Video-Assisted Thoracoscopic Resection of a Large Anterior Mediastinal Mass

Pediatric mediastinal masses pose a challenging case for the pediatric surgeon due to narrow working space and a concentration of vital structures in the area. Mediastinal masses are typically diagnosed on chest radiograph in a child presenting with dyspnea, cough, fever, and/or general malaise, though a large proportion of mediastinal masses are diagnosed as incidental findings on chest radiographs obtained for other reasons. After initial diagnosis, the mass can be further characterized via ultrasound, CT scan, or MRI. The differential diagnosis for mediastinal masses in children is broad and includes neoplastic and non-neoplastic processes. The location of the mass (anterior, middle, or posterior mediastinum) helps to narrow the differential diagnosis. The most common neoplasm of the mediastinum is lymphoma found in all compartments of the mediastinum, followed by neurogenic tumors (ganglioneuroma, ganglioneuroblastoma, neuroblastoma), fou nd primarily in the posterior mediastinum. Thymomas and germ cell tumors (i.e., seminomas and teratomas) are most commonly found in the anterior mediastinum [1]. With the exclusion of lymphomas, which respond to chemotherapy and/or radiotherapy, all mediastinal masses in children should be resected when feasible [2]. When resection is indicated, current surgical management of pediatric mediastinal masses relies primarily on open resection via median sternotomy or posterolateral thoracotomy depending on the anatomical extent of the mass [2]. However, based on a growing body of literature suggesting that a minimally invasive approach is both feasible and safe in appropriately selected adult patients, some pediatric surgeons have adopted video-assisted thoracoscopic surgery (VATS) for resection of mediastinal tumors in children [3, 4]. There is still significant hesitation among pediatric surgeons to employ VATS for resection of mediastinal tumors due to lack of familiarity with the technique and close proximity to vital structures. This video aims to provide a basic framework for VATS resection of anterior mediastinal tumors. References [1] Franco A, Mody NS, Meza MP. Imaging evaluation of pediatric mediastinal masses. Radiologic clinics of North America 2005;43(2):325-53. [2] Tovar JA. chapter 25 - MEDIASTINAL TUMORS. In: Holcomb GW, Murphy JP, Ostlie DJ, editors. Ashcraft's Pediatric Surgery (Fifth Edition). Philadelphia: W.B. Saunders; 2010, p. 322-9. [3] Marshall MB, DeMarchi L, Emerson DA, Holzner ML. Video-assisted thoracoscopic surgery for complex mediastinal mass resections. Ann Cardiothorac Surg 2015;4(6):509-18. [4] Sato T, Kazama T, Fukuzawa T, Wada M, Sasaki H, Kudo H, et al. Mediastinal tumor resection via open or video-assisted surgery in 31 pediatric cases: Experiences at a single institution. Journal of pediatric surgery 2016;51(4):530-3.