Ann Thorac Surg 1999;68:2339-2341
© 1999 The Society of Thoracic Surgeons
Case Reports
Thymic cystectomy through subxyphoid by video-assisted thoracic surgery
Shinji Akamine, MD, PhDa,
Takao Takahashi, MDa,
Tadayuki Oka, MDa,
Koji Kishimoto, MDa,
Hiroyoshi Ayabe, MDa
a First Department of Surgery, Nagasaki University School of Medicine, Nagasaki, Japan
Address reprint requests to Dr Akamine, First Department of Surgery, Nagasaki University School of Medicine, 1-7-1, Sakamoto, 852-8501 Nagasaki, Japan
e-mail: shinji{at}net.nagasaki-u.ac.jp
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Abstract
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In this paper we present a new technique for thymic cystectomy by video-assisted thoracic surgery. The thoracoscope was inserted using a Vein Harvest (Ethicon Endo-Surgery Co, Ltd, Cincinnati, OH) through a 5-cm subxyphoid incision. A Harmonic Scalpel (Ethicon Endo-Surgery) and Cherry Dissector (Ethicon Endo-Surgery) were used for dissection. The thymic cyst was successfully removed through the incision without thoracotomy. The advantage of this technique is that it is less invasive than video-assisted thoracic surgery through the thorax, removing the need for a thoracotomy.
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Introduction
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Video-assisted thoracic surgery (VATS) has become a popular operation for the treatment of thoracic diseases, including benign lung tumors, pneumothorax, lung biopsy, and mediastinal cysts [1], and has shown to be helpful in the management of mediastinal mass lesions. The great advantage of VATS is that it is less invasive and leads to improved recovery times compared to standard thoracotomy. However, some patients who undergo VATS through the thoracic wall still complain of chest pain. This may be caused by damage to the ribs during manipulation of the scope and forceps [2]. Nonetheless, it was hoped we could use this approach to treat an anterior mediastinal cyst without thoracotomy. Here we demonstrate the new surgical technique of thymic cystectomy by VATS.
The patient was a 74-year-old woman who showed an abnormal shadow on chest roentgenogram, following hypertension. Chest roentgenogram showed a mass shadow of 5 cm in diameter at the left hilum. Chest CT showed a low-density, thin wall mass without solid lesion, while chest MRI showed low intensity on T1 and high intensity on T2. Therefore, a thymic cyst in the left thymic lobe was suspected. With informed consent of the patient we proceeded to perform a cystectomy without thoracotomy using a subxyphoid approach. Under general anesthesia, a double-lumen endotracheal tube was employed for one-lung ventilation. The patient was placed in the supine position and a transverse incision of about 5 cm was made at the subxyphoid. A 30-degree, 5-mm operating scope was inserted into the Vein Harvest device (Ethicon Endo-Surgery Co, Ltd, Cincinnati, OH). The sternum was elevated using an Octopus (Yufu Co, Ltd, Tokyo, Japan) and the Vein Harvest (Ethicon Endo-Surgery Co, Ltd) device introduced through the incision to explore the anterior mediastinum. The left thymic gland was first dissected from the pericardium using the top of the Vein Harvest (Ethicon Endo-Surgery Co, Ltd) device and a Cherry Dissector (Ethicon Endo-Surgery Co Ltd) and the cyst was located in the left thymic region. When the left lobe was dissected from the pleura, ventilation of the left lung was turned off, which assisted the visualization of the anterior mediastinum space. Fascicular structures were divided using a Harmonic Scalpel (Ethicon Endo-Surgery Co, Ltd) and the left brachiocephalic vein was explored by blunt dissection using the Cherry Dissector (Ethicon Endo-Surgery Co, Ltd). These instruments were introduced through the incision without a trocar. The thymic gland was transected using the Harmonic Scalpel (Ethicon Endo-Surgery Co, Ltd) and, because according to radiographic findings the lesion was benign, it did not matter that the cystic wall ruptured and the content of serous fluid was released. Histological examination confirmed that the lesion was a benign thymic cyst. Thus, cystectomy in the left lobe of thymus was successfully performed without thoracotomy. The operating time was 2 hours and 30 minutes, with approximately 20 mL intraoperative bleeding. The mediastinal drainage tube was removed within 24 hours postoperatively, and the patient’s postoperative course was uneventful. The patient did not complain of chest pain and was discharged 6 days after surgery.
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Comment
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In this report we have demonstrated a new approach through the subxyphoid to an anterior mediastinal thymic cyst. The surgical technique was established using a Vein Harvest and a Harmonic scalpel (Ethicon Endo-Surgery Co, Ltd). The advantages of this technique were less pain compared to VATS through the chest wall and removal of the need to perform a thoracotomy.
