Chapter 69 Thymectomy and Resection of Mediastinal Masses
INTRODUCTION
The mediastinum can be divided into separate anatomic compartments, the anterior, middle or visceral, and posterior mediastinum.1 Tumors requiring surgical attention generally originate in the anterior and posterior compartments in this three-compartment model. Common anterior mediastinal tumors include thymic tumors, thyroid tumors, lymphomas, and tumors of germ cell origin. Thymic tumors are the most frequently seen among this group. Posterior mediastinal tumors are most often neurogenic in origin, arising from intercostal nerves, sympathetic ganglia cells, or paraganglia cells. This chapter therefore examines complications of mediastinal surgery in the context of thymectomy and resection of posterior mediastinal neurogenic tumors.
Thymectomy
Although it has not been evaluated prospectively, thymectomy has become standard therapy for myasthenia gravis based on significant retrospective data.2,3 Two major surgical approaches for thymectomy have evolved, transsternal and transcervical thymectomies, with video-assisted thoracic surgery (VATS) resection of the thymus also a viable alternative. All procedures allow for extracapsular resection of the thymus but vary in the extent of mediastinal fat removed, which may contain ectopic foci of thymic tissue. Transcervical thymectomy has been shown to be less morbid and costly than the transsternal approach. Controversy exists as to whether response rates are similar with each procedure. For thymomas or thymic carcinomas, however, a transsternal approach is indicated. Major indications for thymectomy include thymic hyperplasia associated with myasthenia gravis, encapsulated or invasive thymomas, and thymic carcinoma.
OPERATIVE STEPS OF TRANSCERVICAL THYMECTOMY5
OPERATIVE PROCEDURE
Median Sternotomy
Sternal Disruption and Mediastinitis
• Consequence
• Repair
Dissection of the Thymus off the Pericardium and Encircling in the Midline
Injury to the Thymic Veins or the Brachiocephalic Vein
• Consequence
• Prevention
Dissection of the Thymus off the Right Pleura and the Pericardium
Phrenic Nerve Injury
As the thymus is dissected off the pleura and pericardium, the phrenic nerve may be contused or divided. Phrenic nerve injuries during thymectomies are reported to occur in 0% to 4.5% of cases.6,7,12,13
• Consequence
• Prevention
Recurrent Laryngeal Nerve Injury
• Consequence
• Prevention
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