Resection Of Anterior Mediastinal Mass Research Articles

Internal jugular vein‐femoral vein diversion during anterior mediastinal mass resection and superior vena cava replacement

SummarySurgery which involves anterior mediastinal mass resection with artificial replacement of the superior vena cava results in significant disruption to the circulatory system. In this case, a pathway was established to divert blood from the internal jugular to the femoral vein after clamping of the superior vena cava. Blood which would ordinarily return to the right atrium via the superior vena cava was now being returned via the inferior vena cava. The mean arterial pressure was maintained at least 50 mmHg higher than the central venous pressure during clamping of the superior vena cava to avoid cerebral hypoperfusion. The combined use of the above strategies aimed to provide satisfactory surgical conditions and cerebral protection.

Risk factors for diaphragmatic injury in subxiphoid video-assisted thoracoscopic surgery.

Subxiphoid video-assisted thoracoscopic surgery (VATS) is considered a safe and feasible operation for anterior mediastinal mass resection. However, diaphragmatic injury, presented as tearing or puncturing, may occur during subxiphoid VATS despite of low incidence. This study aims to explore risk factors for diaphragmatic injury in subxiphoid VATS, as well as strategies to reduce occurrence of the injury. We retrospectively reviewed clinical records of 44 consecutive adult patients who underwent subxiphoid VATS. These patients were divided into two groups: diaphragmatic injury group and non-injury group. Perioperative outcomes and anatomic features derived from 3D CT reconstructions were compared between the two groups. Significant differences were observed in operation time (223.25 ± 92.57 vs. 136.28 ± 53.05, P = 0.006), xiphoid length (6.47 ± 0.85 vs. 4.79 ± 1.04, P = 0.001) and length of the xiphoid below the attachment point on the diaphragm (24.86 ± 12.02 vs. 14.61 ± 9.25, P = 0.029). Odds ratio for the length of the xiphoid below the attachment point on the diaphragm was 1.09 (1.001-1.186), P = 0.048 by binary logistic regression analysis. We identified the length of the xiphoid below the attachment point on the diaphragm as an independent risk factor for diaphragm injury during subxiphoid VATS. Prior to subxiphoid VATS, a 3D chest CT reconstruction is recommended to assess the patients' anatomic variations within the xiphoid process. For patients with longer xiphoid process, a higher incision at the middle and upper part of the xiphoid process, and partial xiphoid process resection or xiphoidectomy is preferred.

Biportal robotic surgery for anterior mediastinal mass.

Robotic-assisted surgery for mediastinal disease has been shown to be beneficial in facilitating easier mediastinal dissection with its three-dimensional views and multi-articulated moving instruments. Herein, we report our experience with the biportal approach of robot-assisted anterior mediastinal mass surgery, including both lateral transthoracic and subxiphoid approaches. We retrospectively analyzed 21 patients who underwent biportal robotic-assisted anterior mediastinal mass resection, without considering the tumor size between May 2018 and September 2022. We reviewed the technical advantages and limitations of the biportal approach and the perioperative outcomes, including operative time, conversion to multiport or open surgery, duration of chest drainage, and postoperative complications, to define the role of robot-assisted surgery using the biportal approach. We approached the thoracic cavity from the right side in five patients, from the left side in three patients, and from the subxiphoid in 13 patients. Thymomas (n=13) and thymic cysts (n=3) were the most common diagnoses. The median operative time was 165 min [interquartile range (IQR), 140-196 min]. There were no conversions to multiport or open surgery. The chest drain was removed at a median of two days (IQR, 1-3 days), and the patients were discharged at a median of four days (IQR, 3-5 days). Perioperative complications were reported in two patients (one with prolonged air leak and one with vocal cord palsy). There were no cases of readmission or delayed complication. The biportal approach for robot-assisted surgery in anterior mediastinal masses is a feasible and safe alternative for treating associated pathologies. The subxiphoid approach for mediastinal surgery provides a better surgical view than the transthoracic approach. The biportal approach also enables the use of robotic staplers and energy devices and minimizes instrumental interference compared to that in the single-port approach.

