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Surgery: Recommendations for Surgeons

  • Mario Santini
  • Alfonso Fiorelli
Chapter
Part of the Current Clinical Pathology book series (CCPATH)

Abstract

Differential diagnosis and treatment of mediastinal mass is challenging. Several strategies are available to obtain a diagnostic tissue and to resect the mass. For mass with well-marked margins and without signs of invasiveness (i.e., neurinoma, cystic lesion, mature teratoma), complete resection is indicated, being diagnostic and therapeutic. The surgical strategy (minimally invasive or open surgery) depends on the characteristics of the mass, its location, and surgeon’s experience. For mass with invasiveness of adjacent structures, a preoperative diagnosis obtained with transcutaneous biopsy, endoscopy, mediastinotomy, mediastinoscopy, or thoracoscopy according to the location of the mass is mandatory before proceeding with surgery.

Keywords

Mediastinum Mediastinotomy Mediastinoscopy Mediastinal tumor Sternotomy 

Notes

Acknowledgment

The authors thank Mario Polverino, MD, and Carlo Santoriello, MD, of Pneumology Unit of Scafati Hospital, Scafati, Italy, for providing Figs. 5.3, 5.4, and 5.5.

References

  1. 1.
    Duwe BV, Sterman DH, Musani AI. Tumors of the mediastinum. Chest. 2005;128:5893–909.CrossRefGoogle Scholar
  2. 2.
    Gupta S, Seaberg K, Wallace MJ, Madoff DC, Morello FA Jr, Ahrar K, Murthy R, Hicks ME. Imaging-guided percutaneous biopsy of mediastinal lesions: different approaches and anatomic considerations. Radiographics. 2005;25(3):763–86.CrossRefPubMedGoogle Scholar
  3. 3.
    Protopapas Z, Westcott JL. Transthoracic needle biopsy of mediastinal lymph nodes for staging lung and other cancers. Radiology. 1996;199:489–96.CrossRefPubMedGoogle Scholar
  4. 4.
    Moulton JS, Moore PT. Coaxial percutaneous biopsy technique with automated biopsy devices: value in improving accuracy and negative predictive value. Radiology. 1993;186:515–22.CrossRefPubMedGoogle Scholar
  5. 5.
    Adler OB, Rosenberger A, Peleg H. Fine-needle aspiration biopsy of mediastinal masses: evaluation of 136 experiences. AJR Am J Roentgenol. 1983;140:893–6.CrossRefPubMedGoogle Scholar
  6. 6.
    Zafar N, Moinuddin S. Mediastinal needle biopsy. A 15-year experience with 139 cases. Cancer. 1995;76:1065–8.CrossRefPubMedGoogle Scholar
  7. 7.
    Sawhney S, Jain R, Berry M. Tru-Cut biopsy of mediastinal masses guided by real-time sonography. Clin Radiol. 1991;44:16–9.CrossRefPubMedGoogle Scholar
  8. 8.
    Morrissey B, Adams H, Gibbs AR, Crane MD. Percutaneous needle biopsy of the mediastinum: review of 94 procedures. Thorax. 1993;48:632–7.CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Nasit JG, Patel M, Parikh B, Shah M, Davara K. Anterior mediastinal masses: a study of 50 cases by fine needle aspiration cytology and core needle biopsy as a diagnostic procedure. South Asian J Cancer. 2013;2(1):7–13.CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    Glassberg RM, Sussman SK. Life-threatening hemorrhage due to percutaneous transthoracic intervention: importance of the internal mammary artery. AJR Am J Roentgenol. 1990;154:47–9.CrossRefPubMedGoogle Scholar
  11. 11.
    Wang Z, Jiang C. Endoscopic ultrasound in the diagnosis of mediastinal diseases. Open Med (Wars). 2015;10(1):560–5.Google Scholar
  12. 12.
