Robotic Assisted Excision of Posterior Mediastinal mass

 

9 year old female child, presented with c/o right sided chest pain for 2 weeks. The child was evaluated and skiagram chest was suggestive of right mediastinal opacity. On further evaluation, Magnetic resonance imaging was suggestive of mass in the right posterior mediastinum, of size approximately 5X5 cm, extending from D2 to D6 vertebra involving spinal nerves and spinal canal at the level of D4 and D5 vertebrae. Computer tomographic guided biopsy revealed a ganglioneuroma, which is a benign tumor of the nerve cells. The child was planned for robotic thoracic surgery to excise the mediastinal mass.

 

The patient was positioned in right lateral position and the robotic Xi Da vinci system was docked from the head end side. 3 robotic ports created in linear fashion in the 6th,7th and 8th intercostal space. The mass was visualized in the right paravertebral from D2-D6 vertebrae. The mass was gently dissected from the adjacent neurovascular structures and removed completely without causing any injury. The estimated blood loss was around 20 ml and the duration of surgery was 15 minutes.

 

Postoperatively the child did well and was discharged on POD II.

Mediastinal tumors are rare in the paediatric age group. Because of their size, small chest cavity and their close relation with major neurovascular structures in the chest and the spine, surgical excision is always challenging. Due to the well established morbidity of thoracotomy surgery, minimal invasive techniques  (VATS – Video Assisted and Robotic Assisted Thoracic Surgery – RATS) have now been commonly used for surgical excision of these lesions.

Open surgery has the disadvantages of large muscle cutting incision, postoperative pain and longer hospital stay. Although thoracoscopic surgery (VATS) is minimally invasive, it has its limitations in form of long learning curve, limited range of movement, less precision in dissection and suboptimal visualization, especially in a small child.

The robotic assisted thoracic surgery (RATS) has overcome these challenges and has revolutionized the management of mediastinal masses in children. It provides high definition magnification along with seven degrees freedom of movement.

 It helps surgeon to perform precise dissection of tumor preserving the neurovascular structures with results equivalent to open surgery with extra advantages of small incision, less postoperative pain and early discharge. Precise dissection helps in avoiding complications of bleeding, postoperative paresthesia, horner’s syndrome and tumor recurrence.

The current available studies suggests that the safety and outcome of RATS surgery are almost same as compare to other conventional surgeries.

Looking at the advantages of robotic surgery it is important for us to provide its benefits in pediatric population.