the 3 rd. surgical unit feb.2009. limits of the superior mediastinum anterior - manubrium of the...
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The 3rd. Surgical UnitFeb.2009
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Limits of the superior mediastinum
anterior - manubrium of the sternum
posterior - anterior surface of bodies of vertebrae T1-T4
superior - plane of the thoracic inlet
inferior - plane of the sternal angle
lateral - mediastinal pleura
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Transverse plane
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Planes in the superior mediastinum from anterior to posterior
- glandular plane - venous plane - arterial-nervous plane
- visceral plane- lymphatic plane
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Manubrium of the sternum + the cartilage of the first rib = anterior boundary of the A-S mediastinum
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The first plane is the glandular plane. It consists of two lobes and is mainly fat in the adult with small islets of active thymic cells scattered throughout
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The second plane is the venous plane and consists of the: left brachiocephalic vein, right brachiocephalic vein, SVC
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The third plane is the arterial-nervous plane aortic arch and its branches : brachiocephalic artery, left common carotid artery, left subclavian artery nerves: left and right vagus nerves, left and right phrenic nerves
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The fourth plane is the visceral plane trachea , esophagus , left recurrent laryngeal nerve
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Esophagus
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Lymphatic plane- thoracic duct
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Anatomy
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COMPARTIMENT ANTERO-SUPERIORFascia endotoracicaTimusTrunchiuri venoase
brahio-cefalice- VCSCrosa aorteiGanglioni
mediastinali sup.Nervii vagiNervii recurentiNervii frenici
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LOJA TIMICA-rapoarteAnterior:
Art. sterno-condro-clavicularaManubriul sternalM. subhioidieniFata post. lig. sterno-pericardic sup.
Posterior:Lama tiro-aorto-pericardica:
Tr. v. br.-cef., VCS, tr. a.br.-cef., carotida stg. Pericard
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TIMUS
Marginit de sinusurile pleurale anterioare
Inconjurat de o capsula fibroasa
Periglandular- tesut conj. lax- disectie usoara
Aderentele –lig. timo-tiroidian si timo-pericardic
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TIMUS- RAPOARTE
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TIMUS-rapoarteRegiunea cervicala
Anterior: m. subhiodieni
Posterior: trahee, vene tir. inf.
Lateral: a. carotida comuna, vena jugulara interna, nervul vag
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TIMUS-rapoarteMediastinul anterior
Anterior: sternul+ primele 4-5 cartilaje costale, vase toracice interne
Posterior: pericard, n.cardiaci, tr. pulmonar, aorta ascendenta, crosa, ramuri, VCS, v. br.-cef.
Lateral: pleure M., nervi frenici, vase frenice sup.
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TIMUS- RAPOARTE
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TIMUS-vascularizatiePedicul superior: art. timice sup. din
art. tiroidiana inf.
Pedicul lateral: art.timice lat. din art. toracice interne sau dfg. sup.
Pedicul mijlociu: art. timica mijlocie din trunchi art. brahiocefalic sau aorta
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TIMUS-vascularizatie, inervatieVenele timice- tr. venos br-cef., 2mm diam,
scurte- punct criticLimfaticele- ggl.parasternali, jugulari,
bronho-mediastinali- duct toracic
Nervii timici- din vag, lant simpatic cervico-toracic si frenic
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WHAT’S THAT ?
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MEDIASTINAL MASS, RETROSTERNALLYLYMPHOMA
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MEDIASTINAL MASSTHYMOMA
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LATERAL VIEW CXRTHYMOMA
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GUIDELINESWhenever you see a mass on a chest x-ray
that is possibly located within the mediastinum, your goal is to determine the following:
Is it a mediastinal mass? Is it in the anterior, middle or posterior
mediastinum? Are you able to characterize the lesion by
determining whether it has any fatty, fluid or vascular components?
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Statistically, it is important to remember the following:
Most masses (> 60%) are: Thymomas Neurogenic Tumors Benign Cysts Lymphadenopathy (LAD)
In children the most common (> 80%) are: Neurogenic tumors Germ cell tumors
In adults the most common are: Lymphomas LAD Thymomas Thyroid masses
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Localize to the mediastinum Left. A lung mass abutts the mediastinal surface and creates acute angles with the lung. Right. A mediastinal mass will sit under the surface of the mediastinum, creating obtuse angles with the lung.
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Localize within the mediastinumThe mediastinum can be divided into
anterior, middle and posterior compartments.It is important to remember that there is no tissue plane separating these compartments.
On the lateral radiograph the anterior and middle compartments can be separated by drawing an imaginary line anterior to the trachea and posteriorly to the inferior vena cava.
The middle and posterior compartments can be separated by an imaginary line passing 1 cm posteriorly to the anterior border of the vertebral bodies.This division allows us to make a more narrow differential diagnosis.
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On the PA film there is a lobulated widening of the superior mediastinum.On the lateral chest film the retrosternal clear space is obliterated.
This happened to be a patient with lymphoma.