    Herth FJ, Rabe KF, Gasparini S, et al. Transbronchial and transoesophageal (ultrasound-guided) needle aspirations for the analysis of mediastinal lesions. Eur Respir J. 2006;28:1264–75.CrossRefPubMedGoogle Scholar
  13. 13.
    Yasuda I, Tsurumi H, Omar S, Iwashita T, Kojima Y, Yamada T, Sawada M, Takami T, Moriwaki H, Soehendra N. Endoscopic ultrasound-guided fine-needle aspiration biopsy for lymphadenopathy of unknown origin. Endoscopy. 2006;38(9):919–24.CrossRefPubMedGoogle Scholar
  14. 14.
    Annema JT, Versteegh MI, Veselic M, et al. Endoscopic ultrasound guided fine-needle aspiration in the diagnosis and staging of lung cancer and its impact on surgical staging. J Clin Oncol. 2005;23:8357–61.CrossRefPubMedGoogle Scholar
  15. 15.
    Tournoy KG, Praet MM, Van Maele G, et al. Esophageal endoscopic ultrasound with fine-needle aspiration with an on-site cytopathologist: high accuracy for the diagnosis of mediastinal lymphadenopathy. Chest. 2005;128:3004–9.CrossRefPubMedGoogle Scholar
  16. 16.
    Tournoy KG, Ryck FD, Vanwalleghem L, Praet M, Vermassen F, Maele GV, van Meerbeeck JP. The yield of endoscopic ultrasound in lung cancer staging: does lymph node size matter? J Thorac Oncol. 2008;3(3):245–9.CrossRefPubMedGoogle Scholar
  17. 17.
    Larsen SS, Krasnik M, Vilmann P, et al. Endoscopic ultrasound guided biopsy of mediastinal lesions has a major impact on patient management. Thorax. 2002;57:98–103.CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    Tournoy KG, De Ryck F, Vanwalleghem LR, Vermassen F, Praet M, Aerts JG, Van Maele G, van Meerbeeck JP. Endoscopic ultrasound reduces surgical mediastinal staging in lung cancer: a randomized trial. Am J Respir Crit Care Med. 2008;177(5):531–5.CrossRefPubMedGoogle Scholar
  19. 19.
    Lee YT, Lai LH, Sung JJ, Ko FW, Hui DS. Endoscopic ultrasonography-guided fine-needle aspiration in the management of mediastinal diseases: local experience of a novel investigation. Hong Kong Med J. 2010;16(2):121–5.PubMedGoogle Scholar
  20. 20.
    Ardengh JC, Bammann RH, Giovani M, Venco F, Parada AA. Endoscopic ultrasound-guided biopsies for mediastinal lesions and lymph node diagnosis and staging. Clinics (Sao Paulo). 2011;66(9):1579–83.CrossRefGoogle Scholar
  21. 21.
    Manucha V, Kaur G, Verma K. Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) of mediastinal lymph nodes: experience from region with high prevalence of tuberculosis. Diagn Cytopathol. 2013;41(12):1019–22.CrossRefPubMedGoogle Scholar
  22. 22.
    Zeppa P, Barra E, Napolitano V, Cozzolino I, Troncone G, Picardi M, De Renzo A, Mainenti PP, Vetrani A, Palombini L. Impact of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) in lymph nodal and mediastinal lesions: a multicenter experience. Diagn Cytopathol. 2011;39(10):723–9.CrossRefPubMedGoogle Scholar
  23. 23.
    Dong X, Qiu X, Liu Q, et al. Endobronchial ultrasound-guided transbronchial needle aspiration in the mediastinal staging of non-small cell lung cancer: a meta-analysis. Ann Thorac Surg. 2013;96:1502–7.CrossRefPubMedGoogle Scholar
  24. 24.
    Silvestri GA, Gonzales AV, Jantz MA, et al. Methods of staging non-small cell lung cancer: diagnosis and management of lung cancer, 3rd edn. American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013;143(5 Suppl):e211S–50S.CrossRefPubMedGoogle Scholar
  25. 25.