An Interesting Case Report of A Concurrent Classic Hodgkin Lymphoma and Gray Zone Lymphoma in the Mediastinum

Abstract Casestudy A 52-year-old female presented with night sweats, chills, anorexia, and weight loss. Computed tomography and positron emission tomography showed a soft tissue infiltration in the anterior mediastinum and hypermetabolic bilateral supraclavicular, mediastinal, right hilar, and left internal mammary lymph nodes. An anterior mediastinal mass resection and thymectomy was subsequently performed. Results Sections of the mediastinal mass showed Hodgkin/Reed-Sternberg cells (HRS) admixed with small lymphocytes, histiocytes, plasma cells, and eosinophils. The HRS cells are positive for CD30, CD15, and MUM1, faintly positive for PAX5, and negative for CD20, CD45, CD79a, and BCL6. The morphology and immunophenotype is diagnostic of nodular sclerosis classic Hodgkin lymphoma (CHL). Sections of the thymectomy specimen showed similar morphology, however, in an area that represents 10-20% of the specimen, there are nodular and diffuse lymphoid infiltrates consisting of small lymphocytes, histiocytes, and large atypical cells. The large atypical cells are positive for CD20, CD23, CD30, CD45, CD79a, BCL2, BCL6, MUM-1, and PAX5, and negative for CD1a, CD3, CD57, and Cyclin D1. The background small CD3-positive lymphocytes form a rosette around most of the large atypical cells. CD21 and CD23 stains highlight residual follicular structures. In situ hybridization for EBV-encoded RNA (EBER) is negative. The presence of residual follicular meshwork with an immunophenotype of large B cell lymphoma supports a diagnosis of a gray zone lymphoma (GZL). Overall, CHL is involving 80-90% and GZL is involving 10-20% of the thymic tissue. The patient was subsequently placed on ABVD chemotherapy and achieved remission. Conclusion An accurate diagnosis of GZL is challenging. GZL is a rare type of lymphoma with morphological features between CHL and diffuse large B-cell lymphoma (DLBCL). It is even rarer to encounter a CHL concurrently present with a GZL. The optimal therapeutic approach for cases with concurrent lymphoma diagnosed with CHL and GZL needs further investigation.

Robot-assisted thoracoscopic surgery for mediastinal masses: a single-institution experience.

The objectives of this study were to evaluate the feasibility and safety of robot-assisted thoracic surgery (RATS) using the da Vinci robotic system for mediastinal mass resection and to describe the surgical approach for masses in different mediastinal regions. We retrospectively reviewed data from 84 patients who underwent RATS for resection of a mediastinal mass from June 2015 to April 2019. The results were analyzed with descriptive statistics. The mediastinal mass was resected successfully in all patients, with one patient requiring conversion to conventional open surgery. There were no intraoperative complications. The most common diagnoses were thymoma (n=17), bronchogenic cyst (n=16), and schwannoma (n=12). The surgical approach was determined by the location of the lesion and the planned extent of surgical resection. Resection was performed in the lateral decubitus position in 29 patients with posterior mediastinal tumor, semi-lateral decubitus position in 42 patients who only need resection of anterior mediastinal mass, and reverse Trendelenburg position in 13 patients undergoing thymectomy. The mean (± standard deviation) operation time was 91.86±56.42 min, duration of chest tube use was 1.83±0.93 days, and postoperative hospital stay was 3.62±7.52 days. Three patients (3.5%) developed postoperative complications: one chylous fistula, which required reoperation, and one case each of atrial fibrillation and pulmonary infection, which were treated conservatively. Our experience demonstrated that different surgical approaches of RATS are safe and feasible for mediastinal mass resection. An appropriate approach can be selected based on the mediastinal region in which the tumor is located.

Robotic assisted minimally invasive thymectomy with simultaneous bilateral thoracoscopy and contralateral phrenic nerve visualization.

