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Thoracic Surgery
Thoracic Surgery
50 Challenging Cases

Edited by
Wickii T. Vigneswaran
Loyola University Health System
Maywood, Illinois
CRC Press
Taylor & Francis Group
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 To Rupy, Yalini, Hari, and Janani
who give relevance to everything that is good and worth a struggle
CONTENTS
Preface xi
Acknowledgments xiii
Editor xv
Contributors xvii

Case 1: Robotic-Assisted Resection of Fibrous Dysplasia of the Ribs 1

Hiroko Nakahama and Wickii T. Vigneswaran
Case 2: Innovative Approach to Minimally Invasive Resection of
a Second Rib Aneurysmal Bone Cyst 7
Mathew Thomas
Case 3: Hybrid Approach to Repair of Acquired Thoracic Dystrophy in
an Adult Patient after Failed Childhood Ravitch Procedure 13
Mathew Thomas
Case 4: Cystic Bone Lesion of the Sternum 19
Wickii T. Vigneswaran
Case 5: Spontaneous Bilateral Sternoclavicular Joint Infections 25
Mathew Thomas
Case 6: Malignant Solitary Fibrous Tumor of the Pleura 31
Amber Redmond, Eric P. Anderson, Christopher W. Seder,
and Nicole M. Geissen
Case 7: Malignant Solitary Fibrous Tumor of the Pleura with
Chest ­Wall Invasion—Treated with Chest Wall Resection,
Reconstruction, and Adjuvant Proton Beam Radiotherapy 35
Mathew Thomas
Case 8: Empyema from Misplacement of Percutaneous Nephrostomy
Tube—A Diagnostic Challenge 41
Raed Abdulkareem and Francis J. Podbielski
Case 9: Malignant Solitary Fibrous Tumor of the Pleura Associated with
a Paraneoplastic Hypoglycemia 47
Evgeny V. Arshava, Adnan Al Ayoubi, and Kalpaj R. Parekh
Case 10: Feculent Empyema after Laparoscopic Appendectomy 55
Raed Abdulkareem and Francis J. Podbielski
Case 11: Robotic Stapled Plication of a Left Hemidiaphragm Eventration 61
Lia Jordano, Christopher W. Seder, and Gary W. Chmielewski
Case 12: Iatrogenic Diaphragmatic Hernia Causing Total Right Lung Atelectasis 65
Brett Curran and Wickii T. Vigneswaran
Case 13: Successful Repair of Right Diaphragmatic Herniation with
Recovery of Liver Function 71
Christian Renz and Wickii T. Vigneswaran
Case 14: Late Presentation of a Post-traumatic Diaphragmatic Hernia 75
Adrian E. Rodrigues and Wickii T. Vigneswaran

vii
 Contents

Case 15: Resection of a Giant Posterior Mediastinal Ganglioneuroma 81

Taylor Jaraczewski and Wickii T. Vigneswaran
Case 16: An Unexpected Schwannoma of the Phrenic Nerve 85
Lambros Tsonis, Anita Ong, and Wickii T. Vigneswaran
Case 17: Acute Life-threatening Mediastinal Complications of Histoplasmosis 91
Evgeny V. Arshava, John Keech, and Kalpaj R. Parekh
Case 18: Mediastinal Liposarcoma after Remote History of Radiation
as an Infant 97
James L. Lubawski Jr. and Wickii T. Vigneswaran
Case 19: Pseudo-aneurysm of Descending Aorta Presenting as
Incarcerated Intrathoracic Stomach 101
Wickii T. Vigneswaran
Case 20: Tracheal Chondrosarcoma 107
Alison Coogan, Lia Jordano, Michael J. Liptay, and Christopher W. Seder
Case 21: Multi-technique Management of Persistent Postintubation
Tracheoesophageal Fistula in a Patient with Achalasia 111
Mathew Thomas
Case 22: Presentation of a Congenital ­Tracheal-Esophageal Fistula
in Adolescence 117
Wickii T. Vigneswaran
Case 23: Repair of a Near Full-Length Malignant Tracheal-Esophageal
Fistula—A 17-Year Success Story 123
Wickii T. Vigneswaran
Case 24: Gastrobronchial Fistula and Central Diaphragmatic Hernia After
Sleeve Gastrectomy 129
Mathew Thomas
Case 25: A Bronchogenic Cyst Masquerading as a Paraesophageal
Hiatal Hernia 135
Stephanie G. Worrell, Kiran H. Lagisetty, and Rishindra M. Reddy
Case 26: The Surgical Treatment of Pulmonary Echinococcosis 139
Gillian Alex, Christopher W. Seder, and Ozuru Ukoha
Case 27: Unusual Case of an Flurodeoxyglucose (FDG)-avid
Non-Malignant Solitary Lung Mass 143
James B. Hendele and Francis J. Podbielski
Case 28: Intralobar Pulmonary Sequestration with Aberrant Venous Drainage 147
Julia Coughlin and Christopher W. Seder
Case 29: Pulmonary Dogworm (Dirofilaria immitis) Infection Presenting as
a Solitary Pulmonary Nodule 151
Mathew Thomas
Case 30: Concurrent Congenital Diaphragmatic Hernia and Extralobar
Pulmonary Sequestration 155
Kate Gallo, Gillian Alex, and Christopher W. Seder
Case 31: Primary Colloid Carcinoma of Lung 159
John Hallsten, Adrian E. Rodrigues, and Wickii T. Vigneswaran

viii
 Contents

Case 32: Pulmonary Mucormycosis with a Staphylococcus epidermidis

Co-infection 163
Albert Pai, Kalpaj R. Parekh, and Evgeny V. Arshava
Case 33: A Complicated Pulmonary Cystic Echinococcosis in Pregnancy 169
Yulia N. Matveeva and Kalpaj R. Parekh
Case 34: Staged Bilateral Uniportal Video-Assisted Thoracoscopic Surgery
(U-VATS) Extended Lung Resection for Chronic Bronchiectasis 177
Mathew Thomas
Case 35: Robotic Lobectomy in a Patient with Bronchiectasis and Diffuse
Pleural Adhesions—Advantages Over Challenges 181
Adrian E. Rodrigues and Wickii T. Vigneswaran
Case 36: Successful Pulmonary Rescue of Adult Onset Granulomatosis
with Polyangiitis Using Extracorporeal Membrane Oxygenation
and Window Thoracostomy 187
Ashish Pulikal, Jason Long, and Benjamin Haithcock
Case 37: Intimal Sarcoma of the Pulmonary Artery 193
Max Lacour and Isabelle Opitz
Case 38: An Obstructing Benign Fibroepithelial Polyp 199
Reilly Hobbs and Rishindra M. Reddy
Case 39: Getting the “Gist” of Esophageal Gastrointestinal Stromal
Tumors (GISTs) 205
Grant Lewin, Samine Ravanbakhsh, Christopher W. Seder, and Ozuru Ukoha
Case 40: Acute Esophageal Necrosis in Prader–Willi Syndrome 211
Danuel V. Laan, Betty Allen, John Agzarian, Phillip G. Rowse,
and Shanda H. Blackmon
Case 41: Enucleation of a Giant Esophageal Leiomyoma with Primary
Esophageal Repair 215
Tessa Watt and Rishindra M. Reddy
Case 42: Primary Colon Cancer in an Interposition Graft Following
Esophagectomy 219
Alexander A. Brescia, Mark B. Orringer, and Rishindra M. Reddy
Case 43: Mixed Cavernous Hemangioma-Lymphangioma of the
Gastroesophageal Junction 225
Kimberly Song, Christopher W. Seder, and Ozuru Ukoha
Case 44: Aortoesophageal Fistula, a Complication of Esophageal
Stent Placement 229
Adrian E. Rodrigues, James L. Lubawski Jr., and Wickii T. Vigneswaran
Case 45: Managing an Unusual Case of a Long Segment Benign
Esophageal Stricture 233
Wickii T. Vigneswaran and James L. Lubawski Jr.
Case 46: Post-esophagectomy Colon Diaphragmatic Herniation 239
Curtis S. Bergquist and Rishindra M. Reddy

