VATS Posterior Mediastinal Mass Excision: A Video Vignette

The patient was a twenty-eight-year-old man with an upper abdominal discomfort and dyspepsia with no comorbidities and no significant family history. Upon examination, his performance status was good. On initial assessment, a USG abdomen showed a well-defined retrohepatic mass. 

A CT scan showed a heterogenous pleural based mass in the right hemithorax abutting the inferior vena cava, pericardium, and right lower lobe of the lung with no obvious infiltration of the lung parenchyma or diaphragm. No other sites of disease were noted. A biopsy characterized it as a benign nerve sheath tumor. 

The patient’s surgery was planned in the semiprone position with a surgeon standing anteriorly. The ports were in the fifth, seventh, and nineth intercostal spaces in posterior, mid, and anterior axillary lines respectively. The seventh space was used as the camera port. A posteriorly based mass was noted along with its relationship with the azygous vein and diaphragm. Based on those findings, another working port was inserted anteriorly. Then three 12mm ports were used to allow changing the position of the camera from time to time. 

Next, the mass and the diaphragm were retracted in opposite directions to create the potential space to start dissection. Then, an anterior pleural cut was made to start. This was done by deepening it further with an energy source to reach the chest wall. After this, the pleural cut was taken cranially, keeping the azygous vein and tributaries safe. 

A bleeding tributary draining into the azygous vein was encountered and optimally managed. 

Then, the dissection of the mass off the chest wall continued, exposing the underlying ribs and intercostal muscles. 

Next, another vessel was carefully clipped. Surgeons then proceeded caudally to take pleural cuts over the diaphragm. 

With an energy device, dissection continued to reach the underlying chest wall. Then, with all pleural cuts defined, the surgeons proceeded to dissect the mass off all its attachments on the chest wall, exposing underlying structures. As dissection proceeded, the mass became more and more mobile and the job became easier. Finally, the mass was completely detached from the chest wall. 

The port sites were then extended, and a wound protector inserted and used as a mall rib-spreader to allow extraction of the specimen. After this, the tumor bed was washed and adequate hemostasis ensured. Local anesthesia infiltration was given to the intercostal spaces. 

Then the intercostal drain was put through one of the ports, a single pericostal stitch was taken with no -1 Vicryl, and overlying skin was closed with staplers. Postoperative recovery was uneventful. The ICD was removed post operative day two, and the ICD was removed on post operative day three. Final HPR showed a 10x10x4cm mass that was a benign nerve sheath tumor favoring Schwannoma. 

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