    Wong M, Yasufuku K, Nakajima T, et al. Endobronchial ultrasound: new insight for the diagnosis of sarcoidosis. Eur Respir J. 2007;29:1182–6.CrossRefPubMedGoogle Scholar
  26. 26.
    Garwood S, Judson MA, Silvestri G, Hoda R, Fraig M, Doelken P. Endobronchial ultrasound for the diagnosis of pulmonary sarcoidosis. Chest. 2007;132:1298–304.CrossRefPubMedGoogle Scholar
  27. 27.
    Kennedy MP, Jimenez CA, Bruzzi JF, et al. Endobronchial ultrasound guided transbronchial needle aspiration in the diagnosis of lymphoma. Thorax. 2008;63:360–5.CrossRefPubMedGoogle Scholar
  28. 28.
    Yasufuku K, Nakajima T, Fujiwara T, Yoshino I, Keshavjee S. Utility of endobronchial ultrasound-guided transbronchial needle aspiration in the diagnosis of mediastinal masses of unknown etiology. Ann Thorac Surg. 2011;91(3):831–6.CrossRefPubMedGoogle Scholar
  29. 29.
    Hwangbo B, Lee GK, Lee HS, et al. Transbronchial and transesophageal fine-needle aspiration using an ultrasound bronchoscope in mediastinal staging of potentially operable lung cancer. Chest. 2010;138:795–802.CrossRefPubMedGoogle Scholar
  30. 30.
    Wallace MB, Pascual JMS, Raimondo M, et al. Minimally invasive endoscopic staging of suspected lung cancer. JAMA. 2008;299:540–6.CrossRefPubMedGoogle Scholar
  31. 31.
    Gelberg J, Grondin S, Tremblay A. Mediastinal staging for lung cancer. Can Respir J. 2014;21(3):159–61.CrossRefPubMedPubMedCentralGoogle Scholar
  32. 32.
    Annema JT, van Meerbeeck JP, Rintoul RC, et al. Mediastinoscopy vs endosonography for mediastinal lymph node staging of lung cancer: a randomized trial. JAMA. 2010;304:2245–52.CrossRefPubMedGoogle Scholar
  33. 33.
    Silvestri GA, Gonzalez AV, Jantz MA, Margolis ML, Gould MK, Tanoue LT, Harris LJ, Detterbeck FC. Methods for staging non-small cell lung cancer: diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013;143(5 Suppl):e211S–50S.CrossRefPubMedGoogle Scholar
  34. 34.
    De Leyn P, Dooms C, Kuzdzal J, Lardinois D, Passlick B, Rami-Porta R, Turna A, Van Schil P, Venuta F, Waller D, Weder W, Zielinski M. Revised ESTS guidelines for preoperative mediastinal lymph node staging for non-small-cell lung cancer. Eur J Cardiothorac Surg. 2014;45(5):787–98.CrossRefPubMedGoogle Scholar
  35. 35.
    Olak J. Parasternal mediastinotomy (Chamberlain procedure). Chest Surg Clin N Am. 1996;6(1):31–40.PubMedGoogle Scholar
  36. 36.
    Watanabe M, Takagi K, Aoki T, Ozeki Y, Tanaka S, Kobayashi H, Aida S. A comparison of biopsy through a parasternal anterior mediastinotomy under local anesthesia and percutaneous needle biopsy for malignant anterior mediastinal tumors. Surg Today. 1998;28(10):1022–6.CrossRefPubMedGoogle Scholar
  37. 37.
    Evans DS, Hall JH, Harrison GK. Anterior mediastinotomy. Thorax. 1973;28(4):444–7.CrossRefPubMedPubMedCentralGoogle Scholar
  38. 38.
    Harken DE, Black H, Clauss R, Farrand RE. A simple cervicomediastinal exploration for tissue diagnosis of intrathoracic disease; with comments on the recognition of inoperable carcinoma of the lung. N Engl J Med. 1954;251:1041–6.CrossRefPubMedGoogle Scholar
  39. 39.
