Robotic Thoracic Enucleation of Esophageal Leiomyoma

A sixty-one-year-old female presented with a history of incidentally noted hypercalcemia and worsening bone pain over the preceding weeks. Her past medical history included gastroesophageal reflux and previous smoking history with no prior thoracic surgeries. Labs demonstrated a calcium level of 11.4 mg/dL with an elevated parathyroid hormone (PTH) of 130 pg/mL. Parathyroid hormone related peptide was negative.

Sestamibi scan noted increased radionucleotide uptake in the middle mediastinum, and CT scan confirmed a 1.7 cm nodule in the aorto-pulmonary window. Because of the lesion’s anterior position relative to the trachea, it was felt it might be best accessed from the right chest. We also felt that potential risk of left recurrent laryngeal nerve injury may be decreased with a right-sided approach.

We began with the patient in left lateral decubitus position with a double-lumen endotracheal tube. Four thoracoport incisions were made, three in the eighth intercostal space and 1 in the anterior sixth space. We began with the 30-degree camera in the eighth space mid axillary line port.

The lung was reflected anteriorly. We proceeded with subcarinal dissection. The esophagus was mobilized from the left tracheobronchial angle. The left mainstem bronchus was then mobilized, such that at this point we had freed up the carina, as well as the inferior trachea and bilateral mainstem bronchi. We then turned our attention to the pleura along the superior vena cava (SVC), incising it and removing level 4 nodes to facilitate further exposure. The azygous vein was divided, and an assistant port was added in the anterior fourth intercostal space to facilitate further dissection along the anterior trachea. At this point, we felt we would be best served by a more direct view of the mediastinum, so an additional instrument port was placed posteriorly in the seventh intercostal space. The camera was moved 1 space posterior, and we proceeded with our dissection.

We dissected further medially, between the trachea and SVC, visualizing the right main pulmonary artery along the inferior aspect of the dissection. The pericardium was entered, with release of some serous fluid, with further dissection demonstrating the ascending aorta. Additional dissection mobilized the middle mediastinal tissue from the surrounding airway and vascular structures. Indocyanine green was administered, allowing for confirmation of the nodule in its expected anatomic location. Using a no touch technique, this was carefully resected. We were able to visualize and avoid the left recurrent laryngeal nerve along the left anterior lateral aspect of the trachea. Ten minutes following resection, a PTH level was sent, with a decrease from 130 to 40 pg/mL. The patient's postoperative course was uncomplicated, and her calcium levels have since normalized.

For any parathyroid surgery, a PTH level should be taken both preoperatively as well as at 5-10 minute intervals following removal of the adenoma. Because of its short half-life, the PTH should drop by at least 50% within 10 minutes of resection. Avoid rupturing the adenoma capsule, as tissue deposits can lead to parathyromatosis, implants of functional tissue resulting in persistent hyperparathyroidism.

Reference(s)

1. LoCicero Ja, LoCicero JIIIa, Shields TW. Shield's General thoracic surgery. Eighth edition / Joseph LoCicero. ed.

2. Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice. 20th ed: Elsevier; 2016.