Thoracoscopic approaches to thymectomy and anterior mediastinal mass resection has become increasingly common due to the potential for decreased blood loss and hospital length of stay. However, contralateral mediastinal and phrenic nerve visualization if often difficult from these unilateral approaches, which may affect the ability to achieve a full phrenic to phrenic dissection Herein, we present our early experience of robotic assisted minimally invasive thymectomy (RAMIT) with simultaneous bilateral thoracoscopy and contralateral phrenic nerve visualization. This was a retrospective review of all sequential patients undergoing RAMIT with simultaneous bilateral thoracoscopy from January 2015 to May 2016. This study was approved by our Institutional Review Board (PRO15080367). Individual patient consent was waived. Twenty-six patients [median age 58 (range, 29-76) years] were included in this study. Sixteen operations were performed for anterior mediastinal mass, 7 for non-thymomatous myasthenia gravis, and 3 for concurrent myasthenia gravis and thymoma. Median blood loss and hospital stay were 25 mL (range, 3-150 mL) and 3 days (range, 2-8 days), respectively. Twenty-one (80.8%) patients experienced an uncomplicated hospital course. The highest graded complication by Clavien Dindo Classification was a grade III due to pleural effusion requiring drainage via pleural catheter. One patient experienced asymptomatic hemidiaphram palsy postoperatively. There were no 90-day postoperative deaths. RAMIT with simultaneous bilateral thoracoscopy is a feasible approach that may allow for enhanced visualization and more complete thymic resection compared to existing unilateral minimally invasive operations. Comparative studies and long-term follow up are needed to adequately assess the potential benefits of RAMIT.

Anesthetic management during anterior mediastinal mass resection in a pediatric patient. A case report

Complications induced by general anesthesia (GA) and neuromuscular relaxation (NMR) in anterior mediastinal mass (AMM) resection can be serious, especially when there are signs of compression of the airway or large vessels (dyspnea, orthopnea, etc.) (1). It is preferable to perform the procedure in spontaneous ventilation to avoid respiratory or cardiovascular collapse due to the supine position or to loss of negative intrathoracic pressure with GA and NMR. If the supine position and NMR are unavoidable, procedures should be performed in a step-wise manner, and rescue strategies should be prepared (rescue position, bronchoscope, sternotomy). Correct preoperative evaluation, adequate planning, and a multidisciplinary approach will ensure patient safety. We present the case of a child with a history of severe orthopnea and a diagnosis of AMM and lymphoblastic lymphoma (respiratory arrest and cardiovascular collapse during sedation for lumbar puncture and bone marrow biopsy) that did not respond to medical treatment and required resection surgery under GA with NMR.

Anterior Mediastinal Kitlelere Cerrahi Yaklaşım

Aim: The aim of this study was to evaluate the clinical progress, type of surgical approach and early results of resection of anterior mediastinal masses. Patients and Methods: We retrospectively reviewed the reports of 25 patients who underwent surgery for an anterior mediastinal mass between 2014 and 2019. Patients’ age, gender, presenting symptoms, preoperative radiological investigations and surgical techniques were recorded. There were eight male and 17 female patients, and their age ranged from 18-89 with a mean of 44.4± 16.9 years. Results: The most frequent presenting symptoms were chest pain (90%) and cough (50%). The most common pathological diagnoses were thymic tumors (n=14, 56%) and lymphoma (n=5, 20%). Surgical approaches applied were median sternotomy in 16 patients, partial sternotomy in five patients and VATS (Video Assisted Thoracic Surgery) in four patients. There were no postoperative deaths or major complications, but eight patients had minor complications. Postoperative stay was 5±5.2 days. Conclusion:Surgery is a safe technique for diagnosis and treatment of anterior mediastinal masses.

