In 2011, the patient, a 29-year-old male, presented to an outside facility with atypical chest pain. A chest x-ray revealed a right paratracheal mass. An MRI showed a 5 x 5 x 6 cm cystic mass, consistent with a bronchogenic cyst. The patient chose to observe the mass. In 2013, repeat imaging with a CT scan revealed that the mass had increased in size to 6 x 6 x 7 cm. The patient consented to a robot-assisted mediastinal mass resection.
Operative Technique
After LMA placement, a flexible bronchoscopy was performed. The trachea was examined from the vocal cords down to the carina, and no tracheal wall involvement was seen.
Positioning
The patient was positioned on a bean bag in the left lateral decubitus position and strapped to the table. The right shoulder was extended over the head and supported by an arm rest. An axillary roll was placed. The patient was placed in the steep reverse Trendelenburg position. The robot was brought in, over-hanging the head just over the right shoulder.
Port Placement
A 4-arm technique was used to perform this operation. Surface anatomy was marked on the chest wall. The tip of the scapula, the hilum, and the location of the mass were drawn out. The port sites were marked. Five ports were placed. The camera port (12 mm) was placed in the posterior axillary line in the 5th intercostal space (ICS). Ports for the robotic arms were placed in the anterior axillary, anterior scapular, and mid-scapular line, each approximately a hand-width apart. An accessory utility 12 mm port was placed in the mid-axillary line, in the 7th ICS. This port was used for suctioning, passing sutures, and removing the specimen. The Blake drain was also brought out through this port site.
Post-Procedure Care
At the end of the procedure, the patient was extubated on table and then recovered in the PACU. A chest x-ray did not reveal any residual pneumothorax. The Blake drain was removed on the first post-operative day and the patient was discharged home.
Conclusion
The robot-assisted technique for mediastinal mass resection is an excellent technique. The 4th arm allows for retraction. The 10X magnification provides excellent visualization of the mediastinal structures. The wristed instruments allow easy dissection of structures. Patients have excellent recovery, as demonstrated in this case.
5 Comments
Kudos to the team!
Nice video, well done, do you routinely close the mediastinal pleura in these situations ? What is the benefit of that in your view ? I have never thought of doing that.
Thanks! Yes we routinely try to close the mediastinal pleura after resection. I think it helps with hemostasis and secondly maintains the tissue planes better in the event that we need to come back for re-do surgery in the area in the future.
Why use robot, with 5 incisions in the chest, if you can do the same procedure by Uniportal VATS with 4 cm single incision and saving money?
One could definitely do the case by uniportal VATS I guess. I have limited experience with uniportal VATS. As a resident doing this case, the robot provides me great dexterity and precision. The dissection is very easy and quick. From my experience in general surgery with SILS, it was always cumbersome, fighting for space with the attending and difficult to dissect. Also, the robot in this case eliminates the need for a well trained assistant. All retraction can be performed by the 4th arm and the operator is in complete control. In my opinion, the robot is here to stay. It is only a matter of time that cheaper robots will available in the market. Also, many hospitals have already made the major investment and bought the robot, it might as well be used!!