ix
 Contents

Case 47: Normalized Blood Gases and Improved Pulmonary Function

after Lung Volume Reduction Surgery in a Patient with
Severe Global Respiratory Insufficiency 243
Claudio Caviezel, Didier Schneiter, and Walter Weder
Case 48: Bilateral Lobar Lung Transplantation with Extra-corporal
Life Support (ECLS) in a Jehovah’s Witness 249
Bastian Grande, Isabelle Opitz, and Ilhan Inci
Case 49: Single-Lung Transplant Recipient with Primary Carcinoma
Metastasis from Native Lung to Donor Lung Allograft 253
Adrian E. Rodrigues and Wickii T. Vigneswaran
Case 50: Multistage Approach to Lung Transplantation in a Cystic
Fibrosis Patient with Chronic Superior Vena Cava Occlusion
and Patent Foramen Ovale 257
Mathew Thomas

Index 263

x
PREFACE
Surgical morbidity and mortality are the direct result of incorrect decisions. Correct diag-
nosis, appropriate procedure(s), the ability of the patient to tolerate the procedure, and the
limitations of the surgeon and team performing it are equally important. On occasion, the
surgeon must alter a procedure due to unexpected findings or events, and the success may
depend how the surgeon adapts to the situation. In this book, we present 50 cases contributed
by thoracic surgeons, describing patients with diagnostic challenges and unconventional and
innovative solutions, adapting to unexpected findings, or describing new techniques to treat
an old problem, and more often than not, all while sweating it out under the glare of the oper-
ating room lights. Each case may bring out a teachable moment for working out a diagnostic
challenge, a therapeutic expertise that may help the novice or an experienced surgeon in their
clinical practice, or an interesting and entertaining reading at leisure. The discussions after
each case make no pretense at being exhaustive, and the references provide a mere starting
point for further inquiry.

xi
ACKNOWLEDGMENTS
I wish to thank the entire group of contributors in making this venture a success. This book
initially started as a single-author book, but it evolved over time inviting other contribu-
tors not because of lack of cases, but to have an infusion of varied training and practice
backgrounds. I am particularly indebted to Drs. Thomas, Seder, Reddy, Opitz, Parekh,
Long, Blakmon, and Podbielski, who not only collected their cases, but also encouraged col-
leagues to contribute their experience. I extend a special thanks to Adrian Gonzales, MD,
who wrote some of the cases with me but, more importantly, assisted me in organizing the
chapters. Without Miranda Bromage of Taylor & Francis Group, I would not have been able
to complete this work. Her encouragement throughout the process is very much appreciated.
I thank Samantha Cook of Taylor & Francis Group for her patience with me and her expert
editorial assistance. Finally, to all the patients who consented to have their stories told in this
book, without them this contribution would have been impossible.

xiii
EDITOR
Professor Wickii T. Vigneswaran, MD, MBA, was born in northern Sri Lanka. After gradu-
ating from Faculty of Medicine, University of Peradeniya, Sri Lanka, he trained in many pres-
tigious institutions in the United Kingdom and the United States. Following his advanced
fellowship training in cardiothoracic surgery at the Mayo Clinic in Rochester, Minnesota,
he started his clinical and academic practice in Chicago, holding academic appointments
at University of Illinois at Chicago, Loyola University Stritch School of Medicine, and the
University of Chicago Pritzker School of Medicine. He served as chief of Thoracic Surgery
at Loyola University Medical Center, associate chief of Cardiac and Thoracic Surgery at
University of Chicago Medical Center, and currently serves as director of Thoracic Surgery at
Loyola University Health System and systems director of Edward and Elmhurst Health. He is
a fellow of the American College of Surgeons, Royal College of Surgeons and Physicians of
Canada, Royal College of Surgeons of Edinburgh, and American College of Chest Physicians.
He is a past president of the International College of Surgeons of the U.S. Section and a for-
mer trustee of the Chest Foundation of the American College of Chest Physicians. He is well-
respected for his expertise in treating patients with end-stage lung disease, including lung
transplantation, robotic thoracic surgery, and treatment of malignant pleural mesothelioma.
He has authored more than 150 manuscripts and edited three books covering lung transplan-
tation and thoracic surgery.

xv
CONTRIBUTORS
Raed Abdulkareem Curtis S. Bergquist
Department of Surgery Department of Surgery
University of Illinois at Chicago University of Michigan
Chicago, Illinois Ann Arbor, Michigan

John Agzarian Shanda H. Blackmon

Division of General Thoracic Surgery Division of General Thoracic Surgery
Department of Surgery Department of Surgery
Mayo Clinic Mayo Clinic
Rochester, Minnesota Rochester, Minnesota

Gillian Alex Alexander A. Brescia

Department of Cardiovascular and Department of Surgery
Thoracic Surgery University of Michigan
Rush University Medical Center Ann Arbor, Michigan
Chicago, Illinois
Claudio Caviezel
Betty Allen Department of Thoracic Surgery
Division of General Surgery University Hospital Zürich
Department of Surgery Zürich, Switzerland
University of Wisconsin
Madison, Wisconsin Gary W. Chmielewski
Department of Cardiovascular and
Eric P. Anderson Thoracic Surgery
Department of Cardiovascular and Thoracic Rush University Medical Center
Surgery Chicago, Illinois
Rush University Medical Center
and Alison Coogan
Department of Cardiothoracic Surgery Department of Cardiovascular and
John H. Stroger Hospital of Cook County Thoracic Surgery
Chicago, Illinois Rush University Medical Center
Chicago, Illinois
Evgeny V. Arshava
Division of Cardiothoracic Surgery Julia Coughlin
Department of Surgery Department of Cardiovascular and
Carver College of Medicine Thoracic Surgery
University of Iowa Rush University Medical Center
Iowa City, Iowa Chicago, Illinois

