Outpatient Excision of a Large Symptomatic Mediastinal Cyst

As thoracic surgery has progressed to more minimally invasive techniques, opportunities to continue innovation and change other aspects of these procedures have arisen. The author's current protocol for mediastinal surgery includes placement of a single lumen tube anesthesia. Lung isolation is achieved through capnothorax. If the dissection has been straightforward, the authors often opt not to place any type of chest tube. As the pleura is an absorptive surface, a small amount of fluid is reabsorbed and does not need to be drained. However, complete evacuation of the capnothorax is critical at the completion of the procedure. The adoption of these additional techniques allows for even complex mediastinal surgery to be performed as an outpatient procedure.

These videos demonstrate the case of a 48-year-old male who presented with shortness of breath. A work-up revealed a large mediastinal cyst. Computed tomography is seen in the video above.

Technique:

Positioning: Lateral decubitus.

Three 5 mm ports were placed. The first was placed while ventilation was being held, with the endotracheal tube disconnected from the ventilator, so as to relive any residual positive pressure on the lung. CO₂ was connected to the trocar and the chest was inspected with the camera. The two additional ports were placed in a triangular configuration. This technique of placement typically avoids injury to the parenchyma. A 30-degree 5 mm camera was used.

The dissected pleural flap appeared to obstruct some of the visualization, so a 3 mm additional port with a grasper was used to provide additional traction. With this configuration the operating surgeon uses both of their hands, and the assistant surgeon does also, holding the camera and providing traction. This additional port is useful when the assistant is the attending, as it allows them to more easily instruct the operating surgeon.

The 30-degree camera is a useful tool in that it offers different perspectives by rotating the light cord and also moving camera ports. When performing these procedures, it is important to maintain perspective by periodically obtaining a panoramic view and not “digging yourself in a hole.” When one stops making progress in a particular direction, the authors recommend they change the area of focus for the dissection and continue from another perspective. When things become unclear, as during the dissection shown in the videos, it is important to maximize your knowledge of the relative anatomy by taking different perspectives, identifying the relevant structures, and minimizing the risk to those structures. In these videos, it appears the cyst is arising from the extension of the pericardium overlying the aorta. Thus, the authors took care to be away from the aorta, so as not to injure it when resecting the cyst.

Once resected, the cyst was extracted. Intercostal blocks were placed, and the lung was reexpanded. The patient was sent home the same day and returned to exercise two days after his operation. His shortness of breath completely resolved, and he was well without symptoms at 6 months.

Summary

This case video highlights some of the techniques the authors have adopted in the performance of minimally invasive mediastinal surgery. These ports and instruments allow incisions to be kept small without compromising visualization or technique. In fact, in the authors’ opinion this technique provides improved visualization. In particular, with cysts, one does not need large incisions as extraction of the pathology can be done through a small port. Excellent lung isolation can be obtained with a single lumen tube and capnothorax. Absence of postoperative drainage of the chest, and excellent pain control with intercostal blocks allows patients to be discharged on the same day of the procedure and return to daily activities readily.