Technique of Thoracoscopic

Resection of Posterior Mediastinal

Tumors
Michael F. Reed, MD
umors of the posterior mediastinum, located in the
paravertebral sulcus, account for about 25% of all
mediastinal tumors. They are typically related to the
sympathetic chain or the rami of intercostal nerves.
Mediastinal neurogenic tumors are among the more
frequent mediastinal masses seen in adults.
Althoughtheyareoftenmalignantinchildren,over9%arebenig
nin the adult population. !urgical resection is usually
indicated.
T
"osterior mediastinal tumors are frequently nerve#related
neoplasms. $eurogenic tumors originate from embryonal
neural crest cells, %hich constitute the ganglia,
paraganglionic, and parasympathetic systems. $erve sheath
tumors are the most common posterior, paravertebral
tumors, accounting for & to '% of all neurogenic tumors.
Appro(imately )% have spinal canal involvement
*+dumbbell, or +hourglass, tumors-, thus impacting the
approach to resection. $erve sheath tumors commonly
originate from !ch%ann cells of intercostal nerves.
Although almost al%ays benign, malignant degeneration
may rarely occur. $eurofibromas also arise from peripheral
nerves, %ith . to &% of neurofibromas occurring in the
setting of neurofibromatosis. Multiple tumors may occur in
these individuals. The patients %ith von /ec0linghausen1s
disease frequently present at a younger age and have a
higher ris0 of malignancy.
2anglioneuromas and ganglioneuroblastomas arise from
sympathetic ganglion nerve cells. Although
ganglioneuromas are benign, they tend to adhere to ad3acent
structures, ma0ing resection more challenging than %ith
sch%annomas. This is the most frequent benign neurogenic
tumor in children. 4n contradistinction to ganglioneuromas,
neuroblastomas frequently metastasi5e.
Most posterior mediastinal neurogenic tumors are benign,
slo% gro%ing, and asymptomatic. They may be present for
a long period of time before diagnosis. 6o%ever, %ith
gro%th, they can produce symptoms by local compression
of ad3acent tissue, bone erosion, and spinal canal
involvement. 7arge intrathoracic tumors may
producedyspnea,pain,andcough.$eurologicdeficitsmayalsoo
ccur. !pinal cord compression from dumbbell tumors may
cause
abnormalgait,urinaryandfecalincontinence,andlossofsensati
o
nbelo% the lesion. /adicular pain at the level of the tumor
may present %ith
adermatomaldistribution.8ccasionallyahighthoracictumorm
ay result in 6orner1s syndrome.
9urrently, most posterior mediastinal tumors are
identified incidentally, often on plain chest radiography
obtained for other, unrelated indications. 9hest computed
tomography is indicated to effectively demonstrate si5e,
location, and relationship to ad3acent structures. Tumors of
nerve sheath origin are typically smooth, spherical, solitary,
and discrete. They usually abut vertebral bodies. 4n the
setting of neurofibromatosis, they may be multifocal and
appear lobulated. 4n contrast, tumors of autonomic ganglion
*nerve cell- origin may be less circumscribed and often are
oblong. :ony changes related to pressure or erosion may be
present. 8ccasionally magnetic resonance imaging *M/4-
may be useful for evaluating pro(imity to the neural
foramen *;ig. )- and for determining spinal cord
involvement %ith dumbbell tumors. "ercutaneous biopsy is
not required for most posterior mediastinal neurogenic
tumors because radiographic diagnosis is sufficient to
mandate resection. 8bservation of posterior mediastinal
tumors is rarely appropriate, unless the patient is at
prohibitively high ris0 for thoracoscopic surgery due to
significant medical comorbidities. !urgical resection
simultaneously provides both diagnosis and therapy.
Moreover, permitting gro%th may result in e(pansion of the
tumor into the neural foramen, requiring a more comple(
multistage operation involving both posterior and anterior
approaches.
<umbbell tumors possess both an intrathoracic and an
intraspinal component. !urgery requires e(posure of the
pleural space and the spinal canal. A number of open
approaches are feasible, including a lateral e(tracavitary
approach as %ell as a combined anterior and posterior
approach using thoracotomy for pleural e(posure. 6o%ever,
video#assisted thoracoscopic surgery *=AT!- offers
equivalent pleural e(posure, avoiding the side effects of
thoracotomy. ;or these patients, a collaborative strategy
involving neurosurgical or orthopedic spine surgeons %ith
thoracic surgeons %ill optimi5e safe preoperative planning.
