A 40-year-old woman was admitted to our hospital because of a posterior mediastinal mass. She had undergone a physical examination in a local hospital 1 month previously and received a diagnosis of a posterior mediastinal mass. One week previously she underwent a second contrast-enhanced computed tomography (CT) scan in our hospital, which showed a posterior mediastinal mass that measured 3.9 cm × 2.4 cm. She had no comorbidities such as diabetes, hypertension or heart disease.
Physical, laboratory and imaging examination
Body temperature was 36.8 °C. Heart rate was 92 beats per minutes. Respiratory rate was 20 breaths per minutes. Blood pressure was 130/78 mmHg. There was no positive sign detected during the physical examination.
Results of laboratory texts upon admission were negative.
Chest contrast-enhanced CT (Figure 1): an oval soft-tissue density mass was found in the right posterior superior mediastinum. It measured 3.9 cm × 2.4 cm and had homogeneous density and smooth margin. No contrast-enhanced signal was found in the opacity.
Conventional skin preparation and preoperative education were performed.
Anesthesia and body position
The operation was conducted using general anesthesia. The patient was placed slightly forward in the left lateral recumbent position with single-lung ventilation. Conventional disinfection and draping were performed.
A 1.2 cm camera port was placed at the 5th intercostal space at the right mid-axillary line. Another two 0.8 cm utility ports were created. One of them was between the right posterior axillary line and the subscapular line, in the 8th intercostal space. The other one was at the 3th intercostal space between the anterior axillary line and midclavicular line.
- The thoracic cavity was inspected and checked for pleural adhesion. An 8-mm artificial pneumothorax was established. The 1st robotic arm was connected to a unipolar cautery hook, and the 2nd robotic arm was connected to a bipolar cautery forceps. The mass and its relation to adjoining tissues and organs were inspected.
- The mediastinal pleura was opened and the tumor was dissociated along its edge.
- The tumor was completely resected.
- Hemostasis of the tumor bed was achieved.
- The dissected tumor was harvested.
- The thoracic cavity was lavaged and the errhysis was inspected.
- An indwelling drainage tube was placed in the camera port. The robot system was withdrawn. The chest was closed after sputum suction and lung recruitment. Total intraoperative blood loss was 5 mL.
After the surgery, the patient received conventional adjuvant remedy. The drainage on postoperative day 1 was 20 mL. The patient was extubated on postoperative day 1. No postoperative morbidity was observed.
Morphology: the mediastinal mass was 4 cm × 3 cm × 1.5 cm. The mass substance was moderately hard and looked like tofu. The pathologic diagnosis was mediastinal neurofibroma.
For this patient, robotic thoracic surgery was safe and efficient. Compared with traditional video-assisted thoracoscopic surgery (VATS), the robotic system provides a clearer and more intuitive enhanced three-dimensional vision and seven degrees of freedom of the robotic arms (1). These advantages improved the ability to dissociate the mediastinal tumor and perform subtle dissection in a confined space. Furthermore, although the incision length is the same as that required for VATS, the robotic surgery caused less friction and injury to the intercostal nerve. It has been 14 years since Ichiro Yoshino conducted the first robotic-assisted extirpation of a posterior mediastinal mass in 2002 (2). Since then, additional studies have confirmed the feasibility, reliability, and superiority of this method (3-5). Furthermore, the learning curve of robotic thoracic surgery for a posterior mediastinal mass is quite short (4). However, to confirm the advantage of robotic surgery regarding postoperative and long-term survival, high-volume design, pain score, and use of postoperative anesthetic and long-term follow up is still needed.
Conflicts of Interest: The authors have no conflicts of interest to declare.
Informed Consent: Written informed consent was obtained from the patient for publication of this manuscript and any accompanying images.
- Schmid T. Robotic Surgery Eur Surg 2002;3:155-7. [Crossref]
- Yoshino I, Hashizume M, Shimada M, et al. Video-assisted thoracoscopic extirpation of a posterior mediastinal mass using the da Vinci computer enhanced surgical system. Ann Thorac Surg 2002;74:1235-7. [Crossref] [PubMed]
- Bodner J, Wykypiel H, Greiner A, et al. Early experience with robot-assisted surgery for mediastinal masses. Ann Thorac Surg 2004;78:259-65; discussion 265-6. [Crossref] [PubMed]
- Cerfolio RJ, Bryant AS, Minnich DJ. Operative techniques in robotic thoracic surgery for inferior or posterior mediastinal pathology. J Thorac Cardiovasc Surg 2012;143:1138-43. [Crossref] [PubMed]
- Al-Mufarrej F, Margolis M, Tempesta B, et al. Novel thoracoscopic approach to difficult posterior mediastinal tumors. Gen Thorac Cardiovasc Surg 2010;58:636-9. [Crossref] [PubMed]
Cite this article as: Guo W, Yang S, Jin R, Zhang Y, Chen X, Wu H, Du H, Han D, Chen K, Xiang J, Li H. Robot-assisted surgery for posterior superior mediastinal mass. AME Med J 2017;2:10.