Adnan Al Ayoubi Brett Curran

Division of Cardiothoracic Surgery Stritch School of Medicine
Department of Surgery Loyola University Medical Center
Carver College of Medicine Maywood, Illinois
University of Iowa
Iowa City, Iowa

xvii
 Contributors

Kate Gallo Taylor Jaraczewski

Department of Cardiovascular and Thoracic Stritch School of Medicine
Surgery Loyola University Health System
Rush University Medical Center Maywood, Illinois
Chicago, Illinois
Lia Jordano
Nicole M. Geissen Department of Cardiovascular and Thoracic
Department of Cardiovascular and Thoracic Surgery
Surgery Rush University Medical Center
Rush University Medical Center Chicago, Illinois
and
Department of Cardiothoracic Surgery John Keech
John H. Stroger Hospital of Cook County Division of Cardiothoracic Surgery
Chicago, Illinois Department of Surgery
Carver College of Medicine
Bastian Grande University of Iowa
Institute of Anesthesiology Iowa City, Iowa
University Hospital of Zürich
Zürich, Switzerland Danuel V. Laan
Division of General Thoracic Surgery
Benjamin Haithcock Department of Surgery
Division of Cardiothoracic Surgery Mayo Clinic
University of North Carolina School of Rochester, Minnesota
Medicine
Chapel Hill, North Carolina Max Lacour
Department of Thoracic Surgery
John Hallsten University Hospital Zürich
Stritch School of Medicine Zürich, Switzerland
Loyola University Medical Center
Maywood, Illinois Kiran H. Lagisetty
Department of Surgery
James B. Hendele University of Michigan
Department of Surgery Ann Arbor, Michigan
Jesse Brown VA Medical Center
Chicago, Illinois Grant Lewin
Department of Cardiovascular and Thoracic
Reilly Hobbs Surgery
Department of Surgery Rush University Medical Center
University of Michigan Chicago, Illinois
Ann Arbor, Michigan
Michael J. Liptay
Department of Cardiovascular and Thoracic
Ilhan Inci
Surgery
Department of Thoracic Surgery
Rush University Medical Center
University Hospital Zürich
Chicago, Illinois
Zürich, Switzerland

xviii
 Contributors

Jason Long Kalpaj R. Parekh

Division of Cardiothoracic Surgery Division of Cardiothoracic Surgery
University of North Carolina School Department of Surgery
of Medicine Carver College of Medicine
Chapel Hill, North Carolina University of Iowa
Iowa City, Iowa
James L. Lubawski Jr.
Department of Thoracic and Cardiovascular Francis J. Podbielski
Surgery Department of Surgery
Loyola University Health System University of Illinois at Chicago
Maywood, Illinois Chicago, Illinois

Yulia N. Matveeva Ashish Pulikal

Department of Family Medicine Division of Cardiothoracic Surgery
Carver College of Medicine University of North Carolina School of
University of Iowa Medicine
Iowa City, Iowa Chapel Hill, North Carolina

Hiroko Nakahama Samine Ravanbakhsh

Department of Surgery Department of Cardiovascular and
Loyola University Health System Thoracic Surgery
Maywood, Illinois Rush University Medical Center
Chicago, Illinois
Isabelle Opitz
Department of Thoracic Surgery Rishindra M. Reddy
University Hospital Zürich Department of Surgery
Zürich, Switzerland University of Michigan
Ann Arbor, Michigan
Anita Ong
Mercy Medical Center Amber Redmond
Loyola University Health System Department of Cardiovascular and
Chicago, Illinois Thoracic Surgery
Rush University Medical Center
Mark B. Orringer Chicago, Illinois
Department of Pathology
University of Michigan Christian Renz
Ann Arbor, Michigan Loyola University Medical Center
Maywood, Illinois
Albert Pai
Division of Cardiothoracic Surgery Adrian E. Rodrigues
Department of Surgery Department of Thoracic and Cardiovascular
Carver College of Medicine Surgery
University of Iowa Loyola University Medical Center
Iowa City, Iowa Maywood, Illinois

xix
 Contributors

Phillip G. Rowse Ozuru Ukoha

Division of General Thoracic Surgery Department of Cardiovascular and
Department of Surgery Thoracic Surgery
Mayo Clinic Rush University Medical Center
Rochester, Minnesota and
Division of Cardiothoracic Surgery
Didier Schneiter John H. Stroger Jr. Hospital of Cook County
Department of Thoracic Surgery Chicago, Illinois
University Hospital Zürich
Zürich, Switzerland Wickii T. Vigneswaran
Department of Thoracic and Cardiovascular
Christopher W. Seder Surgery
Department of Cardiovascular and Loyola University Health System
Thoracic Surgery Maywood, Illinois
Rush University Medical Center
and Tessa Watt
Department of Cardiothoracic Surgery Department of Surgery
John H. Stroger Hospital of Cook County University of Michigan
Chicago, Illinois Ann Arbor, Michigan

Kimberly Song Walter Weder

Department of Cardiovascular and Department of Thoracic Surgery
Thoracic Surgery University Hospital Zürich
Rush University Medical Center Zürich, Switzerland
Chicago, Illinois
Stephanie G. Worrell
Mathew Thomas Department of Surgery
Mayo Clinic University of Michigan
Jacksonville, Florida Ann Arbor, Michigan

Lambros Tsonis
Department of Thoracic and Cardiovascular
Surgery
Mercy Medical Center
Loyola University Health System
Chicago, Illinois

xx
 CASE 1: ROBOTIC-ASSISTED RESECTION OF FIBROUS DYSPLASIA
OF THE RIBS

Hiroko Nakahama and Wickii T. Vigneswaran

Key Words
• Robotic-assisted thoracoscopic surgery
• Fibrous dysplasia
• Chest wall tumor

Introduction
Fibrous dysplasia is a skeletal disorder that replaces medullary bone with benign fibrous con-
nective tissue. These tumors are typically asymptomatic but can present as a painful mass
or with pathologic fractures. Radiographically, they appear as a fibrous bone deformity with
fusiform expansion and cortical thinning [1,2]. Surgical resection is indicated for symptom-
atic lesions or lesions suspicious for malignant disease.
Traditionally, chest wall tumors are resected with a large thoracotomy, often necessitating
reconstruction for large defects. Video-assisted resection has also been described in case
reports; however, their use is limited by the bony chest wall anatomy [3–6]. The robotic sys-
tem has the advantage of high-definition three-dimensional reconstruction of the dissection
plane with fine motor maneuverability through small port sites. Here, we report successful
robotic-assisted thoracoscopic resection of fibrous dysplasia of the ribs.

Case Report
A 68-year-old female with fibrous dysplasia of the ribs presented with right-sided chest pain
and difficulty breathing. She was diagnosed with fibrous dysplasia over 30 years ago and was
clinically followed for the progression of the disease. With a serial computed tomography (CT)
scan, she was found to have an interval increase in size of her tumors; the lateral third rib
tumor measured 7 cm by 6 cm, and the 10th rib tumor measured 4 cm by 2.6 cm compared
to 6 cm by 4.5 cm and 3.1 cm by 1.1 cm, respectively, 8 years prior (Figure 1.1). On physical
exam, she did not have any palpable masses in her chest wall. Due to the expansile nature of
the enlarging tumors, surgical intervention to exclude malignant degeneration was recom-
mended to her.
The patient was given anesthesia and a double-lumen endotracheal tube was inserted for
lung isolation. She was placed in a left-lateral decubitus position. A camera port incision
was made in the subscapular area, and the second and third thoracoports were placed under
direct visualization in the sub-mammary area and paravertebral area and the utility port in
the ninth intercostal space at the anterior area of the second tumor. The robotic da Vinci Si
surgical system was docked in the appropriate position.