115 M.F.Reed
<ue to their frequently benign nature and relatively small
si5e,
posterior mediastinal neurogenic tumors are particularly
amenable to resection using a minimally invasive,
thoracoscopic technique. 4ndeed, as =AT! %as gaining
%ider acceptance in the early )99s, one of its earlier
applications %as removal of pos#
"enn !tate Milton !. 6ershey Medical 9enter, "enn !tate 9ollege of
Medicine, 6eart and =ascular 4nstitute, 6ershey, "ennsylvania.
Address reprint requests to Michael ;. /eed, M<, "enn !tate Milton !.
6ershey Medical 9enter, "enn !tate 9ollege of Medicine, 6eart and
=ascular 4nstitute, 5 >niversity <rive, 6)'5, 6ershey, "A )?...
@#mailA mreedBpsu.edu
114 )522#29&2CD#see front matter E 2) @lsevier 4nc. All rights
reserved.
doiA).)5.C3.optechstcvs.2).'.)
terior mediastinal tumors.
)
Thoracoscopic resection remains
ideal for all but the very large tumors. 9ompared %ith
thoracotomy, =AT! allo%s an equivalent intrathoracic
operation %ith the same resection margin. As %ith other
=AT! procedures, this minimally invasive approach results
in diminished postoperative pain, fe%er complications,
shorter length of stay, and more rapid return to normal
functional status.
Thoracoscopicresectionofposteriormediastinaltumors 116
Operative Technique
Figure 1 M/4 demonstrates that this left posterior mediastinal neurogenic tumor abuts the vertebral body, but
does not invade the intervertebral foramen. *A- A(ial vie%F *:- coronal vie%F *9- sagittal vie%. "athologic analysis
demonstrated a sch%annoma.
117 M.F.Reed
Figure After the induction of general anesthesia, a double lumen endotracheal tube is inserted and its position
is verified bronchoscopically. Alternatively, a bronchial bloc0er may be utili5ed to achieve single#lung ventilation.
The patient is then placed in the lateral decubitus position. "roper positioning of the patient is critical to preventing
certain complications.
2
The operating table fle(ion point is located bet%een the iliac crest and the costal margin. The
arms are e(tended, but shoulder hypere(tension greater than 9G must be avoided to prevent brachial ple(us
neuropathy. The upper arm is supported %ith pillo%s or a padded armrest, ensuring that both ulnar nerves are
protected from pressure damage. The operating table is fle(ed to %iden the intercostal spaces on the operative side,
a simple maneuver that may diminish postoperative pain. @ither soft rolls or a beanbag is used to secure the patient
on the table. The patient is draped as for standard posterolateral thoracotomy.
Thoracoscopicresectionofposteriormediastinaltumors 11!
Figure " The lung and the diaphragm can inhibit adequate visuali5ation of the paravertebral sulcus. To improve
e(posure, the patient can be rotated anteriorly, thereby allo%ing gravity to move the lung a%ay from the posterior
mediastinum. ;or inferior tumors, the reverse Trendelenburg position may permit the diaphragm to drop a%ay from
the tumor, thus further increasing e(posure. The surgeon stands at the patient1s front. The assistant may also stand at
the patient1s front because instrumentation is directed posteriorly.
Figure 4 =AT! allo%s operative e(posure using small incisions. @ven %hen a limited utility incision is required,
no rib spreading occurs. As %ith thoracotomy, morbidity is related to intercostal nerve trauma. <uring =AT!,
intercostal nerve in3ury can be minimi5ed by using the smallest port that is feasible, depending on the necessary
instrumentation. An angled, usually .G, thoracoscope can be used to diminish pressure on the nerve. "ort insertion
should be directed to%ard the intrathoracic region %here the ma3ority of the surgery %ill occur to avoid using the
inferior edge of a rib as a fulcrum for the camera %hen attempting visuali5ation at a%0%ard angles. Typically . port
11# M.F.Reed
sites are chosen. 7ong#acting local anesthetic, such as bupivacaine, can be in3ected into the first planned port site,
anestheti5ing the intercostal nerve. :efore subsequent port insertion, each site can be in3ected %ith local anesthetic
using thoracoscopic visuali5ation to verify medication delivery in the e(trapleural plane. The first port is typically
placed at the anterior a(illary line. ;or higher tumors, this port is located at the fourth
orfifthintercostalspace.;orlo%ertumors,thefirstportcanbeplacedinthesi(thorseventhintercostalspace.T%oadditionalpo
rts are inserted, placed at a sufficient distance from each other, triangulating the ports, to facilitate best instrument
conversion on the target %ithout interfering %ith each other *+s%ordfighting,-. The ports can be used
interchangeably as needed. 4f the lung or diaphragm interferes %ith e(posure, a fourth port can be placed for a
retractor. Additionally, lo% pressure insufflation can be used
tomorerapidlyachievepulmonaryatelectasisandtopushthediaphragminferiorly.Hheninsufflating,attentionshouldbedire
cted to%ard hemodynamics, although instability is rare %ith lo% insufflation pressure.
