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Ann Thorac Surg 1999;67:263-265
© 1999 The Society of Thoracic Surgeons

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How To Do It

Resection of anterior mediastinal masses through an infrasternal approach

^a Department of Surgery, Osaka Prefectural General Hospital, Osaka, Japan

Accepted for publication July 2, 1998.

Address reprint requests to Dr Kido, Department of Surgery, Osaka Police Hospital, 10-31, Kitayama-chou, Tennouji-ku, Osaka, 543-8502, Japan

	Abstract

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A video-assisted surgical technique for benign anterior mediastinal lesions is described. In 3 patients, the Laparolift system was used to lift the lower sternum before resection. This operation is less invasive and cosmetically more pleasing than median sternotomy. Unlike thoracoscopy, this procedure avoids opening the chest and can be performed in patients with pleural adhesions or pulmonary insufficiency in whom differential lung ventilation is impossible. At present, this technique is considered suitable only for benign lesions.

	Introduction

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Recently, because of the improvements in endoscopic procedures, a limited operation for anterior mediastinal lesions that does not require a median sternotomy was developed, and video-assisted surgical intervention with various approaches have been reported [1–3]. In this study, we used the Laparolift System (Origin Co, Ltd), developed for abdominal operations, to lift the sternum and resected anterior mediastinal lesions in 3 patients.

	Technique

Top Abstract Introduction Technique Material and results Comment References

 
General anesthesia was administered with oral intubation and bilateral lung ventilation. The patients were placed in a straddled, supine, and cervically extended position so that the surgeon could place himself in the interfemoral midline to operate on the anterior superior mediastinum. A transverse incision was made about 5 cm above the xiphoid process. The wound was draped with rubber sheeting to prevent skin contamination. The rectus abdominis was detached, and the xiphoid process was excised. The posterior table of the sternum was exposed to insert the Laparofan (Origin, Co, Ltd, Menlo Park, CA) into the lower part of the sternum, and the inferior thoracic wall was lifted with the Laparolift (Origin Co, Ltd) (Fig 1). Then the mediastinoscope, Harmonic Scalpel (Ethicon Endo-Surgery, Inc, Cincinnati, OH), and graspers were inserted into the wound. A monitor was placed on the cranial side of the patient, and resection was conducted with an Olympus 30-degree–angled laparoscope.

View larger version (15K): [in this window] [in a new window]   Fig 1. Position of patient and instruments used. Anterior inferior thoracic wall is lifted with the Laparolift system (**) through the Laparofan (*) in the lower part of the sternum. Camera, grasper, and Harmonic Scalpel are inserted into the wound ().

	Material and results

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View larger version (115K): [in this window] [in a new window]   Fig 2. (A) Intraoperative photograph and (B) interpretation of patient with myasthenia gravis shows thymus (Thy), left lung (L), right lung (R), pericardium (P), and grasper (G).

View larger version (117K): [in this window] [in a new window]   Fig 3. (A) Intraoperative photograph and (B) interpretation of patient with mature cystic teratoma shows right phrenic nerve (Ph), right lung (R), and right edge of cystic tumor (E).

	Comment

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The surgical technique described here uses the episternal region as a fulcrum and therefore provides a larger visual field for the mediastinoscope than does the method of Ito and coauthors [6] in which the whole sternum is lifted. According to them, the only disadvantage is the long duration of operation. Our method is convenient, provides a good visual field under the mediastinoscope, and can be conducted within 3 hours.

Although thoracoscopic procedures other than thymectomy for anterior mediastinal lesions have been reported [2], there have been no studies regarding mediastinoscopic surgical procedures except excision of an upper mediastinal ectopic parathyroid gland with a transcervical approach by the method of Ohno and coworkers [3]. Our findings indicate that our method offers several advantages over median sternotomy: It is associated with lower morbidity as a result of fewer days in the hospital and a more rapid recovery and causes fewer cosmetic problems than a sternotomy because no midline scars remain. Additional advantages are that the pleural cavity is not opened and that our technique can be performed on patients with pleural adhesions, pulmonary insufficiency, or both in whom differential lung ventilation is impossible. Our procedure may provide a viable alternative to the conventional methods of median sternotomy or thoracoscopy in the treatment of benign anterior mediastinal lesions.

	References

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1. Landreneau R.J., Dowling R.D., Castillo W.M., Ferson P.F. Thoracoscopic resection of an anterior mediastinal tumor. Ann Thorac Surg 1992;54:142-144.[Abstract/Free Full Text]
2. Sugarbaker D.J. Thoracoscopy in the management of anterior mediastinal masses. Ann Thorac Surg 1993;56:653-656.[Abstract/Free Full Text]
3. Ohno K., Kuwata K., Yamasaki Y., Yamasaki H., Hatanaka N., Yamamoto S. Mediastinoscopic extirpation of mediastinal ectopic parathyroid gland. Ann Thorac Surg 1997;64:238-240.[Abstract/Free Full Text]
4. Sabbagh M.N., Garza J.S., Patten B. Thoracoscopic thymectomy in patients with myasthenia gravis. Muscle Nerve 1995;18:1475-1477.[Medline]
5. Andou A., Azuma T., Tsukazaki T., et al. Thoracoscopic extended thymectomy with collar incision of the neck in two patients with myasthenia gravis. J Jpn Assoc Chest Surg 1996;10:107-111.
6. Ito S., Tagawa T., Ide S., et al. Mediastinoscopic extended thymectomy using a sternum-lifting method. J Jpn Assoc Chest Surg 1997;11:181-185.

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Kido, T. Articles by Takao, T. Search for Related Content PubMed PubMed Citation Articles by Kido, T. Articles by Takao, T.