1
 Thoracic Surgery: 50 Challenging Cases

Figure 1.1 Preoperative CT scan with axial (left) and sagittal (right) view of fibrous dysplasia
of the third rib

3 2nd rib
5
2

Fibrous dysplasia rib tumor 3rd rib

Figure 1.2 Intrathoracic view of the fibrous dysplasia tumor of the third rib during robotic
dissection

First, the resection of the large tumor on the third rib was performed (Figure 1.2). The intercos-
tal resection was performed using bipolar and unipolar electrocautery. The ribs were divided
on both ends using Dennis rib shears for an en-bloc resection of the tumors, preserving the
chest wall muscles while removing adequate margin and mobilization of the tumor. The large
mass on the third rib was then placed in an Endo-bag.
Next, the tenth rib intercostal space and neurovascular bundle was dissected with a similar
technique using electrocautery. After the tenth rib was sheared, video-assisted thoracoscopic
technique was utilized for resection of the remaining tumor on the tenth rib. Through a 3 cm
skin incision over the tenth rib, the second tumor was removed and extracted through the
2
 Case 1: Robotic-Assisted Resection of Fibrous Dysplasia of the Ribs

incision site. The third rib tumor contained within the Endo-bag was then extracted through
the same incision that was made to remove the tumor on the tenth rib.
The patient recovered well from surgery and was discharged home on the following day.
The large tumor on the third rib and the tumor on the tenth rib measured 9 cm and 5 cm,
respectively, at their greatest dimension. The pathology report confirmed fibrous dysplasia
for both tumors, and the edges showed increased cellularity resembling giant-cell repara-
tive granuloma. There was no atypia or increased mitotic figures identified. At the one-week
and two-month follow-ups, the patient remained without pain or signs of recurrent disease
(Figure 1.3).

Comments
Fibrous dysplasia comprises approximately 30%–50% of benign bone tumors [1]. Fibrous
­ ysplasia can be divided into two types: monostotic with one bone involvement and poly-
d
ostotic with multiple bone involvement. Monostotic fibrous dysplasia occurs in approxi-
mately 70%–80% of cases and arises most commonly in the ribs, proximal femur, tibia, and
skull [1,7]. Polyostotic fibrous dysplasia involves more than one bone and is closely ­associated
with McCune-Albright syndrome [1]. Fibrous dysplasia arises sporadically and affects the
ribs in approximately 6%–20% of cases [8]. Surgical resection is indicated when lesions
become symptomatic and cause significant deformation, or when malignant disease is in
question. Malignant degeneration occurs in approximately 0.5%–4% of cases [8–10].

Figure 1.3 Image of specimen and incision on patient in left-lateral decubitus position
3
 Thoracic Surgery: 50 Challenging Cases

Surgical management of chest wall tumors has traditionally been performed with a thoracot-
omy with wide local excision and chest wall reconstruction for defects greater than 5 cm [2].
This approach is associated with high morbidity caused by altered respiratory mechanics due
to deformed chest wall architecture and perioperative pain. More recently, video-assisted
thoracoscopic rib resection has been reported for various chest wall tumors [3–6]. Although
this approach decreases the pain associated with a large thoracotomy and can preserve chest
wall structure, the instrumentation is largely limited by chest wall anatomy and dependent
on the location of the tumors.
Robotic-assisted thoracoscopic surgery for use in chest wall tumor resection has not been
well described in literature. Robotic-assisted resection of the first rib for Paget-Schroetter
syndrome has been reported [11,12]. A series of cases have demonstrated low rates of neuro-
vascular complications in the setting of superior visualization of the operative field, mini-
mized pain, and long-term patency of the subclavian vein [11,12].
Robotic-assisted thoracoscopic resection of chest wall tumors is a good alternative to thora-
cotomy or video-assisted thoracoscopic resection. This approach has the advantage of high-
definition three-dimensional reconstruction with fine motor maneuverability for dissection
through confined spaces. This method preserves the underlying muscular architecture of the
chest wall, limiting the need for subsequent reconstructive procedures. The small incision
and limited rib retraction significantly reduces perioperative pain and shortens the length
of the hospital stay. The disadvantage of this approach is the cost of the robotic system,
which is shared amongst multiple disciplines at our institution, and may also be offset by the
decreased hospital stay and reduced use of analgesic medications. Although this case took
499 minutes to complete, as this was the first robotic chest resection case done at our institu-
tion, we anticipate the operative time can be significantly reduced with subsequent cases and
training of ancillary staff.
Here, we describe the first robotic-assisted resection of fibrous dysplasia tumors of the rib
with excellent results (Figure 1.4). This method can be applied for any benign lesion of the
ribs and should be considered to reduce perioperative pain and morbidity associated with the
traditional methods.

[H] [H] T
2
5

3 2 1 0

Figure 1.4 Chest X-ray before (left) and after (right) robotic resection of fibrous dysplasia of
the ribs
4
 Case 1: Robotic-Assisted Resection of Fibrous Dysplasia of the Ribs

REFERENCES
1. Smith, S., Keshavjee, S. Primary chest wall tumors. Thorac Surg Clin. 2010;20(4):495–
507. doi:10.1016/j.thorsurg.2010.07.003.
2. Thomas, M., Shen, K. Primary tumors of the osseous chest wall and their management.
Thorac Surg Clin. 2017;27(2):181–193. doi:10.1016/j.thorsurg.2017.01.012.
3. Shim, J., Chon, S., Lee, C., Heo, J. Polyostotic rib fibrous dysplasia resected by video-
assisted thoracoscopic surgery with preservation of the overlying periosteum. J Thorac
Cardiovasc Surg. 2010;140(4):938–940. doi:10.1016/j.jtcvs.2010.03.010.
4. Kara, H., Keenan, J., Balderson, S., D’Amico, T. Video assisted thoracic surgery
with chest wall resection. Video-Assist Thorac Surg. 2018;3:15–15. doi:10.21037/
vats.2018.03.07.
5. Gera, P., Hei, E., Cummins, G., Harvey, J. Thoracoscopy in chest wall Ewing’s sarcoma.
J Laparoendosc Adv Surg Tech. 2006;16(5):509–512. doi:10.1089/lap.2006.16.509.
6. Rocco, G., Fazioli, F., Martucci, N., Cicalese, M., La Rocca, A., La Manna, C., De
Chiara, A. Video-assisted thoracic surgery rib resection and reconstruction with tita-
nium plate. Ann Thorac Surg. 2011;92(2):744–745. doi:10.1016/j.athoracsur.2011.03.019.
7. Rubin, A., Byrns, K., Zhou, D., Freedman, L. Fibrous dysplasia of the rib: AIRP best
cases in radiologic-pathologic correlation. Radiographics. 2015;35(7):2049–2052.
doi:10.1148/rg.2015140335.
8. Traibi, A., El Oueriachi, F., El Hammoumi, M., Al Bouzidi, A., Kabiri, E. Monostotic
fibrous dysplasia of the ribs. Interact Cardiovasc Thorac Surg. 2011;14(1):41–43.
doi:10.1093/icvts/ivr048.
9. O’Connor, B., Collins, F. The management of chest wall resection in a patient with
polyostotic fibrous dysplasia and respiratory failure. J Cardiothorac Vasc Anesth.
2009;23(4):518–521. doi:10.1053/j.jvca.2008.09.009.
10. DiCaprio, M., Enneking, W. Fibrous dysplasia. Pathophysiology, evaluation, and treat-
ment. J Bone Joint Surg Am. 2005;87(8):1848–1864. doi:10.2106/jbjs.d.02942.
11. Kocher, G., Zehnder, A., Lutz, J., Schmidli, J., Schmid, R. First rib resection for tho-
racic outlet syndrome: The robotic approach. World J Surg. 2018;42(10):3250–3255.
doi:10.1007/s00268-018-4636-4.
12. Gharagozloo, F., Meyer, M., Tempesta, B., Gruessner, S. Robotic transthoracic first-rib
resection for Paget–Schroetter syndrome. Eur J Cardiothorac Surg, doi: 10.1093/ejcts/
ezy275.

