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The improved survival impact of achieving residue zero cytoreduction were proven in many studies for ovarian carcinoma (1,2). In those, one of the most commonly involved sites is the diaphragm in up to 40% of cases. Diaphragmatic involvement is one of the most common reasons for the failure to achieve complete or optimal cytoreduction surgery (3). Although there has been improvements in technique, experience, and education over the years, there are still concerns about complications and management of diaphragmatic tumor resection, especially in the presence of full thickness implants. Therefore, we would like to describe a technique for resection of diaphragm full thickness implants without entrance to the pleural space. Firstly, the liver was mobilized. Diaphragm striping was performed up to the full thickness implant. When an unresectable area was reached, the following technique was performed to resect the full thickness implant. The steps of the technique were: (i) after identification of the full thickness implant borderlines, sutures were placed to the medial, middle and lateral edges of the full thickness implant to more easily perform traction (Figure 1); (ii) an automated stapling device, such as thoraco-abdominal stapler DST seriesTM (Figure 2) or gastro-intestinal anastomosis stapler (DST seriesTM) were placed transversally to diaphragm, under the full thickness implant which had been displaced by traction; (iii) in order to avoid lung parenchymal injury, the ventilator was temporarily turned off after exhalation, while the stapler was locked up; (iv) the stapler was locked up to place the sutures automatically; (v) the full thickness implant above the staplers was resected via manual scalpel for thoraco-abdominal stapler or by the integrated automated scalpel for gastro-intestinal anastomosis stapler, and the stapler was opened; (vi) the resection was completed without entrance to pleural space; and (vii) final control for air leakage using a bubble test, was performed. There were either no, or minimal, asymptomatic pleural Unusual usage of the automated stapler in gynecologic oncology: method for diaphragmatic full thickness implant resection without entrance to pleural space

journal of the turkish-german gynecological association

Unusual usage of the automated stapler in gynecologic oncology: method for diaphragmatic full thickness implant resection without entrance to pleural space