Median sternotomy provides excellent exposure for excising anterior mediastinal tumors in children

Abstract

Median sternotomy (M-S) provides excellent exposure and allows dissection of the medial side of an anterior mediastinal tumor (AMT) with minimal risk. We report our experience of resecting AMT using M-S. Five children with AMT were treated using M-S between 1997 and 2004 at our institute. Ages at M-S ranged from 8 months (case 2) to 9 years (case 1) and AMT ranged in size from 5x6x7 cm3 (case 2) to large enough to occupy nearly the entire right thoracic cavity (cases 4 and 5). AMT were resected completely in all cases through M-S with the patient in the supine position. M-S alone was used in cases 1, 2, and 3, and cases 4 and 5 required additional incisions. There were dense adhesions between AMT and important mediastinal structures such as the anterior part of the pericardium (cases 1 and 2), left phrenic nerve (case 3), and pulmonary vessels (case 4, 5), but all were dissected safely under direct vision. There was no respiratory or cardiovascular compromise during M-S due to compression of the healthy lung and mediastinum. Histopathologic findings were mature teratoma in cases 1, 3, and 5, immature teratoma in case 2, and pleuropulmonary blastoma in case 4. Postoperative recovery was unremarkable. After mean follow-up of 3.4 years, cases 1, 2, 3, and 5 are currently well with no signs of recurrence, but case 4 died from disseminated intravascular coagulation during postoperative chemotherapy for massive local tumor recurrence 6 months after surgery. Based on our experience, M-S allows access to all aspects of AMT under direct vision, and provides excellent exposure, thus facilitating complete resection.

The versatility of median sternotomy in general paediatric surgery

“…All patients were admitted to the paediatric intensive care units (PICUs) at Chris Hani Baragwanath Academic Hospital and Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, South Africa, after sternotomy. Pathology included penetrating mediastinal trauma (1), anterior and posterior mediastinal masses (4), acquired tracheooesophageal fistulas secondary to button battery impaction (2), bronchial foreign bodies (2) and bilateral pulmonary metastases secondary to malignancy (5). Nine of the 14 patients were extubated either immediately after the operation or in the PICU the next day.…”

“…[3] If resection of the tumour is required, it can be performed safely via the MS approach. [4,5] For mediastinal tumours that extend into a hemithorax, a lateral extension of the sternotomy into an intercostal space (T-shaped incision) will increase exposure, although we did not require this additional exposure in any of our cases. [6] The main advantage of sternotomy is that it gives excellent exposure with good vascular control on the medial aspect of the tumour, as well as access to both hemithoraces.…”

Giant anterior mature mediastinal teratoma with gastrointestinal tract organoid differentiation: A rare presentation

“…Full sternotomy provides excellent exposure as well as safe access to all important mediastinal structures, which may be adherent or embedded in such large tumour. 7 Surgical removal by thoracotomy may be challenging at times, when the tumour is extremely large, encroaching both thoracic cavity, in paediatric patients, or when it is adherent to vital structures of the mediastinum. 7 10-15% patients may require additional procedures as lobectomy and pericardiectomy for complete tumour removal.…”

Brachial plexus injury during axillary thoracotomy

“…Median sternotomy and traditional thoracotomy provide good exposure of the thoracic cavity and thus facilitate effective and safe resection of the mediastinal tumor, especially a large one. 9 Compared with mediastinal sternotomy and traditional thoracotomy, osteomuscular sparing axillary thoracotomy allows adequate exposure of the pleural cavity without any resection of chest wall structures. In addition, it is easy to perform, faster to repair, and decreases postoperative pain.…”