Laparoscopic Resection of a Diaphragmatic Phrenic Neurilemmoma Compressing the Suprahepatic Inferior Vena Cava Following Thoracoscopic Exploration: A Case Report

TL;DR

A rare case of a diaphragmatic tumor compressing a major blood vessel was successfully removed using minimally invasive surgery, avoiding major complications.

Contribution

This case demonstrates the feasibility of laparoscopic resection for diaphragmatic phrenic neurilemmoma compressing the IVC, with combined thoracoscopic and laparoscopic techniques.

Findings

Laparoscopic resection was safely performed without open conversion or organ removal.

Thoracoscopic evaluation helped confirm tumor location and guide surgical planning.

Histopathology confirmed a benign neurilemmoma with no vascular invasion.

Abstract

Surgical resection of tumors compressing the suprahepatic inferior vena cava (IVC) is challenging, as such lesions may require vascular resection, reconstruction, or extracorporeal circulation. We present a case of a diaphragmatic phrenic neurilemmoma severely compressing the suprahepatic IVC and right hepatic vein, which was successfully resected laparoscopically with both thoracoscopic and laparoscopic assessment.

A 54-year-old woman was referred for evaluation of a thoracic mass detected during a health check-up. Enhanced CT revealed a 2.7-cm, well-circumscribed, heterogeneously enhancing round tumor compressing the suprahepatic IVC and right hepatic vein. Thoracoscopic exploration suggested that the tumor was not intrathoracic, and the right diaphragmatic nerve was identified near the lesion. Laparoscopic resection was then performed with preparation for possible open conversion. After establishing pneumoperitoneum, 4 additional ports were inserted. Dissection of the falciform and coronary ligaments exposed a well-encapsulated tumor originating from the diaphragm. The inferior diaphragmatic vein was transected using ultrasonic shears. The tumor was carefully dissected from the diaphragm without invasion into the IVC or hepatic vein. Complete resection was achieved without removal of adjacent organs, including the diaphragm. The specimen was retrieved via the umbilical incision. Operative time was 54 min, and blood loss was 2 mL. The postoperative course was uneventful. Histopathology revealed benign spindle cells arranged in a storiform pattern, confirming a benign neurilemmoma.

Laparoscopic resection of diaphragmatic phrenic neurilemmoma compressing the suprahepatic IVC can be safe and feasible when combined with careful intraoperative assessment. Thoracoscopic evaluation and preparation for potential vascular involvement are crucial to guide safe resection and manage possible adhesion or invasion.

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