SAT-603 Graves' Disease and an Anterior Mediastinal Mass

Introduction The association between Graves’ disease (GD) and an anterior mediastinal mass (AMM) due to thymic hyperplasia (TH) has been reported. The exact incidence of TH in GD is unknown as chest imaging is not routinely performed. TH in GD typically has a benign course and majority of cases resolved spontaneously with the treatment of GD. However, lack of familiarity of such association may lead to unnecessary surgical intervention. Clinical case A 33-year-old African American lady with Sjogren’s syndrome was presented with progressive shortness of breath and chest discomfort. Exam showed sinus tachycardia, with bilateral exophthalmos and a diffusely enlarged goiter. CTA chest with no pulmonary embolism, however, there was a 11x1.9 cm homogenous mass at anterior mediastinum. She has Graves’ disease, diagnosed 5-year ago with history of non-adherence to methimazole. TFT showed TSH of <0.1 uIU/ml (ref 0.34-5.6), FT4 of 5.38 ng/dl (ref 0.6-1.6), FT3 of >20 pg/ml (ref 2.3-4.2). TSI was elevated to 365% (ref <140). She had thoracoscopic partial resection of anterior mediastinal mass at outside hospital and reported as thymus hyperplasia. Discussion Differential diagnosis of AMM include retrosternal goiter, thymoma, thymic carcinoma, lymphoma and germ cell tumor. TH is the most common etiology of AMM in GD. The risk of thymic malignancy in GD appeared to be low at 3.7% in one study. In a study by Murakami et al, thyrotropin receptors were present in thymic tissue and GD patients had larger thymic size and higher thymic density than age-matched control subjects. TH in GD can be from lymphoid hyperplasia (TLH) due to increased number of lymphoid follicles with germinal centers or true thymic hyperplasia (TTH) from actual enlargement of the thymus. Thymic enlargement is more common in TTH. The mechanism of TH in GD is appeared to be thyroid hormone dependent which affect more on cortex causing TTH and immunologic process which affect more on medullary lymphoid follicles causing TLH. The degree of TH is correlated with the severity of thyrotoxicosis and the level of TSH receptor antibodies (TRAb). Treatment with anti-thyroid causes regression of TH by reducing levels of thyroid hormone and TRAb. In a literature review by Haider et al, 31 out of 47 GD-associated TH patients had an average of 62% reduction in thymic volume with the treatment of GD. The time to regression of TH under medical treatment varies considerably from 2 to 24 months, however, majority of cases showed >50% volume reduction at six months of therapy. Clinical lesson As TH in GD is a benign reversible autoimmune process, AMM in GD can be followed with repeat imaging. Thymic biopsy may be considered only if the size of the mass does not decrease with euthyroid state or patients with concerning radiological features of AMM such as cystic or necrotic changes, invasion to surrounding structure, or calcification.

Verification of the diagnostic strategy for anterior mediastinal tumors.

For thymic epithelial tumors (TETs), the National Comprehensive Cancer Network guideline has suggested that complete excision of the tumor should be performed without a preoperative biopsy when resectable. However, little evidence has been provided to support this strategy. The purpose of this study was to review our diagnostic process and to evaluate the validity of radical resection of anterior mediastinal masses (AMMs) without pathological confirmation. A total of 254 patients underwent surgical resection for AMMs between 2004 and 2015. This study included 181 patients with likely TETs according to clinical features, serum levels of tumor markers and autoimmune-antibodies, and radiological findings. In addition, AMMs likely TETs were classified into resectable or unresectable tumors. We retrospectively reviewed the diagnostic process of those patients and validated surgical resection of AMMs without a definitive diagnosis. Among 254 patients, 181 were suspected of having a TET based on the serum levels of tumor markers and autoimmune-antibodies and the radiological findings. Of them, 157 patients were deemed resectable and underwent surgical resection without histological confirmation, and 144 (92%) were diagnosed with TETs in the final pathological examinations. In 13 patients with non-TETs, the tumors were difficult to differentiate from TETs by imaging and clinical findings alone. A total of 92% of patients suspected of having a TET and who underwent complete resection without pathological confirmation were accurately diagnosed and properly treated. Surgical resection without a definitive diagnosis was feasible in patients suspected of having a TET when they were considered resectable.

Robot-assisted en bloc anterior mediastinal mass excision with pericardium and adjacent lung for locally advanced thymic carcinoma.

Robot-assisted surgery for anterior mediastinal mass resection has been increasingly adopted as an alternative method to open sternotomy and conventional video-assisted thoracic surgery. However, more evidence is needed to expand the indication of this technique to more complicated cases. We present a case of robot-assisted en bloc resection of a 7-cm anterior mediastinal mass with pericardium and adjacent lung for thymic squamous cell carcinoma, accompanied by reconstruction of pericardium with polytetrafluoroethylene patch. In conclusion, complex anterior mediastinal mass excision is feasible with robotic thoracic surgery.

P2.04-004 Thymectomy without Definitive Diagnosis Could Be Feasible in Patients with Suspicious of Thymic Epithelial Tumor: Topic: Thymic Malignancies Clinical and Translational

