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Video-assisted thoracic surgery for superior posterior mediastinal neurogenic tumour in the supine position.

Darlong LM - J Minim Access Surg (2009)

Bottom Line: Video-assisted thoracic surgery (VATS) for a superior posterior mediastinal lesion is routinely done in the lateral decubitus position similar to a standard thoracotomy using a double-lumen endotracheal tube for one-lung ventilation.This is an area above the level of the pericardium, with the superior thoracic opening as its superior limit and its inferior limit at the plane from the sternal angle to the level of intervertebral disc of thoracic 4 to 5 vertebra lying behind the great vessels.Thus, in the selected cases, 'VATS in supine position' allows an invasive procedure to be completed in the most stable anatomical posture.

View Article: PubMed Central - PubMed

Affiliation: Department of Surgery, North East Indira Gandhi Regional Institute of Health & Medical Sciences, Shillong, India.

ABSTRACT
Video-assisted thoracic surgery (VATS) for a superior posterior mediastinal lesion is routinely done in the lateral decubitus position similar to a standard thoracotomy using a double-lumen endotracheal tube for one-lung ventilation. This is an area above the level of the pericardium, with the superior thoracic opening as its superior limit and its inferior limit at the plane from the sternal angle to the level of intervertebral disc of thoracic 4 to 5 vertebra lying behind the great vessels. The lateral decubitus position has disadvantages of the double-lumen endotracheal tube getting malpositioned during repositioning from supine position to the lateral decubitus position, shoulder injuries due to the prolonged abnormal fixed posture and rarer injuries of the lower limb. There is no literature related to VATS in the supine position for treating lesions in the posterior mediastinum because the lung tissue falls in the dependent posterior mediastinum and obscures the field of surgery; however, VATS in the supine position is routinely done for lesions in the anterior mediastinum and single-stage bilateral spontaneous pneumothorax. Thus, in the selected cases, 'VATS in supine position' allows an invasive procedure to be completed in the most stable anatomical posture.

No MeSH data available.


Related in: MedlinePlus

The superior posterior mediastinal neurogenic tumor with the lung displaced inferiorly
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Figure 0003: The superior posterior mediastinal neurogenic tumor with the lung displaced inferiorly

Mentions: One-lung ventilation using a double-lumen endotracheal tube was used for the isolation of the lung. With the patient already in the supine position, we achieved further widening of the rib space in the anterior and lateral chest wall by placing sandbags in-between the shoulder blades. The upper limb on the side of the lesion is abducted to 90 degrees thus exposing the axilla well. Following this, the anterior and posterior axillary folds become well marked and prominent. The lung on the side of the lesion is collapsed thus allowing easy access and improved visualization of the superior posterior mediastinum. The camera port is sited at about the fifth intercostal space in the mid-axillary line using a 1.5 cm incision. Two additional working ports of size 1.5 cm are also made, one at the third intercostal space along the anterior axillary line and another at the fourth intercostal space along the posterior axillary line [Figure 2]. Using these two working ports, adhesionolysis and further decompression of the lung tissue are done, so as to isolate the lung inferiorly and free the superior mediastinal mass. For the further displacement of the lung inferiorly, the patient can be positioned in a slight reverse Trendelenburg position thus taking advantage of its superior posterior mediastinal location [Figure 3]. Following this, an attempt to dissect smaller lesion with a narrow base from the posterior mediastinum can be done. However, for a lesion with a broad base or size > 6 cm, an 8 cm utility mini-axillary thoracotomy [Figure 4] is done by joining the two port sites in the anterior and posterior axillary lines [Figure 2]. In our case, because of the size of the lesion, this mini-axillary thoracotomy was made following removal of lung adhesion from the tumor. This utility mini-axillary thoracotomy site is then used as a working channel which normally would have been required even if dissection was completed via thoracoscope for the extraction of the specimen.[34] The other advantage of this utility mini-axillary thoracotomy allowed the use of normal conventional, long, hand instruments without restriction when using through the 1.5 cm port wound. Following the complete extraction of the specimen through the mini-axillary thoracotomy wound and haemostasis, a chest tube was inserted through a stab wound below the camera port. The mini-axillary thoracotomy wound which is approximately 8 cm in length is then closed. Thus with the supine positioning of the patient we were able to complete an invasive procedure in the most anatomically stable position.


