Left-Sided Uniportal VATS Enucleation of a Large Esophageal Leiomyoma

Esophageal leiomyoma is the most common benign tumor of the esophagus. Surgical enucleation is indicated for symptomatic or large lesions and is typically performed via a right-sided approach.

Case Presentation

A 42-year-old, non-smoking, otherwise healthy male presented with abdominal discomfort. An abdominal computed tomography (CT) scan was performed and demonstrated no intra-abdominal pathology; however, a mediastinal mass was incidentally identified within the partially visualized thoracic cavity. A contrast-enhanced chest CT scan confirmed a 2.2 × 3.1 × 4.7 cm paraesophageal mass in the upper mediastinum.

Esophagogastroscopy identified a submucosal lesion located 23 cm from the incisors. The biopsy was nondiagnostic, as only mucosal tissue was obtained. Positron emission tomography (PET)/CT demonstrated no fluorodeoxyglucose (FDG) avidity and no evidence of metastatic disease.

Based on imaging findings, esophageal leiomyoma was suspected, and the patient was referred for surgical management.

Surgical Technique

Given the tumor’s left-sided position beneath the aortic arch and its proximity to the tracheal bifurcation, aortic arch, and major vessels, a right-sided approach was deemed suboptimal due to the need for extensive esophageal mobilization and limited exposure.

A left-sided uniportal video-assisted thoracoscopic surgery (VATS) approach was therefore selected. A 3.5 cm incision was made in the fifth intercostal space. After entering the pleural cavity, the mediastinal pleura was widely opened. The vagus nerve was identified and preserved. Lymph node dissection and exposure of the left pulmonary artery were performed to improve access.

The caudal aspect of the tumor, located beneath the aortic arch, was dissected first, followed by the cranial portion after incising the pleura along the left subclavian artery. A stay suture facilitated traction and exposure.

The tumor was carefully enucleated from the muscularis propria, preserving mucosal integrity as much as possible.

Due to limited access to the tumor bed behind the aortic arch, the esophagus was encircled with a vessel loop passed beneath the arch. Gentle traction allowed adequate exposure for repair. The muscular layer was closed using interrupted 4-0 polydioxanone (PDS) sutures over a nasogastric tube.

A chest drain was placed, and the lung was reinflated.

Postoperative Course

The postoperative course was uneventful. The patient received total parenteral nutrition initially. On postoperative day five, a contrast-enhanced CT scan showed no evidence of esophageal leak, and oral intake was resumed.

The chest drain was removed on postoperative day six, and the patient was discharged on postoperative day 10.

Histopathological examination confirmed esophageal leiomyoma, demonstrating spindle cells arranged in bundles with positive smooth muscle actin and negative DOG1 expression.

Discussion

Thoracoscopic enucleation is the standard treatment for symptomatic esophageal leiomyomas. The right-sided approach is generally preferred due to better exposure of the thoracic esophagus. However, lesions located in the upper esophagus or on the left side—particularly those beneath the aortic arch—pose significant technical challenges.

In this case, a left-sided approach provided more direct access to the tumor and surrounding structures, avoiding extensive esophageal mobilization.

Careful preoperative imaging and planning are essential in determining the optimal surgical approach, particularly in anatomically complex cases.

References

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3. Macke RA, Nason KS. Minimally Invasive Resection of Benign Esophageal Lesions. Oper Tech Thorac Cardiovasc Surg. 2014;19(4):396-413. doi:10.1053/j.optechstcvs.2014.12.002
4. Chan EE, Agasthian T. Left video-assisted thoracoscopic enucleation of a giant horseshoe oesophageal leiomyoma. J Vis Surg. 2017;3:63. Published 2017 May 4. doi:10.21037/jovs.2017.03.19
5. A-Lai GH, Hu JR, Yao P, Lin YD. Surgical Treatment for Esophageal Leiomyoma: 13 Years of Experience in a High-Volume Tertiary Hospital. Front Oncol. 2022;12:876277. Published 2022 Apr 11. doi:10.3389/fonc.2022.876277
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