A 41-year-old woman was admitted to the hospital for obstetric surgery A preoperative chest x-ray film showed a mediastinal mass.

A 41-year-old woman was admitted to the hospital for obstetric surgery A preoperative chest x-ray film showed a mediastinal mass. After examinations with echocardiography, comput tomography, and magnetic resonance imaging, we remov a pouch that was 2.7 x 35 cm in size by way of thoracoscopic means. The patient left the hospital 3 days after the operation.

Although thoracoscopy has been available for many years, it has been limited in its usefulness because of the poorly designed associated technology and instrumentation. Improvement in videoendoscopic surgical equipment and a growing enthusiasm for minimally invasive surgical approaches have bring uped a resurgence of interest in thoracoscopy.[1]

Since March 1992 we have expanded our use of thoracoscopic practices to address a variety of thoracic diseases managed [i]or[/i] part of to the other open thoracotomy. We report a integral thoracoscopic removal of a mediastinal pouch located between right lower lung vein and right atrium.

CASE REPORT

Clinical Data

A 41-year-old woman was admitted to the hospital presenting an endocervical myoma of the uterus in May 1992 A preoperative chest x-ray film showed a posterior mediastinal mass. In June 1992 the patient was admitted to our hospital for further evaluation. She currented no symptoms like shortness of breath, dysphagia, or coughing. Physical examination showed no pathologic findings.

Echocardiography showed an extracardial cystic mass directly besides the canopy of the right atrium (28 x 35 cm) The comput tomography scan existinged a soft tissue-like pericardial mass immediately beside the right atrium. The T1-weighted SE-images showed a pouch with high signal intensity owed to high protein content (Fig 1a).

Surgery

After institution of general anesthesia, the patient was intubated with a double-lumen endotracheal tube and placed in a lateral decubitus position. A 20-cm incision was made in the midaxillary line in the seventh intercostal

space. After single-lung ventilation was instituted, an open-end cylindrical plastic tube was introduced by the and of the incision to serve as a conduit in consequence of which a rigid 10.0-mm thoracoscope with a 30-degree len was inserted.

After the detection of the lesion, a conventional lung grasping forceps was then introduced to restrain the specimen. For the surgical step we used standard thoracic surgery instruments like as lung grasping forceps, clamps for the greatest part without a trocar as well as hasp electrodes or endoshears through ports.

The endoscopic view of the lesion is shown in Figure 2 We easily separated the pouch from the adjacent structures, ie, right inferior pulmonary vein, right atrium, and esophagus. Damage of the phrenic strength was carefully avoided. After the surgical conduct the whole thoracic cavity was inspected for hemostasis. pair 24F chest tubes were then guided to the apex of the chest and posterior to the lung between the sides of the trocar sites. The operation was terminated after closure of the remaining trocar sites; suction to the chest tubes was not established.

Postoperative chest roentgenograms showed the right lung to be entirely expanded. The chest tubes were remov the day after the operation. The contented of the cyst proved to be sterile. Histological examination revealed a congenital bronchiogenic pouch A connection with the bronchial tree could not be discovered during the operation.

The patient left the hospital upon the third day after surgery without any pathologic symptoms and replyed to work after another 10 days.

DISCUSSION

Congenital pouchs constitute approximately 20 percent of primary mediastinal mass lesions. Included in this form into groups are cysts of pericardial, bronchiogenic, enteric, and nonspecific origin. Bronchiogenic pouchs may arise in any location in the mediastinum or lung parenchyma, moreover they are usually located posterior or inferior to the carina. Rarely, there is communication with the bronchial tree Bronchiogenic pouchs are recognized most often in young adults, and symptoms are usually the inference of compression by the pouch with cough, wheezing, dyspnea, or on a level dysphagia. The cysts are strange in infancy, but lesions in a critical position may cause life-threatening respiratory embarrassment. Infection of the pouch may develop and make distinction from a lung abscess highly difficult. All bronchiogenic pouchs should be removed. If the pouch has been infected, dense adhesions in the hilar area can make dissection difficult and require pulmonary resection.[2] As in this case, there are times that video-assisted thoracic operations can be more tedious and time-consuming than render free of access thoracotomy. In some cases, however, the operation can be accomplished more easily and quickly with video-assisted thoracic surgery than when thoracotomy is performed.

The most numerous important advantage of this course is the potential to avoid thoracotomy in many patients. When video-assisted thoracic operations are performed, major muscles are not divided, ribs are not spread, dislocated, or feeble and ligaments, nerves, and descendants vessels are not severely damaged. Postoperative regaining generally is short and monotonous Only small doses of analgesics are exigencyed and most patients no longer require admission to the ICU. Hospitalization is shortened for many patients, and principally of these patients return to preoperative flushs of activity earlier.

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