Robotic excision of paraesophageal bronchogenic cyst in a 9-year-old child
Identifieur interne : 000059 ( Pmc/Curation ); précédent : 000058; suivant : 000060Robotic excision of paraesophageal bronchogenic cyst in a 9-year-old child
Auteurs : Belal Bin Asaf [Inde] ; Arvind Kumar [Inde] ; C. L. Vijay [Inde]Source :
- Journal of Indian Association of Pediatric Surgeons [ 0971-9261 ] ; 2015.
Abstract
Bronchogenic cysts are often asymptomatic and discovered as an incidental finding. They may become symptomatic due to esophageal compression as they increase in size or from development of infection. We report a case of a 9-year-old male with an asymptomatic bronchogenic cyst who underwent successful robotic assisted thoracoscopic excision.
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DOI: 10.4103/0971-9261.164256
PubMed: 26628812
PubMed Central: 4586983
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<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Robotic excision of paraesophageal bronchogenic cyst in a 9-year-old child</title><author><name sortKey="Asaf, Belal Bin" sort="Asaf, Belal Bin" uniqKey="Asaf B" first="Belal Bin" last="Asaf">Belal Bin Asaf</name><affiliation wicri:level="1"><nlm:aff id="aff1">Department of Thoracic Surgery, Institute of Robotic Surgery, Sir Ganga Ram Hospital, New Delhi, India</nlm:aff><country xml:lang="fr">Inde</country><wicri:regionArea>Department of Thoracic Surgery, Institute of Robotic Surgery, Sir Ganga Ram Hospital, New Delhi</wicri:regionArea></affiliation></author><author><name sortKey="Kumar, Arvind" sort="Kumar, Arvind" uniqKey="Kumar A" first="Arvind" last="Kumar">Arvind Kumar</name><affiliation wicri:level="1"><nlm:aff id="aff1">Department of Thoracic Surgery, Institute of Robotic Surgery, Sir Ganga Ram Hospital, New Delhi, India</nlm:aff><country xml:lang="fr">Inde</country><wicri:regionArea>Department of Thoracic Surgery, Institute of Robotic Surgery, Sir Ganga Ram Hospital, New Delhi</wicri:regionArea></affiliation></author><author><name sortKey="Vijay, C L" sort="Vijay, C L" uniqKey="Vijay C" first="C. L." last="Vijay">C. L. Vijay</name><affiliation wicri:level="1"><nlm:aff id="aff1">Department of Thoracic Surgery, Institute of Robotic Surgery, Sir Ganga Ram Hospital, New Delhi, India</nlm:aff><country xml:lang="fr">Inde</country><wicri:regionArea>Department of Thoracic Surgery, Institute of Robotic Surgery, Sir Ganga Ram Hospital, New Delhi</wicri:regionArea></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">26628812</idno><idno type="pmc">4586983</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4586983</idno><idno type="RBID">PMC:4586983</idno><idno type="doi">10.4103/0971-9261.164256</idno><date when="2015">2015</date><idno type="wicri:Area/Pmc/Corpus">000059</idno><idno type="wicri:Area/Pmc/Curation">000059</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Robotic excision of paraesophageal bronchogenic cyst in a 9-year-old child</title><author><name sortKey="Asaf, Belal Bin" sort="Asaf, Belal Bin" uniqKey="Asaf B" first="Belal Bin" last="Asaf">Belal Bin Asaf</name><affiliation wicri:level="1"><nlm:aff id="aff1">Department of Thoracic Surgery, Institute of Robotic Surgery, Sir Ganga Ram Hospital, New Delhi, India</nlm:aff><country xml:lang="fr">Inde</country><wicri:regionArea>Department of Thoracic Surgery, Institute of Robotic Surgery, Sir Ganga Ram Hospital, New Delhi</wicri:regionArea></affiliation></author><author><name sortKey="Kumar, Arvind" sort="Kumar, Arvind" uniqKey="Kumar A" first="Arvind" last="Kumar">Arvind Kumar</name><affiliation wicri:level="1"><nlm:aff id="aff1">Department of Thoracic Surgery, Institute of Robotic Surgery, Sir Ganga Ram Hospital, New Delhi, India</nlm:aff><country xml:lang="fr">Inde</country><wicri:regionArea>Department of Thoracic Surgery, Institute of Robotic Surgery, Sir Ganga Ram Hospital, New Delhi</wicri:regionArea></affiliation></author><author><name sortKey="Vijay, C L" sort="Vijay, C L" uniqKey="Vijay C" first="C. L." last="Vijay">C. L. Vijay</name><affiliation wicri:level="1"><nlm:aff id="aff1">Department of Thoracic Surgery, Institute of Robotic Surgery, Sir Ganga Ram Hospital, New Delhi, India</nlm:aff><country xml:lang="fr">Inde</country><wicri:regionArea>Department of Thoracic Surgery, Institute of Robotic Surgery, Sir Ganga Ram Hospital, New Delhi</wicri:regionArea></affiliation></author></analytic><series><title level="j">Journal of Indian Association of Pediatric Surgeons</title><idno type="ISSN">0971-9261</idno><idno type="eISSN">1998-3891</idno><imprint><date when="2015">2015</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><p>Bronchogenic cysts are often asymptomatic and discovered as an incidental finding. They may become symptomatic due to esophageal compression as they increase in size or from development of infection. We report a case of a 9-year-old male with an asymptomatic bronchogenic cyst who underwent successful robotic assisted thoracoscopic excision.