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Ann Thorac Surg 2003;75:602-604
© 2003 The Society of Thoracic Surgeons

How to do it

Videothoracoscopic resection of neurogenic tumors of the superior sulcus using the harmonic scalpel

François Pons, MDa*, Loïc Lang-Lazdunski, MD, PhDa, Pierre Mathieu Bonnet, MDa, Léon Meyrat, MDa, René Jancovici, MDa

a Department of Thoracic Surgery, Percy Military Hospital, Clamart, France

Accepted for publication August 1, 2002.

* Address reprint requests to Dr Pons, Service de Chirurgie Thoracique, Hôpital d’Instruction des Armées Percy, 101 ave Henri Barbusse, 92141 Clamart Cedex, France
e-mail: fpons{at}mail3.imaginet.fr


   Abstract
Top
 Abstract
Introduction
 Technique
 Comment
 References
 
Resection of neurogenic tumors located in the paravertebral sulcus carries a risk of injury to the adjacent nervous structures and also to critical intercostal arteries supplying the anterior spinal artery. To avoid such complications, we have used the Harmonic Scalpel (Ethicon Endo-Surgery, Cincinnati, OH) for the dissection of neurogenic tumors in 2 consecutive patients operated on by videothoracoscopy. The Harmonic Scalpel functions with ultrasonic energy, producing less heat than a regular electrocautery and allows a safer dissection of tumors located in the posterior mediastinum, particularly those located in the superior paravertebral sulcus.


   Introduction
Top
 Abstract
 Introduction
Technique
 Comment
 References
 
Videothoracoscopic resection of neurogenic tumors located in the posterior mediastinum has been reported feasible and safe in most patients [1, 2]. However, depending on their precise location, resection of such tumors can result in damage to the adjacent nervous and vascular structures or even to the spinal cord through critical segmental artery injury [3]. The Harmonic Scalpel (Ethicon Endo-Surgery, Cincinatti, OH) has been used successfully for endoscopic harvesting of the internal mammary artery and for port-access first rib resection [4, 5].

We report herein the use of the Harmonic Scalpel during videothoracoscopic resection of neurogenic tumors of the superior paravertebral sulci in 2 patients, to reduce the risk of neurologic or vascular injury during tumor dissection.


   Technique
Top
 Abstract
 Introduction
 Technique
Comment
 References
 
The Harmonic Scalpel functions with ultrasonic energy, vibrating to 55,500 Hz [4, 5]. This device allows for the coagulation and division of tissues with less heat and less smoke than a regular electrocautery (less than 100°C compared with more than 100°C, respectively).

Beginning on July 2001, 2 consecutive patients have been operated on with the Harmonic Scalpel during videothoracoscopic resection of neurogenic tumors of the superior paravertebral sulci (Table 1). Both patients had preoperative chest magnetic resonance imaging (Fig 1) and neurosurgical consultation to rule out intradural extension of the tumor, which would have required a combined neurosurgical and thoracic surgical approach [6]. Neither patient had von Recklinghausen’s disease.


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  		Table 1. Clinical Information for the 2 Patients

 


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  		Fig 1. Magnetic resonance imaging of a neurofibroma of the right superior sulcus. The segmental level is T1–T2. There is no invasion of the spinal canal. The tumor lies in close contact with the stellate ganglion and with the subclavian artery (arrow).

 
After establishment of general anesthesia with a double-lumen endotracheal tube to allow complete collapse of the left or right lung, the patient was placed in a full lateral decubitus position. Patients were draped as for a standard posterolateral thoracotomy. A first port was placed in the sixth intercostal space, on the midaxillary line and two other ports were placed anteriorly in the fourth and sixth intercostal spaces. We used a 10-mm 0-degree lens introduced through the posterior trocar. We used exclusively endoscopic instruments and 5-mm Harmonic Scalpel scissors or hook blade throughout the procedure (Fig 2). The pleural cavity was explored and the nervous and vascular structures surrounding the tumor were identified. The parietal pleura overlying the tumor was incised with the hook blade of the Harmonic Scalpel (power setting level 5) and tumor dissection was carried out along its border (Fig 3). Enucleation of the tumor was performed step by step, avoiding excessive traction of the tumor, and by gently handling the tumor superiorly, laterally, and inferiorly. We started the dissection on a rib, thereby avoiding injury to the intercostal bundles. Then, tissues were coagulated and divided with the Harmonic Scalpel (power setting level 3 to 5), trying to identify the intercostal nerves and vessels. The attachment of the tumor to the sympathetic chain or intercostal nerve was divided last. All the tumors were removed using an endoscopic bag to prevent potential contamination of a trocar incision with malignant cells should the tumor prove to be malignant. A 20F chest tube was placed in the paravertebral sulcus and the incisions were closed in layers. The patients were discharged home within 4 days of operation and have been well since that time.



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  		Fig 2. Operative view of the Harmonic Scalpel. The hook blade was used for incision of the parietal pleura surrounding the tumor.

 


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  		Fig 3. Resection of the schwannoma. The tumor was grasped and progressively dissected free from intercostal nerves and vessels with the hook blade. Care was taken to respect the stellate ganglion.

