Robotic-Assisted Resection of a Large Solitary Fibrous Tumor Followed by Repair of Iatrogenic Diaphragmatic Hernia

Solitary fibrous tumors (SFT) are rare neoplasms representing less than 5% of pleural tumors (1, 2). Sixty to eighty percent of SFTs arise from the visceral pleura (3, 4), but they can also arise from the parietal pleura and intrapulmonary (5). Primary therapy for SFT is wide surgical resection to reduce local tumor recurrence. Smaller and pedunculated SFTs have been removed minimally invasively, but large ones usually require a thoracotomy (5).Postoperative iatrogenic diaphragmatic hernia is a rare complication after thoracic and abdominal operations (6). Diaphragmatic hernias can result from an injury to the diaphragm or resection of the diaphragm with subsequent breakdown of the repair, as demonstrated. Repair can be performed using a thoracoabdominal approach (6), a laparotomy (7), or a transthoracic approach (8). Transthoracic robotic repair of an iatrogenic diaphragmatic hernia has not been previously described.This video demonstrates the robot-assisted resection of a large SFT followed by repair of iatrogenic diaphragmatic hernia. A 66-year-old woman developed left upper abdominal and flank pain. A computed tomography (CT) scan of her chest and abdomen revealed a 10.7 x 9 x 7 cm pleural-based mass. CT-guided needle biopsy demonstrated that the mass was an SFT.She underwent robot-assisted resection. The patient was placed in the right lateral decubitus position. A 12 mm port was placed anteriorly in the sixth intercostal space, an 8 mm port placed in the seventh intercostal space midaxillary line, an 8 mm port placed 8 cm posterior to the camera port, and another 8 mm port placed 6 cm more posteriorly. A 12 mm assistant port was placed between the anterior port and camera port over the tenth rib and over the diaphragm. The mass was successfully resected en bloc, including a 4.5 x 2 cm segment of diaphragm and a 7 x 4 x 2.5 cm wedge of the left lower lobe. The diaphragm was primarily repaired utilizing a 2-0 nonabsorbable barbed suture.Postoperatively, she did well and was transferred to a skilled nursing unit on postoperative day three. Her immediate postoperative chest x-ray showed that the left hemidiaphragm was down, but on postoperative day one the left hemidiaphragm was elevated. It was felt that the patient had developed a left phrenic nerve paresis. Her pathology demonstrated a 14 x 11 x 7.5 cm mass with spindle cells. Tests for CD34, CD99, BCL2, STAT6, and beta-catenin were positive and tests for pan-cytokeratin and calretinin were negative, thus confirming an SFT. The lymph nodes at station 5, 6, 7, 8, and 9 were benign and reactive. The diaphragm was fibrous adhesions. The left lower lobe was involved and had clear margins. The patient continued to have marked left-sided chest pain and nausea postoperatively. CT scan of her chest on postoperative day 28 demonstrated a diaphragmatic hernia with herniation of her stomach into the chest.The patient was returned to the operating room on postoperative day 32, where she underwent robot-assisted reduction of the stomach and repair of the diaphragmatic hernia. The patient was again placed in the right lateral decubitus position, but the ports were placed higher than the original ports on the chest and the boom of the robot was flipped to look inferiorly. An 8 mm port was placed anteriorly in the fifth intercostal space, an 8 mm camera was placed anterior to the tip of the scapula, an 8 mm port was placed 8 cm more posteriorly and posterior to the tip of the scapula, and another 8 mm port was placed 6 cm more posteriorly. A 12 mm assistant port was placed superior to and between the anterior port and the camera port. A double patch was utilized to repair the 5 x 6 cm diaphragmatic hernia. An extracellular matrix derived from urinary bladder was placed for the abdominal patch and a Gore-Tex for the thoracic patch. Postoperatively, she did very well and was discharged home on postoperative day three. A follow-up chest x-ray on postoperative day 20 showed that the left hemidiaphragm was down with atelectasis of the left lower lobe.ReferencesBalduyck B, Lauwers P, Govaert K, Hendriks J, De Maeseneer M, Van Schil P. Solitary fibrous tumor of the pleura with associated hypoglycemia: Doege-Potter syndrome: a case report. J Thorac Oncol. 2006;1(6):588-590.Langman G. Solitary fibrous tumors: a pathologic enigma and clinical dilemma. J Thorac Dis. 2011;3(2):86-87.Ordóñez NG. Localized (solitary) fibrous tumor of the pleura. Adv Anat Pathol. 2000;7(6):327-340.Jeon HW, Kwon SS, Kim YD. Malignant solitary fibrous tumors of the pleura slowly growing over 17 years: case report. 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