As for thymic epithelial tumors (TETs), National Comprehensive Cancer Network guideline has suggested that complete excision of tumor should be performed without preoperative biopsy when resectable. However, there have been very few evidences on this strategy of diagnosis and treatment. The purpose of this study is to evaluate the validity of radical resection of anterior mediastinal masses (AMMs) without pathological confirmation. Two hundred and fifty-eight patients with AMMs underwent surgical resection between 2004 and 2015 at the Nagoya University Hospital. Among them, 186 patients were suspected to have TETs by clinical features, serum tumor markers, and the findings of computed tomography (CT) and positron emission tomography (PET). We retrospectively reviewed cases of the patients with AMMs and evaluated the strategy of treatment for them. Of the186 patients with suspicious of TETs, 56 patients received preoperative biopsy and had the pathological diagnosis. The method included CT-guided needle biopsy in 49 patients (26%) and video-associated thoracic surgery biopsy in 4 (2%) to plan neoadjuvant therapy and/or to distinguish from malignant lymphomas or malignant germ cell tumors, and intraoperative pathologic examination using frozen section of the tumor in 3 (1.6%). The remaining 130 patients (70%) underwent thymectomy without pathological confirmation. Among them, the tumors in 115 patients (88%) were finally diagnosed as TETs including 100 thymomas, 11 thymic carcinomas and 4 thymic carcinoids. The patients except one received complete resection. The remaining 15 patients (12%) were diagnosed as 4 thymic cysts, 4 lymphomas of mucosa-associated lymphoid tissue type (MALT), 2 bronchogenic cysts, 2 mature teratomas and 3 other tumors. Thymic cysts with thick wall in part and small MALT lymphomas with intermediate accumulation of PET were sometimes difficult to distinguish from TETs preoperatively. Eighty-eight percent of the patients with suspicious of TETs who underwent thymectomy without biopsy were accurately diagnosed and properly treated with complete resection. Thymectomy without a definitive diagnosis could be feasible in patients with suspicious of TETs when they are considered resectable, although there are some tumors such as thymic cyst and MALT lymphoma hard to distinguish from TETs.

Robotic Thymectomy in Anterior Mediastinal Mass: Propensity Score Matching Study With Transsternal Thymectomy

Robot-assisted thymectomy (RT) has been increasingly performed for treating anterior mediastinal masses. The aim of this study was to compare the early and long-term outcomes between RT and transsternal thymectomy (ST). A total of 429 patients who underwent surgical resection of anterior mediastinal masses were included in this study. RT was performed in 117 patients (27%). Propensity score matching was performed between RT and ST, and 100 patients were selected for each group. RT and ST were performed for anterior mediastinal masses, including thymic epithelial tumor and mediastinal cysts. Thymic epithelial tumor was the most common type of tumor, and distribution of pathologic stages was not significantly different between RT and ST (41% versus 39% in stage I, 46% versus 50% in stage II, 9% versus 5% in stage III, and 4% versus 5% in stage IV, p= 0.96). The RT group had significantly less intraoperative blood loss (100.9 ± 105.4 mL versus 354.5 ± 412.4 mL, p < 0.001), lower incidence of postoperative complication (1% versus 12%, p= 0.002), and shorter length of postoperative hospital stay (2.5 ± 1.2 days versus 6.4 ± 6.6 days, p < 0.001) compared with the ST group. Three-year overall survival rates and freedom from recurrence were not significantly different (100% versus 100%; p= 0.88 and 92% versus 99%, p= 0.12) between RT and ST. RT demonstrated excellent early outcomes compared with ST, and RT could also achieve comparable long-term oncologic outcomes with ST in thymic epithelial tumor. Therefore, RT should be considered as an alternative surgical option for treating anterior mediastinal masses.

A Rare Cause of Progressive Paresthesias, Cramps, Fasciculations and Weakness in a Collegiate Volleyball Player

HISTORY: A 21 year old female collegiate volleyball player presented with exertional paresthesias involving her cheeks, lips and chest. Her symptoms evolved to include twitching, stiffness and cramping of the thighs and calves, which forced discontinuation of participation in volleyball. She went on to develop upper extremity cramping and abnormal posturing of her hands, even at rest. She noticed symmetric hypertrophy of her calves and quadriceps muscles and increased sweating and salivation. Her cramping and leg stiffness worsened to the point that she needed aid of a walker for ambulation. PHYSICAL EXAMINATION: General medical exam was unremarkable. Her quadriceps and calves seemed abnormally muscular for body habitus. Movements of the upper and lower limbs were slow and stiff with visible cramping of calf and quadriceps muscles with activation. Neurological exam showed diminished reflexes. Strength testing was difficult due to non-painful muscle cramps with isolated testing of muscles. Sensation was normal. DIFFERENTIAL DIAGNOSIS: 1) Myotonia (DM1, DM2)/ Neuromyotonia 2) Diffuse Myopathy 3) Multiple Sclerosis 4) Peripheral Neuropathy TEST AND RESULTS: MRI brain and cervical spine: - No evidence of demyelination, inflammation, or infarction EMG: - Nearly persistent motor unit activity in upper and lower limb muscles with spontaneous, iterative, high frequency discharges consistent with neuromyotonia Laboratory Testing: - Blood tests for hereditary and acquired causes of myotonia/neuromyotonia were inconclusive PET Scan/MRI: - Showed focal, hypermetabolic activity in the thymus with two peripherally enhancing soft tissue nodules FINAL WORKING DIAGNOSIS: Hodgkin’s Lymphoma with presentation of paraneoplastic neuromyotonia (Isaac’s Syndrome) TREATMENT AND OUTCOMES: 1. Intravenous immunoglobulin was poorly tolerated with no clear benefit. 2. Gabapentin and mexiletine were started as membrane stabilizing agents with significant improvement in symptoms. 3. With imaging findings concerning for neoplasm, anterior mediastinal mass resection with total thymectomy was performed. 4. Surgical pathology showed interfollicular Hodgkin’s lymphoma with no abnormality in the thymus. 5. The patient recovered well from surgery, reports 80% improvement in symptoms and is exercising consistently

