Shinshu Med J, 67⑶：205～208, 2019

Video-assisted Thoracic Surgery with a Kirschner Wire Traction
for an Anterior Mediastinal Tumor : A Case Report
Shunichiro Matsuoka＊ and Ryoichi Kondo
Department of Thoracic Surgery, National Hospital Organization Matsumoto Medical Center

Currently, there are three main approaches to surgery for anterior mediastinal tumors : median sternotomy,
video-assisted thoracic surgery (VATS), and robotic-assisted thoracic surgery (RATS). We describe one of thesurgical options for anterior mediastinal tumors. A 79-year-old woman with a mediastinal tumor was referredto our hospital. Computed tomography revealed a small-sized tumor that did not invade the surrounding tissue
in the left of the anterior mediastinum. We performed surgical resection of the tumor via VATS with aKirschner wire. The Kirschner wire was inserted into the subcutaneous tissue approximately 10 cm in the thirdintercostal space across the sternum. Then, the wire was connected with the Kirschner Traction Bow®. The
bow was lifted using the Octopus Retractor®to elevate the anterior chest wall as much as possible to obtain abetter operative field in the limited mediastinal space. The pathological diagnosis was mediastinal hemangioma,
and the patient has been recurrence-free for 2 years postoperatively. These combined procedures seem to besafer than VATS alone and more cost effective than RATS. Altogether, VATS with elevation of the anterior
chest wall using a Kirschner wire may be an effective treatment option for anterior mediastinal tumors, as it isminimally invasive, simple, affordable, and safe. Shinshu Med J 67 : 205―208, 2019
(Received for publication November 12, 2018 ; accepted in revised form February 4, 2019)
Key words : elevation, anterior chest wall, Kirschner wire, mediastinal hemangioma, VATSⅠ Background

ⅡCase Presentation

The traditional approach for mediastinal tumors isA 79-year-old woman was referred to our hospitalto perform a median sternotomy (MS). However, re­because of a mediastinal tumor. Single-phase con­cent developments in video-assisted thoracic sur­

trast-enhanced computed tomography (CT) showed

gery (VATS) and robotic-assisted thoracic surgery(RATS) have improved the minimally invasive ap­
proaches for the resection of mediastinal tumors in alimited mediastinal space. In Japan, RATS has re­cently started being covered by health insurance formediastinal tumors and malignant lung tumors sinceApril 2018. However, the high costs of RATS associ­ated with advances in medical technology are still
important considerations. Herein, we describe a caseof mediastinal hemangioma resected via VATS witha Kirschner wire.
＊Corresponding author : Shunichiro Matsuoka
Department of Thoracic Surgery, National Hospital
Organization Matsumoto Medical Center, 2-20-30
Muraimachiminami, Matsumoto, Nagano 399-0021, Japan
E-mail : himanji@shinshu-u.ac.jp

No. 3, 2019a heterogeneous, lobulated tumor (41×26 mm) with
scattered calcifications in the left anterior mediasti­num (Fig. 1). To make a definitive diagnosis, we de­cided to perform surgery. The left lobe of the thy­mus, including the tumor, was resected via VATS,
and the anterior chest wall was elevated using aKirschner wire and a rigid endoscope with variablevisual field directions. First, we inserted the Kirschner
wire (φ2.4 mm) into the subcutaneous tissue approx­
imately 10 cm in the third intercostal space acrossthe sternum while the patient was in a slightly leftside-up position. Then, the wire was connected withthe Kirschner Traction Bow®. Finally, the bow waslifted using the Octopus Retractor®to elevate theanterior chest wall as much as possible (Fig. 2A-D).
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Matsuoka・Kondo

Fig. 1 Contrast-enhanced computed tomography scan showing a lobulated tumor with slight heterogeneousenhancement and calcifications in the left side of the anterior mediastinum (arrow).

