 1.0 mmHg) and middle levels (13.7 +/- 0.9 mmHg) of left atrial pressure. At high left atrial pressures, the end-diastolic PCP over the lateral left ventricle was 9.1 +/- 2.4 mmHg compared with 4.3 +/- 2.3 mmHg over the lateral right ventricle (P less than 0.05). At middle levels of left atrial pressures, end-diastolic PCP was 6.2 +/- 3.5 mmHg over the left ventricle and 1.5 +/- 2.4 mmHg over the right ventricle (P less than 0.05). These variations in PCP persisted after severing the pericardial diaphragmatic attachments and after turning the dogs such that one or the other balloon was dependent. Regional distribution of PCP was studied by positioning a single balloon sequentially at multiple ventricular sites. PCP was consistently higher over the lateral wall of the left ventricle than either the anterior or posterior walls of the right or left ventricle. After aortic occlusion, end-diastolic PCP increased more over the left than right ventricle. In contrast, with pulmonary artery occlusion, end-diastolic PCP increased more over the right than left ventricle. Pericardial pressure varies regionally, and a single pericardial pressure may be an oversimplification when used to describe pericardial restraint on the cardiac volume.

Partial splenic decapsulation: A simplified operation for splenic pseudocyst

Splenic pseudocysts have traditionally required splenectomy because of the risks imposed by partial splenectomy or excision of the cyst lining. During the past 2 years, a 6-year-old boy and a 9-year-old girl presenting with vague upper abdominal discomfort, palpable splenomegaly, and a large unilocular sonolucent cyst within the spleen, were treated by partial splenic decapsulation with preservation of the hilar blood supply. This procedure involves mobilizing the spleen by dividing the renal, colic, and diaphragmatic attachments; decompressing the liquefied cyst contents through a thoracostomy trochar; excising the outer splenic capsule and gaining hemostasis of the splenic wall with a running interlocked silk suture; and providing external tube drainage of the left upper quadrant. During the follow-up period of 26 and 12 months, splenic size has returned to normal. Serial nuclear scan and ultrasound show a small residual crescent-shaped deformity of the functioning splenic remnant. We conclude that partial splenic decapsulation for splenic pseudocyst is simpler and safer than other preservation procedures attempted, and carries no increased risk of recurrence from leaving a portion of the pseudocyst wall.

In vivo mechanical behavior of canine pericardium.

We examined the in vivo mechanical behavior of the pericardium by measuring simultaneous atrial and intrapericardial pressures and mutually orthogonal, circumferential, and longitudinally oriented pericardial segment lengths (ultrasonic gauges) in 10 open-chest dogs. Venous return was varied by a combination of caval occlusion followed by volume loading. Up to a mean left atrial pressure of 25 mmHg, the pericardium lengthened virtually exclusively in the circumferential direction (n = 9). Thus, at an intrapericardial pressure of 6.0 +/- 1.0 (+/- SD) mmHg, circumferential strain (normalized to length at pericardial pressure 0 mmHg) was 0.30 +/- 0.28, whereas longitudinal strain was 0.02 +/- 0.06 (P less than 0.05). In five of these dogs, alteration of external pericardial loading by severing the pericardial diaphragmatic attachments did not change the difference between circumferential and longitudinal strain, and in two the same directional strain difference was observed during production of cardia tamponade. In three additional dogs the square of the circumferential segment length was closely correlated with the directly measured intrapericardial volume when saline was infused into the pericardial space in an in situ, arrested heart preparation. Our results indicate that there is marked directional variability in lengthening of the pericardium when the volume of its contents is altered in vivo. This phenomenon is probably the result of complex interactions between the properties of the pericardial tissue and the influence of its internal and external loads.

The anterior diaphragmatic attachments: an anatomic and radiologic study with clinical correlates.

A study of the anterior attachments of the respiratory diaphragm was performed using gross anatomic specimens, plain radiography, and computed tomography with multiplanar image reformatting. The anterior portions of the diaphragm are affixed to the lower six ribs and the sternum. The line of attachment of each hemidiaphragm begins at the anterior axillary line and extends cranially and medially to meet at the xiphoid process. These structures can be visualized along with contiguous pathologic subdiaphragmatic and/or infradiaphragmatic air collections. In the semierect patient, free intraabdominal air may preferentially collect in the anterior subdiaphragmatic regions rather than below the domes of the diaphragm, providing a subtle but reliable indication of pneumoperitoneum. An understanding of the normal anatomy of the anterior diaphragmatic attachments is valuable in assessing a variety of anterior paradiaphragmatic air collections.

Traumatic calcific nonconstrictive pericarditis

A 65 year old woman is described who, 22 years after a steering wheel injury to the chest, was found to have a severe pectus excavatum, a heart completely torn free of its diaphragmatic attachments and with heavy pericardial calcification. Despite evidence of severe cardiac damage, she had only minimal impairment of cardiac function. Angiocardiographic findings are presented. Cardiac catheterization revealed no evidence of restriction, but there was a small systolic pressure gradient from right ventricle to pulmonary artery. Possible causes of the anatomic and functional findings are discussed.