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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5193_Библиотеки_им_академика_М_И_Перельмана.pdf
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Fig. 33.5 Identication of
the innominate vein. The
innominate vein and vein
branch draining the thymus
is identied
Fig. 33.6 Identication of
the internal mammary
vessels. Denes the
superior and anterior
dissection plane
B. Williams and M. Sancheti
Fig. 33.7 Identication of
the right superior
thymic pole
inserted into the pleural cavity through the inferior incision. The right lung is then
observed reinating. The port sites are then closed with 3–0 Vicryl suture followed
by 4–0 Monocryl subcuticular skin closure. The anterior mediastinal mass was
found to be a thymoma, Masaoka stage I on pathology.
33 Mediastinal Procedures
Fig. 33.8 Identication of
the left superior
thymic pole
Fig. 33.9 Completion of
the anterior mediastinal
mass resection
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Approach toMiddle Mediastinal Pathology
Middle mediastinal masses include most commonly lymph nodes and congenital
bronchogenic and pericardial cysts [6]. Lymph nodes in the middle mediastinum are
addressed mainly via endobronchial ultrasound (EBUS), image-guided percutaneous biopsy, or less frequently mediastinoscopy. Lymph nodes not amenable to the
aforementioned sampling approaches are often referred for robotic-assisted excisional biopsy. Bronchogenic cysts and pericardial cysts are rare congenital entities
but have been addressed with robotic assistance in several case reports [7–9].
Indications forResection
Bronchogenic cysts can be symptomatic due to extrinsic compression, infection,
and rarely, transformation to malignant lesions [10]. Resection is indicated for
lesions that are either symptomatic or asymptomatic but amenable to
480
B. Williams and M. Sancheti
straightforward resection to avoid future complications. Surveillance of the lesion
may be more appropriate for asymptomatic lesions in high-risk patients. Resection
for diagnostic purposes is also indicated if the type of mediastinal cyst is in question. Pericardial cysts are benign lesions where resection is indicated for rare symptomatic lesions or for diagnostic purposes.
Middle Mediastinal Mass Example Case Scenario
The patient is a 66-year-old woman with history of mantle cell lymphoma who
underwent computed tomography scan revealing an incidental middle mediastinal
cyst in the aortopulmonary window that abutted the esophagus, trachea, pulmonary
artery, and aorta (Fig.33.10). Differential diagnosis included bronchogenic cyst,
pericardial cyst, and less likely a foregut cyst. Observation versus resection was
discussed with the patient, including discussion of risk of injury to the great vessels,
trachea, esophagus, left vagus, and recurrent laryngeal nerve. The patient elected for
resection due to her concerns with prior malignancy.
Surgical equipment used:
da Vinci robotic Xi system
da Vinci 30-degree camera
Long bipolar grasper
Fig. 33.10 Computed
tomography scan for
middle mediastinal cyst.
Red arrow points to the
cyst. The cyst abuts the
aorta, pulmonary artery,
esophagus, trachea, and
left main stem bronchus.
(a) Axial, (b) coronal, (c)
sagittal
a
b c
33 Mediastinal Procedures
481
EndoWrist Cadiere forceps
Vessel sealer extend
8mm instrument cannula × 3 (including one Optiview)
12mm AirSeal trocar
Patient Positioning andPort Placement
For middle mediastinal masses, patient positioning will depend on the location of
the tumor. In most cases, a right or left lateral decubitus position will be appropriate
for resection. A right lateral decubitus position, left side up, on a reversed OR table
was used for the example case due to the laterality of the lesion and to allow space
for docking the robot.
The left pleural space is accessed with an 8mm Optiview trocar in the eighth
intercostal space along the posterior axillary line. The pleural cavity was then insufated to 8mmHg. Next under direct visualization, two additional ports were placed
in the same intercostal space approximately 8cm anterior (port #2) and posterior
(port #1) to the camera port. Special care must be taken for posteriorly positioned
ports to ensure the placement is anterior and lateral to the paraspinal muscles to
avoid oozing. An assistant 12mm AirSeal trocar was triangulated inferior to and
between the camera and port #2. (Fig.33.11).
Fig. 33.11 Port placement for middle mediastinal cyst excision. Camera port is blue, robotic port
1 is yellow, robotic port 2 is green, and robotic port 3 is red. Assistant port is white
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Fig. 33.12 Robot position in respect to the patient for middle mediastinal cyst resection
B. Williams and M. Sancheti
The robot is then driven into the operative eld as depicted in Fig.33.12. The
ports are then secured into the robotic arms. The 8mm 0-degree da Vinci camera is
passed into the center camera port. The Cadiere forceps are placed in port #1 and the
long bipolar grasper in port #2. The long bipolar grasper is chosen for dissection due
to proximity of the left vagus nerve and recurrent laryngeal nerve.
Middle Mediastinal Cyst Excision Operative Steps
The lung is pushed away anteriorly using the robotic arm 3 with the Cadiere forceps
instrument to expose the aortopulmonary window (Fig.33.13). The mediastinal
pleura was entered using robotic arms 1 and 2 centered around the camera port to
begin the dissection of the cyst away from vital structures starting with the aorta
(Fig.33.14). The access port is used for suctioning and retraction assistance. As the
dissection is carried medially toward the trachea, the left vagus and recurrent laryngeal nerve is visualized and preserved (Fig.33.15). The cyst is then released from
the trachea and esophagus. Blunt dissection is carried anteriorly while retracting the
cyst anteriorly and laterally away from the pulmonary artery (Fig.33.16). Once the
cyst is fully released, a sterile cut glove nger was placed into the apex of the thoracic cavity via the access port and the specimen was then removed (Fig.33.17).
The middle mediastinal cyst was lined with mesothelial cells on pathology consistent with a pericardial cyst.