Video-assisted thoracic surgery for superior posterior mediastinal neurogenic tumour in the supine position.

Darlong LM - J Minim Access Surg (2009)

The superior posterior mediastinal neurogenic tumor with the lung displaced inferiorly
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC2734902&req=5

Figure 0003: The superior posterior mediastinal neurogenic tumor with the lung displaced inferiorly
Mentions: One-lung ventilation using a double-lumen endotracheal tube was used for the isolation of the lung. With the patient already in the supine position, we achieved further widening of the rib space in the anterior and lateral chest wall by placing sandbags in-between the shoulder blades. The upper limb on the side of the lesion is abducted to 90 degrees thus exposing the axilla well. Following this, the anterior and posterior axillary folds become well marked and prominent. The lung on the side of the lesion is collapsed thus allowing easy access and improved visualization of the superior posterior mediastinum. The camera port is sited at about the fifth intercostal space in the mid-axillary line using a 1.5 cm incision. Two additional working ports of size 1.5 cm are also made, one at the third intercostal space along the anterior axillary line and another at the fourth intercostal space along the posterior axillary line [Figure 2]. Using these two working ports, adhesionolysis and further decompression of the lung tissue are done, so as to isolate the lung inferiorly and free the superior mediastinal mass. For the further displacement of the lung inferiorly, the patient can be positioned in a slight reverse Trendelenburg position thus taking advantage of its superior posterior mediastinal location [Figure 3]. Following this, an attempt to dissect smaller lesion with a narrow base from the posterior mediastinum can be done. However, for a lesion with a broad base or size > 6 cm, an 8 cm utility mini-axillary thoracotomy [Figure 4] is done by joining the two port sites in the anterior and posterior axillary lines [Figure 2]. In our case, because of the size of the lesion, this mini-axillary thoracotomy was made following removal of lung adhesion from the tumor. This utility mini-axillary thoracotomy site is then used as a working channel which normally would have been required even if dissection was completed via thoracoscope for the extraction of the specimen.[34] The other advantage of this utility mini-axillary thoracotomy allowed the use of normal conventional, long, hand instruments without restriction when using through the 1.5 cm port wound. Following the complete extraction of the specimen through the mini-axillary thoracotomy wound and haemostasis, a chest tube was inserted through a stab wound below the camera port. The mini-axillary thoracotomy wound which is approximately 8 cm in length is then closed. Thus with the supine positioning of the patient we were able to complete an invasive procedure in the most anatomically stable position.

Bottom Line: Video-assisted thoracic surgery (VATS) for a superior posterior mediastinal lesion is routinely done in the lateral decubitus position similar to a standard thoracotomy using a double-lumen endotracheal tube for one-lung ventilation.This is an area above the level of the pericardium, with the superior thoracic opening as its superior limit and its inferior limit at the plane from the sternal angle to the level of intervertebral disc of thoracic 4 to 5 vertebra lying behind the great vessels.Thus, in the selected cases, 'VATS in supine position' allows an invasive procedure to be completed in the most stable anatomical posture.

View Article: PubMed Central - PubMed

Affiliation: Department of Surgery, North East Indira Gandhi Regional Institute of Health & Medical Sciences, Shillong, India.

ABSTRACT
Video-assisted thoracic surgery (VATS) for a superior posterior mediastinal lesion is routinely done in the lateral decubitus position similar to a standard thoracotomy using a double-lumen endotracheal tube for one-lung ventilation. This is an area above the level of the pericardium, with the superior thoracic opening as its superior limit and its inferior limit at the plane from the sternal angle to the level of intervertebral disc of thoracic 4 to 5 vertebra lying behind the great vessels. The lateral decubitus position has disadvantages of the double-lumen endotracheal tube getting malpositioned during repositioning from supine position to the lateral decubitus position, shoulder injuries due to the prolonged abnormal fixed posture and rarer injuries of the lower limb. There is no literature related to VATS in the supine position for treating lesions in the posterior mediastinum because the lung tissue falls in the dependent posterior mediastinum and obscures the field of surgery; however, VATS in the supine position is routinely done for lesions in the anterior mediastinum and single-stage bilateral spontaneous pneumothorax. Thus, in the selected cases, 'VATS in supine position' allows an invasive procedure to be completed in the most stable anatomical posture.

No MeSH data available.


Related in: MedlinePlus