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J Thorac Cardiovasc Surg 2003;125:432-434
© 2003 The American Association for Thoracic Surgery
Brief Communications |
From the Departments of Thoracic and Cardio-Vascular Surgery CHRU de Caen, Caen, France.
Received for publication May 28, 2002. Accepted for publication June 13, 2002. Address for reprints: Philippe Icard, MD, Department of Thoracic and Cardio-Vascular Surgery, CHRU de Caen, 14033 Caen Cedex, France (E-mail: icard-p{at}chu-caen.fr).
Various minimally invasive surgical approaches have recently been proposed for the management of valvular heart disease
1,2 and of myasthenia gravis related to thymic hyperplasia. 3,4 In this report we review our preliminary experience of anterior mediastinal tumor resection through a ministernotomy.
Patients
Since October 2000, a total of 10 patients (6 men and 4 women, mean age 5 years, range 19-73 years) underwent surgical resection through a ministernotomy of a suspected anterior mediastinal tumor or mass measuring less than 7 cm on computed tomographic (CT) scan. The characteristics of all patients and tumor findings are presented in Table 1.
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The opening technique was the same as that for aortic and mitral valve operation, a technique that has been previously described in our department by Massetti and colleagues. 2 In brief, a midline skin incision (6-7 cm long) was made according to the location of the lesion or tumor visible on CT scan, generally going from the second to the fourth interspace or from the third to the fifth interspace. In all cases the incision was clearly less than half of the length of the sternal bone. The skin and subcutaneous tissue were dissected, and a median sternotomy (manubrium and body) was carried out with a sagittal saw (Zimmer Micro 100; Linvatee, Largo, Fla); the portion of the sternum under the skin flap (cephalad and caudal) was easily divided with the aid of an illuminating disposable retractor (USSC Mini Harvest; United States Surgical Corporation, Norwalk, Conn). Once the thoracic retractor (such as a Tuffier device) was inserted, the spreading of the two sternal edges was limited to 5 to 6 cm. The section of the sternal bone ended at the xiphoid appendage, which was preserved. According to Port and Ginsberg, 5 all surgical principles for resection of mediastinal tumors were strictly respected; that is, en bloc resection with extracapsular dissection avoiding intrapleural dissection of any tumors (especially stage I and II thymomas) to prevent pleural spreading, and complete thymectomy including the upper cervical poles of the gland. Special care was taken to respect the phrenic nerves. In case of an overly large or invasive tumor that might require en bloc resection of pleura, pericardium, lung, innominate vein, or superior vena cava, conversion of the ministernotomy to a standard sternotomy could be easily and immediately performed. One or two mediastinal drains were left in place. We used Redon drainage (B. Braun, Melsungen, Germany) each time the pleura or the pericardium was left intact.
Results
Complete resection was achieved in all cases, without any difficulties. All patients were extubated immediately after surgery. None received blood transfusions. Mediastinal drains were removed on postoperative day 2 or 3. Postoperative recovery of patients was fast, and all patients were able to walk on the medical unit starting from postoperative day 2 or 3. All were discharged between postoperative days 4 and 6, at which time they returned to their homes (Figure 1).
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Our series demonstrates that a less invasive approach of anterior mediastinal tumors and diseases is possible in many cases when preoperative imaging does not show a large, extended, or invasive tumor. Recently Shimokawa and colleagues 6 also recommended a limited skin incision approach to resect noninvasive thymomas. In their case report, Shimokawa and colleagues 6 used an upper part sternotomy with hemitransection of the sternum to resect a stage II thymoma in a 71-year-old patient. We also think that every time the tumor or the mediastinal lesion does not seem too large and is clearly limited on preoperative CT scan (the reasonable limit is probably around 8 cm in diameter), complete surgical resection can be attempted through a modified median sternotomy, reducing the size of the skin incision. In case of technical difficulties or when the lesion appears too large or invasive to be removed safely through this small incision, conversion to standard median sternotomy can be performed immediately and easily. No modifications from the standard surgical technique are necessary except for the need for a good light, such as the one provided by the illuminating disposable retractor that we used. A special sternal bone retractor, such as those used for cardiac valve replacement, may also be helpful. 2 A standard retractor such as the Tuffier seems sufficient to expose the anterior mediastinal space.
Complete excision of the tumor by an extracapsular dissection with strict avoidance of intrapleural dissection is strictly mandatory for resecting mediastinal tumors (such as stage I and II thymomas) and for preventing pleural spread. A videothoracoscopic approach has recently been proposed for resection of thymic hyperplasia in myasthenia gravis. 3,4 However, every time a tumor is suspected on the basis of a preoperative CT scan, we think that this video-assisted surgical technique should not be used to avoid the risk of any pleural spread. The cosmetic and psychologic advantages of ministernotomy are obvious and are of particular interest to young patients (6 of 10 patients in our series were <35 years old) and in female patients (Table 1
). We intend to compare in a prospective study standard thoracotomy and ministernotomy for postoperative pain and duration of hospitalization, because these two variables appeared at first sight to be improved after this modified sternotomy. Postoperative discomfort of patients seemed to be reduced, maybe because of the narrower spreading of the two sternal edges that reduces the stretch on all thoracic ligaments and diaphragm attachments. The mean hospitalization was 5 days, rather than the 10 days seen after standard sternotomy in our department. Even if a randomized study does not demonstrate any physical or economic advantages of a reduced sternal skin incision, however, the esthetic and psychologic benefits argue for this approach every time it is possible.
References
This article has been cited by other articles:
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  E. Davenport and R. A. Malthaner The Role of Surgery in the Management of Thymoma: A Systematic Review Ann. Thorac. Surg., August 1, 2008; 86(2): 673 - 684. [Abstract] [Full Text] [PDF]
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M. Boaron Reply Ann. Thorac. Surg., June 1, 2006; 81(6): 2337 - 2338. [Full Text] [PDF]
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M. Massetti, D. Buklas, S. Bichi, and E. Neri Minimally Invasive Thoracic Retractors Ann. Thorac. Surg., June 1, 2006; 81(6): 2336 - 2337. [Full Text] [PDF]
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 M. Watanabe, R. Yozu, and K. Kobayashi Preliminary experience with minimally invasive video-assisted surgery for thymic diseases, including myasthenia gravis, through a horizontal ministernotomy J. Thorac. Cardiovasc. Surg., September 1, 2005; 130(3): 912 - 913. [Full Text] [PDF]
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