Intercostal Transdiaphragmatic Port Insertion During Laparoscopic Resection of Liver Tumors Below the Right Diaphragmatic Dome Based on Costal and Pulmonary Anatomy: A Systematic Review

Abstract

Several reports advocate placement of ports between ribs for performing laparoscopic liver resection involving segments 7 and 8, but adoption of this method still is debated. Further, precise positioning of these intercostal transdiaphragmatic ports (ICPs) is required to avoid complications. We undertook a literature search to compare outcomes of laparoscopic resection between use and nonuse of ICPs. We further included review of pertinent anatomic features aiming to guide safe introduction of ICPs. Among 380 articles screened, 6 compared aspects of outcomes with respect to ICPs. ICPs reduced frequency of conversion to laparotomy in 3 of these 6; less intraoperative blood loss and shorter hospital stays were observed in 1 each. More favorable long-term survival was achieved in 1. One report found increased operating time, while another noted no differences. As for anatomic details, ports should be inserted into intercostal spaces at least 12 cm ventrally to spinous processes in order not to injure costal arteries or their branches. To avoid pulmonary injury, ports should enter the 7th intercostal space or lower at a point ventral to the anterior axillary line, the 8th intercostal space or lower at a point ventral to the midaxillary line, or the 9th intercostal space or lower at any position within the zone of apposition. Further studies and systematic reviews are needed to determine whether ICPs have decisive advantages. However, with appropriate precautions and positioning, ICPs can be inserted with minimal morbidity while obtaining clear visualization of hepatic lesions underlying the diaphragmatic dome.