    Fiorelli A, Sagan D, Mackiewicz L, Cagini L, Scarnecchia E, Chiodini P, Caronia FP, Puma F, Santini M, Ragusa M. Incidence, risk factors, and analysis of survival of unexpected N2 disease in stage I non-small cell lung cancer. Thorac Cardiovasc Surg. 2015;63(7):558–67.CrossRefPubMedGoogle Scholar
  40. 40.
    Block MI, Tarrazzi FA. Invasive mediastinal staging: endobronchial ultrasound, endoscopic ultrasound, and mediastinoscopy. Semin Thorac Cardiovasc Surg. 2013;25:218–27.CrossRefPubMedGoogle Scholar
  41. 41.
    Lemaire A, Nikolic I, Petersen T, et al. Nine-year single center experience with cervical mediastinoscopy: complications and false negative rate. Ann Thorac Surg. 2006;82:1185–90.CrossRefPubMedGoogle Scholar
  42. 42.
    Ahmed-Nusrath A, Annamanneni R, Wyatt R, Leverment J. Management of major hemorrhage during mediastinoscopy. J Cardiothorac Vasc Anesth. 2006;20(5):762–3.CrossRefPubMedGoogle Scholar
  43. 43.
    Park BJ, Flores R, Downey RJ, Bains MS, Rusch VW. Management of major hemorrhage during mediastinoscopy. J Thorac Cardiovasc Surg. 2003;126(3):726–31.CrossRefPubMedGoogle Scholar
  44. 44.
    Urschel JD. Conservative management (packing) of hemorrhage complicating mediastinoscopy. Ann Thorac Cardiovasc Surg. 2000;6(1):9–12.PubMedGoogle Scholar
  45. 45.
    Bille´ A, Pelosi E, Skanjeti A, et al. Preoperative intrathoracic lymph node staging in patients with non-small-cell lung cancer: accuracy of integrated positron emission tomography and computed tomography. Eur J Cardiothorac Surg. 2009;36:440–5.CrossRefPubMedGoogle Scholar
  46. 46.
    Cerfolio RJ, Bryant AS, Eloubeidi MA. Accessing the aortopulmonary window (#5) and the paraaortic (#6) lymph nodes in patients with non-small cell lung cancer. Ann Thorac Surg. 2007;84:940–5.CrossRefPubMedGoogle Scholar
  47. 47.
    Gomez-Caro A, Garcia S, Reguart N, et al. Incidence of occult mediastinal node involvement in cN0 non-small-cell lung cancer patients after negative uptake of positron emission tomography/computer tomography scan. Eur J Cardiothorac Surg. 2010;37:1168–74.CrossRefPubMedGoogle Scholar
  48. 48.
    Ginsberg RJ, Rice TW, Goldberg M, Waters PF, Schmocker BJ. Extended cervical mediastinoscopy. A single staging procedure for bronchogenic carcinoma of the left upper lobe. J Thorac Cardiovasc Surg. 1987;94(5):673–8.PubMedGoogle Scholar
  49. 49.
    Ginsberg RJ. Extended cervical mediastinoscopy. Chest Surg Clin N Am. 1996;6(1):21–30.PubMedGoogle Scholar
  50. 50.
    Freixinet Gilart J, García PG, de Castro FR, et al. Extended cervical mediastinoscopy in the staging of bronchogenic carcinoma. Ann Thorac Surg. 2000;70:1641–3.CrossRefPubMedGoogle Scholar
  51. 51.
    Metin M, Sayar A, Turna A, et al. Extended cervical mediastinoscopy in the diagnosis of anterior mediastinal masses. Ann Thorac Surg. 2002;73:250–2.CrossRefPubMedGoogle Scholar
  52. 52.
    Yendamuri S, Demmy TL. Is VAMLA/TEMLA the new standard of preresection staging of non-small cell lung cancer? J Thorac Cardiovasc Surg. 2012;144:S14–7.CrossRefPubMedGoogle Scholar
  53. 53.