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FDG-PET images of the same patient.There are multiple lymphatic masses in the anterior, middle and even posterior mediastinum, spreading to the neck.
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On the chest film there is a mass that has obtuse angles with the mediastinum, so it is a mediastinal mass.The anterior location was confirmed on a CT.Most commonly this will be a mass of thymic or lymphatic origin.This proved to be a lymphoma in a HIV-positive patient.
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Substernal parathyroid adenoma CT revealed an encapsulated mass of 3 cm in the upper anterior mediastinum behind the sternum-clavicular joints, with marked peripheral enhancement (arrow).
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Tc-99m-sestamibi substraction image showed an area of intense uptake below the inferior pole of the left thyroid lobe, in the upper mediastinum, in the left median position and normal thyroid with homogenous radiopharmaceutical uptake (arrow)
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Cystic masses
The anterior mediastinum is an important location
for cystic masses.
Masses can be entirely cystic (thymic cysts) or have solid components (lymphoma or cystic thymoma).
Some masses are cystic with enhancing septations - in these cases you should think of a germ cell tumor.
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The CT shows an anterior mediastinal mass with water density attenuation.This is typical for a thymic cyst.
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The CT shows a mass located in the anterior mediastinum.The mass is cystic but has solid enhancing septa.This finding is very specific for a germ cell tumor.
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The CT shows a mass located in the anterior mediastinum.The mass is cystic but has solid enhancing components, so ? lymphoma, germ cell tumor and cystic thymoma.This proved to be a cystic thymoma.
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TIMUS HIPERPLAZIC TIMUS ATROFIC
TUMORI TIMICETIMUS NORMAL
+/- MIASTENIA GRAVIS sau alte BOLI AUTOIMUNE
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MIASTENIA GRAVISDefinitie, Kirschner, 1991Clinic- fatigabilitatea muschilor voluntari la
efort repetitiv, cu refacere la odihnaElectrofiziologic- raspuns decrement la
stimularea repetitiva-EMGFarmacologic- raspuns pozitiv la tensilonPatologic- modificari histo-pat. timice si
structurale la nivelul R. Ach. si placa n-m.Imunologic- prezenta Ac. antiR Ach. si
raspuns favorabil la imunosupresie
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BV, 17 ani, MG-Oss-IIB, op.1998,AP-HPT, remisie completa
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NA, 39ani, MG-Oss-IV (6 ani istoric)op.12-III-1997, AP-HLT, deces- 20.III.1997
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MIASTENIA GRAVIS
Boala autoimuna dobindita – necunoscute???Ce declanseaza aparitia bolii?De ce sunt miastenici sero-negativi?De ce exista variabilitate mare de raspuns la
tratament: remisie completa, remisie farmacologica, ameliorare, agravare, fara raspuns, deces- insuf. resp. acuta?
De ce un timus normal poate induce boala?De ce apare miastenia dupa indepartarea unui
timom?
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Patogenie autoimuna
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Modificari de placa neuro-musculara
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MIASTENIA GRAVIS
Tratamentul- nu este inca standardizat;
Discipline implicate in management: neurologie, imunopatologie, histopatologie, endocrinologie, radiologie, medicina nucleara, chirurgie, anesteziologie, oncologie ( radioterapeut, chimioterapeut)
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CAI DE ABORDMEDIASTINUL ANTERIORTORACOTOMIESTERNOTOMIECERVICOTOMIEABORD MIXT
TORACOSCOPICMEDIASTINOSCOPIC
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TORACOTOMIA ANTERO-LATERALAAVANTAJE:
Poate fi prelungita posteriorPoate fi prelungita prin sectiunea transversala a
sternuluiPoate fi asociata cu o cervicotomieExpune bine pediculul pulmonar si vasele mariIncizie estetica situata in santul submamar
DEZAVANTAJEAcces dificil pentru planul traheo-bronsicextremitatea sa interna ramine un punct slab, greu
de inchis
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TORACOTOMIA ANTERIOARA TRANSPECTORALA
Se efectueaza in zona de insertie a m. pectorali(I5 c-ic)
De la linia parasternala ant. pina la linia axilara ant.
Poate fi prelungitaEste rezervata prelevarii de tesut biopsic
mediastinal
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TORACOTOMIA BILATERALA CU STERNOTOMIE TRANSVERSALA
Ofera cimp vizual asupra mediastinului si ambelor cavitati pleurale
Pentru leziuni mediastinale extinse lateralArt. mamara interna ligaturata bilateralSe deschid ambele cavitati pleurale
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STERNOTOMIA MEDIANA LONGITUDINALAAvantaje:
Acces facilExpune bine loja timicaExpune bine o leziune cu extensie bilateralaPoate fi asociata cu cervicotomiaPermite ventilarea ambilor plaminiEvita compresiuni, tractiuni pe cord, vase mari,
trahee in cursul manevrelor chirurgicale
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STERNOTOMIA MEDIANA LONGITUDINALA
Dezavantaje:
Nu da acces bun spre hilul pulmonarLasa cicatrice inestetica
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STERNOTOMIE MEDIANA LONGITUDINALA
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Incizia longitudinala a periostului sternal
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Incizie longitudinala mediana
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Sternotomie longitudinala cu sternotomul
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Ecartarea celor doua jumatati longitudinale de stern
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Ann Thorac Surg 2000;70:1423-1424 Reversed-T Upper Mini-Sternotomy for Extended Thymectomy in Myasthenic Patients
Jan G. Grandjean, MD, PhD, Marco Lucchi, MD, and Massimo A. Mariani, MD, PhDThorax Center, University Hospital of Groningen, Groningen, The Netherlands
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Reversed-T Upper Mini-Sternotomy for Extended Thymectomy in Myasthenic Patients
The reversed-T upper mini-sternotomy provides an exposure of the mediastinum that allows us to perform a complete resection of the thymus and of all the anterior mediastinal fatty tissue.
