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The 3 rd. Surgical Unit Feb.2009. Limits of the superior mediastinum anterior - manubrium of the sternum posterior - anterior surface of bodies of vertebrae.

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Presentation on theme: "The 3 rd. Surgical Unit Feb.2009. Limits of the superior mediastinum anterior - manubrium of the sternum posterior - anterior surface of bodies of vertebrae."— Presentation transcript:

1 The 3 rd. Surgical Unit Feb.2009

2

3 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

4 Transverse plane

5 Planes in the superior mediastinum from anterior to posterior - glandular plane - venous plane - arterial-nervous plane - visceral plane - lymphatic plane

6 Manubrium of the sternum + the cartilage of the first rib = anterior boundary of the A-S mediastinum

7 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

8 The second plane is the venous plane and consists of the: left brachiocephalic vein, right brachiocephalic vein, SVC

9 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

10 The fourth plane is the visceral plane trachea, esophagus, left recurrent laryngeal nerve

11 Esophagus

12 Lymphatic plane- thoracic duct

13 Anatomy

14 COMPARTIMENT ANTERO-SUPERIOR Fascia endotoracica Timus Trunchiuri venoase brahio-cefalice- VCS Crosa aortei Ganglioni mediastinali sup. Nervii vagi Nervii recurenti Nervii frenici

15 LOJA TIMICA-rapoarte Anterior: Art. sterno-condro-claviculara Manubriul sternal M. subhioidieni Fata post. lig. sterno-pericardic sup. Posterior: Lama tiro-aorto-pericardica: Tr. v. br.-cef., VCS, tr. a.br.-cef., carotida stg. Pericard

16 TIMUS Marginit de sinusurile pleurale anterioare Inconjurat de o capsula fibroasa Periglandular- tesut conj. lax- disectie usoara Aderentele –lig. timo-tiroidian si timo-pericardic

17 TIMUS- RAPOARTE

18 TIMUS-rapoarte Regiunea cervicala Anterior: m. subhiodieni Posterior: trahee, vene tir. inf. Lateral: a. carotida comuna, vena jugulara interna, nervul vag

19 TIMUS-rapoarte Mediastinul 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.

20 TIMUS- RAPOARTE

21 TIMUS-vascularizatie Pedicul 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

22 TIMUS-vascularizatie, inervatie Venele timice- tr. venos br-cef., 2mm diam, scurte- punct critic Limfaticele- ggl.parasternali, jugulari, bronho- mediastinali- duct toracic Nervii timici- din vag, lant simpatic cervico-toracic si frenic

23 WHAT’S THAT ?

24 MEDIASTINAL MASS, RETROSTERNALLY LYMPHOMA

25 MEDIASTINAL MASS THYMOMA

26 LATERAL VIEW CXR THYMOMA

27 GUIDELINES Whenever 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?

28 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

29 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.

30 Localize within the mediastinum The 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.

31 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.

32 FDG-PET images of the same patient. There are multiple lymphatic masses in the anterior, middle and even posterior mediastinum, spreading to the neck.

33 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.

34 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).

35 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)

36 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.

37 The CT shows an anterior mediastinal mass with water density attenuation. This is typical for a thymic cyst.

38 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.

39 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.

40 TIMUS HIPERPLAZIC TIMUS ATROFIC TUMORI TIMICE TIMUS NORMAL +/- MIASTENIA GRAVIS sau alte BOLI AUTOIMUNE

41 MIASTENIA GRAVIS Definitie, Kirschner, 1991 Clinic- fatigabilitatea muschilor voluntari la efort repetitiv, cu refacere la odihna Electrofiziologic- raspuns decrement la stimularea repetitiva-EMG Farmacologic- raspuns pozitiv la tensilon Patologic- modificari histo-pat. timice si structurale la nivelul R. Ach. si placa n-m. Imunologic- prezenta Ac. antiR Ach. si raspuns favorabil la imunosupresie

42 BV, 17 ani, MG-Oss-IIB, op.1998, AP-HPT, remisie completa

43 NA, 39ani, MG-Oss-IV (6 ani istoric) op.12-III-1997, AP-HLT, deces- 20.III.1997

44 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?

