Robotic Chest Wall Schwannoma Resection in Schwannomatosis

Schwannomas are benign nerve sheath tumors that most commonly occur singularly in otherwise normal individuals. Multiple schwannomas in a single patient are most often seen in neurofibromatosis type 2 (NF2), but several recent reports suggest that schwannomatosis may also be a distinct clinical entity (1). Most patients have peripheral nerve tumors presenting with pain, and many also have spinal nerve root and cranial nerve tumors (2). Thoracic neurogenic tumors usually present as benign nerve sheath tumors that can be resected via transthoracic or posterior approaches, depending on the anatomical location. Robot-assisted thoracic surgery (RATS) is increasingly being used for the transthoracic approach and is now considered feasible and safe (3).  

This video describes the case of a symptomatic thoracic schwannoma (40 x 37 mm in diameter) arising from the ninth left intercostal space in a patient already diagnosed with schwannomatosis. The patient was placed in the right lateral decubitus, and a three-port robotic approach (Da Vinci Xi) was used. The anterior port was used for fenestrated bipolar forceps, the middle lower port for a 30° endoscope, and the posterior port for a Maryland robotic dissector. Single-lung ventilation and CO2 insufflation were adopted. 

The parietal pleura was incised, and the schwannoma was easily resected by both sharp and blunt dissection, thus minimizing operative bleeding. Hemostatic control was achieved using both robotic coagulation and argon beam laser. The postoperative course was uneventful, and the patient was discharged on postoperative day two. 

References

1. Evans DG, Mason S, Huson SM et-al. Spinal and cutaneous schwannomatosis is a variant form of type 2 neurofibromatosis: a clinical and molecular study. J. Neurol. Neurosurg. Psychiatr. 1997;62 (4): 361-6
2. Maccollin M, Woodfin W, Kronn D et-al. Schwannomatosis: a clinical and pathologic study. Neurology. 1996;46 (4): 1072-9. Neurology
3. Niedermaier B, Griffo R, Grott M, Deissner H, Muley T, Neumann JO, Winter H, Eichhorn M. Robotic thoracic surgery for neurogenic tumors. J Neurosurg. 2024 May 31:1-9

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