Thoracoscopicresectionofposteriormediastinaltumors 1$
Figure 5 The tumor is identified and potential
involvement of ad3acent structures is assessed.
"ro(imity to the neural foramen is verified. Most
benign tumors are not invasive and can be mobili5ed
thoracoscopically in a straightfor%ard manner.
<issection may be performed %ith electrocautery,
e(cept %hen close to critical neural structures such as
the phrenic nerve, recurrent laryngeal nerve, and stellate
ganglion. Alternatively, ultrasonic shears can be
utili5ed. The pleura is incised circumferentially around
the tumor, allo%ing a reasonable edge to achieve an
adequate margin. ;urthermore, the rim of normal pleura
can be used for grasping to facilitate retraction.
Additional retraction can be achieved by gently
manipulating the tumor %ith a blunt#tipped instrument.
<issection is continued to e(pose the base of the lesion
and then to develop a %ell#defined plane bet%een the
lesion and the prevertebral fascia.
Figure 6 The pleura overlying the tumor
may have increased vascularity. 4ntercostal
vessels may also require division.
Additionally, radicular vessels are present in
a random distribution, %ith some entering
intervertebral foramina. Hhen possible, they
should be preserved, although resection of
dumbbell tumors frequently requires their
sacrifice. 6emostasis is maintained %ith
electrocautery for smaller blood vessels.
7arger vessels should be controlled %ith
endoscopic clips.
Figure 7 After the tumor has been
completely e(cised, it is placed in an
endoscopic bag to minimi5e the ris0 of
seeding the tract %ith tumor cells. Also, if
the tumor is fractured during removal, the
pleural space %ill not be contaminated %ith
tumor cells. The bag is brought through one
of the port sites. Typically, it should be
removed through the most inferior and
anterior port because the intercostal spaces
are %ider at this location. ;requently the
port incision needs to be slightly enlarged,
carefully limiting trauma to the intercostal
nerve, to %ithdra% the specimen through the
chest %all. @ven %ith larger tumors, rib
spreading should be avoided because that
negates much of the benefit of =AT!.
Figure ! Multimodal analgesic strategies
should be employed for minimally invasive
thoracoscopic surgery, as for thoracotomy.
Hith shorter lengths of stay and less acute
pain, thoracic epidural anesthesia is less frequently required for =AT! procedures. 6o%ever, it should be considered
in patients at increased ris0 of severe postoperative pain, pulmonary dysfunction, or postthoracotomy pain
syndrome. ;or most patients undergoing =AT!, other regional analgesic strategies can be applied. The intercostal
nerve at port sites can be locally anestheti5ed and multilevel in3ection may achieve intercostal nerve bloc0ade.
7ong#acting local anesthetic such as .25% bupivacaine can be in3ected using thoracoscopic visuali5ation. The
needle is placed percutaneously and is carefully advanced into the intercostal space, avoiding in3ury to the vessels.
Hith the needle tip in the e(trapleural plane, appro(imately 2 m7 can be in3ected, thereby raising a pleural bubble.
:y placing intercostal bloc0s from at least ) level above the highest port site, to at least ) level belo% the most
inferior port site, effective analgesia can be achieved during the early postoperative period. Additional analgesia can
11 M.F.Reed
be achieved using continuous catheter
infusion of local anesthetic into the
paravertebral e(trapleural space, providing
multilevel intercostal nerve bloc0ade.
"atients can be safely discharged %ith the
continuous infusion apparatus in place.
Figure # The spinal cord and the pro(imal portion of
the emerging nerve roots are located in the spinal canal.
The nerve roots traverse the intervertebral foramina,
formed cephalad and caudad by the pedicles,
posteriorly by the superior and inferior articular facets,
and anteriorly by the vertebral bodies and intervertebral
discs. *A- The term dumbbell refers to the shape of the
tumor %ith intrathoracic and intraspinal components
connected by a narro% %aist at the intervertebral
foramen. *:- Attempted transthoracic resection %ithout
e(posure of the spinal canal can result in traction on the
tumor and subsequent hemorrhage in the spinal canal,
resulting in devastating neurologic in3ury.
