Professional Documents
Culture Documents
Hanan Fathy Pediatric Nephrology Unit University of Alexandria
Hanan Fathy Pediatric Nephrology Unit University of Alexandria
He was previously fit and well, had not been febrile, and
his only medical history was a recent visit to his general
practitioner because he “found it hard to catch his breath
at night.”
12
Airway compression
Myasthenic symptoms
easy fatigability, drooping eyelid,
Constitutional symptoms double vision, dysarthria
of malignancy
Adults Children
Anterior mediastinum 54% 43%
Middle mediastinum 20% 18%
Posterior mediastinum 26% 40%
Laboratory tests
Suspected thymoma: CBC and acetylcholine
receptor antibody
Chest x-ray
CT scan with intravenous contrast enhancement
MRI
Trans-oesophageal echocardiogram
Barium swallow
Testicular ultrasound
Chest X-ray
A CXR often initiates the evaluation of
mediastinal disorders but is rarely diagnostic
eggshell calcifications, teeth or bones within a
mass, air fluid levels).
Approach for diagnosis in x-ray
1. Is the mass actually in the mediastinum or is it in
the lung?
Mass
“disappears”
at clavicle
Thoracoabdominal
sign
Can you
see the
outline of the
mass below
the diaphragm?
Hilum overlay
Hilum can
be seen
through
mass
Thyroid goiter
Trachea is
deviated
to left
Summary
Remember the approach:
1. Is the mass actually in the mediastinum or is it in
the lung?
2. If in the mediastinum, then in which
compartment? Use the signs
3. What is the differential diagnosis for the mass?
Use clinical and radiographic clues
CT scan
CT helps delineate anatomic location, extent of disease,
tissue invasion, and tissue density.
Thymic Cyst
Thymoma
Teratoma
Pericardial Cyst
Foregut Duplication
Meningocoele
Neuroenteric Cyst
Cystic Lymphadenopathy
Lymphangioma
Fat containing masses
Thymolipoma
Teratoma (Germ cell tumors)
Esophageal lipoma
Fat deposition
Lipoma
Lipoblastoma
Liposarcoma
Extramedullary hematopoiesis
Magnetic resonance imaging (MRI)
MRI is superior to CT for imaging nerve plexus
and blood vessels, distinguishing tissue planes and
invasion, and imaging in non-trans axial planes.
E
because the articulating instruments may be capable of circumnavigating around a intraoperative photo shows a calified portion of the mass (figure 5-3). Pathology
rigid mass which may be difficult with standard rigid laparoscopic and thoracoscopic demonstrated a mature teratoma. Follow-up scans have shown no evidence of
equipment. We present our initial results using robotic surgery to resect benign and recurrence 6 months after surgery.
malignant thoracic masses. Figure 5-1 Figure 5-3
Figure 5-2
Methods
E
We performed surgical resections of chest masses in 5 patients using the Da Vinci 3-
arm Surgical Robot (Intuitive Surgical, Sunnyvale, CA). Our version of the Da Vinci Case 3 Robot Location
has one 3-D 12 mm camera arm and two 5 mm instrument arms. In one case, we An 11 year old boy presented with fatigue. After an initial chest x-ray showed a large Instrument
Arms
used a 5 mm 2-D scope. All patients had pre-operative scans showing a mediastinal mass, an MRI demonstrated a right anterior mediastinal (figure 3-1) tumor. His beta- Accessory
mass. Two children had a posterior solid mediastinal mass, 2 had an anterior solid HCG and AFP were normal. He underwent resection using 4 ports as shown in figure Port
mediastinal mass, and one had a posterior mass extending around the right lung 3-2. An intraoperative photograph is shown in figure 3-3 during the dissection of the Camera
hilum with central necrosis. phrenic nerve. In addition to the phrenic nerve, the tumor was adherent to the SVC,
right lung, and the heart. The tumor was resected enbloc. Pathology demonstrated a Patien Age Wt. Diagnosis Trocar Trocar Docking Robot Total Tumor Length Follow-
Case 1 germ cell tumor. He underwent chemotherapy and currently no evidence of recurrence
t (kg) s Placemen
t
Time Time Time Size (cm) of Stay up
A 2 year old girl had a mass found on chest x-ray for mild pulmonary symptoms. A CT 15 months after resection. 1 2 years 13. Ganglioneuroblasto 3 10 min 3 min 56 min 69 min 6.5 x 4.2 1 day 18 mo.
scan showed a superior and posterior right mediastinal mass with small calcifications 9 ma x 1.7
2 16 61. Inflammatory Mass 4 10 min 3 min 143 min 156 min 6.0 x 4.0 3 days 15 mo.
(Figure 1-1). The mass was adherent to the azygous vein and superior vena cava
(SVC). She underwent complete resection using 3 ports; a 12 mm camera port and
two 5 mm robot instrument ports (figure 1-2). An intraoperative photo is shown in
Figure 3-1 E
Figure 3-2
Figure 3-3
3
years
11
years
7
40.
0
Germ Cell Tumor 4 14 min 4 min 131 min 146 min
x 2.0
12.0 x
14.0 x 5.2
1 day* 15 mo.
figure 1-3. She went home on post-operative day #1. Pathology demonstrated a 4 4 years 21. Ganglioneuroma 3 18 min 4 min 22 min 44 min 4.0 x 2.0 1 day 13 mo.
5 x 2.5
ganglioneuroblastoma. She did not require any further therapy and she has been 5 17 70. Teratoma 4 8 min 3 min 140 min 151 min 5.6 x 4.7 1 day 6 mo.
disease free for 18 months. years 5 x 2.9
Figure 1-2 Figure 1-3 Avg. 9.8 41. - - 12.5 min 3.4 min 98.4 min 113.2 - 1.4 13.4 mo
Figure 1-1 Robot Location years 5 min days
Robot Location Camera
Phrenic Nerve
* - The patient with the germ cell tumor was ready for discharge on post-op day #1 but required chemotherapy.
Therefore, he was transferred to the oncology service for 2 additional days of inpatient chemotherapy.
Instrument Discussion
E
Arms Case 4 Complete resection of the primary mass was achieved in all patients. No open
A 4 year old boy presented with mild flu-like symptoms. Work up revealed a chest conversions were required. Subjectively, the articulating instruments allowed
Camera
mass unrelated to his complaints (figure 4-1). Complete resection was accomplished dissection of the mass seem superior to standard non articulating minimally
using 3 ports; a 5 mm 2-D robot camera port and two 5 mm instrument ports. invasive instruments. Treacherous areas such as the SVC, azygous vein,
Pathology revealed a ganglioneuroma. pulmonary hilum, phrenic nerve, and heart were dissected with relative ease
Robot Location Figure 4-3 and no complications occurred. Times for trocar placement are comparable to
Figure 4-1
Case 2 our thoracoscopic experience and docking times are relatively insignificant.
A 16 year old athlete had and fevers, fatigue, and cough. She had been on antibiotics
E