Ann Thorac Surg 2002;74:1724-1726
© 2002 The Society of Thoracic Surgeons
How to do it
Cosmetic approach to anterior mediastinal masses
Charles F. Bellows, MDa,
Renee S. Hartz, MDa*,
Carey Cullinane, MDa,
John D. Pigott, MDa
a Department of Surgery, Tulane University School of Medicine, New Orleans, Louisiana, USA
Accepted for publication May 1, 2002.
* Address reprint requests to Dr Hartz, Department of Surgery, SL22, Tulane University School of Medicine, 1430 Tulane Ave, New Orleans, LA 70122, USA.
e-mail: rshartzmd{at}aol.com
 |
Abstract
|
|---|
A new approach for the removal of thymic tissue or any anterior mediastinal pathology is described. It uses a novel low U-shaped skin incision combined with a J-shaped upper mini-sternotomy. This technique was designed to provide wide exposure of the mediastinum and to be cosmetically appealing. Our study included 12 patients, 4 with a preoperative diagnosis of myasthenia gravis. There were no operative mortality and three complications. This procedure allows for complete removal of all thymic tissue under direct vision, and is less invasive that full sternotomy.
|
Introduction
|
|---|
Considerable controversy is encountered whenever surgical approaches to thymectomy are discussed, especially when myasthenia gravis is present. Although median sternotomy is the most common approach, procedures vary from video-assisted thoracoscopic removal of the thymus or tumor to transcervical–transsternal maximal thymectomy [1, 2]. We have developed a modification of the partial sternotomy technique described by Trastek [3], which combines the advantages of "no touch thymectomy" with a more limited approach. A low U-shaped skin incision combined with a transsternal J incision that avoids inadvertent sternal fractures is the main differences in our technique. This report outlines the important aspects of this minimally invasive technique and our experience in patients with mediastinal masses.
|
Technique
|
|---|
The patient is placed in the supine position with a transverse shoulder roll providing neck extension. A double lumen endotracheal tube is unnecessary. First, a low U- shaped skin incision is made from a midline point 2 cm beneath the manubrial–sternal junction and extending bilaterally toward the midclavicular lines (Fig 1).
A subcutaneous flap is created cephalad until the sternal notch is well visualized. Inferiorly, the dissection is continued until the third or fourth intercostal space (based on preoperative radiologic examinations) is exposed. Electrocautery is used to deeply inscribe a J-shaped groove in the periosteum of the sternum, which starts at the sternal notch and is extended as a "J" just to the third or fourth interspace on the side of the sternum to be transected. The sternotomy is then made from the sternal notch to the superior border of the fourth or fifth rib using a mini-sternotomy saw or hammer and chisel (Fig 2).
Extreme care is taken to avoid injury to the internal mammary artery on the ipsilateral side, and the sternum is not fractured. Extension into the pleural cavity can be undertaken if a malignant process is encountered or if other intrathoracic pathology must be addressed.
View larger version (33K):
[in this window]
[in a new window]
|
Fig 1. A low U-shaped skin incision is made from a midline point 2 cm beneath the manubrial–sternal junction and extending bilaterally toward the midclavicular lines.
|
|
View larger version (33K):
[in this window]
[in a new window]
|
Fig 2. A J-shaped sternal incision is then made from cephalad to caudad to the superior border of the third (solid line) or fourth (dashed line) rib.
|
|
After sweeping the pleural spaces laterally with blunt dissection, a pediatric sternal retractor is placed. We do not use the Upper Hand Retractor (Specialty Surgical Instrumentation, Nashville, TN) but often use an internal mammary artery retractor (such as the Delacroix Chevalier [Johnson and Johnson Health Care Systems, Piscataway, NJ] with miniature blades) to elevate each side of the sternum separately. Keeping in mind the principles of complete removal of all thymic tissue and avoidance of traction of the gland (especially in patients with myasthenia gravis) the thymectomy is started. We find it easier to dissect the upper poles first, and completely skeletonize the innominate vein as the dissection is continued toward the diaphragm. Mediastinal fat and pleura are included with the specimen. When removing the lower poles, a surgical assistant retracts the lower end of the sternum toward the ceiling so that the entire gland can be removed under direct vision. It is essential to identify and avoid injury to the phrenic nerves. However, when the decision is made to remove one nerve in a patient with good respiratory function and a malignant thymoma, the ipsilateral pleural space can be opened widely. After the thymectomy is completed, the sternum is closed with heavy Mersilene (or wire) sutures (Ethicon, Inc, Somerville, NJ). A figure of eight suture is placed around the ribs and lower sternum if the sternum is especially friable, but is not necessary in all patients. A drain is placed in the mediastinum and another beneath the subcutaneous flap. The fascia and subcutaneous tissue are then closed in layers.