</p></div></front><back><div1 type="bibliography"><listBibl><biblStruct><analytic><author><name sortKey="Laurent, F" uniqKey="Laurent F">F Laurent</name></author><author><name sortKey="Latrabe, V" uniqKey="Latrabe V">V Latrabe</name></author><author><name sortKey="Lecesne, R" uniqKey="Lecesne R">R Lecesne</name></author><author><name sortKey="Zennaro, H" uniqKey="Zennaro H">H Zennaro</name></author><author><name sortKey="Airaud, Jy" uniqKey="Airaud J">JY Airaud</name></author><author><name sortKey="Rauturier, Jf" uniqKey="Rauturier J">JF Rauturier</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Jeung, My" uniqKey="Jeung M">MY Jeung</name></author><author><name sortKey="Gasser, B" uniqKey="Gasser B">B Gasser</name></author><author><name sortKey="Gangi, A" uniqKey="Gangi A">A Gangi</name></author><author><name sortKey="Bogorin, A" uniqKey="Bogorin A">A Bogorin</name></author><author><name sortKey="Charneau, D" uniqKey="Charneau D">D Charneau</name></author><author><name sortKey="Wihlm, Jm" uniqKey="Wihlm J">JM Wihlm</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Rowe, Mi" uniqKey="Rowe M">MI Rowe</name></author><author><name sortKey="O Eill, Ja" uniqKey="O Eill J">JA O’Neill</name></author><author><name sortKey="Grosfeld, Jl" uniqKey="Grosfeld J">JL Grosfeld</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Wychulis, Ar" uniqKey="Wychulis A">AR Wychulis</name></author><author><name sortKey="Payne, Ws" uniqKey="Payne W">WS Payne</name></author><author><name sortKey="Clagett, Ot" uniqKey="Clagett O">OT Clagett</name></author><author><name sortKey="Woolner, Lb" uniqKey="Woolner L">LB Woolner</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Takahashi, K" uniqKey="Takahashi K">K Takahashi</name></author><author><name sortKey="Al Janabi, Nj" uniqKey="Al Janabi N">NJ Al-Janabi</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Duwe, Bv" uniqKey="Duwe B">BV Duwe</name></author><author><name sortKey="Sterman, Dh" uniqKey="Sterman D">DH Sterman</name></author><author><name sortKey="Musani, Ai" uniqKey="Musani A">AI Musani</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Hebra, A" uniqKey="Hebra A">A Hebra</name></author><author><name sortKey="Othersen, Hb" uniqKey="Othersen H">HB Othersen</name></author><author><name sortKey="Tagge, Ep" uniqKey="Tagge E">EP Tagge</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Van Biezen, Fc" uniqKey="Van Biezen F">FC Van Biezen</name></author><author><name sortKey="Bakx, Pa" uniqKey="Bakx P">PA Bakx</name></author><author><name sortKey="De Villeneuve, Vh" uniqKey="De Villeneuve V">VH De Villeneuve</name></author><author><name sortKey="Hop, Wc" uniqKey="Hop W">WC Hop</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Tolg, C" uniqKey="Tolg C">C Tölg</name></author><author><name sortKey="Abelin, K" uniqKey="Abelin K">K Abelin</name></author><author><name sortKey="Laudenbach, V" uniqKey="Laudenbach V">V Laudenbach</name></author><author><name sortKey="De Heaulme, O" uniqKey="De Heaulme O">O de Heaulme</name></author><author><name sortKey="Dorgeret, S" uniqKey="Dorgeret S">S Dorgeret</name></author><author><name sortKey="Lipsyc, Es" uniqKey="Lipsyc E">ES Lipsyc</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Koontz, Cs" uniqKey="Koontz C">CS Koontz</name></author><author><name sortKey="Oliva, V" uniqKey="Oliva V">V Oliva</name></author><author><name sortKey="Gow, Kw" uniqKey="Gow K">KW Gow</name></author><author><name sortKey="Wulkan, Ml" uniqKey="Wulkan M">ML Wulkan</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Toker, A" uniqKey="Toker A">A Toker</name></author><author><name sortKey="Ayalp, K" uniqKey="Ayalp K">K Ayalp</name></author><author><name sortKey="Grusina Ujumaza, J" uniqKey="Grusina Ujumaza J">J Grusina-Ujumaza</name></author><author><name sortKey="Kaba, E" uniqKey="Kaba E">E Kaba</name></author></analytic></biblStruct></listBibl></div1></back></TEI><pmc article-type="case-report"><pmc-dir>properties open_access</pmc-dir>
