Ann Thorac Surg 2009;88:1371-1373. doi:10.1016/j.athoracsur.2009.01.032
© 2009 The Society of Thoracic Surgeons
How To Do It
Thorascopic Mediastinal Resection After Median Sternotomy and Mediastinotomy
M. Blair Marshall, MD*
Division of Thoracic Surgery, Department of Surgery, Georgetown University Medical Center, Washington, DC
Accepted for publication January 13, 2009.
* Address correspondence to Dr Marshall, Division of Thoracic Surgery, Department of Surgery, 4 PHC, Georgetown University Medical Center, 3800 Reservoir Rd, NW, Washington, DC 20007 (Email: mbm5{at}gunet.georgetown.edu).
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Abstract
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Previous mediastinal surgery may be considered a contraindication to minimally invasive resection of anterior mediastinal masses. We have found video-assisted thoracoscopic resection of anterior mediastinal masses to be technically feasible after sternotomy or chamberlain procedures. Changes in positioning and port location may facilitate these procedures.
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Introduction
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As thoracic surgeons increase their experience with minimally invasive techniques, the potential for their use is broadened. Minimally invasive surgery in the setting of previous thoracic procedures is feasible, but often technically challenging [1]. Standard port placement for thorascopic pulmonary surgery is not optimally suited for resection of superior anterior mediastinal masses in scarred tissue planes. Techniques to facilitate minimally invasive resection of anterior mediastinal masses after prior mediastinal surgery are described.
Patient 1 is a 74-year-old man who underwent a chamberlain procedure for diagnosis of a thymoma at an outside hospital (Fig 1). Resection of the second rib and ligation of the mammary vessels was performed during the procedure. His postoperative course was complicated by a hematoma. It was recommended that he undergo sternotomy for complete resection, but he sought a less invasive approach. He underwent a transcervical approach for resection, but due to extensive scarring, this was not safe for a complete resection. A left-sided video thoracoscope was placed and the resection was completed. The thymus with the thymoma and underlying pericardium was placed in a bag and removed through the cervical incision. His postoperative course was complicated by atrial fibrillation. He was discharged on postoperative day 4 in sinus rhythm. His final pathology revealed thymoma with negative margins.
Patient 2 is a 49-year-old man with metastatic thyroid cancer who previously underwent thyroidectomy and sternotomy for resection of synchronous primary and metastatic thyroid cancers. During this operation, he suffered a right vocal cord paralysis. Over the next several years, he subsequently underwent three additional cervical explorations for recurrent disease that was refractory to I131. He was evaluated for a new left paratracheal and two anterior mediastinal recurrences (Figs 2A–C). He was referred for surgical resection and requested, if possible, a less invasive approach. He underwent a combined repeat cervical resection and left-video assisted resection of his anterior mediastinal disease. Pathology demonstrated metastatic thyroid cancer; all margins were negative. He had no complications and was discharged on postoperative day 1.
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Fig 2. Computed tomographic image demonstrating (A) left-sided cervical recurrence and (B, C) two additional anterior mediastinal lesions.
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Technique
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For resection of thymomas or other anterior mediastinal masses, it may be useful to have the patient supine as the cervical incision may be used to free up the cervical portion of the gland, as well as the branches of the mammary vessels attached to the gland on the opposite side. To maintain exposure of the suprasternal notch and lateral chest wall, the patient is positioned with a support under the left chest (Fig 3A). This maintains exposure of the suprasternal region and the anterior chest, as well as the axilla.
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Fig 3. (A) Supine positioning used for simultaneous exposure of the cervical, pectoral, and lateral chest regions. (B) Thorascopic incisions demonstrated with the 5-mm pectoral port site circled.
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The left arm is extended on an arm board. The supine positioning is adequate for the transcervical approach, as well as the thorascopic superior mediastinal dissection. However, when working on the lower thymic poles over the heart, additional steps facilitate exposure: rotating the bed away from the surgeon, standing on the patient's left side, and placement of a retraction stitch (was made) through the pericardium. These maneuvers aid in improving visualization. Three 5-mm port sites and one 10-mm port are placed as shown (Fig 3B). The lateral port sites are clustered around the superior aspect of the anterior axillary line, away from the heart as shown, as was encountered with both of these cases. The most challenging portion of the procedure is the safe dissection of disease at the level of the mammary vessels, innominate vein, and phrenic nerve. In both of these patients, these areas had been previously dissected and were fairly scarred. The standard placement of a thoracoscope does not give adequate visualization of this region from multiple directions. Thus, a superior 5-mm trocar is placed in the infraclavicular region through the second intercostal space at the mid-clavicular line. This pectoral port site allows one to work safely at the level of the inlet near the mammary vessels and phrenic nerve. Also, as the trocar at this location needs to be angled toward the superior anterior mediastinum, the 5-mm size minimizes trauma to the surrounding soft tissues. With the 30°-angled thoracoscope the visualization from multiple angles, through multiple port sites gives the best anatomic details of the scarred complex anatomy. The camera is frequently moved from one port site to the other as the dissection proceeds. In addition, the 5-mm endoscopic bipolar device (Gyrus Medical, Southborough, MA) is commonly used for these cases to avoid injury to the phrenic nerve. Once the left side has been completely dissected, a Valsalva maneuver is performed on the right lung to push the right side of the gland toward the left to complete the dissection. Last, multiple intercostal blocks and a small 20-French chest tube are placed.
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Comment
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Video-assisted resection of anterior mediastinal masses in the setting of previous mediastinal surgery is challenging. Although this is not the first reported minimally invasive mediastinal resection after median sternotomy [2], the previously reported case demonstrated residual thymus in the aortopulmonary window after sternotomy. The dissection for these cases is different in that the disease was in the superior mediastinum at the level of the innominate vein. For such cases, alternatives in positioning and port placement seem to facilitate thorascopic superior mediastinal dissection.
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References
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- Yim AP, Liu HP, Hazelrigg SR, et al. Thorascopic operations on reoperated chests Ann Thorac Surg 1998;65:328-330.[Abstract/Free Full Text]
- Vyas S, Agasthian T, Goh MH, Shankar S. Thoracoscopic thymectomy in a previous sternotomy Asian Cardiovasc Thorac Ann 2006;14:e108-e110.[Abstract/Free Full Text]
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Abstract
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