5
 CASE 2: INNOVATIVE APPROACH TO MINIMALLY INVASIVE
RESECTION OF A SECOND RIB ANEURYSMAL BONE CYST

Mathew Thomas

Key Words
• Aneurysmal bone cyst
• Rib resection
• Minimally invasive surgery

Introduction
Primary bony tumors arising from the chest wall are uncommon tumors and can be either
benign or malignant in nature. Surgical resection plays a major role in the management of
most bony chest wall tumors as the primary modality of treatment. However, resection of the
chest wall is often a morbid procedure that commonly involves large incisions and extensive
division of both soft tissues and bone. Minimally invasive chest wall resection (MICR) and
reconstruction is not commonly performed either due to lack of suitable thoracoscopic instru-
ments or tumor characteristics such as size and location that would require a large incision
for access and removal. In this report, we describe our innovative approach to resection of an
aneurysmal bone cyst (ABC) of the second rib using video-assisted thoracoscopy, along with
a laparoscopic balloon dissector to assist with subpectoral dissection.

Case Report
A 62-year-old female presented with gradually worsening right-sided anterior chest wall pain
that had been present over several months. Imaging with chest X-ray and computed tomog-
raphy (CT) scan showed an expansile 3 cm mass along the anterolateral aspect of the right,
second rib (Figure 2.1). A percutaneous core needle biopsy was performed and reported to be
consistent with ABC. Her comorbidities included hypothyroidism, obesity, and hypertension.
On our examination, she was noted to have generalized central obesity with large breasts.
The edge of the tumor was barely palpable under the lateral part of the pectoralis muscle in
the axilla and was fixed to the bony chest wall. Due to her symptoms, surgical resection using
a video-assisted approach to resect the second rib was recommended.
After induction of general anesthesia, a double-lumen endotracheal tube was placed for sin-
gle, left-lung ventilation. The patient was then positioned in a sloppy lateral thoracotomy
position with the right arm draped overhead on a padded arm board (Figure 2.2). The right
breast was retracted to the left side using adhesive tapes. The entire right chest from the ster-
num to the posterior axillary line was then prepared and draped in a sterile fashion.
In addition to the standard thoracoscopic instruments, we used a laparoscopic balloon dis-
sector (Spacemaker Plus Dissector System, Covidien, USA), commonly used for minimally

7
 Thoracic Surgery: 50 Challenging Cases

(a) (b)

Figure 2.1 (a) Axial and (b) lateral preoperative CT scan images showing second rib aneurys-
mal bone cyst (arrows) with internal septations

Figure 2.2 Intraoperative photo showing positioning of patient for thoracoscopic second
rib resection

