Robot-Assisted Mediastinal Mass Resection

In 2011, the patient, a 29-year-old male, presented to an outside facility with atypical chest pain. A chest x-ray revealed a right paratracheal mass. An MRI showed a 5 x 5 x 6 cm cystic mass, consistent with a bronchogenic cyst. The patient chose to observe the mass. In 2013, repeat imaging with a CT scan revealed that the mass had increased in size to 6 x 6 x 7 cm. The patient consented to a robot-assisted mediastinal mass resection.

Operative Technique

After LMA placement, a flexible bronchoscopy was performed. The trachea was examined from the vocal cords down to the carina, and no tracheal wall involvement was seen.

Positioning

The patient was positioned on a bean bag in the left lateral decubitus position and strapped to the table. The right shoulder was extended over the head and supported by an arm rest. An axillary roll was placed. The patient was placed in the steep reverse Trendelenburg position. The robot was brought in, over-hanging the head just over the right shoulder.

Port Placement

A 4-arm technique was used to perform this operation. Surface anatomy was marked on the chest wall. The tip of the scapula, the hilum, and the location of the mass were drawn out. The port sites were marked. Five ports were placed. The camera port (12 mm) was placed in the posterior axillary line in the 5th intercostal space (ICS). Ports for the robotic arms were placed in the anterior axillary, anterior scapular, and mid-scapular line, each approximately a hand-width apart. An accessory utility 12 mm port was placed in the mid-axillary line, in the 7th ICS. This port was used for suctioning, passing sutures, and removing the specimen. The Blake drain was also brought out through this port site.

Post-Procedure Care

At the end of the procedure, the patient was extubated on table and then recovered in the PACU. A chest x-ray did not reveal any residual pneumothorax. The Blake drain was removed on the first post-operative day and the patient was discharged home.

Conclusion

The robot-assisted technique for mediastinal mass resection is an excellent technique. The 4th arm allows for retraction. The 10X magnification provides excellent visualization of the mediastinal structures. The wristed instruments allow easy dissection of structures. Patients have excellent recovery, as demonstrated in this case.