Thoracoscopic resection of bulky intrathoracic benign lesions

Clinical efficiency of three-port inflatable robot-assisted thoracoscopic surgery in mediastinal tumor resection

BACKGROUND

Aimed to assess clinical effect of three-port inflatable robot-assisted thoracoscopic surgery in mediastinal tumor resection by comparing results of the robot group with the video group.

METHODS

Retrospectively analyze 179 patients diagnosed with anterior mediastinal tumor from May 2017 to August 2021. Two groups were divided according to the surgical approach, including 92 cases in the RATS group and 87 cases in the VATS group. The results were analyzed between two groups with variables of age, sex, BMI, tumor size, and diagnosis. Perioperative clinical data was gathered to compare.

RESULT

There were no significant differences between the 2 groups with regards to demographic data and clinical features. There were no significant differences inoperative time and duration of chest tube via RATS vs. VATS. The intraoperative blood loss was statistically significantly different among the RATS and VATS groups (75.9 ± 39.6 vs. 97.4 ± 35.8 ml p = 0.042). The postoperative stay of patients in RATS group were significantly shorter than that in VATS group (2.3 ± 1.0 vs. 3.4 ± 1.4 day p = 0.035), CONCLUSION: Three-port inflatable robot-assisted thoracoscopic surgery for mediastinal tumor is feasible and reliable it is more advantageous, and it provides the surgeon with advice on treatment choice.

Comparison of the surgical outcomes of the posterior approach, video-assisted thoracic surgery, and combined approach for thoracic dumbbell tumors based on a new classification: a retrospective study

The appropriate surgical treatment strategy was based on the regions of tumor invasion. There is no classification to aid the surgeon in selection. A retrospective study of the clinical data of patients who underwent resection of thoracic dumbbell tumors at the Neurosurgery and Thoracic Surgery Department of Hospital between January 1, 2016, and December 31, 2021 was conducted. Patient data, images, and surgical outcome data were collected. The thoracic spine was divided into areas A, B, and C with respect to the line through the middle of the intervertebral foramen and the line of the costo-transverse joint lateral margin in the horizontal plane. Type I tumors were located in areas A or A and B, type II tumors were located in areas B or B and C, and type III tumors were located in areas A, B, and C. Fifty-five patients with thoracic dumbbell tumors were surgically treated (mean age, 43.1 years; 22 (40%) female). The patients with type I and III tumors underwent the posterior approach, type III tumors had more bleeding during the operation and longer operation times than type I. Among the patients with type II tumors who underwent video-assisted thoracic surgery and the posterior approach, the posterior group had more bleeding and a longer operation time than the others. The patients with type III tumors underwent the combined approach and the posterior approach; although there was no clear difference in the bleeding volume or operation time, the combined approach group had a lower incidence of complications. The new classification of different types of thoracic dumbbell tumors can simply and effectively guide the selection of surgery.

Analysis of the efficacy of the da Vinci robot in surgery for posterior mediastinal neurogenic tumors

BACKGROUND

The present research is designed to evaluate the short-term outcome of robot-assisted thoracoscopic surgery (RATS) for the treatment of posterior mediastinal neurogenic tumors.

METHODS

We retrospectively analyzed clinical data on 39 consecutive patients with mediastinal neurogenic tumors after RATS treatment completed by the same operator in the Department of Thoracic Surgery, Gansu Provincial People's Hospital from January 2016 to September 2022. There were 22 males and 17 females with a mean age of (35.1 ± 6.9) years in this analysis report. The tumors of the patients were localized and evaluated preoperatively using magnetic resonance imaging (MRI) or enhanced CT.

RESULTS

All 39 patients successfully underwent the resection of posterior mediastinal neurogenic tumors under RATS, and no conversion to thoracotomy occurred during the operations. The average operative time was (62.1 ± 17.2) min, the average docking time was (10.1 ± 2.5) min, the average intraoperative bleeding was (32.8 ± 19.5) ml, the average 24-h postoperative chest drainage was (67.4 ± 27.9) ml, the average postoperative chest drainage time was (2.2 ± 1.3) days and the average post-operative hospital stay was (3.2 ± 1.3) days. Postoperative complications occurred in 3 patients, including 2 patients with transient Horner's syndrome after surgery and 1 patient with transient anhidrosis of the affected upper limb after surgery.

CONCLUSION

RATS for posterior mediastinal neurogenic tumors is safe, effective, feasible and bring the superiority of robotic surgical system into full play.