33 Mediastinal Procedures
Fig. 33.13 Exposure of
the aortopulmonary
window. Red arrow points
to the aortopulmonary
window. Aorta is labeled.
Cephalad, caudad, anterior,
and posterior locations
depicted for orientation
Fig. 33.14 Dissection of
the middle mediastinal cyst
away from the aorta. Aorta
is labeled
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Fig. 33.15 Identication
of the left recurrent
laryngeal nerve for
preservation. Red arrow
points to the left recurrent
laryngeal nerve. The aorta
and middle mediastinal
cysts are labeled
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Fig. 33.16 Dissection of
the cyst away from the
pulmonary artery
Fig. 33.17 Removal of
the specimen using a cut
sterile glove nger
B. Williams and M. Sancheti
Approach toPosterior Mediastinal Pathology
Posterior mediastinal pathologies for which robotic surgery has been utilized
include neurobroma, schwannoma, neuroganglioma, ganglioneuroblastoma, paraganglioma, and foregut duplication cysts. Mediastinal foregut duplications cysts are
rare entities with case reports found in literature regarding the use of robotics in the
pediatric population. Therefore, descriptions of such operations are outside the
scope of this section. The most common adult posterior mediastinal masses are
neurogenic in origin.
33 Mediastinal Procedures
485
Indications forRobotic Posterior Mediastinal Mass Resection
Most adult neurogenic tumors are benign; however, resection is usually indicated in
adults due to rare risk of malignancy [6]. There are preoperative considerations for
posterior mediastinal solid tumors concerning for neurogenic origin. Patients with
suspicious history of hypertension are evaluated for a functional paraganglioma
with serum and urine catecholamine levels, as hypertensive crisis is a possible fatal
intraoperative complication without the appropriate preoperative medical treatment
[6]. Patients with neurogenic posterior mediastinal masses are screened for compressive spinal cord symptoms because such symptoms may indicate an intraspinal
involvement of the tumor. Magnetic resonance imaging is the diagnostic study of
choice in patients with neurogenic tumors, as this imaging modality is sensitive for
identifying dumbbell or hourglass-shaped involvement of the intravertebral foramen [6]. If intraspinal involvement is detected, a combined robotic and posterior
neurosurgical approach may be necessary for complete resection.
Posterior Mediastinal Mass Case Scenario
A 59-year-old man presents to the clinic with previously discovered posterior mediastinal mass that has grown in size on comparison computed tomography scan (Fig.33.18).
Fig. 33.18 Computed
tomography scan of the
posterior mediastinal mass.
Red arrows point to the
posterior mediastinal mass.
The mass abuts the aorta.
(a) Axial, (b) coronal, (c)
sagittal
a
b c
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B. Williams and M. Sancheti
Past medical history was signicant for previous lymphoma that had been in remission
for over 5years and well-controlled hypertension. The patient denied headaches, palpitations, or night sweats. He was referred for CT-guided biopsy of this mass with pathology consistent with schwannoma. Magnetic resonance imaging was obtained which did
not identify involvement of the intravertebral foramen. After discussion about continued
surveillance versus resection, the patient elected for surgical management.
Surgical equipment used:
da Vinci Xi robotic system
da Vinci 30-degree camera
EndoWrist® (Monopolar) permanent cautery spatula
Long bipolar grasper
Tip-Up fenestrated grasper
EndoWrist® Grasper—Cadiere forceps
EndoWrist® Clip applier—small and large
Kittner roll gauze sponges
8mm trocars × 4
12mm AirSeal
Endo Catch bag
Patient Positioning
Posterior mediastinal mass resections are approached from either right or left lateral
decubitus position depending on the location of the mass. For the case example, the
patient was placed in the right lateral decubitus position.
Port sites were determined by preoperative imaging studies (Fig.33.18). In our
example, a posterior mediastinal mass was found in the left pleural cavity at the
level of the T9 vertebral body. The camera port was positioned along the posterior
axillary line eighth intercostal space. Robotic port 1 was positioned anteriorly in the
seventh intercostal space. Two additional ports were placed posterior to the camera,
7cm apart, in the eighth intercostal space. The assistant port was marked for the
tenth intercostal space triangulated between the camera and port 1 (Fig.33.19).
Port Insertion andPositioning oftheRobot
Entry into the thoracic cavity is accomplished using the Optiview technique as
described in the anterior and middle mediastinal sections of this chapter. The pleural
cavity is insufated with carbon dioxide and assessed. The 8mm reusable instrument cannulas were placed into the robotic port sites previously marked. The ports
are then secured into the robotic arms. The 12mm 30-degree da Vinci camera is
33 Mediastinal Procedures
Fig. 33.19 Port placement for the posterior mediastinal mass resection. Camera port is blue.
Robotic port 1 is yellow. Robotic port 2 is green. Assistant port is white
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passed into the camera port. The monopolar cautery spatula was placed into the port
site 2 followed by the Cadiere forceps into port site 1 and the Tip-Up fenestrated
grasper in port site 3.
Posterior Mediastinal Mass Excision Operative Steps
The lung is retracted with the Tip-Up fenestrated grasper to expose the posterior
mediastinal mass. Robotic arm 1 was used to retract the mass superiorly to initiate
dissection of the mass along inferiorly using the monopolar cautery spatula
(Fig.33.20). Feeding vessels are identied during the dissection (Fig.33.21). An
intercostal artery branch was found feeding the tumor inferiorly requiring clips
(Fig.33.22). Long bipolar graspers were used once dissection became close to the
vertebral foramina and decrease risk of nerve stimulation. The dissection is carried
over medially with continued retraction using robotic arm 1 medially and anteriorly
(Fig.33.23). The anteromedial dissection is accomplished with retraction of the