Totally Endoscopic Port-Access Atrial Myxoma Resection Without Robotic Assistance

The video presents the technique of surgical excision of the right atrial myxoma using a totally endoscopic port-access without robotic assistance.

A 51-years-old female was admitted to the hospital because of chest pain just one day before. She had a normal medical history. Transthoracic echocardiography revealed a giant neoplasm in the right atrium, a mass measuring 48x36 mm had a stalk attached to the interatrial septum. The computed tomography for metastatic workup was negative.

Because the tumor was mobile, moved deeply into the right ventricle during diastole that led to high risk of pulmonary embolism, so she had underwent an urgent operation, using the technique of totally endoscopic port-access. The surgical manipulations were done through 3 trocars <1.2cm, under 3D video screen.

The patient was placed in supine position, under general anaesthesia with double-lumen endotracheal intubation. The right side of the chest was slightly elevated at 300, two arms along the body. External defibrillator patches were placed to subtend the maximum cardiac mass.

A 2 cm tranverse incision was made in the right groin and vessel cannulas were established with indirect artery cannulation via a Dacron graft (8mm in diameter), anastomosed end-to-side to the right  common femoral artery. Venous drainage with bicaval cannulation was performed via the right femoral vein and right internal jugular vein, using Seldinger technique.

Three trocars were placed in the right chest of the patient: one 10 mm trocar in the 5th intercostal space (ICS) at midaxillary line for the 3D camera, one 12-mm trocar in the 5th ICS between anterior axillary line and midclavicular line for main surgical instruments (electrosurgical knife, needle holder, scissors…), one 5-mm trocar in the 4th ICS at anterior line for secondary instruments.

CPB was initiated, CO2 inflowed into the chest cavity. After lung deflation, the pericardium was opened 2 cm anterior to the phrenic nerve and 2-0 polyester traction sutures were made. Superior vena cava was snared using a perlon suture thread size 2, passed out through the 5mm trocar, IVC was left free. Patient was in Trendelenburg position. Right atriotomy was performed and 4-0 prolene atrial wall traction sutures were made for tumor exposure.

Exposure revealed a mass soft, gelatinous, reddish brown, sphere in shape, smooth surface with estimated dimensions of 5 cm, attached to the fossa ovalis and completely detached from the septal tricuspid annulus.

A nylon bag was put into thoracic cavity via 12mm trocar, preparation for tumor harvest. After the tumor was located, the tumor was meticulously and completely resected from the interatrial septal attachment, delivered into the nylon bag,

The heart chambers were carefully inspected with the 3D endoscope to ensure complete tumor removal without any debriment residues.

The right atriotomy was closed using double-layer continuous 4/0 prolene running sutures.

Closed the pericardium with continuous stiches, 18Fr drain was placed in pericardial cavity.

Withdrew the 12mm trocar, the tumor containing nylon bag was pulled out through 12mm trocar hole (after extraction in reducing tumor volume).

The 32 Fr pleural cavity drain was inserted through the 10 mm trocar position.

The total operative time and bypass time was 120 minutes and 45 minutes, respectively.

Postoperative mechanical ventilation: 10 hours, ICU time: 20 hours . Postoperative drainage in the first 24 hours was 50 ml. The postoperative hospital stay was 6 days. The pathologic examinations confirmed myxoma.

The authors hope the video would be useful to you. Do not hesitate to contact us (via email bacsyhuu@gmail.com or Telephone +84 912168887) if you have any questions about this video.

Thank you!

References

1. Han Li et al. Clinical Features and Surgical Results of Right Atrial Myxoma. J Card Surg 2016;31
2. Quang-Huy Dang . Totally Endoscopic Resection of Giant Left Atrial Myxoma without Robotic Assistance. Innovations 2018;13
3. Gao et al .Excision of atrial myxoma using robotic technology. J Thorac Cardiovasc Surg 2010;139
4. Totally Endoscopic Robotic Cardiac Tumor Resection (Atrial Myxoma). https://roboticheartsurgeon.com/robotic-atrial-myxoma-surgery/

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