    Li WW, van Boven WJ, Annema JT, Eberl S, Klomp HM, de Mol BA. Management of large mediastinal masses: surgical and anesthesiological considerations. J Thorac Dis. 2016;8(3):E175–84.CrossRefPubMedPubMedCentralGoogle Scholar
  54. 54.
    Baltayiannis N, Chandrinos M, Anagnostopoulos D, Zarogoulidis P, Tsakiridis K, Mpakas A, Machairiotis N, Katsikogiannis N, Kougioumtzi I, Courcoutsakis N, Zarogoulidis K. Lung cancer surgery: an up to date. J Thorac Dis. 2013;5(Suppl 4):S425–39.PubMedPubMedCentralGoogle Scholar
  55. 55.
    Marshall MB, DeMarchi L, Emerson DA, Holzner ML. Video-assisted thoracoscopic surgery for complex mediastinal mass resections. Ann Cardiothorac Surg. 2015;4(6):509–18.PubMedPubMedCentralGoogle Scholar
  56. 56.
    Caronia FP, Fiorelli A, Santini M, Lo Monte AI. Uniportal video-assisted thoracoscopic surgery resection of a giant midesophageal diverticulum. Ann Thorac Surg. 2017;103(4):e365–7.CrossRefPubMedGoogle Scholar
  57. 57.
    Caronia FP, Fiorelli A, Arrigo E, Trovato S, Santini M, Monte AI. Bilateral single-port thoracoscopic extended thymectomy for management of thymoma and myasthenia gravis: case report. J Cardiothorac Surg. 2016;11(1):153.CrossRefPubMedPubMedCentralGoogle Scholar
  58. 58.
    Caronia FP, Fiorelli A, Santini M, Cottone S. Uniportal bilateral video-assisted thoracoscopic extended thymectomy for myasthenia gravis: a case report. J Thorac Cardiovasc Surg. 2015;150(1):e1–3.CrossRefPubMedGoogle Scholar
  59. 59.
    Santini M, Fiorelli A, Santagata M, Tartaro GP. Resection of costal exostosis using piezosurgery associated with uniportal video-assisted thoracoscopy. Ann Thorac Surg. 2015;99(3):1080–2.CrossRefPubMedGoogle Scholar
  60. 60.
    Roviaro G, Varoli F, Nucca O, Vergani C, Maciocco M. Videothoracoscopic approach to primary mediastinal pathology. Chest. 2000;117(4):1179–83.CrossRefPubMedGoogle Scholar
  61. 61.
    Roviaro G, Varoli F, Vergani C, Maciocco M. Video-assisted thoracoscopic surgery (VATS) major pulmonary resections: the Italian experience. Semin Thorac Cardiovasc Surg. 1998;10(4):313–20.CrossRefPubMedGoogle Scholar
  62. 62.
    Mouroux J, Padovani B, Maalouf J, Bourgeon A, Richelme H. Pleuropericardial cysts: treatment by videothoracoscopy. Surg Laparosc Endosc. 1996;6(5):403–4.CrossRefPubMedGoogle Scholar
  63. 63.
    Dell’Amore A, Asadi N, Bartalena T, Bini A, Stella F. Thoracoscopic resection of a giant mediastinal parathyroid cyst. Gen Thorac Cardiovasc Surg. 2014;62(7):444–50.CrossRefPubMedGoogle Scholar
  64. 64.
    Pons F, Lang-Lazdunski L, Bonnet PM, Meyrat L, Jancovici R. Videothoracoscopic resection of neurogenic tumors of the superior sulcus using the harmonic scalpel. Ann Thorac Surg. 2003;75(2):602–4.CrossRefPubMedPubMedCentralGoogle Scholar
  65. 65.
    Novellino L, Longoni M, Spinelli L, et al. “Extended” thymectomy, without sternotomy, performed by cervicotomy and thoracoscopic technique in the treatment of myasthenia gravis. Int Surg. 1994;79:378–81.PubMedGoogle Scholar
  66. 66.