45 Patogenie autoimuna

46 Modificari de placa neuro-musculara

47 MIASTENIA GRAVIS Tratamentul- nu este inca standardizat; Discipline implicate in management: neurologie, imunopatologie, histopatologie, endocrinologie, radiologie, medicina nucleara, chirurgie, anesteziologie, oncologie ( radioterapeut, chimioterapeut)

48 CAI DE ABORD MEDIASTINUL ANTERIOR TORACOTOMIE STERNOTOMIE CERVICOTOMIE ABORD MIXT TORACOSCOPIC MEDIASTINOSCOPIC

49

50 TORACOTOMIA ANTERO-LATERALA AVANTAJE: Poate fi prelungita posterior Poate fi prelungita prin sectiunea transversala a sternului Poate fi asociata cu o cervicotomie Expune bine pediculul pulmonar si vasele mari Incizie estetica situata in santul submamar DEZAVANTAJE Acces dificil pentru planul traheo-bronsic extremitatea sa interna ramine un punct slab, greu de inchis

51 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 prelungita Este rezervata prelevarii de tesut biopsic mediastinal

52 TORACOTOMIA BILATERALA CU STERNOTOMIE TRANSVERSALA Ofera cimp vizual asupra mediastinului si ambelor cavitati pleurale Pentru leziuni mediastinale extinse lateral Art. mamara interna ligaturata bilateral Se deschid ambele cavitati pleurale

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54 STERNOTOMIA MEDIANA LONGITUDINALA Avantaje: Acces facil Expune bine loja timica Expune bine o leziune cu extensie bilaterala Poate fi asociata cu cervicotomia Permite ventilarea ambilor plamini Evita compresiuni, tractiuni pe cord, vase mari, trahee in cursul manevrelor chirurgicale

55 STERNOTOMIA MEDIANA LONGITUDINALA Dezavantaje: Nu da acces bun spre hilul pulmonar Lasa cicatrice inestetica

56 STERNOTOMIE MEDIANA LONGITUDINALA

57 Incizia longitudinala a periostului sternal

58 Incizie longitudinala mediana

59 Sternotomie longitudinala cu sternotomul

60 Ecartarea celor doua jumatati longitudinale de stern

61 Ann Thorac Surg 2000;70: Reversed-T Upper Mini-Sternotomy for Extended Thymectomy in Myasthenic Patients Jan G. Grandjean, MD, PhD, Marco Lucchi, MD, and Massimo A. Mariani, MD, PhD Thorax Center, University Hospital of Groningen, Groningen, The Netherlands

62 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.

63 Reversed-T Upper Mini-Sternotomy for Extended Thymectomy in Myasthenic Patients Technique The 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.

64 Technique The 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.

65 An en bloc resection of the thymus and mediastinal fat performed through the mini-sternotomy.

66 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.

67 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.

68 Arguments In 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.

69 CERVICOTOMIA Incizia Kocher Pentru leziunile cervico-toracice Cimp vizual limitat

70 TORACOSCOPIA VIDEO-ASISTATA Cerinte: Intubare cu sonda cu dublu lumen Torace la 45 grade 4 trocare Pneumomediastinul faciliteaza disectia Conversia este rara daca se selecteaza atent pacientii

71 ALEGEREA CAII DE ABORD IN FUNCTIE DE LEZIUNEA DE EXTIRPAT Leziuni mici- toracotomie antero-laterala Leziuni medii-sternotomie mediana sau toracotomie antero-laterala Leziuni mari si bilaterale- sternotomie transversala cu toracotomie anterioara bilaterala Leziuni foarte mari, unilaterale- toracotomie postero-laterala

72 Scopul operatiei Indepartarea intregului tesut timic din mediastin Timus+ectopii mediastinale anterioare Chirurgii: minimalisti si maximalisti Minimalistii: prin incizii mici, cosmetice, timectomie adecvata Maximalistii: timectomia+excizia grasimii mediastinului anterior- sternotomie mediana completa

73 Gradul de rezecţie a ţesutului timic din mediastinul anterior dup ă diferite tehnici (dup ă Jeretzki) Tehnic ă Grad de rezecţie timic ă timectomie maximal ă % timectomie extins ă 85-95% timectomie toracoscopic ă 80-85% timectomie transcervical ă 75-80% timectomie simpl ă transsternal ă 70-75% timectomie simpl ă transcervical ă 49-50%

74 Sternotomie mediana longitudinala Corn timic cervical, prevenos UG, femeie, 31 ani, MG-OSS.IIB, op. 2008

75 UG,31 ani, Hiperplazie limfoida timica cu ectopii Remisie completa post op.

76 Hiperplazie limfoida timica, UD, femeie, 54 ani, MG-Oss.III+Tiroidita Hashimoto, op.2008 iulie, deces-sept.2008 Insuf. resp. ac.-ventilatie prelungita, traheostoma gastrostoma percutana, escare, ulcere corneene, sdr.consumptiv

77 Hiperplazie limfoida timica, ML, femeie, 28 ani, MG-Oss IIB, op. 2008, corn timic retrovenos, RC


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