 

   Comment
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 Abstract
 Introduction
 Technique
 Comment
References
 
Videothoracoscopy is a minimally invasive and safe approach for resecting intrathoracic neurogenic tumors [1, 2]. Even in those tumors with intradural extension, videothoracoscopy can be used safely after a neurosurgical resection has been performed first in the neural canal [1, 2]. A limited minithoracotomy is usually required for tumors larger than 6 cm [1, 2].

Resection of neurogenic tumors located in the posterior mediastinum may result in damage to intercostal nerves or vessels. When these tumors are located in the superior sulcus, other structures such as pneumogastric and phrenic nerves, brachial plexus, stellate ganglion, subclavian and vertebral arteries, or thoracic duct, may also be damaged during tumor resection. Spinal cord injury is unusual, but may result from injury to some critical intercostal arteries supplying the anterior spinal system [7]. Because of this possible complication, we routinely perform preoperative selective angiography of intercostal arteries to localize the segmental arteries that supply the anterior spinal system in patients with tumors located in the paravertebral sulci between the T5 and T12 level. Thus, the Adamkiewicz artery can arise either from a left intercostal artery (75%) or a right intercostal artery (25%), and mostly between T9 and L1 [7]. However, postoperative paraplegia has also been reported in patients with neurogenic tumors located in the T1 to T5 area [3]. Electrically induced injury to the spinal cord can also result in postoperative neurologic deficit [8]. Considering this dreaded complication, we now routinely use the Harmonic Scalpel to remove all tumors located in the posterior mediastinum.

The Harmonic Scalpel represents an attractive alternative to electrocautery because it has the advantage of producing less smoke and less heat [4, 5]. Because it functions with ultrasonic energy, electrically induced injury can also be avoided [4]. Both hook blade or scissors can be used with different power setting levels (1 to 5) for tissues coagulation and division. Descottes and collaborators have shown that coagulating 3 seconds with identical power settings (50 W with monopolar diathermy, 50 W with bipolar diathermy, and level 3 with the Harmonic Scalpel) resulted in much lower temperature on the site of application with the Harmonic Scalpel: 206° ± 37°C, 91.5° ± 26°C, and 44° ± 9.8°C, respectively [9]. Moreover, thermal spreading, depth and width of tissue lesions were less with the Harmonic Scalpel [9].

We started using the Harmonic Scalpel in 1999, performing videothoracoscopic thoracic sympathectomies and splanchnicectomies. Then, we have used it routinely for to perform videothoracoscopic pericardial window, and for videothoracoscopic resection of mediastinal tumors, without detrimental effect. Coagulation of small vessels (including intercostal veins or arteries) is safe and efficient and can avoid the use of endoscopic clips, making the procedure faster and simpler [4]. In addition, the Harmonic Scalpel produces virtually no smoke, optimizing the visualization of the operative field; that is particularly important when using a videothoracoscopic approach. Thus, all procedure can be achieved in a safe and minimally invasive way using a three-ports technique, a 0-degree lens, an endoscopic grasper, and the Harmonic Scalpel.

We believe that the use of the Harmonic Scalpel simplifies VATS resections of intrathoracic neurogenic tumors.


   References
Top
 Abstract
 Introduction
 Technique
 Comment
 References
 

  1. Riquet M., Mouroux J., Pons F., et al. Videothoracoscopic excision of thoracic neurogenic tumors. Ann Thorac Surg 1995;60:943-946.[Abstract/Free Full Text]
  2. Liu H.P., Yim A.P., Wan J., et al. Thoracoscopic removal of intrathoracic neurogenic tumors: a combined chinese experience. Ann Surg 2000;232:187-190.[Medline]
  3. Giudicelli R., Pellet W., Fuentes P., Heurte P., Barthelemy A., Reboud E. Danger to the spinal cord arterial blood supply during surgery for posterior mediastinal neurinomas. Ann Chir 1991;45:692-694.[Medline]
  4. Ohtsuka T., Wolf R.K., Hiratzka L.F., Wurnig P., Flege J.B. Thoracoscopic internal mammary artery harvest for MICABG using the Harmonic Scalpel. Ann Thorac Surg 1997;63:S107-109.
  5. Ohtsuka T., Wolf R.K., Dunsker S.B. Port-access first rib resection. Surg Endosc 1999;13:940-942.[Medline]
  6. Grillo H.C., Ojemann R.G., Scannel J.G., Zervas N.T. Combined approach to dumbbell intrathoracic and intraspinal tumors. Ann Thorac Surg 1983;36:402-407.[Abstract/Free Full Text]
  7. Lazorthes G., Gouaze A., Zadeh J.O., Santini J.J., Lazorthes Y., Burdin P. Arterial vascularization of the spinal cord. Recent studies of the anastomotic substitution pathways. J Neurosurg 1971;35:253-262.[Medline]
  8. Kumagai Y., Shimoji K., Honma T., et al. Problems related to dorsal entry zone lesions. Acta Neurochir (Wien) 1992;115:71-78.
  9. Descottes B, Durand–Fontanier S, Sodji M, Deleuze A. Therral spread with various modalities on different tissues. Proceeding of the 8th International Congress of the European Association for Endoscopic Surgery. Monduzzi, ed. 2000:187–90.



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