Journal of Robotic Surgery

, Volume 13, Issue 3, pp 525–528 | Cite as

Successful robotic extirpation of diaphragmatic seeding of hepatocellular carcinoma after previous rupture

  • Kit Fai LeeEmail author
  • Hon Ting Lok
  • Andrew K. Y. Fung
  • Charing C. N. Chong
  • Yue Sun Cheung
  • John Wong
  • Paul B. S. Lai
Case Report


A 51-year-old man who was a hepatitis B carrier presented with ruptured hepatocellular carcinoma (HCC). Hepatic arterial embolization was performed for control of bleeding which was followed by staged open left lateral sectionectomy for tumor removal. Pathology confirmed a 3.5 cm ruptured subcapsular HCC in a cirrhotic liver with clear resection margin. However, the alpha-fetoprotein (AFP) increased from 14 to 72 µg/L after 7 months. A 1.7 × 0.8 cm nodule at left subdiaphragmatic region abutting on the spleen but no intrahepatic lesion was seen on computed tomography (CT). Dual tracer positron emission tomography suggested the nodule was a HCC seeding with no other recurrent tumor noted. Robotic exploration was offered to patient with the possibility of splenectomy. During operation, the nodule was adherent to the diaphragm with no splenic involvement. The lesion was locally excised. The diaphragmatic defect was closed with non-absorbable suture. Recovery was uneventful and the patient was discharged on postoperative day 4. Pathology confirmed HCC cells infiltrating to skeletal muscle and fibrous tissue. The resection margin was clear. Post-operatively AFP normalised. Serial abdominal CT and ultrasound revealed no evidence of recurrent disease. Patient had a disease-free survival of 47 months after excision of tumor seeding.


Hepatocellular carcinoma Tumor rupture Tumor seeding Robotic surgery 



None of the authors assume any financial interest or support.

Compliance with ethical standards

Conflict of interest

Dr. Kit Fai Lee declares that he has no conflict of interest. Dr. Hon Ting Lok declares that he has no conflict of interest. Dr. Andrew KY Fung declares that he has no conflict of interest. Dr. Charing CN Chong declares that she has no conflict of interest. Dr. Yue Sun Cheung declares that he has no conflict of interest. Dr. John Wong declares that he has no conflict of interest. Prof. Paul BS Lai declares that he has no conflict of interest.

Ethical approval

This article does not contain any studies with human participants or animals performed by any of the authors.

Informed consent

Written informed consent was obtained from the patient for publication of this Case Report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.


  1. 1.
    Jemal A, Bray F, Center MM, Ferlay J, Ward E, Forman D (2011) Global cancer statistics. CA Cancer J Clin 61(2):69–90CrossRefGoogle Scholar
  2. 2.
    Chen CY, Lin XZ, Shin JS, Lin CY, Leow TC, Chen CY, Chang TT (1995) Spontaneous rupture of hepatocellular carcinoma. A review of 141 Taiwanese cases and comparison with nonrupture cases. J Clin Gastroenterol 21(3):238–242CrossRefGoogle Scholar
  3. 3.
    Matsukuma S, Sato K (2011) Peritoneal seeding of hepatocellular carcinoma: clinicopathological characteristics of 17 autopsy cases. Pathol Int 61(6):356–362CrossRefGoogle Scholar
  4. 4.
    Hsueh KC, Fan HL, Chen TW, Chan DC, Yu JC, Tsou SS, Chang TM, Hsieh CB (2012) Management of spontaneously ruptured hepatocellular carcinoma and hemoperitoneum manifested as acute abdomen in the emergency room. World J Surg 36(11):2670–2676CrossRefGoogle Scholar
  5. 5.
    Fung AKY, Chong CCN, Lee KF, Wong J, Cheung YS, Fong AKW, Lai PBS (2017) Outcomes of emergency and interval hepatectomy for ruptured resectable hepatocellular carcinoma: a single tertiary referral centre experience. Hepatoma Res 3:196–204Google Scholar
  6. 6.
    Lin CH, Hsieh HF, Yu JC, Chen TW, Yu CY, Hsieh CB (2006) Peritoneal lavage with distilled water during liver resection in patients with spontaneously ruptured hepatocellular carcinomas. J Surg Oncol 94(3):255–256CrossRefGoogle Scholar
  7. 7.
    Ho CL, Chen S, Yeung DW, Cheng TK (2007) Dual-tracer PET/CT imaging in evaluation of metastatic hepatocellular carcinoma. J Nucl Med 48(6):902–909CrossRefGoogle Scholar
  8. 8.
    Kosaka A, Hayakawa H, Kusagawa M, Takahashi H, Okamura K, Mizumoto R, Katsuta K (1999) Successful surgical treatment for implanted intraperitoneal metastases of ruptured small hepatocellular carcinoma: report of a case. Surg Today 29(5):453–457CrossRefGoogle Scholar
  9. 9.
    Ryu JK, Lee SB, Kim KH, Yoh KT (2004) Surgical treatment in a patient with multiple implanted intraperitoneal metastases after resection of ruptured large hepatocellular carcinoma. Hepatogastroenterology 51(55):239–242Google Scholar
  10. 10.
    Hai S, Okada T, Iimuro Y, Hirano T, Suzumura K, Fujimoto J (2015) Successful laparoscopic extirpation of peritoneal dissemination after hepatectomy for ruptured hepatocellular carcinoma. Asian J Endosc Surg 8(4):465–467CrossRefGoogle Scholar
  11. 11.
    Eriguchi N, Aoyagi S, Okuda K, Tamae T, Fukuda S, Kanazawa N, Hamada S, Kawabata M, Nishimura K, Kodama T (2000) Successful surgical treatment for implanted intraperitoneal metastases of hepatocellular carcinoma. J Hepatobiliary Pancreat Surg 7(5):520–523CrossRefGoogle Scholar
  12. 12.
    Yeh CN, Chen MF, Jeng LB (2002) Resection of peritoneal implantation from hepatocellular carcinoma. Ann Surg Oncol 9(9):863–868CrossRefGoogle Scholar
  13. 13.
    Chou HS1, Lee KF, Yeh CN, Chen MF, Jeng LB (2005) Long-term survival following resection of peritoneal implantation from hepatocellular carcinoma: a case report. Hepatogastroenterology 52(64):1221–1223Google Scholar

Copyright information

© Springer-Verlag London Ltd., part of Springer Nature 2018

Authors and Affiliations

  1. 1.Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Prince of Wales HospitalThe Chinese University of Hong KongHong Kong SARChina

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