<front><journal-meta><journal-id journal-id-type="nlm-ta">J Indian Assoc Pediatr Surg</journal-id><journal-id journal-id-type="iso-abbrev">J Indian Assoc Pediatr Surg</journal-id><journal-id journal-id-type="publisher-id">JIAPS</journal-id><journal-title-group><journal-title>Journal of Indian Association of Pediatric Surgeons</journal-title></journal-title-group><issn pub-type="ppub">0971-9261</issn><issn pub-type="epub">1998-3891</issn><publisher><publisher-name>Medknow Publications & Media Pvt Ltd</publisher-name><publisher-loc>India</publisher-loc></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">26628812</article-id><article-id pub-id-type="pmc">4586983</article-id><article-id pub-id-type="publisher-id">JIAPS-20-191</article-id><article-id pub-id-type="doi">10.4103/0971-9261.164256</article-id><article-categories><subj-group subj-group-type="heading"><subject>Case Report</subject></subj-group></article-categories><title-group><article-title>Robotic excision of paraesophageal bronchogenic cyst in a 9-year-old child</article-title></title-group><contrib-group><contrib contrib-type="author"><name><surname>Asaf</surname><given-names>Belal Bin</given-names></name><xref ref-type="aff" rid="aff1"></xref></contrib><contrib contrib-type="author"><name><surname>Kumar</surname><given-names>Arvind</given-names></name><xref ref-type="aff" rid="aff1"></xref><xref ref-type="corresp" rid="cor1"></xref></contrib><contrib contrib-type="author"><name><surname>Vijay</surname><given-names>C. L.</given-names></name><xref ref-type="aff" rid="aff1"></xref></contrib></contrib-group><aff id="aff1">Department of Thoracic Surgery, Institute of Robotic Surgery, Sir Ganga Ram Hospital, New Delhi, India</aff><author-notes><corresp id="cor1"><bold>Address for correspondence:</bold> Prof. Arvind Kumar, Department of Thoracic Surgery, Institute of Robotic Surgery, Room No. 2328, Super Specialty Block, Sir Ganga Ram Hospital, New Delhi - 110 060, India. E-mail: <email xlink:href="arvindreena@gmail.com">arvindreena@gmail.com</email></corresp></author-notes><pub-date pub-type="ppub"><season>Oct-Dec</season><year>2015</year></pub-date><volume>20</volume><issue>4</issue><fpage>191</fpage><lpage>193</lpage><permissions><copyright-statement>Copyright: © Journal of Indian Association of Pediatric Surgeons</copyright-statement><copyright-year>2015</copyright-year><license license-type="open-access" xlink:href="http://creativecommons.org/licenses/by-nc-sa/3.0"><license-p>This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.</license-p></license></permissions><abstract><p>Bronchogenic cysts are often asymptomatic and discovered as an incidental finding. They may become symptomatic due to esophageal compression as they increase in size or from development of infection. We report a case of a 9-year-old male with an asymptomatic bronchogenic cyst who underwent successful robotic assisted thoracoscopic excision.</p></abstract><kwd-group><title>KEY WORDS</title><kwd>Bronchogenic cyst</kwd><kwd>paraesophageal bronchogenic cyst</kwd><kwd>robotic surgery</kwd><kwd>robotic pediatric surgery</kwd></kwd-group></article-meta></front><body><sec sec-type="intro" id="sec1-1"><title>INTRODUCTION</title><p>Majority of the bronchogenic cysts are often asymptomatic and are usually discovered as an incidental finding. They may become symptomatic due to pressure on the surrounding structures such as trachea and esophagus, as they increase in size or develop infection. We report the case of a 9-year-old male with a paraesophageal bronchogenic cyst who underwent successful robotic assisted thoracoscopic excision. To the best of our knowledge, this is the first report of use of the da Vinci Surgical System (Intuitive Surgical, Sunnyvale CA) for thoracoscopic excision of bronchogenic cyst in the pediatric age group from India.</p></sec><sec id="sec1-2"><title>CASE REPORT</title><p>A 9-year-old boy was detected to have a retrocardiac mass lesion on the left side, which was detected incidentally on a chest X-ray done for fever. The child had no history of stridor, dysphagia, hemoptysis, or chest pain. His examination revealed no abnormalities, and the laboratory work up was within normal limits at the time of presentation.</p><p>Computed tomography (CT) scan of the chest [<xref ref-type="fig" rid="F1">Figure 1</xref>] revealed a well-circumscribed unilocular and homogenous cyst in the left chest measuring approximately 4.6 cm × 3.4 cm directly adjacent to the esophagus just above the hiatus. No air fluid level or mediastinal adenopathy. An upper gastrointestinal endoscopy was normal. With these findings, the diagnosis of either an esophageal duplication cyst or bronchogenic cyst was kept in mind. A robotic assisted thoracoscopic approach was utilized to remove the lesion.