|
Results
|
|---|
This procedure was performed on 12 patients during the period from 1998 to 2001. The mean patient age was 49 years (range 21 to 71 years) and 58% were women. Indications for operation and final pathology were thymoma or thymic hyperplasia (8 patients, 4 of whom had myasthenia), pericardial cyst (1 patient), necrotic germ cell tumor (1 patient), necrotizing lymphadenitis (1 patient), and desmoid tumor (1 patient). All patients were extubated on the operating room table. One was reintubated 48 hours later and required plasmapheresis and increases in her medications for myasthenia before again extubating her. The mean length of hospital stay was 4.4 days (range 3 to 11 days). Mean follow-up was 8.1 months (1 to 30 months), and 1 patient was lost to follow-up.
There was no related mortality and only three complications, none of which resulted in long-term disability. One patient, a 42-year-old steroid-dependent, asthmatic woman with a malignant thymoma was found to have nonunion of her sternum at 6-month follow-up. There was no deterioration in her pulmonary function and she refused operation to correct the nonunion. Another patient developed a small seroma beneath the skin flap that resolved in less than 2 weeks without surgical intervention, and a third patient required a single thoracentesis for a postoperative pleural effusion.
Two male patients with myasthenia gravis best exemplify the benefits of this technique. The first, a 35-year-old 148-kg patient underwent thymectomy and was discharged on postoperative day 3. He has had no recurrence of his myasthenia at 1-year follow-up. Figure 3
demonstrates the cosmetic result obtained with our technique and also points out that the operation can be easily accomplished in large patients. The second, a 34-year-old with severe myasthenia required hospitalization and repeated plasmapheresis for 1 week before operation. This patient underwent thymectomy and was discharged within 3 days of operation. His myasthenia medications were gradually tapered and finally discontinued at home.
View larger version (109K):
[in this window]
[in a new window]
|
Fig 3. A 3-month postoperative photo of a 148-kg, 35-year-old patient after thymectomy for myasthenia gravis. Note the low, short skin incision (arrow).
|
|
|
Comment
|
|---|
In this era of limited access surgery, patients present to their physicians expecting little postoperative pain, short hospital stays, and excellent cosmetic results. In the case of thymectomy, these goals should not be compromised. Therefore, we devised a minimally invasive technique that combines a novel, highly cosmetic skin incision with a partial sternotomy, providing excellent exposure of the entire mediastinum while still maintaining the objectives of minimal postoperative pain and short hospitalizations.
An important merit of this technique, like other partial sternotomy variants [4], is that it reduces the surgical trauma to the chest wall. It also makes possible the complete removal of thymic tissue and avoidance of postoperative myasthenic crisis by avoiding excessive manipulation of the gland. However, our technique may offer an advantage in respect to cosmesis. Another advantage in our approach is that the sternum is purposely transected on the desired side rather than fractured. One-half of the body of the sternum is left intact and in union with the manubrium, thus allowing for greater sternal stability in the postoperative setting. Avoidance of major morbidity and short hospital stays suggest that this is a safe and feasible surgical option in the treatment of anterior mediastinal pathology including thymectomy for myasthenia gravis.
|
References
|
|---|
- Landreneau R.J., Mack M.J., Hazelrigg S.R., et al. Video-assisted thoracic surgery. basic technical concepts and intercostal approach strategies. Ann Thorac Surg 1992;54:800-807.[Abstract/Free Full Text]
- Jaretzki A., III, Penn A.S., Younger D.S., et al. Maximal thymectomy for myasthenia gravis: results. J Thorac Cardiovasc Surg 1988;95:747-757.[Abstract]
- Trastek V.F. Thymectomy. In: Kaiser L.R., Kron I.L., Spray T.L., eds. Mastery of cardiothoracic surgery. Philadelphia: Lippincott-Raven, 1998:105-111.
- Grandjean J.G., Lucchi M., Mariani M.A. Reversed-T upper mini-sternotomy for extended thymectomy in myasthenic patients. Ann Thorac Surg 2000;70:1423-1424.[Abstract/Free Full Text]
This article has been cited by other articles:
|
|
|
|
 
M. Boaron
Reply
Ann. Thorac. Surg.,
June 1, 2006;
81(6):
2337 - 2338.
[Full Text]
[PDF]
|
|
|
|
|
|
|
M. A. Boaron
A new retraction-suspension device for limited upper sternotomy
Ann. Thorac. Surg.,
March 1, 2004;
77(3):
1107 - 1108.
[Abstract]
[Full Text]
[PDF]
|
|
|
Top
Abstract
Introduction
