Recent advances in video-assisted thoracoscopic approach to posterior mediastinal tumours

Robotic excision of posterior mediastinal neurogenic tumours: Technique and surgical outcomes

INTRODUCTION

Neurogenic tumours are the most common tumours of the posterior mediastinum and account for 75% of the tumours in this region. Till recently, open transthoracic approach has been the standard of care for their excision. Thoracoscopic excision of these tumours is being commonly employed because of lesser morbidity and shorter hospital stay. The robotic surgical system offers a potential advantage over conventional thoracoscopy. We herein report our technique and surgical outcomes of excision of posterior mediastinal tumours using the Da Vinci Robotic Surgical System.

MATERIALS AND METHODS

We retrospectively reviewed 20 patients who underwent Robotic Portal-Posterior Mediastinal Tumour (RP-PMT) Excision at our centre. The demographic data, clinical presentation, characteristics of the tumour, operative and post-operative variables including, total operative time, blood loss, conversion rate, duration of the chest tube, hospital stay and complications were noted.

RESULTS

Twenty patients underwent RP-PMT Excision and were included in the study. The median age was 41.2 years. The most frequent presentation was chest pain. Schwannoma was the most common histopathological diagnosis. There were two conversions. The total operative time was 110 min with an average blood loss of 30 mL. Two patients developed complications. The postoperative hospital stay was 2.4 days. With a median follow-up of 36 months (6-48 months), all except patients are recurrence-free, except the patient with malignant nerve sheath tumour who developed local recurrence.

CONCLUSION

Our study demonstrates the feasibility and safety of robotic surgery for posterior mediastinal neurogenic tumours with good surgical outcomes.

Use of the harmonic blade scalpel as a novel technique for thoracoscopic resection of pediatric paraspinal masses in children

INTRODUCTION

Data support use of video-assisted thoracoscopic surgery (VATS) for safe and effective resection of paraspinal masses in children. Our aim was to describe outcomes following this operation using a novel technique and to compare its use with that of other established techniques.

SUBJECTS AND METHODS

We performed a retrospective chart review of all children (<18 years old) undergoing thoracoscopic resection of paraspinal masses in 2000-2011. Demographics, operative details, and clinical outcomes were summarized and compared between those undergoing resection using a Harmonic (Ethicon Endo-Surgery, Blue Ash, OH) blade scalpel (HBS) and those who did not.

RESULTS

Sixteen cases were identified (median age, 57.5 months; range, 2-204 months). Six cases (37%) underwent VATS with use of the HBS, and 10 (63%) did not. Demographic and clinical factors were well matched. Median tumor diameter was larger in the HBS group (49.2 cm(3) versus 18.7 cm(3); P=.07). Operative time was similar between groups (121 versus 138 minutes; P=.25), as was the estimated blood loss (10 mL versus 30 mL; P=.91) and chest tube duration (2.1 versus 1.8 days; P=.78). Three cases of Horner's syndrome developed in the standard resection group, and one complication occurred in the HBS group.

CONCLUSIONS

The Harmonic blade scalpel can be used as a simple alternative to standard dissection techniques for thoracoscopic resection of paraspinal masses in children.

Robot-assisted thoracoscopic surgery: current status and prospects

The most favorable advantage of robotic surgery is the markedly free movement of joint-equipped robotic forceps under 3-dimensional high-vision. Accurate operation makes complex procedures straightforward, and may overcome weak points of the previous thoracoscopic surgery. The efficiency and safety improves with acquiring skills. However, the spread of robotic surgery in the general thoracic surgery field has been delayed compared to those in other fields. The surgical indications include primary lung cancer, thymic diseases, and mediastinal tumors, but it is unclear whether the technical advantages felt by operators are directly connected to merits for patients. Moreover, problems concerning the cost and education have not been solved. Although evidence is insufficient for robotic thoracic surgery, it may be an extension of thoracoscopic surgery, and reports showing its usefulness for primary lung cancer, myasthenia gravis, and thymoma have been accumulating. Advancing robot technology has a possibility to markedly change general thoracic surgery.

Extended indications for robotic surgery for posterior mediastinal tumors

Previously, we evaluated use of the da Vinci Surgical System for anterior and middle mediastinal tumors in clinical cases, focusing on feasibility, safety, and appropriate settings. In this study, we evaluated extending the indications for robotic surgical treatment of posterior mediastinal tumors to include those located adjacent to the upper vertebrae or aorta. Three patients with mediastinal tumors located immediately adjacent to the vertebrae or aorta, underwent resection with the da Vinci Surgical System. All resected tumors were benign histologically. Robotic surgery enabled treatment of tumors located in the posterior mediastinum, which are very difficult to reach, making resection with the conventional video-assisted thoracoscopic surgery technique extremely difficult. All procedures were performed safely, smoothly, and extremely precisely. Crucial to the success of these operations were the appropriate placement and angle of the special da Vinci surgical ports in relation to the target and the patient's position, which varied according to the tumor location.