Ann Thorac Surg 2001;72:632-633
© 2001 The Society of Thoracic Surgeons
How to do it
New technique for the cystic mediastinal tumor by video-assisted thoracoscopy
Akinori Iwasaki, MD, PhDa,
Masafumi Hiratsuka, MD, PhDa,
Katsunobu Kawahara, MD, PhDa,
Takayuki Shirakusa, MD, PhDa
a Second Department of Surgery, School of Medicine, Fukuoka University, Fukuoka, Japan
Accepted for publication February 4, 2001.
Address reprint requests to Dr Iwasaki, Second Department of Surgery, School of Medicine, Fukuoka University, 45-1, 7 chome Nanakuma, Jonan-ku, Fukuoka 814-0180, Japan
e-mail: iwasaki{at}fukuoka-u.ac.jp
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Abstract
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Thoracoscopic operations for benign mediastinal tumors have been useful. However, it is difficult to remove cystic mediastinal tumors completely because of their cystic structure. We herein describe a useful technique of tumor cannulation that allows for the simple and safe removal of these tumors.
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Introduction
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Video-assisted thoracic surgery (VATS), performed with increasing frequency, appears to offer the potential benefit of reduced morbidity compared with standard thoracotomy. The procedure is used in numerous settings such as evaluating and treating pulmonary disease, pleural disease, and mediastinal disease. It has also been adapted to treat mediastinal tumors. However, difficulties arise in treating cystic mediastinal tumors; when VATS is applied, thin cystic walls rupture easily and cannot be removed completely. Tension cysts also interfere with thoracoscope vision and increase the likelihood of complications resulting from injury to the neighboring vessels and nerves.
Incomplete resection may result in a recurrence or continued fluid production by the residual cyst wall Therefore, it is important to resect cystic mediastinal tumors completely, as noninvasively as possible, and remove them without rupture. We describe a simple new technique to facilitate complete cyst removal.
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Technique
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Patients are placed in a semilateral position. Three 11.5-mm trocars are inserted into the eighth and fourth intercostal space (ICS) (Fig 1A). A 10-mm, 30° angled thoracoscope is used. After deflating the lung, a small guide needle (3.3 mm) punctures the intercostal space and is placed firmly in front of the tumor. Then, a cannula with a balloon chorangiography catheter (Arrow International Inc, Reading, PA; catalog number CS-1700) is inserted through the guide needle. The diameter of this tube is 1.32 mm and consists of two lumens, one for the balloon and one for the outflow or inflow port. The proximal catheters are connected to syringes (Fig 1B).
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Fig 1. (A) Three 11.5-mm trocars are placed in the eighth and fourth intercostal space. A catheter is placed against the tumor through the intercostal space. (B) The instrument for cannulation (A = air injection port; B = outflow or inflow port; C = balloon; D = top of instrument) (diameter 1.32 mm, made of silicone).
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The guide needle directly punctures the center of the cystic tumor and a cannula is inserted quickly (Fig 2A). The balloon is then inflated with air and sealed as soon as possible. After this maneuver, the guide needle is removed. Leakage from the tumor can be avoided because the air-filled balloon floats and adheres to the cystic inner wall (Fig 2B). Next, the cystic liquid is gradually removed through the other catheter by the syringe. The expanded tumor is easily deflated cleanly by this catheter (Fig 2C). This enables reduction of the high pressure against the cyst wall to accurately show the anatomy surrounding the tumor. During the operation, this technique allows for cytologic diagnosis if necessary. After deflating the tumor, a distinct margin between the thin cystic wall and surrounding tissue remains and is easily visualized. However, complete collapse of the cyst is not useful because it makes identification of the cyst difficult. Therefore, aspiration of the cyst must be controlled. If too much suction is applied, the cyst is simply refilled with an adequate volume of saline to detect the wall. The entire cystic mediastinal tumor can then be resected safely and placed into a covered bag. The cannula is then extracted. Finally, the cystic tumor is removed from the thoracic cavity. After this complete resection, the cannula is reinserted into the removed tumor and filled with saline to confirm its integrity (Fig 3).
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Fig 2. Cannula application for thoracoscopic resection of the cystic mediastinal tumor. (A = puncture; B = ballooning; C = drainage and deflation.)
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Comment
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Recently, VATS has been applied to benign mediastinal tumors [1, 2]. These generally can be separated into two types, solid and cystic, with cystic tumors generally being bronchogenic, pericardial, or thymic cysts. To prevent cystic rupture and subsequent complications, we developed a new technique using a small, double-lumen cannula with a balloon.
One of the documented advantages of this technique is that the balloon floats in the tumor’s inner liquid space, and adjusts to the thin wall. The other advantage is evacuation of cyst fluid through the second lumen simultaneously without leakage. This method improves vision and facilitates resection without causing injury to the tumor during VATS. Improved visualization is important because VATS typically requires a wide surgical field. After the operation, we confirm complete and intact resection by refilling the removed tumor with saline. We consider this new technique of cannulating cystic mediastinal tumors beneficial during VATS We have successfully treated 3 patients using this technique.
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References
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Sugerbaker D.J. Thoracoscopy in the management of anterior mediastinal masses. Ann Thorac Surg 1993;56:653-656.[Abstract/Free Full Text]
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Naunheim K.S. Video thoracoscopy for masses of posterior mediastinum. Ann Thorac Surg 1993;56:657-658.[Abstract/Free Full Text]
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Abstract
Introduction
