A novel surgical approach to refractory hepatic hydrothorax

Hepatic hydrothorax is defined as the presence of a pleural effusion in a patient with liver cirrhosis in the absence of cardiopulmonary disease, and it is a devastating complication impairing quality of life in the end stage of liver disease. The management of the effusion is challenging, and chest tube drainage can sometimes cause more serious complications by removing massive amounts of protein-rich fluid. Though the most plausible mechanism is the influx of ascites to the pleural cavity through a small diaphragmatic defect, the defect often cannot be found. Hepatic hydrothorax could be controlled by repairing an invisible defect of the diaphragm. With pneumoperitoneum after intraperitoneal administration of indocyanine green, the defect, clearly dyed green, appeared on the diaphragm. This novel combination technique could be useful for ensuring the surgical repair of an invisible diaphragmatic defect.