9erebrospinal fluid lea0s can also be a complication.
Additionally, incomplete e(cision of tumor in the canal
is associated %ith recurrence, often manifesting %ith
neurologic deficits. A thoracoscopic approach is
feasible for dumbbell tumors. A 2#stage operation in a
single setting is most appropriate.
.
The intraspinal
portion of the tumor is e(cised first by the neurosurgeon
or orthopedic spine surgeon. *9- Hith the patient prone,
a vertical midline incision is created over the spinous
processes, centered at the level of the involved
intervertebral foramen. 7aminectomy %ith e(tensive
foraminal enlargement is then performed. The nerve
root is divided at its medial attachment to the tumor.
After resection, the dura is closedF the foramen is sealed
to prevent spinal fluid lea0, and the posterior incision is
closed. The patient is then repositioned to lateral
decubitus and the thoracic surgeon achieves
thoracoscopic completion of the resection.
%onclusions
!urgical resection is the ideal treatment for
posterior mediastinal neurogenic tumors. :enign
neurogenic tumors rarely recur and no ad3uvant
therapy is required. Minimally invasive resection
%ith thoracoscopic techniques is safe. !tandard
ris0s of thoracic surgery, including bleeding,
infection, and pulmonary complications, are rare.
The ris0s specific to resection of neurogenic
tumors are related to nerve in3ury. <eficits such as
6orner1s syndrome, partial sympathectomy,
recurrent laryngeal nerve in3ury, and phrenic nerve
in3ury are possible %hen the tumors originate from
these specific nerves. Many of these complications can be
avoided by precise identification of the specific neurologic
structures and avoidance of electrocautery %hen dissecting
in close pro(imity to them.
;or benign posterior mediastinal lesions, complete
resection is typically achieved %ith a thoracoscopic
strategy. Minimally invasive resection is not usually
indicated %hen an invasive malignant tumor is identified
preoperatively. 4n this setting, resection of ad3acent bony
structures is often required, typically negating the benefits
of =AT!.
<umbbell tumors are amenable to =AT! resection. Hhen
an intraspinal component is clearly compressing the cord, a
combined posterior and anterior approach is indicated to
achieve negative margins. @ven %hen slight intraforaminal
involvement is present, based on computed tomography and
M/4, a combined thoracic surgery and spinal surgery
approach is safest. /esection of the posterior mediastinal
neurogenic tumor %ith intraforaminal involvement, %hile
relying only on =AT! e(posure, or even thoracotomy alone,
Thoracoscopicresectionofposteriormediastinaltumors 1
may require e(cessive retraction of the mass. "otential
undetected
hemorrhage in the spinal canal can result in devastating
neurologic sequelae.
Thoracoscopic resection of posterior mediastinal tumors
results in shorter duration of the operation, compared %ith
the open approach. This is primarily due to avoidance of the
time required to open and close a thoracotomy. As %ith
numerous other thoracic procedures, the adoption of =AT!
techniques for resection of posterior mediastinal neurogenic
tumors is associated %ith diminished postoperative
morbidity, including shorter length of stay, less pain, better
shoulder function, fe%er pulmonary complications, and
more rapid return to normal functional status.
&
4t is the
preferred approach for the resection of benign posterior
mediastinal tumors, including dumbbell tumors.
Thoracotomy is reserved for very large tumors, in %hich rib
spreading %ould be required for removal through the chest
%all, as %ell as for patients %ith significant adhesions from
prior ipsilateral thoracic surgery or pleural intervention.
References
). 7andreneau /I, <o%ling /<, ;erson ";A Thoracoscopic resection of
aposterior mediastinal neurogenic tumor. 9hest )2A)2JJ#)29, )992
2. /eed M;A Thoracic incisions, inA 9omplications in 9ardiothoracic
!urgery. Avoidance and Treatment *ed 2-. Hest !usse(, >K, Hiley#
:lac0%ell, 2), pp 22#5.
.. =allieres @, ;indlay IM, ;raser /@A 9ombined microsurgical and
thoracoscopic removal of neurogenic dumbbell tumors. Ann Thorac !urg
59A&'9#&?2, )995
&. McKenna /I Ir, 6ouc0 H, ;uller 9:A =ideo#assisted thoracic
surgerylobectomyA e(perience %ith ),) cases. Ann Thorac !urg J)A&2)#
&2', 2'