invasive repairs of inguinal hernias. Other special instruments used in this case were the
Kerrison bone punch and the Giertz-Stille rib shears, also known as the Guillotine rib cutter.
To begin with, the right lung was deflated and a 1.2 cm thoracoscopic port was placed in
the seventh intercostal space in the midaxillary line. The right thoracic cavity was exam-
ined with a 10 mm thoracoscopic camera showing the rib mass arising from the second rib.
Pneumothorax was obtained using CO2 gas insufflation to a pressure of 8 mm Hg to assist
with exposure.
8
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 Deacon. Again and again.... Vide page 142.
Kathisma, tone vi.
Verily everything is vain, and life a shadow is, a dream; for vainly
every earth-born one disquieteth himself, as saith the scripture.
When we have gain’d the world, then dwell we in the grave, where
kings and beggars are as one. Therefore, Christ God, as lover of
mankind, to thy departed servant give thou rest.
Glory. Both now. Theotokion.
All-holy Bringer-forth of God, in my life’s time forsake me not, to
human mediation leave me not; but me thyself defend, and be thou
merciful to me.
Ode iv. Irmos.
Christ is my might, the God and Lord....
Of greatest wisdom shewing sign, and of rewards’ perfectionment,
O gracious Lord, with Angels thou the choirs of martyrs number’d
hast.
Of thy narrateless glory count him worthy to participate, who unto
thee translated is, where, Christ, their dwelling is who joy, and where
pure gladness’ voice resounds.
Glory.
Him that extols thy might divine, whom thou from earth received
hast, do thou accept, creating him a child of light; and cleanse him
from the gloom of sin, O thou Most Merciful.
Both now. Theotokion.
O tabernacle thou most pure, temple all-undefil’d, all-holy ark,
virginal place of sanctity, of Jacob thou the excellence, the Lord hath
chosen thee.
Ode v. Irmos.
With thy divine light, O Blessed One....
Like an oblation sacred, and human nature’s first-fruits, the
martyrs, who were offer’d for God’s glorifying, for our salvation ever
mediate.
Of heavenly dwelling, of grace’s distribution, thy faithful servant
gone before, count worthy, Lord, and give him ransom from
iniquities.
Glory.
Thou that alone by nature life-effector art, and grace’s trackless
depth, him that is gone, count worthy of thy kingdom, Pitiful, thou
sole immortal one.
Both now. Theotokion.
The strength, and song, and saving of the lost is he become that
to the world was born of thee, O Queen, delivering them, who thee in
faith call bless’d, from hades’ gates.
Ode vi. Irmos.
Life’s sea perturb’d....
Nail’d on the cross the choir of martyrs thou hast gather’d to
thyself, them that thy passion imitate, O Blessed One. Therefore, we
thee beseech, Rest him that now betaketh him to thee.
When thou in thy narrateless glory all the world to judge shalt on
the clouds in terror come, Deliverer, be thou pleas’d that he, thy
faithful servant, whom thou from earth received hast, may meet thee
shiningly.
Glory.
Being life’s fount, O Lord, who, through divine humanity, didst lead
the fetter’d forth; thy servant, who to thee in faith is gone, place thou
in joys of paradise.
Both now. Theotokion.
We have been turned back to earth for breaking the divine
command of God; but, through thee, Virgin, unto heaven from earth
are rais’d again, shaking off death’s corruption.
Deacon. Again and again.... Vide page 142.
Condakion, tone viii.
 Rest with the Saints, O Christ, thy servant’s soul, where is no pain,
nor grief, nor sighing, but life that endeth not.
Icos.
Thyself alone immortal art, who madest and didst fashion man; for
out of earth we mortals fashion’d were, and unto that same earth
shall go, as thou who madest me hast given command, and sayest
unto me, Earth thou art, and unto earth shalt thou return. And thither
all we mortals go, making the funeral wail, even the song, the
Alleluia.
And again.
Rest with the Saints, O Christ....
Ode vii. Irmos.
The angel made the furnace to bedew....
From the primeval fall were sav’d the martyrs by thy blood, and,
with their own blood sprinkled, they clearly thy slaying image forth.
Blessed art thou, our fathers’ God.
O life-originating Word, thou hast slain raging death; and him O
now receive, O Christ, who sleeps in faith, and sings, and says,
Blessed art thou, our fathers’ God.
Glory.
Divine-originating Lord, who me, a man, with breath divine
sufflated hast; vouchsafe thy kingdom unto him departed hence,
who, Saviour, sings to thee, Blessed art thou, our fathers’ God.
Both now. Theotokion.
Most undefil’d, conceiving God, who crush’d death’s gates and
burst the bars, thou higher than all creatures art. Therefore, we
faithful thee, O pure, extol as Mother of God.
Ode viii. Irmos.
From flame thou didst a dew outpour on reverend ones....
Martyrs of Christ, who sufferings bore, who in the strifes were
steadfast prov’d, ye are adorn’d with victory’s crown, crying, O
Christ, to ages thee we set on high.
The faithful ones who life depart in sacred wise, and unto thee, O
Master, go, gently, as loving-kind, receive, that they may rest, and
thee to ages set on high.
Glory.
Now in the land of gentle ones, Saviour, be pleas’d to stablish all
who fallen have on sleep afore, and who in thee, by faith and grace,
are justified, and thee to ages set on high.
Both now. Theotokion.
All-blessed one, we thee all bless, who didst bring forth the Word
who is blessed indeed, who for our sake incarnate was, and whom
on high to ages we set up.
Ode ix. Irmos.
Mortals may not see God....
Hope made the choirs of martyrs strong, and flam’d them ardently
towards thy love, prefiguring unto those to come a rest in verity
undisturb’d; and unto this, O Blessed One, may thy departed faithful
one be counted worthy to attain.
Of thine illumination, Christ, which bright and godlike is, be pleas’d
that he, departed hence in faith, may share, to him, as being
merciful, in Abraham’s bosom giving rest, and granting him eternal
blessedness.
Glory.
O thou that art by nature good and loving-kind, and mercy willest,
and a depth of loving-kindness art, his lot, whom, Saviour, thou from
this ill place removed hast, and from the shades of death, appoint
where shines thy light.
Both now. Theotokion.
A holy tabernacle thee we own to be, O Pure, an ark likewise, and
breastplate of the law and grace; for pardon is bestow’d, through
thee, on them, All-undefil’d, that have, by his blood justified been,
who of thy womb incarnate was.
Deacon. Again and again in peace let us pray to the Lord. Vide
page 142.
We begin the idiomela of John the monk.
Tone i.
What sweet of life abideth unaccompanied with grief? what glory
stayeth upon earth unchang’d? All is the feeblest shade, all the most
cheating dream: one moment, and death taketh all these things. But
in thy face’s light, O Christ, and in the sweetness of thy beauty, grant
rest to him whom thou hast call’d, as lover of mankind.
Tone ii.
Woe unto me, what agony hath the soul when it is from the body
torn! alas, then how it weeps, and none is merciful to it! To Angels
lifting eyes, without effect it prays; to men extending hands, it findeth
none to help. Therefore, my brethren lov’d, musing on our brief life,
let us for the departed ask for rest from Christ, and for great mercy
for our souls.
Tone iii.
All human things are vanity which last not after death: riches abide
not, nor doth glory stay; for when death cometh, these all disappear.
Then let us cry to the immortal Christ, O rest him who is gone away
from us where is the dwelling-place of all that joy.
Tone iv.
Where is the predilection of the world? where their imaginings who
fade? where is the silver and the gold? where servants’ multitude
and noise? All dust, all ashes, all a shade. But, come ye, let us say
to the immortal King, O Lord, him, who hath been remov’d from us,
of thine eternal blessings worthy count, him resting in thine ageless
happiness.
Tone v.
 I remember’d what the prophet said, I am earth, and I am dust;
and again I meditated in the graves, and saw the naked bones, and
said, Who now is king, or warrior who, or who is rich, or who is poor,
or who the just, or he that sinn’d? But, with the just, thy servant rest,
O Lord.
Tone vi.
To me thy life-effecting bidding was substance and origin; for,
willing me to form a living one from nature that unseen is and is
seen, my body thou didst make of earth, and, by thy breathing life-
creating and divine, me gavest soul. Therefore, O Christ, thy servant
rest in tract of them that living are, and in the dwellings of the just.
Tone vii.
After thine image and resemblance in the beginning making man,
in paradise thou him didst place to be of thy creation lord; but, by the
devil’s enviousness beguil’d, he ate the fruit, transgressing thy
commands. Therefore, again to earth, whence he was taken, thou
hast doom’d him to return, O Lord, and beg for rest.
Tone viii.
I weep and I lament when I reflect on death, and see the
comeliness, according to God’s image, that was shap’d for us lying
in the graves disfigured, and bereft of glory and of form. O wonder!
what is this mystery concerning us? how to corruption have we been
assign’d? how unto death conjoin’d? Verily by God’s command, as it
is written, who giveth the departed rest.
The beatitudes, tone vi.
When in thy kingdom thou shalt come, O Lord, remember us.
Blessed are the poor in spirit, for theirs is the kingdom of heaven.
Blessed are they that mourn, for they shall be comforted.
Blessed are the meek, for they shall inherit the earth.
Blessed are they that hunger and thirst after righteousness, for
they shall be filled.
 Blessed are the merciful, for they shall obtain mercy.
Christ, who, aforetime, for his penitence, didst make the thief a
citizen of paradise when on the cross to thee he cried, Remember
me, of this even me, unworthy, worthy count.
Blessed are the pure in heart, for they shall see God.
Thou who dominion hast o’er life and death, rest in the courts of
saints him whom from things of time thou taken hast; and think on
me, when in thy kingdom thou shalt come.
Blessed are the peacemakers, for they shall be called the children
of God.
Thou who o’er souls and bodies lordship hast, thou in whose hand
