Outpatient Excision of a Large Symptomatic Mediastinal Cyst

As thoracic surgery has progressed to more minimally invasive techniques, opportunities to continue innovation and change other aspects of these procedures have arisen. The author's current protocol for mediastinal surgery includes placement of a single lumen tube anesthesia. Lung isolation is achieved through capnothorax. If the dissection has been straightforward, the authors often opt not to place any type of chest tube. As the pleura is an absorptive surface, a small amount of fluid is reabsorbed and does not need to be drained. However, complete evacuation of the capnothorax is critical at the completion of the procedure. The adoption of these additional techniques allows for even complex mediastinal surgery to be performed as an outpatient procedure.Video 1:These videos demonstrate the case of a 48-year-old male who presented with shortness of breath. A work-up revealed a large mediastinal cyst. Computed tomography is seen in the video above.Technique: Positioning: Lateral
decubitus. Video 2:Three 5 mm ports were placed. The first was placed while ventilation was being held, with the endotracheal tube disconnected from the ventilator, so as to relive any residual positive pressure on the lung. CO2 was connected to the trocar and the chest was inspected with the camera. The two additional ports were placed in a triangular configuration. This technique of placement typically avoids injury to the parenchyma. A 30-degree 5 mm camera was used.Video 3:The dissected pleural flap appeared to obstruct some of the visualization, so a 3 mm additional port with a grasper was used to provide additional traction. With this configuration the operating surgeon uses both of their hands, and the assistant surgeon does also, holding the camera and providing traction. This additional port is useful when the assistant is the attending, as it allows them to more easily instruct the operating surgeon.Video 4: The 30-degree camera is a useful tool in that it offers different perspectives by rotating the light cord and also moving camera ports. When performing these procedures, it is important to maintain perspective by periodically obtaining a panoramic view and not “digging yourself in a hole.” When one stops making progress in a particular direction, the authors recommend they change the area of focus for the dissection and continue from another perspective. When things become unclear, as during the dissection shown in the videos, it is important to maximize your knowledge of the relative anatomy by taking different perspectives, identifying the relevant structures, and minimizing the risk to those structures. In these videos, it appears the cyst is arising from the extension of the pericardium overlying the aorta. Thus, the authors took care to be away from the aorta, so as not to injure it when resecting the cyst.Video 5:Once resected, the cyst was extracted. Intercostal blocks were placed, and the lung was reexpanded. The patient was sent home the same day and returned to exercise two days after his operation. His shortness of breath completely resolved, and he was well without symptoms at 6 months.Read the full article at: https://www.ctsnet.org/article/outpatient-excision-large-symptomatic-mediastinal-cyst

随着胸外科技术向更加微创的方向发展，继续创新并改变这些手术的其他方面的机会也应运而生。作者目前的中纵隔手术方案包括单腔麻醉管的放置。通过二氧化碳胸膜外技术实现肺隔离。如果解剖过程顺利，作者通常选择不放置任何类型的胸腔引流管。由于胸膜为吸收性表面，少量液体被重新吸收，无需引流。然而，在手术完成时，完全清除二氧化碳胸膜外区域至关重要。采用这些额外的技术使得复杂的纵隔手术能够作为门诊手术进行。视频1：这些视频展示了48岁男性患者因呼吸困难就诊的病例。检查结果显示患者存在一个大的纵隔囊肿。视频上可见计算机断层扫描图像。技术：体位：侧卧位。视频2：放置了三个5毫米的切口。第一个切口在保持通气的同时进行，此时将气管导管从呼吸机中移除，以缓解肺内残留的阳性压力。将二氧化碳连接到 trocar 上，并使用摄像头检查胸腔。另外两个切口以三角形状放置。这种放置技术通常可以避免对实质组织的损伤。使用了30度的5毫米摄像头。视频3：解剖的胸膜瓣似乎阻碍了部分视野，因此使用了一个额外的3毫米切口并配备了抓钳，以提供额外的牵引力。在这种配置下，主刀医生可以使用双手，助手医生同样可以使用双手，握住摄像头并提供牵引力。当助手为上级医生时，这个额外的切口非常有用，因为它使得上级医生能够更轻松地指导主刀医生。视频4：30度摄像头是一种有用的工具，因为它可以通过旋转光缆和移动摄像头端口提供不同的视角。在执行这些程序时，通过定期获取全景视图，而不是“陷入困境”，非常重要。当在特定方向上停止进展时，作者建议他们改变解剖的焦点区域，并从另一个视角继续进行。当事情变得不明确时，如在视频中展示的解剖过程中，通过采取不同的视角，识别相关结构，并最大限度地减少对这些结构的风险，这一点非常重要。在这些视频中，囊肿似乎起源于覆盖主动脉的心包延伸。因此，作者在切除囊肿时特别注意避开主动脉，以免在切除过程中损伤它。视频5：一旦切除囊肿，将其取出。放置肋间神经阻滞，并重新扩张肺部。患者当天出院，并在术后两天开始锻炼。他的呼吸困难完全缓解，在6个月时，他身体状况良好，无任何症状。阅读完整文章请访问：https://www.ctsnet.org/article/outpatient-excision-large-symptomatic-mediastinal-cyst