Video-assisted thoracoscopic thymectomy is feasible for large thymomas: a propensity-matched comparison

OBJECTIVES

Video-assisted thoracoscopic thymectomy is becoming the preferable approach for early-stage thymoma. However, large thymomas are still recognized as a relative contraindication due to the possible risk of incomplete resection or capsular disruption. Thus, the aim of this study is to evaluate the feasibility of video-assisted thoracoscopic thymectomy for large thymomas.

METHODS

Patients diagnosed with Masaoka stage I-IV thymoma between April 2001 and December 2018 were retrospectively reviewed. All patients were divided into 2 groups: thymoma <5.0 cm (group A) and thymoma ≥5.0 cm (group B). Propensity score matching analysis was performed to compare postoperative results. Recurrence-free survival and overall survival were compared for oncological evaluation.

RESULTS

A total of 346 patients were included in this study. In the propensity score matching analysis, 126 patients were included both in group A and group B. There was no significant difference between these 2 groups in terms of the R0 resection rate (95.2% vs 94.4%, P = 1.000), conversion rate (1.6% vs 3.2%, P = 0.684), operation time (119.4 ± 48.4 vs 139.1 ± 46.6 min, P = 0.955), blood loss (93.2 ± 231.7 vs 100.5 ± 149.3 ml, P = 0.649), duration of chest drainage (2.7 ± 1.6 vs 2.8 ± 2.0 days, P = 0.184), length of hospitalization (5.0 ± 3.9 vs 5.2 ± 2.9 days, P = 0.628) or postoperative complications (5.9% vs 8.5%, P = 0.068). There was no significant difference between these 2 groups in terms of the overall survival (P = 0.271) and recurrence-free survival (P = 0.288).

CONCLUSIONS

Video-assisted thoracoscopic thymectomy is a safe and effective approach for large thymomas (≥5 cm) with comparable surgical and oncological results.

Clinical efficacy of robot-assisted thoracoscopic surgery for posterior mediastinal neurogenic tumors

Background

Robot-assisted thoracic surgery (RATS) has an increasing usage throughout the world. This retrospective cohort study aimed to objectively compare the surgical results between video-assisted thoracic surgery (VATS) and RATS in posterior mediastinal neurogenic tumors (PMNT).

Methods

We retrospectively reviewed the clinical data of 130 patients diagnosed with posterior mediastinal neurogenic tumor between 2015 and 2018. Magnetic resonance imaging (MRI) or enhanced computed tomography scan (CT-scan) was used to locate the tumor and investigate the Adamkiewicz’s artery preoperatively. The individual surgical approach was determined by both tumor size and patient’s willings.

Results

The surgical time in RATS (43.2±12.6 min) was tended to be less than that in VATS (47.4±11.9 min) (P=0.054). Meanwhile, the estimated blood loss in RATS group (85.8±22.6 mL) was significantly less than that in VATS group (95.3±28.4 mL) (P=0.040). However, the duration of chest tube (days) and volume of drainage (mL) had no significant difference between two groups (P=0.12 and P=0.68, respectively). The postoperative hospital stay (days) of patients in RATS group (2.2±0.4 days) was significantly shorter than that in VATS group (2.4±0.6 days) (P=0.031). There were no significant differences between two groups in the incidence of the postoperative complications and adverse reactions.

Conclusions

RATS has the superiorities in terms of surgical blood loss and postoperative hospital stay over VATS for posterior mediastinal neurogenic tumor. In conclusion, RATS could be a feasible and safe way for resecting posterior mediastinal neurogenic tumor.

Evaluation of surgical procedures in primary mediastinal cysts and tumors: single-center experience

Aim

In this study, we aimed to evaluate the results of our patients with a primary mediastinal mass and the surgical techniques applied in our clinic retrospectively.

Material and methods

Between March 2015 and March 2019, the results and treatment protocols of 32 patients with a primary mediastinal mass or cysts who were followed up and treated in our clinic were evaluated retrospectively. Twenty-six patients who underwent surgery for biopsy or resection were included in the study.

Results

Sixteen of our patients were male and 10 were female. The mean age was 39 years. 80.2% of our patients were symptomatic and 19.2% were asymptomatic and a mediastinal mass was incidentally detected in these asymptomatic patients. The most common symptom was dyspnea with frequency of 38.4%. In terms of localization, the mass was lateralized on the right side in 7 patients, on the left side in 5 patients. In 13 patients, the tumor was located in the posterior mediastinum. 8 patients underwent anterior mediastinotomy and 1 patient underwent biopsy with video-assisted thoracoscopic surgery (VATS). Most commonly a thymus-derived mass was seen. Fifteen patients underwent excision with VATS, 3 thoracotomy, 2 sternotomy and in 1 patient VATS assisted anterior minithoracotomy was performed.

