Thoracoscopic resection of a pericardial cyst: A case report

Abstract

Mediastinal or paramediastinal tumors are most often asymptomatic and detected incidentally on a chest radiograph. The differential diagnosis includes a long list with various possibilities. Repeated radiologic studies are generally performed to confirm a suspected diagnosis. However, only the histopathologic examination of the tumor is conclusive. Thoracoscopy enables, with a fast and minimally invasive method, definitive diagnosis and treatment of many of these tumors. Recently, a 49-year-old patient was admitted to the Department of Surgery at University Hospital Zurich because of an asymptomatic tumor in the anterior mediastinum, detected on a chest radiograph. The history and physical examination revealed normal parameters. Computed tomographic scan (Fig. 1) showed a well-defined cyst in the right cardiophrenic angle, without contact with the heart. A thoracoscopy was performed with a double-lumen tube and a left lung ventilation, with the patient under general anesthesia. A 1 cm trocar was inserted in the eighth intercostal space in midaxillary line and a video camera was inserted (Wolf CCD-Endocam 5370; Richard Wolf GmbH, Knittlingen, Germany). Two 0.5 cm trocars were in serted through the eighth intercostal space in the anterior and posterior axillary line. The inspection of the chest showed a thin-walled pericardial cyst measuring 4 × 3 cm connected to the pericardium by a pedicle (3 mm diameter). The duct was divided with scissors (Fig. 2) and the cyst was emptied of clear, yellowish fluid and extracted through the trocar. Fig. 2The cyst was connected to the pericardium by a pedicle. This was severed and the cyst was removed thoracoscopically.View Large Image Figure ViewerDownload Hi-res image Download (PPT)A chest tube was inserted through a trocar and left for 24 hours. Operation time was 15 minutes. The patient returned to work after 3 days. Pericardial cysts are in general an asymptomatic malformation1Lambert AV. Etiology of thin-walled thoracic cysts.J THORAC SURG. 1940; 10: 1-7Google Scholar of the pericardium and found incidentally on a routine roentgenogram. Their typical location is the right cardiophrenic angle, but they can be located at other sites. Their radiologic appearance is normally cystic but can be exceptionally solid.2Stoller JK Shaw C Matthay RA Enlarging, atypically located pericardial cyst: recent experience and literature review.Chest. 1986; 89: 402-406Abstract Full Text Full Text PDF PubMed Scopus (67) Google Scholar Removal is indicated to confirm the diagnosis. Thoracoscopy allows, with a minimally invasive method, diagnosis and treatment of such cysts; in the case of another mediastinal or intrathoracic tumor (such as a dermoid, a neurogenic tumor, cyst of the foregut, or others) resection is often possible as part of the procedure. We consider thoracoscopy to be the method of choice if a radiologically indicated pericardial cyst is to be confirmed by resection.