Robot-Assisted Resection of a Large Posterior Mediastinal Mass

Abstract

Introduction: Ganglioneuromas are rare, typically benign, tumors that arise from tissues that have a neural crest cell origin. They typically occur in patients ranging in age from 10 to 40 years and are classically found in the adrenal glands. Ganglioneuromas are frequently asymptomatic and discovered incidentally while another condition is being investigated. The video demonstrates a difficult dissection that offers technical advantages over traditional thoracoscopy instruments by the articulating instruments of the robot with run time of 4 minutes 31 seconds. Background: An 18-year-old woman who was being followed for scoliosis was found to have a large left chest mass on a chest x-ray. A chest CT scan revealed a 10×7.5×6.5-cm mass in the left upper chest, consistent with a bronchogenic cyst. She had no reports of fever, shortness of breath, or chest pain, although she did endorse frequent feelings of left chest/shoulder tightness. In an attempt to avoid a large thoracotomy or sternotomy, we proceeded with a robot-assisted resection of the large mass. Methods: The patient was laid supine with the left chest slightly elevated and her left arm extended above her head. She was intubated with a Carlens tube for single lung ventilation. With the left lung deflated, an 8-mm robotic trocar was placed in the left midaxillary line (sixth intercostal space), an 8-mm robotic trocar was placed in left anterior axillary line (fifth intercostal space), and an 8-mm trocar was placed posterior to scapula (fourth intercostal space). An additional 5-mm step trocar was placed as an assistant port, lower left midchest in the posterior axillary line. Using hook cautery and graspers with bipolar cautery, the tumor was dissected free from the surrounding tissues and the blood vessels cauterized. The mass seemed to arise from the left sympathetic ganglia chain, which had to be sacrificed for tumor removal. The tumor extended into the apex of the left chest and into the lower part of the left neck just behind the head of the clavicle. The tumor was resected free and placed into an endocatch bag, where it was cut to facilitate its removal. The anterior axillary line trocar was removed and widened to ∼5 cm to allow specimen removal. A 28F chest tube was used because the larger tube was less likely to clog, and the chest hole was already large enough to accommodate it. The operative time was 5.5 hours, with 5 to 10 minutes of setup for the robot. Final pathology revealed a ganglioneuroma. Results: She was admitted to the step down unit postoperatively with patient-controlled anesthesia pain control. She was transitioned to oral pain medicine with a general diet on postoperative day 1. Her chest tube was removed and she was discharged on postoperative day 2. She was seen in clinic the following month with some left arm numbness and slight symptoms of Horner's syndrome (left eye ptosis and miosis when tired). Twelve months later, she reports being asymptomatic from her Horner's syndrome. Conclusions: Robot-assisted thoracic surgery provides great 3D visualization and articulating instruments that can be used to dissect large intrathoracic tumors and possibly avoid a large thoracotomy or sternotomy. No competing financial interests exist. Runtime of video: 4 mins 31 secs This work was presented as a poster at the 2014 IPEG conference in Scotland.