Video-Assisted Thoracoscopic Surgery Approach for Resection of a Posterior Mediastinal Cyst in an Infant

Abstract

Introduction:

Bronchogenic cysts are one type of bronchopulmonary foregut malformation that arise from anomalous budding of the foregut during development, however, the cysts fail to communicate with the tracheobronchial tree. ¹ Newborns with bronchogenic cysts can develop respiratory distress, wheezing, and feeding difficulty caused by rapid enlargement and mass effect on the respiratory tract and esophagus. ² Once a diagnosis is confirmed in symptomatic infants, urgent surgery is indicated to prevent further respiratory failure. Video-assisted thoracoscopic surgery (VATS) is a minimally invasive approach that has reduced complication and mortality rates compared with open thoracotomies. ³ We demonstrate proper technique in identifying and avoiding critical neurovascular structures during posterior mediastinal bronchogenic cystectomy through a VATS approach.

Materials and Methods:

The patient is an 8-month-old full-term girl with a history of 3 weeks of developmental milestone regression with reluctance to eat pureed foods. Computed tomography of chest displayed concern for a posterior mediastinal cyst consistent with a foregut duplication with mass effect on the left mainstem bronchus and left pulmonary artery and veins. An esophagram demonstrated right lateral, upward, and posterior deviation of the proximal thoracic esophagus secondary to the mass. Esophagoscopy, bronchoscopy, and VATS were recommended for posterior mediastinal cyst resection.

Results:

Esophagoscopy and bronchoscopy revealed compression and occlusion of the left mainstem bronchus, as well as external compression of the esophagus. Right thoracoscopic access was achieved with the flexible esophagoscope in place. The flexible endoscope facilitated the delineation of the cyst and esophageal border for dissection. Although the cyst was entered inadvertently, the loss of cyst turgor greatly enhanced traction, dissection, and resection. Once completely dissected, the mass appeared to originate from the bronchus, and any possible connection was ligated using an Endoloop. The final pathology analysis demonstrated a bronchial cyst. After discharge on postoperative day 1, she quickly re-established her developmental milestones and thrived.

Conclusions:

Our case demonstrates how VATS can be a safe and effective approach for resection of posterior mediastinal bronchogenic cysts that are surrounded by critical neurovascular structures.

No competing financial interests exist.

Runtime of video: 3 mins 16 secs

Previous Communication:

This video was presented at the American College of Surgeons Clinical Congress on October 25, 2023 in Boston, MA.

Patient Consent:

Author(s) have received and archived patient consent for video recording/publication in advance of video recording of the procedure.

Acknowledgment:

The source of the study is the Division of Pediatric Surgery at Penn State Milton S. Hershey Medical Center.