</p><fig id="F1" position="float"><label>Figure 1</label><caption><p>Computed tomographic scan image of the paraesophageal bronchogenic cyst</p></caption><graphic xlink:href="JIAPS-20-191-g001"></graphic></fig><sec id="sec2-1"><title>Operative details</title><p>General anesthesia with 26 Fr left sided double lumen endobronchial tube was used. We prefer the placement of a double lumen endobrochial tube wherever feasible. A uninvent tube with a bronchial blocker may be used as an alternative. However, it results in a slow collapse of the lung. Only as a last resort a normal endotracheal tube may be inserted into the right bronchus to achieve a left sided collapse. However, it sometimes leads to ineffective right upper lobe ventilation due to blockade of right upper lobe bronchus and may lead to hypoxia during the surgery. We do not routinely advocate the use of central line and arterial line for intraoperative monitoring.</p><p>The patient was placed in a semi-prone position with left side up. Three ports were placed triangulating toward the target anatomy. One 12 mm port was used for the robotic camera and two 8 mm ports were used for robotic arm one and two. A 5 mm port was placed between the camera and arm two, to be used as an assistant port. The cyst was seen in the retrocardiac area overlying the posterior pericardium with its medial aspect applied closely to esophagus for a short segment. The left lower lobe was moderately adherent to the cyst and was freed using bipolar cautery [<xref ref-type="fig" rid="F2">Figure 2</xref>]. All around mobilization was done and a complete excision of the cyst was achieved. The ports were closed with a single chest tube. The overall operating time was 120 min with actual console time of 60 min. The chest tube was removed on postoperative day 1. And the patient discharged the following day. He was seen at follow-up 2 weeks and then 3 months after surgery which revealed a normal chest X-ray with no symptoms. Final pathology revealed a bronchogenic cyst without signs of malignant degeneration or infection.</p><fig id="F2" position="float"><label>Figure 2</label><caption><p>Intra-operative view of the cyst</p></caption><graphic xlink:href="JIAPS-20-191-g002"></graphic></fig></sec></sec><sec sec-type="discussion" id="sec1-3"><title>DISCUSSION</title><p>Mediastinal primary cysts represent 15-20% of all primary mediastinal masses.[<xref rid="ref1" ref-type="bibr">1</xref><xref rid="ref2" ref-type="bibr">2</xref>] Bronchogenic cysts comprise approximately 6% of all mediastinal masses in children, while foregut cysts as a group account for 15%.[<xref rid="ref3" ref-type="bibr">3</xref>] They have been found to account for 18% of all mediastinal tumors in adults.[<xref rid="ref4" ref-type="bibr">4</xref>] Bronchogenic cysts are embryological remnants that are isolated from the normal development of the foregut. They are lined by respiratory epithelium and their capsule contains cartilage, smooth muscle, and mucous gland tissue. Common locations are near carina (52%) and in the paratracheal region (19%).[<xref rid="ref5" ref-type="bibr">5</xref>] Air within the cyst is suggestive of secondary infection and communication with the tracheobronchial tree.</p><p>Approximately, 40% of bronchogenic cysts are symptomatic, resulting in cough, dyspnea or chest pain[<xref rid="ref6" ref-type="bibr">6</xref>] while most others are detected incidentally. The treatment is excision because continued growth may lead to compression of surrounding structures. There is also the risk of rare but reported possibility of malignant degeneration.[<xref rid="ref7" ref-type="bibr">7</xref>] Differential diagnosis is difficult with several entities including congenital cystic adenomatoid malformations, esophageal duplication, neurenteric cyst, pericardial cysts, and lymphangioma. Duplication cysts are detected adjacent to or within the esophageal wall and are indistinguishable from bronchogenic cysts on CT and magnetic resonance imaging. Mediastinal neuroenteric cysts are associated with multiple vertebral anomalies and with neurofibromatosis. Pericardial cysts on the other hand are unilocular and commonly located in the right cardiophrenic space. However, they may occur anywhere in relation to the pericardium.