The use of VATS is growing in popularity and the number of indications is increasing. The reasons for this advancement are due to developments in light optics and improved operating instruments and stapling devices. A wide range of thoracic disorders now indicate the use of VATS, including lung neoplasmas, pneumothorax, emphysema, thoracic sympathectomy, mediastinal tumors such as neurogenic tumors, pericardial cysts, thymic cysts, and thymoma. Although the indication of VATS for lobectomy and thymectomy are still controversial, the use of VATS for mediastinal cysts is becoming more accepted. The VATS technique has been established in our institution since 1992, and we have carried out approximately 200 operations for pulmonary disorders, mediastinal cysts, and neurogenic tumors. Approaches to the anterior mediastinum by VATS have been reported using the unilateral or bilateral thoracic routes [3]. Although postoperative pain is remarkably reduced after VATS compared to conventional thoracotomy [4], and VATS is less invasive, some patients still complain of chest pain, which was probably related to the trocar for the scope and forceps [2].
The first benefit of the subxyphoid approach to the mediastinum was that it is less painful than VATS through the chest wall. Pain after VATS may be due to the frequent manipulations of the instruments through the trocars [2], which may injure the intercostal nerve. Therefore, we attempted to carry out thymic cystectomy without going through the chest wall. The pain may also be associated with the narrow intercostal space between the ribs and the size of the trocar. In the past, our institution used a 10-mm trocar, however, because 3-mm scopes and instruments are now available, the pain associated with 10-mm trocars has been reduced. Although the patient stayed in hospital for 6 days after the surgery, the patient was cleared to be discharged at the second postoperative day.
Another benefit of the subxyphoid approach was that it removed the need to perform a thoracotomy. When VATS through the chest wall is performed, one-lung ventilation is necessary in providing surgical exposure. However, patients with respiratory disorders had an increased risk of systemic hypoxia. Moreover, VATS could not be carried out through the thorax in cases with adhesions in the thorax, due to previous thoracotomy, for example. Although one-lung ventilation facilitated the dissection of the cyst from the left side of the pleura in this report, it may be possible to remove such cysts without one-lung ventilation.
The main potential problem with this procedure was the lack of surgical visualization. The space between the sternum and pericardium was narrow and restricted the manipulation of the forceps. To solve this problem, we used an Octopus (Yofu Co, Ltd) retractor; however, the force of retraction used was not enough to lift the sternum. The Vein Harvest device was developed by Ethicon Endo-Surgery Co, Ltd for harvesting the saphenous vein for use during coronary bypass procedures [5]. It enables the dissection of the vein with good visualization along the entire vein being harvested. The scope is, placed into the Vein Harvest (Ethicon Endo-Surgery Co, Ltd) device and inserted into the anterior mediastinum, the scope surface thus protected by a pellucid cover. When the Vein Harvest (Ethicon Endo-Surgery Co, Ltd) device was used for this operation, it was inserted directly through the incision of the subxyphoid and directed behind the body of the sternum. The thymic cyst could then be easily identified. Another key product development was the Harmonic Scalpel (Ethicon Endo-Surgery Co, Ltd), which is an ultrasonically activated surgical device for cutting and coagulating tissue. It is able to coagulate vessels up to 3 mm diameter [6]. Like electrosurgery and laser surgery, the Harmonic Scalpel (Ethicon Endo-Surgery Co, Ltd) forms a coagulum by heating tissues to denatured protein. Vessels are then sealed by tamponading and coating with the denatured protein coagulum. The cutting mechanism of the Harmonic Scalpel (Ethicon Endo-Surgery) is by cavitational fragmentation; the actual cutting power is produced by a blade vibrating at 55,500 times per second. Therefore, we were able to perform this procedure without generating smoke.
The indications for this procedure would be benign anterior mediastinal lesions. As thymomas involve malignant potential, we suggest thymic tumors should be a contraindication. In this report, the mass was determined to be a benign cyst by radiographic findings, and was therefore removed without prior needle aspiration or cytology of the contents.
In conclusion, the subxyphoid approach is an effective option to expose the anterior mediastinum. The advantages of this procedure are the reduction in pain compared with conventional VATS through the chest wall, and removal of the need for a thoracotomy.
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References
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Jordan W.D., Jr, Voellinger D.C., Schroeder P.T., McDowell H.A. Video-assisted saphenous vein harvest. J Vasc Surg 1997;26:405-412.[Medline]
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Accepted for publication May 9, 1999.
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Abstract
Introduction