    Takeo S, Tsukamoto S, Kawano D, Katsura M. Outcome of an original video-assisted thoracoscopic extended thymectomy for thymoma. Ann Thorac Surg. 2011;92:2000–5.CrossRefPubMedGoogle Scholar
  67. 67.
    Ohta M, Hirabayasi H, Okumura M, Minami M, Matsuda H. Thoracoscopic thymectomy using anterior chest wall lifting method. Ann Thorac Surg. 2003;76:1310–1.CrossRefPubMedGoogle Scholar
  68. 68.
    Hsu CP, Chuang CY, Hsu NY, Shia SE. Subxiphoid approach for video-assisted thoracoscopic extended thymectomy in treating myasthenia gravis. Interact Cardiovasc Thorac Surg. 2002;1:4–8.CrossRefPubMedGoogle Scholar
  69. 69.
    Caronia F, Fiorelli A, Monte AL. Bilateral thoracoscopic thymectomy using a novel positioning system. Asian Cardiovasc Thorac Ann. 2014;22(9):1135–7.CrossRefPubMedGoogle Scholar
  70. 70.
    Lee CY, Kim DJ, Lee JG, Park IK, Bae MK, Chung KY. Bilateral video-assisted thoracoscopic thymectomy has a surgical extent similar to that of transsternal extended thymectomy with more favorable early surgical outcomes for myasthenia gravis patients. Surg Endosc. 2011;25:849–54.CrossRefPubMedGoogle Scholar
  71. 71.
    Ng CS, Wan IY, Yim AP. Video-assisted thoracic surgery thymectomy: the better approach. Ann Thorac Surg. 2010;6:S2135–41.CrossRefGoogle Scholar
  72. 72.
    Zahid I, Sharif S, Routledge T, Scarci M. Video-assisted thoracoscopic surgery or transsternal thymectomy in the treatment of myasthenia gravis [review]? Interact Cardiovasc Thorac Surg. 2011;12:40–6.CrossRefPubMedGoogle Scholar
  73. 73.
    Chetty GK, Khan OA, Onyeaka CV, Ahmad F, Rajesh PB, Waller DA. Experience with video-assisted surgery for suspected mediastinal tumours. Eur J Surg Oncol. 2004;30(7):776–80.CrossRefPubMedGoogle Scholar
  74. 74.
    Fiorelli A, Mazzella A, Cascone R, Caronia FP, Arrigo E, Santini M. Bilateral thoracoscopic extended thymectomy versus sternotomy. Asian Cardiovasc Thorac Ann. 2016;24(6):555–61.CrossRefPubMedGoogle Scholar
  75. 75.
    Liu Z, Yang J, Lin L, Huang J, Jiang G. Unilateral video-assisted thoracoscopic extended thymectomy offers long-term outcomes equivalent to that of the bilateral approach in the treatment of non-thymomatous myasthenia gravis. Interact Cardiovasc Thorac Surg. 2015;21(5):610–5.CrossRefPubMedGoogle Scholar
  76. 76.
    Tomulescu V, Popescu I. Unilateral extended thoracoscopic thymectomy for nontumoral myasthenia gravis—a new standard. Semin Thorac Cardiovasc Surg. 2012;24(2):115–22.CrossRefPubMedGoogle Scholar
  77. 77.
    Sonett JR, Jaretzki A 3rd. Thymectomy for nonthymomatous myasthenia gravis: a critical analysis. Ann N Y Acad Sci. 2008;1132:315–28.CrossRefPubMedGoogle Scholar
  78. 78.
    Demmy TL, Krasna MJ, Detterbeck FC, Kline GG, Kohman LJ, MM DC Jr, Wain JC. Multicenter VATS experience with mediastinal tumors. Ann Thorac Surg. 1998;66(1):187–92.CrossRefPubMedGoogle Scholar
  79. 79.