</p><p>Traditionally, open thoracotomy has been the method of choice for bronchogenic cysts excision. In children however, it may lead to scoliosis and has a lot of morbidity.[<xref rid="ref8" ref-type="bibr">8</xref>] Video-assisted thoracoscopic surgery (VATS) may be considered as an alternative to thoracotomy to prevent scoliosis, although no study demonstrated this finding yet. Several reports claim that VATS is superior to the open approach with low complication rates and shorter postoperative hospital stay[<xref rid="ref9" ref-type="bibr">9</xref>] but are not enough to demonstrate VATS as the first line tool for bronchogenic cyst resections in pediatric patients, especially in those who are in the first decade of their life.[<xref rid="ref9" ref-type="bibr">9</xref><xref rid="ref10" ref-type="bibr">10</xref>] Bronchogenic cysts are usually adherent to adjacent structures, which makes a complete resection by conventional thoracoscopy difficult. The three-dimensional visualization and endo-wristed instruments offering greater maneuverability may prove robotic system to be ideally suited for resection of mediastinal cysts without the morbidity of a thoracotomy. In terms of cosmesis however Robotic offers minimal or no advantage over VATS.</p><p>Toker <italic>et al</italic>.,[<xref rid="ref11" ref-type="bibr">11</xref>] reported their experience with robotic assisted excision of a sub-carinal bronchogenic cyst. They concluded the da Vinci Surgical System for such indications, especially for patients who are in the first decade of their life, may provide higher technical capabilities in a smaller room when compared with VATS. We believe that anything that can be approached by VATS can be better addressed using robotic assistance due to improved visualization and better maneuverability of instruments.</p><p>The major limitation in using robotic assistance in pediatric thoracic surgery is the size of robotic instruments in relation to the patient's size. Moreover the narrow intercostal spaces in pediatric age group make it difficult and traumatic to place 8 mm or 12 mm ports for robotic instruments and camera respectively. However, a range of 5 mm robotic instruments and even an 8 mm telescope are available for pediatric cases. In this particular case, we believe that the robotic approach gave us a lot more confidence because of the extended dexterity offered by the articulating robotic instruments leading to a more efficient utilization of a tight space in the retrocardiac area where long rigid nonarticulated VATS instruments would have been more tedious. The loss of tactile feedback when using the robotic system is another major concern. However, till date, we have not encountered any injuries or complications as a direct result of lack of haptic feedback.</p><p>The most important limitation of the use of robotic system is the cost involved. There is an initial cost of approximately 1.5-2.0 million dollars for purchasing the robot. There is also a recurring cost of instruments, drapes, and annual maintenance. In our hospital, the initial cost has been absorbed by the hospital and only the cost of consumables is transferred to the patients.</p></sec><sec sec-type="conclusions" id="sec1-4"><title>CONCLUSIONS</title><p>We strongly believe that robotic assisted thoracoscopic excision of paraesophageal bronchogenic cyst is a safe and effective method to deal with bronchogenic cysts particularly in difficult areas and involves considerably less morbidity than thoracotomy does and may be better suited than VATS for this indication. With more experience in robotic pediatric thoracic surgery its acceptance as a superior alternative to VATS in most cases of bronchogenic cysts will become more widespread.</p></sec></body><back><fn-group><fn fn-type="supported-by"><p><bold>Source of Support:</bold> Nil</p></fn><fn fn-type="conflict"><p><bold>Conflicts of Interest:</bold> None declared.</p></fn></fn-group><ref-list><title>REFERENCES</title><ref id="ref1"><label>1</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Laurent</surname><given-names>F</given-names></name><name><surname>Latrabe</surname><given-names>V</given-names></name><name><surname>Lecesne</surname><given-names>R</given-names></name><name><surname>Zennaro</surname><given-names>H</given-names></name><name><surname>Airaud</surname><given-names>JY</given-names></name><name><surname>Rauturier</surname><given-names>JF</given-names></name><etal></etal></person-group><article-title>Mediastinal masses: 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