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EP1006 Subxiphoid approach for the resection of enlarged supradiaphragmatic cardiophrenic lymph nodes during primary cytoreduction for advanced ovarian cancer: a case report

Introduction/Background In ovarian cancer, metastatic cardiophrenic lymph nodes are associated with FIGO stage IV disease. The goal of debulking surgery should be no residual disease and resection of those lymph nodes is mandatory. The aim of this case report is to present the subxiphoid approach, as an alternative for the exploration of both cardiophrenic spaces from one incision, in contrast to the transdiaphragmatic approach. Methodology The patient was a 45 years old female. Preoperative work-up revealed an elevated CA-125 of 2521 and a CT-scan showing a pelvic mass, ascites, omental cake, diaphragmatic disease and enlarged supradiaphragmatic cardiophrenic lymph nodes, without pleural effusion. The patient underwent primary debulking surgery. Cytoreduction included type II radical oophorectomy (en bloc modified radical abdominal hysterectomy, bilateral salpingo-oophorectomy, pan-pelvic peritonectomy, rectosigmoid colectomy), appendicectomy, cholecystectomy, radical omentectomy, paracolic gutters peritonectomy, small - large bowel mesentery electro-coagulation, right diaphragm full-thickness resection and subxiphoid resection of supradiaphragmatic cardiophrenic lymph nodes. Results The cardiophrenic incision surgical steps included: subxiphoid peritoneal dissection, cutting of the transverse abdominis muscle, dissection of the retrosternal peritoneum laterally from the midline, digital development of the cardiophrenic space and removal of the enlarged lymph nodes. Total operative time was 450 min and estimated blood loss 700 ml, with no residual disease. Post-operative intensive care unit (ICU) admission was necessary for three days due to mild hemodynamic instability and the patient was discharged from hospital on the 17th postoperative day. The pathological report showed a grade III serous adenocarcinoma, with metastases to six of seven resected cardiophrenic lymph nodes. Conclusion Subxiphoid resection of supradiaphragmatic cardiophrenic lymph nodes is a feasible alternative approach for the exploration of both cardiophrenic spaces with no direct diaphragmatic trauma. Disclosure Nothing to disclose.