Conclusions

Mediastinal tumors and cysts have different histopathological features. Robotic surgery and VATS-assisted surgery are increasingly used in surgical excision.

Hybrid robotic thoracic surgery for excision of large mediastinal masses

Between April 2016 and October 2017, we retrospectively reviewed all patients undergoing excision of large mediastinal masses using a hybrid robotic thoracic approach at the Unit of Thoracic Surgery of Monaldi Hospital in Naples. The inclusion criteria for this approach were: evident unilateral predominance of the mass; absence of invasion to surrounding structures. Planned conversion to sternotomy was necessary in one patient for tenacious adhesions between the mediastinal goiter and the left innominate vein. In all cases the postoperative course was uneventful. The hybrid robotic approach, adopted in our Unit, consists of a thoracic procedure performed completely with articulated surgical instruments under three-dimensional vision and followed by final extension of a port-site incision to retrieve the voluminous specimen. This approach uses all the advantages of robotic technology that enables to perform a fine dissection in the small space of the anterior mediastinum and at the same time, through the simple extension of a minimally invasive access, avoids the painful sequelae of thoracotomy. In selected cases, with increased experience in robotic surgery, it can be proposed for excision of large mediastinal masses, although a longer follow-up period is necessary to validate our findings.

Giant mediastinal mass: one-port video-assisted thoracoscopic surgery

A 45-year old man with intermittent dyspnea was found to have a large mediastinal mass on chest radiograph. Computerized tomography scan revealed a 14.7 cm anterior mediastinal mass with cystic and solid components. The patient underwent a thoracoscopic resection of the mass without complication. Techniques utilized during this surgery may be helpful in avoiding pitfalls for other surgeons.

Thoracoscopic thymectomy is a feasible and less invasive alternative for the surgical treatment of large thymomas

OBJECTIVES

Thoracoscopic surgery is widely used for the surgical treatment of thymoma. However, large-sized thymomas are typically treated using open surgery. This study evaluated the feasibility of performing thoracoscopic thymectomy (TT) for thymoma ≥50 mm.

METHODS

A retrospective review was conducted on 135 patients who underwent TT or open thymectomy (OT) for Masaoka stage I-IVa thymoma between 1996 and 2014.

RESULTS

Patients were first divided into two groups based on thymoma size: thymoma ≥50 mm and thymoma <50 mm groups. There was no significant difference in the 5-year disease-free survival (DFS) between the groups ( P  = 0.5352). Patients in the thymoma ≥50 mm group were further subdivided into TT and OT groups. The length of postoperative hospital stay was significantly shorter in the TT group than in the OT group (5 vs 14 days, P  < 0.0001), with significantly fewer postoperative complications (6 patients vs 14 patients, P  = 0.0008). There was no significant difference in the 5-year DFS between patients with thymoma ≥50 mm in the TT and OT groups ( P  = 0.3501). Finally, patients undergoing TT were further subdivided into thymoma ≥50 mm and thymoma <50 mm groups and, no significant difference in the 5-year DFS was found between these groups ( P  = 0.6661). Masaoka stages III-IV, but not thymoma size, were an independent prognostic factor for DFS.

CONCLUSIONS

These results demonstrate the decreased invasiveness and feasibility of TT for large-sized thymomas.

Video-assisted thoracoscopic surgery versus open thymectomy for thymoma: a systematic review

BACKGROUND

Video-assisted thoracoscopic surgery (VATS) thymectomy is an increasingly utilized alternative to traditional open approaches for the resection of thymomas. Recent studies have suggested comparable survival and oncological efficacy as well as reduced perioperative morbidity when using the VATS approach. This current systematic review thus aimed to critically evaluate existing evidence for the efficacy and safety of VATS versus open (transsternal or transthoracic) thymectomy for thymomas.

METHODS

Six electronic databases were searched from their date of inception to April 2015. Relevant studies were identified using specific eligibility criteria and data were extracted and analyzed based on predefined primary and secondary endpoints.

RESULTS

Fourteen comparative observational studies with a total of 1,061 patients were obtained for qualitative assessment, data extraction and analysis. Five-year overall survival and 10-year recurrence-free survival was similar or higher in patients undergoing VATS compared to open thymectomy. On average, the VATS group also demonstrated reduced intraoperative blood loss (131.8 vs. 340.5 mL), shorter hospital stays (7.0 vs. 9.8 days), and lower rates of postoperative pneumonia (1.9% vs. 4.1%). The mean rate of conversion from VATS to open thymectomy was relatively low (3.1%), while 30-day mortality remained low in both the VATS and open groups (0 vs. 0.3%).

