IPEG 2018 - THORACOSCOPIC RESECTION OF LARGE THYMIC CYST EXTENDING INTO THE LEFT NECK

And thank you again for giving me the opportunity to present this video. This video will show a total thoracoscopic resection of a large thymic cyst that extends into the left neck. Our patient is a 15 month old male with a history of an intermittent cough and rash and was diagnosed with hand, foot, and mouth disease. During his workup. He had a chest X-ray that showed right tracheal deviation as well as a mediastinal mass. A CT chest was then done that showed a large anterior mediastinal cystic mass. He underwent an echocardiogram which ruled out cardiac involvement. He then was taken for an MRI of his chest that showed a 5 by 3.1 centimeter. cystic lesion in the right lobe of the thymus that was abutting the SVC, left brachiocephalic vein, and the ascending aorta. It was also found to extend into the left neck, and it can be seen here splaying out the left internal jugular vein and the left common carotid artery. He was then taken to the OR for a right thoracoscopic resection of this mediastinal mass. Of note, the patient was able to lay down flat without any shortness of breath. He was placed upon with a bump under his right side. To elevate him to 30 degrees, the procedure is performed with a 5 millimeter camera port and 3 additional instruments through 3 millimeter stab incisions in the fourth intercostal space at the mid axillary line and the 7th and 8th intercostal spaces in the anterior mid axillary line. Upon entering the chest, the mediastinal mass is easily identified. We start the procedure by dissecting the cysts from the anterior chest wall using a combination of blunt dissection and electrocautery. We continue to work circumferentially around the cysts, continuing to use a combination of blunt dissection and electrocautery. On the lateral side of the cyst, the right phrenic nerve can be seen clearly. We never had a clear view of the left phrenic nerve during the procedure. We start our dissection laterally away from the phrenic nerve, making sure to stay directly on the cyst and continue proximately. The cyst can be seen directly abutting the SVC here. As we continue dissecting it off the SVC, we can see that the SVC branches here into the left brachiocephalic vein signified by the blue arrow and the right brachiocephalic vein signified by the yellow arrow. We start work immediately to free the cyst from the pericardium. The thymus can be seen here extending into the left chest. A portion of the left chest pleura was excised to completely remove the thymus. We continue to work circumferentially to free the mass. A view of the thyroid vein can be seen here in relation to the SVC, left brachiocephalic vein, and the right brachiocephalic vein. We continue our dissection and now start working superiorly. You can see the cyst here clearly entering the left neck. The cyst ruptures at this point of the dissection, and suction is used to remove the fluid, and a portion of the fluid is sent off for cytology. Dissection is continued superiorly directly on the cyst wall. The cyst is able to be freed from the left neck after careful dissection. It is then removed from the chest cavity after extending one of the stab incisions. A right chest tube was placed at the end of the procedure, and it was removed on post-op day 2. The patient did well postoperatively and was discharged home on post-op day 4. The final pathology returned as a thymic cyst. Thank you and I'll be happy to take any questions.