Robotic Resection of a Posterior Mediastinal Nerve Sheath Tumor

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A 60-year-old female with a significant history of CREST syndrome, chronic obstructive pulmonary disease (COPD), and a brief history of smoking presented to the emergency department after a fall from a bicycle. She was noted to have a head injury and a right shoulder injury. An MRI of the brain performed as part of the workup revealed a left paraspinal thoracic inlet mass invading the T2 vertebra. 
 
The superior mediastinal mass in the thoracic inlet was shown to be abutting the T2 vertebra and invading between the lamina into the spinal canal, but it did not involve the dura or neural tube. The lamina was being distracted by the tumor. The patient was evaluated by neurosurgery with no neurological deficit and was referred to thoracic surgery, where she consented to a combined resection. 
 
The neurosurgical portion of the procedure was performed first, approaching the T1-T2 left extradural mass posteriorly in an open technique via a T1 hemi laminectomy with T2 subtotal medial facetectomy. This video presents the thoracic portion of the surgery. A robotic approach was employed for access to the pleural space, with four body arms and an assistant port. Upon entry, the lesion near the brachial plexus and blood vessels was identified. 
 
The pleura was carefully removed from the tumor, starting with the medial portion. Nerve sheath tumors are usually benign, slow-growing masses that carry a risk for local invasion (1). Hence, this tumor needed to be removed due to the proximity to the spinal canal, which can potentially cause neurological symptoms and morbidity to the patient (2). Since this was a nerve sheath tumor, the authors carefully navigated around the tumor boundaries to avoid any injury to the brachial plexus nerves and associated vessels.  
 
The decompressed portion indicates the part of the tumor within the canal that extended out of the foramen and anteriorly into the vertebral body, where it was widespread. The authors observed the intercostal nerve associated with this tumor, which was circumferentially separated from the tumor both above and below. The vessels supplying the tumor, as well as the nerve sheath and the intercostal nerve itself, were carefully dissected after circumferentially separating the tumor. This was achieved by cauterization with bipolar dissection. 
 
Dissection continued around the tumor, applying gentle tension to pull the tumor away from the cavity between the thoracic inlet and the body of the vertebra until reaching the posterior dissection conducted by the neurosurgery team. At this point, blood encountered showed the posterior collection from their dissection, which was gently absorbed and packed. By working directly on the pseudocapsule of the tumor and removing it, the authors were able to facilitate the posterior packing for the neurosurgery team. 
 
With further dissection, the tumor was completely removed from the canal and separated from the cavity. The intercostal nerve was dissected off the tumor, and the tumor was completely excised. The specimen was placed in a specimen bag and extracted from the body. Hemostasis was achieved with Surgicel. The area was checked under saline to ensure that there was no bleeding. The dissection bed on the spinal canal was packed with Surgicel, and a 28Fr chest tube was placed. 
 
On postoperative day two, the chest tube was removed, and the patient was discharged without any significant neurological deficits. The three-month follow-up CT showed no evidence of recurrence, and the patient was doing remarkably well. 

References

1. Thoracic neurogenic tumors: a clinicopathologic evaluation of 42 cases. Akyildz EU, 1. Yalcinkaya U. http://www.neurology-asia.org/articles/neuroasia-2015-20(1)-059.pdfNeurol Asia. 2015;1:59–63.
2. Neurogenic tumors of the thorax Ribet ME, Cardot GR. Ann Thorac Surg. 1994;58:1091–5. doi: 10.1016/0003-4975(94)90464-2.

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