Uniportal video-assisted thoracic surgery thymectomy.

A 47-year-old gentleman presented with an incidental discovery of a 2.5-cm anterior mediastinal mass. Following radiological review, the diagnosis of likely thymoma is made and the patient is referred for surgical resection. The patient is currently self-employed and working as a carpenter. He is very concerned about the possibility of having a sternotomy as it would impact on his recovery and return to work. A single port, muscle sparing technique seems the best option for this gentleman. He undergoes surgery and is discharged 2 days later. He is back at work in 2 weeks. Over the past 10 years, video-assisted thoracic surgery (VATS) has replaced median sternotomy for the resection of anterior mediastinal masses, including thymoma. In 1993, the thoracoscopic approach to thymectomy was first reported by Sugarbaker from Boston, as well as a Belgian group (1,2). To date, the VATS approach has become the preferred and standard operation for the treatment of thymic disease. Numerous studies confirmed that, compared to standard sternotomy, VATS thymectomy results in less post-operative pain, better preserved pulmonary function, improved cosmesis (which can be particularly important to many young female myasthenia gravis patients) and is oncologically feasible for noninvasive thymomas as long as en bloc resection of the tumor is achieved (3-5). Most published reports regarding this procedure have focused on the right-sided approach, which has been adopted by most surgeons as the space in the right chest cavity is relatively large, with little interference from the heart, and the superior vena cava acts as an anatomical landmark. The current trend is to reduce the number of ports and minimize the length of incisions to further decrease postoperative pain, chest wall paresthesia, and length of hospitalization. Single-port thoracoscopy for mediastinal mass resection is not new. In our early experience with uniportal VATS thymectomy, we adopted the use of a singular access device (SILS port, Covidien) that permits the insertion of three or four instruments, together with CO2 insufflation, through a right-sided single 3-cm incision, without rib spreading.

Early clinical outcomes of robot-assisted surgery for anterior mediastinal mass: its superiority over a conventional sternotomy approach evaluated by propensity score matching†

We performed this study to assess early clinical outcomes of robot-assisted surgery for anterior mediastinal mass by comparing results of the robot group with those of the sternotomy group after propensity score matching. Between 2008 and 2012, 145 patients underwent resection of anterior mediastinal mass. Robot-assisted surgery was performed in 37 patients, and conventional surgery by sternotomy in 108 patients. Propensity score matching was done between two groups with variables of age, sex, size of the mass, myasthenia gravis, resection of other organ and pathological diagnosis. Thirty-four patients from the robot group and 34 from the open group were matched, fitting the model. The clinical outcomes of matched groups were compared. In the robot group, mediastinal cyst consisted of 47.1% (16 of 34), thymoma 32.4% (11 of 34), thymic carcinoma 8.8% (3 of 34), thymic hyperplasia 8.8% (3 of 34) and liposarcoma 2.9% (1 of 34). The mean duration of follow-up was 1.11 ± 0.21 and 1.85 ± 0.19 years for the robot and open groups, respectively. There were no mortality or recurrence in both groups during the follow-up. There were no significant differences in operation time, postoperative white blood cell and C-reactive protein increase, maximum visual analogue scale score for pain as well as postoperative intensive care unit care between the two groups. The robot group revealed a lesser number of drains (1.09 ± 0.1 vs 1.41 ± 0.1) and 24-h tube drainage (189.4 ± 20.5 vs 397.6 ± 52.6 ml), lower haemoglobin loss (0.54 ± 0.4 vs 1.35 ± 0.1 g/dl) and haematocrit decrease (1.92 ± 0.5 vs 3.85 ± 0.4%), shorter chest tube days (1.53 ± 0.2 vs 3.06 ± 0.2) and length of hospital stay (2.65 ± 0.2 vs 5.53 ± 0.8) after operation, which were all statistically significant. Although statistically insignificant, there were no postoperative complications in the robot group, but there were 5 (14.7%) in the open group (P = 0.063). In carefully selected patients with relatively smaller sized masses, robot-assisted surgery resulted in excellent early clinical outcomes with lesser tube drainage, lower blood loss, shorter tube days and length of hospital stay without any postoperative complications, compared with the matched open group. Further investigation for long-term clinical outcomes and oncological outcomes is required for a robotic approach. Particularly, long-term follow-up for the local recurrence rate according to the pathological diagnoses is required.