is held our breath, who mourners’ consolation art; rest in the land of
righteous ones thy servant whom thou hast removed hence.
Blessed are they that are persecuted for righteousness’ sake....
Christ rest thee in the land of living ones, and open paradise’s
gates to thee, and of the kingdom thee declare a citizen, and give
thee pardon of those things wherein in life thou sinned hast, O thou
of Christ belov’d.
Blessed are ye when men shall revile you....
Let us go forth and muse among the graves; for man is naked
bones, the food of worms, and of an odour ill; and let us learn what
riches are, yea, beauty, strength, and comeliness.
Rejoice, and be exceeding glad....
Let us give ear to what the Almighty saith, Woe unto them that
seek to see the Lord’s most fearful day! for it is one of gloom: for
everything with fire shall be tried.
Glory.
By the unbeginningness, and the begetting, and the proceeding, I
bow me to the Father who begat, the Son begotten I extol, I sing the
Holy Ghost, co-shining with the Father and the Son.
Both now. Theotokion.
 How, Virgin, from thy breast flow’d milk? how didst thou nurture
him, creation’s nurturer? It was as was the springing forth of water
from the rock, as streams of waters for a thirsty folk, as hath been
written.
After this the deacon saith, Let us attend.
Priest. Peace to all.
And the choir singeth, prokimenon, tone vi,
Blessed is the way wherein thou goest to-day, O soul, because a
place of rest hath been prepared for thee.
Verse. Unto thee have I cried, O Lord.
Deacon. Wisdom.
Reader. The epistle to the Thessalonians, section cclxx.
Brethren, I would not have you to be ignorant ... ending, be ever
with the Lord.[31]
Priest. Peace to thee. Alleluia.
Tone vi.
Blessed is he whom thou hast chosen and received, O Lord.
The gospel from John, section xvi.
The Lord spake unto the Jews that came unto him, Verily, verily, I
say unto you ... ending, the Father which hath sent me.[32]
Deacon.
Have mercy upon us, O God, according to thy great mercy, we
pray thee, hear, and have mercy.
Lord, have mercy, thrice.
Furthermore let us pray for the repose of the soul of the servant of
God, name, who hath fallen asleep, and that to him may be remitted
every transgression, voluntary and involuntary.
Lord, have mercy, thrice.
 That the Lord God may place his soul where the righteous rest.
Lord, have mercy, thrice.
The mercy of God, the kingdom of heaven, and the forgiveness of
his sins let us ask of Christ, our immortal King and God.
Vouchsafe, O Lord.
Deacon. Let us pray to the Lord.
Lord, have mercy.
And after the conclusion of this the first of the priests, or the
archpriest, if one happen to be there, saith the prayer, O God of
spirits.... with a loud voice, standing nigh unto the dead.
And in like manner all the priests that be present.
And be it known that as many times as the petition is said by the
deacon, while the petition is being said by him, each of the priests in
his order saith the above mentioned prayer in a low voice nigh unto
the dead, and exclaimeth,
For thou art the resurrection....
And now by the first priest, or by the archpriest, the prayer, O God
of spirits.... is said with a loud voice, as is mentioned above.
And, after the exclamation, the kiss is given.
And we sing the present stichera of similar rhythm.
When from the tree....
Tone ii.
Come, brethren, let us give the last kiss to the dead, and render
thanks to God; for he hath left his kinsfolk, and hasteneth to the
grave: to him there is no care concerning vanities and carnal toil.
Where now are kinsfolk and where friends? Lo, we are parted from
him, whom, Lord, we pray thee to give rest.
What, O ye brethren, is this parting? what this weeping? what this
wailing in the present hour? Come, kiss ye then him whom but lately
was with us; for he is given to the grave, is cover’d with a stone, in
darkness dwelleth, is buried with the dead, and now is parted from
all kinsfolk and from friends; and him, O Lord, we pray thee to give
rest.
Now is life’s evil boast of vanity destroy’d; for from its dwelling-
place the soul is gone, the clay is ashen, the casket broken, it
voiceless is, no feeling hath, is dead and motionless. And him
consigning to the grave, let us beseech the Lord to give him
everlasting rest.
What is our life? a flower, a smoke, and, verily, a morning dew. O
come ye then, let us, with open eyes, regard the graves. Where is
the beauty of the body? where youth? where eyes, and carnal form?
All are consum’d as grass, all vanish’d. Come, fall we down to Christ
in tears.
Great is the weeping and the wailing, great is the sighing and the
need at parting from the soul. Hades and destruction wait; and
transitory life appears a fleeting shade, a dream of error; and the toil
of earthly life unseemly phantasy. Far let us fly from every worldly
sin, that heaven may be our heritage.
Gazing on him that lieth dead, O take we all a likeness of our final
hour; for he is pass’d as vapour from the earth, is wither’d as a
flower, as grass cut down, wrapp’d in a winding-sheet, and hid in
earth. And, leaving him unseen, let us pray Christ to give him
everlasting rest.
Adam’s descendants, come ye, let us see laid low in earth a
likeness of ourselves, which hath all beauty lost, is in the grave’s
decay dissolv’d, in darkness is by worms consum’d, and in the earth
is hid. And, leaving him unseen, let us pray Christ to give him
everlasting rest.
When from the body parted is the soul by force by Angels dread,
all kinsfolk and acquaintance it forgets, and is impress’d concerning
standing at the judgment-seat to come, that shall decide the things of
vanity and carnal toil. Then, praying to the judge, let us all beg the
Lord to pardon him what he hath done.
 Come, brethren, let us within the grave behold the ashes and the
dust whereof we formed were. Where go we now? and what
become? what is the poor, or what the rich? or what the lord, and
what the free? Are not all dust? The beauty of the countenance is
gone, and death hath wasted all the flower of youth.
Verily vain and perishing are all the things of life, seeming, and
gloriousless; for we all go away, all die, kings and princes, judges
and them that mighty be, the rich and poor, and every mortal man;
for now they that aforetime liv’d are cast into the grave, whom that
the Lord may rest we pray.
Now all the organs of the body idle are beheld, which active were
but late, all without motion, without feeling, dead; for closed are the
eyes, the feet are bound, the hands are listless, and with them the
ears; the tongue is clos’d in silence, consigned to the grave: all
human things are vanity indeed.
Save them that put their trust in thee, O Mother of the Sun that
setteth not, thou Bringer-forth of God: with thine entreaties, we
beseech thee, pray the most good God to rest him now departed
hence where rest the righteous souls; him of divine good things
declare thou heir in halls of righteous ones, unto remembrance
everlasting, thou all undefil’d.
Glory. Tone vi.
Me, lying voiceless and depriv’d of breath, beholding, bewail ye
me, O brethren and O friends, O kinsfolk and acquaintances; for
yesterday I spake with you, and suddenly on me came the dread
hour of death. But, come ye, all that love me, and kiss me with the
final kiss; for never shall I go with you again, or further converse hold
with you. For I depart unto the judge, where no respect of persons is,
where slave and lord together stand, the king and warrior, rich and
poor, in equal worthiness; for each, according to his deeds, is
glorified or sham’d. But I beg all, and all entreat unceasingly to pray
Christ God for me, that, for my sins, I be not bidden unto torment’s
place, but that he may appoint my lot where is the light of life.
Both now. Theotokion, the same tone.
 Through her entreaties who to thee gave birth, O Christ, and those
of thy forerunner, and of apostles, prophets, hierarchs, venerables,
and just, and of all Saints, unto thy sleeping servant give thou rest.
Then, Trisagion. O most holy Trinity.... Our Father....
Priest. For thine is the kingdom....
Then, With the spirits of the righteous.... and the rest.
The petition by the deacon, Have mercy upon us, O God,
according to thy great mercy....
Vide page 142. And after the exclamation, Glory. Both now. And
the dismissal.
He that arose from the dead, Christ our true God, through the
prayers of his most pure Mother, of the holy glorious and all-praised
apostles, of our venerable and God-bearing fathers, and of all the
Saints, place the soul of his servant, name, departed from us, in the
tabernacles of the just, rest it in the bosom of Abraham, and number
it with the righteous, and have mercy upon us, as being good and
the lover of mankind. Amen.
And the archpriest, or the principal priest, saith himself this thrice.
Thy remembrance is everlasting, O our deservedly blessed and
ever remembered brother.
Thrice.
Then the singers sing thrice,
Everlasting remembrance.
And straightway the archpriest, if he happen to be there, or the
priest, readeth the prayer of absolution with a loud voice.
The Lord Jesus Christ our God, who gave divine commandments
unto his holy disciples and apostles to bind and loose the sins of the
fallen, and from whom we have again received authority to do the
like, forgive thee, O spiritual child, whatever thou hast done in the life
that now is, voluntarily or involuntarily, now and ever, and to ages of
ages. Amen.
 And so, taking up the remains, we go forth to the grave, followed
by all the people, and preceded by the priests, and singing, Holy
God.... O most holy Trinity.... Our Father.... and the rest.
And they lay the remains in the grave; and the archpriest, or the
priest, taking earth upon a shovel, casteth it crosswise over the
remains, saying,
The earth is the Lord’s, and the fulness thereof, the world and all
they that dwell therein.
And after this he poureth over the remains oil from the lamp, or
scattereth ashes out of the censer, and so they fill up the grave as
customarily, meantime singing the troparia, With the spirits of the
righteous.... and all the rest. Vide page 138.
And the dismissal.
 Chapter XVII.
THE ORDINANCE THAT IS OBSERVED
CONCERNING THE CARRYING FORTH OF THEM
THAT FALL ASLEEP IN HOLY PASCHA, AND IN
ALL THE BRIGHT WEEK.

