intrathoracic procedures [4], and previous reports ofsuccessful laparoscopic retrieval of intrapelvic or intra-abdominal pins supported our attempt to approach re-moval in a less invasive manner [5].

However, we were prepared for conversion to imme-diate thoracotomy if initial thoracoscopy found that theforeign body traversed the mediastinum or if extractionproduced bleeding or significant air leak. Our approachwas successful and we removed the pin without incidentand saved the patient the associated morbidity of athoracotomy. In summary, we propose that thoracoscopicremoval of intrathoracic foreign bodies can be accom-plished safely if the object can be withdrawn through aport site, if it does not traverse the mediastinum, and ifthe patient can tolerate single-lung ventilation.

References

1. Lyons F, Rockwood C. Migration of pins used in operationson the shoulder. J Bone Joint Surg 1990;72-A:1262–7.

2. Liu H, Chang C, Lin P, et al. Pulmonary artery perforationafter Kirschner wire migration: case report and review of theliterature. J Trauma 1993;34:154–6.

3. Mazet RJ. Migration of a Kirschner wire from the shoulderregion into the lung. J Bone Joint Surg 1943;255:477.

4. Rao A, Bansal A, Rangraj M, et al. Video-assisted thoracicsurgery. Heart Lung 1999;28:15–9.

5. Kottmeier S, Born CT, Saul H. Laparoscopic retrieval of amigrating intrapelvic pin: case report and a review of theliterature. J Trauma 1993;35:952–5.

INVITED COMMENTARY

These authors were faced with the dilemma of an ortho-pedic implant which had migrated into the thoracic cagein a patient who was asymptomatic. Historically, theremoval of the implant would have required a thoracot-omy. The report describes the successful use of videoassisted thoracoscopy (VATS) to remove it. This casecaptures the essence of the expanding role of VATS, atechnique previously unknown to many orthopedic sur-geons. The procedure brought about a collaborativetransdisciplinary resolution to a patient’s dilemma withminimal morbidity to the patient. VATS represents theultimate integration of anesthesia, access surgeon, ortho-pedics and high tech.

From the orthopedists perspective, this report adds tothe expanding role of VATS which has included drainageof intervertebral abscess cavity, intervertebral discec-tomy, anterior release and fusion of severe spinal defor-mities, incisional/excisional biopsy, repair of spinal fu-sion pseudarthrosis and recently spinal deformitycorrection and instrumentation. The low morbidity, highpatient satisfaction when compared to thoracotomy sat-isfies all the tenets of quality improvement with anexcellent outcome.

Alvin Crawford, MD

3333 Burnet AveCincinnati, OH 45229e-mail: crawa0@chmcc.org.

Ruptured Thymoma CausingMediastinal Hemorrhage Resectedvia Partial SternotomyShinji Shimokawa, MD, Shun-ichi Watanabe, MD, Koh-ichi Sakasegawa, MD, and Atsushi Tani, MD

Second Department of Surgery and Department of Radiology,Kagoshima University Faculty of Medicine, Kagoshima, Japan

A case of a ruptured thymoma causing mediastinal hem-orrhage and hemothorax that was electively resected by apartial sternotomy approach is presented. This case andothers previously reported illustrate that a sudden onsetof dyspnea and chest pain accompanied by acute medi-astinal widening on chest roentgenogram in a previouslyhealthy patient should suggest the diagnosis of a rup-tured thymoma. An upper part sternotomy approach maybe as safe and effective as a less invasive surgical proce-dure in resection of noninvasive thymomas, even ifdense tumor adhesion exists.

(Ann Thorac Surg 2001;71:370–2)© 2001 by The Society of Thoracic Surgeons

Athymoma may present with various symptoms orsigns caused by its local extent and an associated

systemic or autoimmune disorder. Very rarely a thy-moma may rupture spontaneously [1–3]. We report a rarecase of a ruptured thymoma causing mediastinal hemor-rhage and hemothorax that was electively resected by apartial sternotomy approach as a less invasive surgicalprocedure.

A 71-year-old previously healthy woman had a suddenonset of chest pain and dyspnea accompanied by mildhypotension. On admission to an outside institution, achest roentgenogram showed a widened mediastinum.Chest computed tomographic (CT) scans revealed ananterior mediastinal mass within calcification and hem-orrhage, mediastinal hemorrhage, bilateral pleural effu-sion, and a normal aorta and great vessels (Fig 1). Shehad no abnormality in blood coagulation system. Thediagnosis of hemomediastinum and bilateral hemothoraxcaused by rupture of the anterior mediastinal mass wassuspected. Conservative treatment made her stable. Thesize of the mass and the amount of pleural effusiongradually decreased. She was referred to our departmentfor operation 40 days after the onset. She did not presentwith any symptoms or signs associated with a systemic orautoimmune disorder. Physical examination was unre-markable. Serum tumor markers showed normal values.

Accepted for publication April 3, 2000.

Address reprint requests to Dr Shimokawa, Second Department ofSurgery, Kagoshima University Faculty of Medicine, 8-35-1 Sakuragaoka,Kagoshima 890-8520, Japan; e-mail: simokawa@med6.kufm.kagoshima-u.ac.jp.

370 CASE REPORT SHIMOKAWA ET AL Ann Thorac SurgRUPTURED THYMOMA RESECTED BY PARTIAL STERNOTOMY 2001;71:370–2

© 2001 by The Society of Thoracic Surgeons 0003-4975/01/$20.00Published by Elsevier Science Inc PII S0003-4975(00)02234-7