부산대학교 도서관

A 74-year-old man, who had undergone low anterior resection for rectal cancer and segmental hepatectomy (S5 and S6) for synchronous liver metastases approximately 2 years previously, was detected to have a 12×10 mm solitary lung nodule and a 11×9 mm nodule located between the diaphragm and right lobe of the liver. Lung and liver metastases were suspected.We planned a transdiaphragmatic approach using video-assisted thoracoscopic surgery for the resection of these lesions to evade adhesions by hepatectomizing it of the last time.The operation was started with a use of preoperative three-dimensional (3D)-computed tomography (CT) visualization system (SYNAPSE VINCENT) in a left lateral decubitus that was the same position as he postured during surgery.During the operation, we first performed thoracoscopic partial resection of the lung (S9) and confirmed the portion of the diaphragm located directly above the nodule by using intraoperative thoracoscopic ultrasonography. Subsequently, we cut and opened the diaphragm and resected the subphrenic nodule using ultrasonic incision and a coagulation device. Using non-absorbable thread, we closed the diaphragm with 6 stiches.The post-operative pathological diagnoses were lung metastasis and pleural dissemination derived from rectal cancer.In conclusion, the approach through the diaphragm using thoracoscopy is useful and safe for tumor resection in the subphrenic area, and the operation performed by using a preoperative 3D-CT visualization system facilitates the identification of accurate port positions for the thoracoscope, and confirms the location of the tumor.