We then used three ports at the third and fifth in­

However, the hospitalization cost for RATS is highertercostal spaces of the left anterior axillary line, andthan that for VATS2）, and RATS requires perform­

the sixth intercostal space of the left anterior axil­

ing more than 300 operations per year in each in­lary or midclavicular line. The tumor had a hyper­

stitution to avoid financial deficit with the current

vascular appearance and showed no invasion of sur­robotic surgical management3）. Moreover, intraoper­

rounding tissues and great vessels. Microscopically,

ative artificial pneumothorax with CO2 insufflation

several dilated vessels were covered with normal

poses a potential risk of difficult ventilation with aendothelial and smooth muscle cells, and somedouble-lumen endotracheal tube4）.

fibrin thrombi and phleboliths were observed (Fig. 3).

The preoperative diagnosis of anterior mediastinal

The pathological diagnosis was mediastinal venous

tumors is difficult because of similar radiologicalhemangioma. The patient has been recurrence-free

findings and the risks of preoperative biopsy, which

for 2 years postoperatively.

are related to their location near the great vessels

Ⅲand heart. Calcifications, called phleboliths, in theDiscussion

tumor are the one of the features of mediastinal

MS, VATS, and RATS are the main surgical ap­

hemangioma and represent organized thrombosis5）.

proaches for treating mediastinal tumors. AmongIn addition, the features on dynamic CT have beenthese approaches for early-stage thymomas, RATS

reported as persisting and gradually increasing en­

and VATS, which utilize an artificial pneumothorax

hancement6）, and early peripheral nodular enhance­with carbon dioxide (CO 2 ) insufflation to gain ament and progressively centripetal fill-in7）. In ourbetter surgical field in the mediastinal space, arecase, mediastinal hemangioma was first considered1）

more feasible and safer for resection than MS . Fur­based on the presence of scattered calcifications.

thermore, RATS is less invasive than VATS, withThus, we performed resection of the left thymus

shorter postoperative pleural drainage duration, re­lobe, including the tumor, by VATS with a Kirschner

duced drainage volume, and shorter hospital stay.

wire for reaching a definitive diagnosis.

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Shinshu Med JVol. 67

VATS with Kirschner wire for mediastinal tumor

Fig. 2 This figure depicts the right-side approach. (a) A Kirschner wire penetrated the subcutaneous tissue.
(b) The wire was connected with a traction bow. (c) The bow was lifted using the Octopus Retractor®
to elevate the anterior chest wall as much as possible. (d) Three ports were utilized in this case.

This method has been adapted for anterior medi­

traoperative performance.

astinal tumors with no invasion of surrounding tis­

It is necessary to have a sufficient working spacesues, and is used even in extended thymectomy forwithin the mediastinum to perform safe and com­myasthenia gravis with thymoma in our hospital.

fortable surgery for anterior mediastinal tumors.

The right side approach is convenient because theAltogether, VATS with elevation of the anterior chest

right thoracic cavity is larger than the left thoracic

wall using a Kirschner wire may be an effective treat‑cavity. In this case, the reason for approaching fromment option for anterior mediastinal tumors, as it is

the left side was the location of the tumor. If neces­minimally invasive, simple, affordable, and safe.

sary, one port under the xiphoid process is added,

Consent for Publication

and we sometimes use a total of four ports. To ap­
proach from the right side, the same procedure must

Written informed consent was obtained from thebe performed as for the left side. Moreover, using apatient for publication of this case report and any

rigid endoscope with variable visual field directions isaccompanying images. A copy of the written consent

also effective in obtaining a better surgical field in theis available for review by the Editor-in-Chief of thislimited mediastinal space. Compression of the anterior

journal.

chest wall for a few minutes is necessary after re­

Acknowledgement

moving the wire to prevent subcutaneous bleeding.
Such instruments are sterilizable and reusable andhelp conserve medical resources. These procedures

The author would like to thank KI for the patho­
logical diagnosis.

lead to stress reduction and improve the ease of in­No. 3, 2019207

Matsuoka・Kondo

Fig. 3 Hematoxylin-eosin-stained sections (high power field) showing dilated vessels covered with normal
endothelial cells and smooth muscles and some fibrin thrombus (arrows) and phleboliths (arrowhead).

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