CONCLUSIONS

The current evidence suggests that VATS thymectomy for thymoma has at least equal if not superior oncological efficacy and survival outcomes, as well as reduced perioperative complications, compared to open surgery. Further adequately powered studies and future randomized trials are required to confirm these findings.

Video-assisted thoracoscopic surgery for complex mediastinal mass resections

Minimally invasive surgery has changed the way operative procedures are performed in many specialties. As surgeons have become progressively facile with these techniques, the opportunities to use them have expanded. In thoracic surgery, many surgeons now use minimally invasive techniques to resect small, uncomplicated pathologies of the mediastinum as well as to perform thymectomy for myasthenia gravis. Experience with these techniques has allowed new knowledge to be gained and expansion of the use of these techniques for more complicated mediastinal pathology. This keynote address will outline the instrumentation and techniques that we have adopted over a decade of using these techniques for more complicated mediastinal pathology.

[Cystic mediastinal schwannoma appended to the vagus nerve]

INTRODUCTION

Schwannomas are a form of rare tumor, arising from neural tissue and representing 2 % of mediastinal tumors. They are usually located in the posterior mediastinum, most often in the paravertebral gutters and typically appended to intercostal nerves.

CASE REPORTS

We report two cases of unusual mediastinal schwannomas, appended to the vagus nerve. The schwannoma was located in the subcarinal region in the first case and in the right para-tracheal region in the second case. The lesions were thought to be bronchogenic cysts preoperatively in both cases because of a cystic appearance on preoperative CT scan and endobronchial ultrasonography. A surgical approach was adopted to remove the tumors. Video-assisted thoracoscopy was used in one case and robotic-assisted surgery in the second case, without any complication, allowing for complete resection and to establish a certain pathological diagnosis.

CONCLUSION

Despite this location and cystic presentation being unusual, schwannoma should be considered as a possible cause of cystic lesions in the mediastinum. Minimally invasive surgery allows for complete resection and definitive pathological diagnosis.

Videothoracoscopy in the treatment of mediastinal cysts

Introduction

Progress in the development of surgical techniques has led to the growing use of video-assisted thoracoscopic surgery (VATS) techniques in mediastinal cyst treatment.

Aim

To present our experience of treating mediastinal cysts with the minimally invasive technique.

Material and methods

Fifty patients with mediastinal cysts were treated from 2001 to 2011. There were 32 women and 18 men. The age of the patients ranged from 17 to 72, the mean age being 42 years. All patients underwent basic preoperative diagnostic tests of the chest: X-ray, computed tomography (CT), bronchoscopy and spirometry; 4 patients underwent endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) and 3 fine needle aspiration biopsy (FNAB) of the described lesions.

Results

The VATS was performed in each case. Conversion was carried out due to superior mediastinal location in 10 cases and pleural adhesions in 3 cases. The partial resection of a cyst was performed in 3 patients. One patient was treated conservatively due to heart failure. In that patient the transthoracic needle aspiration of a cyst under ultrasound guidance using alcoholisation with 76% ethanol with a good effect was performed twice. Cyst recurrence was observed in 1 case.

Conclusions

The surgical access depends on the location of a cyst. The VATS resection of a superior mediastinal cyst is not always feasible. Surgery of mediastinal cysts is both diagnostic and curative.

Extraction of mediastinal teratoma contents for complete thoracoscopic resection

OBJECTIVES

Video-assisted thoracic surgery is widely applied for resection of mediastinal tumors. The mediastinal mature teratoma, however, is usually operated on via an open approach because it is generally large, making it difficult to dissect under a thoracoscopic view and remove it from the thoracic cavity. We attempted to extract intracystic material during video-assisted thoracic surgery to facilitate dissection and removal of the tumor from the thoracic cavity.

METHODS

From January 1998 to April 2013, 13 patients (9 women, 4 men; mean age 33 years, range 17-54 years) with mediastinal mature teratomas were operated on via video-assisted thoracic surgery. Intracystic contents of the tumor were aspirated before dissection or after the teratoma was dissected and placed in the retrieval pouch.

RESULTS

None of the patients required conversion to an open procedure. Operating time was 95-184 min (mean 132 min). Blood loss during the operation amounted to 10-300 mL (mean 78 mL). The tumor size ranged from 5 to 12 cm (mean 8 cm). In all cases, the tumors were confirmed pathologically to be mature cystic teratomas with no malignant components. During and after follow-up, all patients continue to do well without recurrence.

CONCLUSION

Extraction of intracystic contents enabled thoracoscopic resection of large mature mediastinal teratomas.