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Reversed-T Upper Mini-Sternotomy for Extended Thymectomy in Myasthenic Patients
TechniqueThe patient is positioned as for the standard
sternotomy.An 8- to 10-cm midline skin incision is performed
starting about 1 cm under the jugulum, then the sternum is divided up to the third intercostal space.
At this level, the sternum is transversely transected by means of an oscillating saw .
A Finocchietto-like pediatric retractor is positioned to spread the sternum.
The resection starts from the fat of the inferior mediastinum. This step can easily be accomplished putting a hand-held retractor under the sternum and lifting it.
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TechniqueThe anterior mediastinal fat is removed beginning
from the diaphragm going upward. Then, the gland is elevated toward the brachiocephalic
trunk, and the draining veins and the thymic branches of internal mammary artery are ligated.
The cervical horns of each lobe are resected by a blunt dissection.
At the end of the procedure, a 20F drain is placed in the retrosternal space through a subxiphoid incision, if the pleurae was not opened, otherwise in an intercostal space.
The horizontal and vertical sternal edges are wired together with separate wires.
A subcuticular suture is used for skin closure.
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An en bloc resection of the thymus and mediastinal fat performed through the mini-sternotomy.
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Mediastinal approach
The reversed-T upper ministernotomy is a minimally invasive approach that results in a less operative trauma to the chest structure and function than a full sternotomy.
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Rationale
Considering that myasthenic patients with generalized symptoms may have or develop respiratory muscle weakness leading to impaired lung expansion, saving the integrity of the lower part of the chest may further decrease the incidence of respiratory failure requiring mechanical ventilation.
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ArgumentsIn this approach, the sternum is divided to the
third intercostal space and there is no need to ligate the internal mammary arteries.
Patients who may later require coronary artery bypass in their future will benefit from the presence of the mammary arteries.
Last, but not least, in case of thymic tumor or bleeding, the skin as well as the sternum incision can be easily extended to a complete median sternotomy.
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CERVICOTOMIA
Incizia Kocher
Pentru leziunile cervico-toracice
Cimp vizual limitat
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TORACOSCOPIA VIDEO-ASISTATACerinte:
Intubare cu sonda cu dublu lumenTorace la 45 grade4 trocarePneumomediastinul faciliteaza disectiaConversia este rara daca se selecteaza atent pacientii
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ALEGEREA CAII DE ABORD IN FUNCTIE DE LEZIUNEA DE EXTIRPAT
Leziuni mici- toracotomie antero-lateralaLeziuni medii-sternotomie mediana sau
toracotomie antero-lateralaLeziuni mari si bilaterale- sternotomie
transversala cu toracotomie anterioara bilaterala
Leziuni foarte mari, unilaterale- toracotomie postero-laterala
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Scopul operatieiIndepartarea intregului tesut timic din
mediastinTimus+ectopii mediastinale anterioareChirurgii: minimalisti si maximalistiMinimalistii: prin incizii mici, cosmetice,
timectomie adecvataMaximalistii: timectomia+excizia grasimii
mediastinului anterior- sternotomie mediana completa
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Gradul de rezecţie a ţesutului timic din mediastinul anterior după diferite tehnici (după Jeretzki)
Tehnică Grad de rezecţie timică
timectomie maximală 98-100%
timectomie extinsă 85-95% timectomie toracoscopică 80-85% timectomie transcervicală 75-80% timectomie simplă transsternală 70-75%
timectomie simplă transcervicală 49-50%
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Sternotomie mediana longitudinala Corn timic cervical, prevenosUG, femeie, 31 ani, MG-OSS.IIB, op. 2008
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UG,31 ani, Hiperplazie limfoida timica cu ectopii Remisie completa post op.
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Hiperplazie limfoida timica, UD, femeie, 54 ani, MG-Oss.III+Tiroidita Hashimoto, op.2008 iulie, deces-sept.2008Insuf. resp. ac.-ventilatie prelungita, traheostoma gastrostoma percutana, escare, ulcere corneene, sdr.consumptiv
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Hiperplazie limfoida timica, ML, femeie, 28 ani, MG-Oss IIB, op. 2008, corn timic retrovenos, RC