    Cirino LM, Milanez de Campos JR, Fernandez A, Samano MN, Fernandez PP, Filomeno LT, Jatene FB. Diagnosis and treatment of mediastinal tumors by thoracoscopy. Chest. 2000;117(6):1787–92.CrossRefPubMedGoogle Scholar
  80. 80.
    Yoshino I, Hashizume M, Shimada M, et al. Thoracoscopic thymomectomy with the da Vinci computer-enhanced surgical system. J Thorac Cardiovasc Surg. 2001;122:783–5.CrossRefPubMedGoogle Scholar
  81. 81.
    Yoshino I, Hashizume M, Shimada M, et al. Video-assisted thoracoscopic extirpation of a posterior mediastinal mass using the da Vinci computer enhanced surgical system. Ann Thorac Surg. 2002;74:1235–7.CrossRefPubMedGoogle Scholar
  82. 82.
    Rea F, Marulli G, Bortolotti L, et al. Experience with the “da Vinci” robotic system for thymectomy in patients with myasthenia gravis: report of 33 cases. Ann Thorac Surg. 2006;81:455–9.CrossRefPubMedGoogle Scholar
  83. 83.
    Fleck T, Fleck M, Müller M, Hager H, Klepetko W, Wolner E, Wisser W. Extended videoscopic robotic thymectomy with the da Vinci telemanipulator for the treatment of myasthenia gravis: the Vienna experience. Interact Cardiovasc Thorac Surg. 2009;9(5):784–7.CrossRefPubMedGoogle Scholar
  84. 84.
    Augustin F, Schmid T, Bodner J. The robotic approach for mediastinal lesions. Int J Med Robot. 2006;2:262–70.CrossRefPubMedGoogle Scholar
  85. 85.
    Marulli G, Schiavon M, Perissinotto E, Bugana A, Di Chiara F, Rebusso A, Rea F. Surgical and neurologic outcomes after robotic thymectomy in 100 consecutive patients with myasthenia gravis. J Thorac Cardiovasc Surg. 2013;145(3):730–5.CrossRefPubMedGoogle Scholar
  86. 86.
    Cakar F, Werner P, Augustin F, Schmid T, Wolf-Magele A, Sieb M, Bodner J. A comparison of outcomes after robotic open extended thymectomy for myasthenia gravis. Eur J Cardiothorac Surg. 2007;31(3):501–4.CrossRefPubMedGoogle Scholar
  87. 87.
    Rückert JC, Swierzy M, Ismail M. Comparison of robotic and nonrobotic thoracoscopic thymectomy: a cohort study. J Thorac Cardiovasc Surg. 2011;141:673–7.CrossRefPubMedGoogle Scholar
  88. 88.
    Melfi F, Fanucchi O, Davini F, Viti A, Lucchi M, Ambrogi MC, Mussi A. Ten-year experience of mediastinal robotic surgery in a single referral centre. Eur J Cardiothorac Surg. 2012;41(4):847–51.CrossRefPubMedGoogle Scholar
  89. 89.
    Melfi FM, Fanucchi O, Mussi A. Minimally invasive mediastinal surgery. Ann Cardiothorac Surg. 2016;5(1):10–7.PubMedPubMedCentralGoogle Scholar
  90. 90.
    Bains MS, Ginsberg RJ, Jones WG 2nd, McCormack PM, Rusch VW, Burt ME, Martini N. The clamshell incision: an improved approach to bilateral pulmonary and mediastinal tumor. Ann Thorac Surg. 1994;58(1):30–2.CrossRefPubMedGoogle Scholar
  91. 91.
    Dartevelle PG, Chapelier AR, Macchiarini P, Lenot B, Cerrina J, Ladurie FL, Parquin FJ, Lafont D. Anterior transcervical-thoracic approach for radical resection of lung tumors invading the thoracic inlet. J Thorac Cardiovasc Surg. 1993;105(6):1025–34.PubMedGoogle Scholar

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© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Thoracic Surgery Unit, Department of Translational Medical ScienceUniversità degli Studi della Campania ‘Luigi Vanvitelli’NaplesItaly

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