Successful thoracoscopic removal of a giant teratoma following extraction of cystic conponents: a case report

Video-assisted thoracoscopic surgery is a type of minimal-access surgery. The nature of the surgery means that there are limitations on the size of a tumor that can be removed through an access incision. Herein, we report our experience removing a giant teratoma (16 × 14 × 13 cm in size) from the anterior mediastinum of a young girl. We employed video-assisted thoracoscopic surgery to remove the teratoma through a mini-thoracotomy following the extraction of the cystic components.

Video-assisted thoracoscopic resection of a bronchogenic esophageal cyst

Bronchogenic cysts are lesions of congenital origin derived from the primitive foregut. The usual presentation of bronchogenic cyst in the mediastinum is related to cyst infection or adjacent organs compression. A case of a bronchogenic esophageal cyst presenting with progressive dysphagia in a 46-year-old man is described. A video-assisted thoracoscopic excision was performed successfully. Details of the procedure are discussed.

Thoracoscopic resection of a giant teratoma compressing the right heart

A 26-year old female had an incidental finding of a cystic mediastinal mass (10.8 × 9.4 × 10.0 cm) in the inferior-anterior mediastinum. It had compressed the superior vena cava, right atrium and right ventricle, and additional imaging studies could not exclude right heart involvement. She underwent exploration via right thoracoscopy (video-assisted thoracoscopy), and the right groin vessels were isolated for bypass, if needed. Examination of the mass revealed its extrapericardial origin from the thymus. Complete resection was achieved with minimally invasive techniques through a 2.5-cm incision using a three-port approach. She was discharged on postoperative day one. The interdisciplinary planning and cooperation in this case avoided thoracotomy or sternotomy and allowed for a safe and complete minimally invasive resection.

Oncological outcomes of thoracoscopic thymectomy for the treatment of stages I-III thymomas

OBJECTIVES

Thoracoscopic thymectomy has gradually replaced conventional sternotomy for resection of thymoma; however, a thoracoscopic approach for thymoma remains controversial. We evaluated the oncological outcomes of thoracoscopic thymectomy for the treatment of stages I-III thymomas.

METHODS

Sixty-two patients who underwent thoracoscopic thymectomy for the treatment of thymoma were retrospectively reviewed between July 2005 and September 2011 at Jikei University Hospital. Surgical outcomes and pathological results between stages I+II and stage III were compared.

RESULTS

Twenty-nine patients had Masaoka stage I, 28 had stage II and 5 had stage III. Three stage III patients needed conversions to open surgery. Masaoka stage III comprised pathological type B3 in 3 patients and thymic carcinoma in 2. For all patients, the 5-year overall survival rate was 100%. Three recurrences, diagnosed as thymic carcinoma, were observed in the Masaoka stage II or III patients. The 5-year disease-free survival rate was 94.2% for all patients, 100% for Masaoka stage I, 96.1% for stage II and 37.5% (55 months) for stage III (P=0.002). The 5-year disease-free survival rate was 100% for the World Health Organization classification types A, AB and B1-3 and 0% for thymic carcinoma (P<0.0001). Significant differences were found in the 5-year disease-free survival stratified by the Masaoka stage or WHO classification, but not by surgical procedures.

CONCLUSIONS

Thoracoscopic thymectomy for Masaoka stages I and II thymomas presented acceptable oncological outcomes. Further investigation in a large series with longer follow-up is required. Masaoka stage III thymoma requires careful consideration of the approaches, including median sternotomy.

Morcellation technique to remove large tumor in thoracoscopic surgery

Extraction of tumors remains a major problem in thoracoscopic surgery. In this study, we used an efficient instrument to morcellate a tumor during thoracoscopic surgery. The cosmetic result of this technique was satisfactory; thus, we suggest that this technique is a reliable option for use during thoracoscopic surgery for benign solid tumors.

[Neurogenic tumors of the mediastinum in adults]

In adults, mediastinal neurogenic tumours constitute the third group of mediastinal tumours, after thymomas and lymphomas. If the group of neurogenic tumour is frequent, each type of tumour is relatively unusual in everyday's clinic. Among them, nerve sheath tumours are the more frequent, followed by tumour of the autonomic system. Askin tumour remains uncommon. Treatment of this tumour requires complete preoperative work-up, including standard radiography, CT-scan, MRI, and sometimes nuclear imaging. In most cases, the treatment is based on surgical resection, and may be associated with radiotherapy or chemotherapy in case of malignant tumour or incomplete resection. Better understanding of these tumours, including their molecular abnormalities, may lead to new changes in their classifications, and to their management.