Robotic Resection of an Apically Located Posterior Mediastinal Mass After Prior Thoracotomy

This video demonstrates the robotic resection of an extremely apically located posterior mediastinal mass in a patient who had a prior ipsilateral thoracotomy. It highlights the fact that robotic surgery can be utilized in patients with a prior thoracotomy and may even provide an advantage in the resection of extremely apical posterior mediastinal masses, which may be difficult to access by a redo posterolateral thoracotomy. 

The case involves a fifty-year-old woman with a history of mediastinal neurofibroma that was resected via a right posterolateral thoracotomy seventeen years prior to presentation. She was being worked up for shortness of breath, and a CT scan revealed a 3.2cm soft tissue mass in an extremely apical location of the posterior mediastinum. It is important to note that the patient developed Horner’s syndrome after her first surgery.  

On axial cuts of the CT scan, the soft tissue mass was seen located in the posterior mediastinum, in the right paratracheal and paraesophageal region. On the coronal view, it appeared to abut the apex of the right upper lobe with extension into the base of the neck. The patient also underwent an MRI, which delineated the lobulated soft tissue mass separate from the spinal column and with no involvement of the neural foramen. 

The patient was taken to the operating room for resection. She was intubated with a double lumen tube and placed in a left lateral decubitus position. The camera was placed through an 8mm port in the seventh intercostal space at the posterior axillary line. Two additional 8mm ports were also placed in the seventh intercostal space, and they were used for the cautery and tip-up fenestrated grasper. An 8mm port was also placed anteriorly two rib spaces above and served for the bipolar Maryland and clip applier. The camera was inserted, and the robot was targeted for optimal arm positioning. Then the instruments were inserted as previously described.  

Adhesions were present at the level of the previous thoracotomy, which were lysed. The apex of the right upper lobe was also adhered to the chest wall and was separated with the bipolar cautery. The mass was then visualized posteriorly at the level of the first rib. Next, the pleura was incised and circumferential dissection was performed starting at the base. Dissection was continued superiorly to the base of the neck to ensure completed resection of the mass. The subclavian vessels were near the mass, and care was taken to avoid injury. Once the mass was completely freed with the capsule intact, it was placed into a specimen retrieval bag and removed. 

The patient had an uneventful post-operative course and was discharged home the day after surgery. Final pathology revealed schwannoma. 

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