It behoveth to know that if any pass away on holy pascha, or on

any day whatever of the bright week until the sunday of Thomas,
somewhat less of the customary song for them that have fallen
asleep is sung, because of the majesty and honour of the joyful
festival of the resurrection; for it is a festival of joy and gladness, and
not of lamentation. And since all who die in hope of resurrection and
eternal life are through the resurrection of Christ, removed from the
griefs of this world to things that are joyful and glad, the church at the
time when Christ is risen proclaimeth this by the resurrection song
over them that have fallen asleep; and, by somewhat less song,
ectenias and prayer for them that have fallen asleep, we are assured
that he that dieth in penitence, if he have not yet made satisfaction
concerning his iniquities, these are remitted to him by the prayers of
the church, and that he is freed from their bond.
The priest then having come, with his clerks, to the house in which
the body of the dead lieth, and put on him the epitrachelion and the
phelonion, and censed the remains, beginneth as customarily,
Blessed be our God.... And the clerk singeth, Christ is risen.... in
tone v. And the priest saith the customary verses, that is to say, Let
God arise.... and all the rest.
And while these are being sung, the priest sprinkleth the body of
the dead with sanctified water, and his coffin without and within, and
straightway they lay him therein. And, the song being ended, the
deacon saith the customary ectenias for them that have fallen
asleep. And the priest in a low voice readeth the prayer, that is to
say, O God of Spirits.... Vide page 139. And after the exclamation
they read,
Having seen the resurrection of Christ....
And taking up the remains of him that hath fallen asleep, they go
forth to the church, the priests, deacons, and every clerk going
before, and the lay people following; and, as they go, the clerks and
singers sing the paschal canon, that is to say, It is the day of
resurrection....
This in order until they come even unto the church. And in the
church, having put down the remains, they conclude the canon that
hath been begun, while the priests cense according to the customary
rite. And at the fourth ode, the customary diaconals for them that
have fallen asleep, with the prayer.
And he exclaimeth,
For thou art the resurrection, and the life....
Then, Preventing the dawn....
And after this the ivth ode is sung in order.
And after the sixth ode, the customary diaconals for them that
have fallen asleep with the prayer.
And he exclaimeth, For thou art the resurrection and the life....
Then the condakion, Rest with the saints.
And the icos, Thyself alone immortal art.... Vide page 149.
And, instead of the trisagion,
As many as have been baptized into Christ....
The epistle in the Acts for the day being.[33] Alleluia in tone ii.
The first resurrection gospel.[34]
And after this, Having seen the resurrection of Christ, we adore....
 And the other odes of the canon.
And after the conclusion of the canon is read or sung the
exapostilarion, Asleep in flesh.... twice.
After these we sing, Blessed art thou, O Lord: O teach me thy
statutes.
The angelic council was amaz’d....
Then the stichera of pascha, with their verses.
Glory. Both now.
It is the day of resurrection.... and Christ is risen.... thrice.
And these stichera having been sung, the customary kiss of him
that hath fallen asleep taketh place, saying,
Christ is risen.
And after the stichera the customary diaconals for them that have
fallen asleep with the prayer, which is read with a loud voice by the
archpriest, or the priest, nigh unto the remains.
And he exclaimeth,
For thou art the resurrection and the life....
And the customary dismissal is made.
Then the prayer of absolution.
The Lord Jesus Christ our God.... Vide page 163.
And we go forth to the grave, bearing the body of him that hath
fallen asleep to the burial. And the priests with all the clerks,
preceding the remains, sing,
Christ is risen....
And they bury them with thanksgiving and joy, doing and saying all
that is written at page 157 for the burial of a lay person.
And singing the troparion.
O earth that yawnest, take thou that that out of thee was made.
 End of the order of the burial of them that fall asleep in the days of
the bright week.
 Chapter XVIII.
THE MORTUARY ORDER OVER A DEPARTED
PRIEST.

When one of the secular priests departeth to the Lord, three

priests come and lift him from the bed, and lay him on the floor upon
a mat. And since it behoveth not that he be washed, being naked, by
the priests, they sponge him with pure oil. Then they clothe him in
his customary garments, and after that with all the priestly
vestments, and cover his face with the aër, and lay the holy gospel
upon him. Then the priests come vested in the priestly vestments.
And the president maketh, Blessed be our God....
And they that are standing by begin,
Holy God.... O most holy Trinity.... and Our Father.... For thine is
the kingdom....
And straightway they sing these troparia, tone iv.
With the spirits of the righteous.... Page 138.
The deacon saith,
Have mercy upon us, O God.... Vide page 139.
And straightway the priests take the remains, and carry them into
the porch of the temple, and lay the holy gospel over him, as
aforesaid, and candlesticks crosswise with tapers, and the singer
beginneth,
The undefiled in the way, alleluia.
In tone vi.
Then, Blessed are the undefiled.... Page 141.
After the first stasis, deacon, Again and again.... Page 142.