Is a Vessel-Sealing System Useful for Resection of Anterior Mediastinal Mass?

To valuate if the LigaSure (Valleylab, Boulder, Colorado, United States) vessel-sealing system could reduce operative time, intraoperative blood loss, drainage duration, and hospital stay in patients with anterior mediastinal mass undergoing open resection. Forty consecutive patients having resection of anterior mediastinal mass were randomized into two groups according to whether LigaSure was used (n = 20) or not (n = 20). Tumor size, operative time, intraoperative blood loss, chest tube output and duration, length of hospital stay, morbidity, and mortality were prospectively recorded, then intergroup differences were statistically analyzed. Both groups were well matched for age, tumor size, pathologic diagnosis, and incidence of complications. LigaSure significantly reduced operative duration (p < 0.0001) compared with the traditional technique but without leading to any significant reduction in intraoperative blood loss (p = 0.2), chest tube output (p = 0.2) and duration (p = 0.2), and length of hospital stay (p = 0.5). The reduced operative time using LigaSure translates into less exposure to general anesthesia, which is particularly important for patients with myasthenia and potentially reducing cost.

Thoracic Techniques: Robotic Thymectomy for Thymoma

The traditional approach to resection of anterior mediastinal masses has been via sternotomy. This approach has been associated with an average length of stay of 4–5 days, sternal precautions for 6 weeks, a visible scar, and in some cases, long term discomfort. Although some surgeons have attempted VATS resection of thymomas and other anterior mediastinal masses, we have found that a robotic assisted resection, with its enhanced vision (due to the 10× magnification) and endowrist movements, are ideal for the compact space of the anterior mediastinum [1]. Herein, we describe our technique of total thymectomy for thymoma, highlight some adjunctive techniques, discuss the results of robotic thymectomy, and identify the controversies around robotic resection for thymoma.

Single-Port Thymectomy Through an Infrasternal Approach

We report a surgical procedure in which a port and devices designed for single-incision endoscopic surgery are employed for thymectomy through an infrasternal approach. As this single-port thymectomy procedure can be performed through a single 3.5-cm incision in the abdominal region usually concealed under clothes, it is esthetically excellent and is among the least invasive thymectomy procedures because no sternal incision is applied and no intercostal nerve is injured. Investigation of the safety of this procedure and long-term therapeutic outcomes for myasthenia gravis and anterior mediastinal tumors is necessary.

Robotic surgery for mediastinal tumors

BACKGROUND: The surgical approach to mediastinal tumors has changed during the last two decades. Median sternotomies and thoracotomies have been replaced in part by minimally invasive procedures. Aim of this review is to highlight applications of a robotic-assisted approach in mediastinal tumor surgery. METHODS: Review of the current literature. RESULTS: A robotic approach for thymectomy, anterior mediastinal mass resection, pericardial cyst resection, diagnostic sampling of enlarged lymph nodes in the middle mediastinum, resection of benign neurogenic tumors in the posterior mediastinum and esophageal procedures was shown to be feasible. Postoperative outcomes as well as the contraindications and limitations of a robotic approach are discussed. CONCLUSIONS: For appropriate indications minimal invasive surgery with a surgical robot can safely be performed for tumors in the anterior, middle, and posterior compartments of the mediastinum.