Department of Surgery, Mt. Sinai St. Luke’s-Roosevelt Hospital Center, New York, NY, USA (all authors)

ABSTRACT

Introduction: Obturator hernias represent a rare cause of small-bowel obstruction. When diagnosed on computed tomographic (CT) scan in a stable patient, timely surgical repair is indicated. Because of the absence of large-scale studies, the ideal operative approach has yet to be defined.

Case Description: A 75-year-old woman presented to the emergency department with an incarcerated left-side obturator hernia manifesting as a small-bowel obstruction. The hernia was diagnosed on CT scan, and the patient was taken to the operating room for laparoscopic reduction and repair. During surgery, a contralateral obturator hernia and bilateral indirect inguinal hernias were discovered. Hybrid transabdominal preperitoneal (TAPP) and total extraperitoneal (TEP) approaches were used to reduce and demonstrate the viability of the incarcerated bowel and then to repair all 4 defects with mesh. The procedure was well tolerated, and the patient was discharged uneventfully after the return of bowel function.

Discussion: This case provides an example of how a hybrid TAPP/TEP laparoscopic approach can be effective for visualizing and repairing an obturator hernia as well as an incidentally discovered inguinal hernia.

Key Words: Obturator hernia, TEP, TAPP, Mesh repair

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Department of Surgery, St. Luke’s-Roosevelt Hospital Center, New York, NY, USA (Drs. Teng, Wexelman, Schwartz, Belsley). Department of Obstetrics and Gynecology, St. Luke’s-Roosevelt Hospital Center, New York, NY, USA (Dr. Nezhat). Department of Hematology and Oncology, St. Luke’s-Roosevelt Hospital Center, New York, NY, USA (Dr. Sara). Department of Thoracic Surgery, St. Luke’s-Roosevelt Hospital Center, New York, NY, USA (Drs. Bhora, Connery).

ABSTRACT

Introduction: Ovarian serous carcinoma is an aggressive malignancy, often with metastases at presentation. Cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy has been studied as a treatment option for intraperitoneal spread of ovarian cancer. Hyperthermic intrathoracic chemotherapy, the thoracic counterpart to hyperthermic intraperitoneal chemotherapy, is emerging as a treatment option for both primary and secondary pleural cancers but has not previously been reported for treatment of ovarian metastases. The use of minimally invasive thoracoscopic techniques, including robotic assistance, for intrathoracic chemotherapy is rare. We present a case report of a patient with pleural metastasis of ovarian serous carcinoma treated with cytoreductive surgery and intrathoracic chemotherapy.

Case Description: In a 55-year-old woman who underwent a total abdominal hysterectomy and bilateral salpingooophorectomy with cytoreduction in July 2011 for ovarian cancer, a right-sided pleural effusion developed on postoperative radiographs. After chemotherapy treatment, she had a 7-month remission until positron emission tomography/computed tomography scan identified an isolated pleural metastasis. The findings of diagnostic laparoscopy were negative for occult abdominal disease. We performed robotic-assisted right-sided video-assisted thoracoscopic surgery, partial pleurectomy, and resection of pleural, diaphragmatic, mediastinal, and pericardial nodules, followed by perfusion with heated cisplatinum for 60 minutes. The surgical procedure was uncomplicated, and the patient was discharged on postoperative day 3. The serum creatinine level remained normal. The pathologic specimens showed poorly differentiated/high-grade adenocarcinoma consistent with the patient’s ovarian primary. At 10 months postoperatively, she had no evidence of early recurrence and had a normal Karnofsky performance score (100).

Conclusion: We report the first case of robotic-assisted hyperthermic intrathoracic chemotherapy to treat ovarian carcinoma. Intrathoracic chemotherapy may be an important tool in the treatment of ovarian metastases in the chest.

Key Words: ovarian carcinoma, thoracic metastases, cytoreductive surgery, perfusion hyperthermic chemotherapy, robotic assistance.

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