Video-assisted Thoracoscopic PGA Sheet Coverage of the Entire Diaphragm for Refractory Hepatic Hydrothorax—A Case Report—

Abstract

A 74-year-old man with previous histories of liver cirrhosis, hepatocellular carcinoma, spinal cord injury, colon cancer, and lung cancer in the left upper lobe was brought into our emergency room with dyspnea. He was admitted to the hospital for thoracic cavity drainage due to massive right pleural effusion. Repeated pleurodesis procedures were not effective. Thus, surgery was performed with video-assisted thoracoscopy through an access thoracotomy together with laparoscopy. Air leak through the diaphragm could not be observed after filling the thoracic cavity with normal saline during insufflation of the peritoneal cavity with 12 cmH₂O. However, visualization through the laparoscope revealed a defect in the central tendon of the diaphragm, which was sutured, though the diaphragm was fragile and became torn from the needle puncture. Direct closure was abandoned, and the entire diaphragm was covered with polyglycolic acid (PGA) sheets that were fixed with fibrin glue. The chest tube was removed on postoperative day 9, with no re-accumulation of pleural fluid observed thereafter. In the present case, while direct closure could not be achieved because of the thinned diaphragm, hepatic hydrothorax was successfully treated with PGA sheet coverage of the entire diaphragm.