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Thoracoscopic resection of a mature anterior mediastinal teratoma

This video is a step by step depiction of the diagnostic tools and the thoracoscopic mobilization and resection of a mature mediastinal teratoma.

We present the case of a 13 year old boy who presented with recurrent episodes of asthma and who was incidentally found to have a right mediastinal mass histologically diagnosed as a mature teratoma.
The mediastinum is the most common extragonadal location in which germ cell tumors are found (5-10%). The most frequently found tumor is a mature teratoma. There is an increased incidence of mediastinal germ cell tumors in Klinefelter syndrome. Surgical removal is the treatment of choice for both teratomas and malignant GCTs of the mediastinum. Many surgeons still use a median sternotomy with or without subcostal extension as the standard surgical approach. Thoracoscopic mobilization and resection is an established method in select centers.
Surgeons may be faced with the challenging problem of adhesion of the lesion to major organs and vessels, which could lead to potentially life-threatening situations. Moreover, considering the risk of iatrogenic lesions of phrenic nerves, anesthesiological management is also of critical importance, since the loss of spontaneous respiratory activity during anesthesia may result in further compression of the airway by the mass.
Patient is layed in 45 degrees pronated left lateral position on the operating room table. Ports are placed in triangular position in right midaxillary and anterior axillary line. CO2 insufflation is maintained at 5mm Hg to secure ipsilateral lung collapse.
Chest XR ap and lateral and Chest CT
The anterior compartment extends from the posterior surface of the sternum to the anterior surface of the pericardium and great vessels. It normally contains the thymus gland, adipose tissue, and lymph nodes. The vast majority of teratomas and other germ cell tumors arise in this area of the mediastinum.
"Advantages: Thoracoscopic tumor mobilization affords the advantage of clearly identifying the mass and safely ligating the primary tumor supplying vascular structures, thereby avoiding the risk of major bleeding throughout the subsequent tumor mobilization. The thoracoscopic approach also allows accurate dissection of nerval structures like the phrenic nerve under direct vision. A thoracotomy can be prevented in most cases. Diasadvantages: Learning curve, specialized equipment."
One may be faced with the challenging problem of adhesion of the lesion to major organs and vessels, which could lead to potentially life-threatening situations. This could demand a switch to an open approach via thoracotomy or sternotomy.
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"Mediastinal mature teratoma in a child- A case report. Liew WX, Lam HY, Narasimman S, Navarasi S, Mohd Hamzah K. Med J Malaysia. 2016 Feb;71(1):32-4. Mediastinal Germ Cell Tumors in Pediatric Patients: A Report From the Italian Association of Pediatric Hematology and Oncology. De Pasquale MD, Crocoli A, Conte M, Indolfi P, D'Angelo P, Boldrini R, Terenziani M, Inserra A. Pediatr Blood Cancer. 2016 May;63(5):808-12. Thoracoscopic removal of a bulky cystic mediastinal mature teratoma in a 4-year-old child: report of one case and few surgical tricks. Codrich D, Lembo MA, Schleef J. Eur J Pediatr Surg. 2012 Aug;22(4):318-20"

Review Thoracoscopic resection of a mature anterior mediastinal teratoma.

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