Removal of a Superior Mediastinal Nodal Tumour Mass

This surgical video case shows the utility of robotic surgery in performing precise dissection in difficult to access locations in the chest, in this case in the superior mediastinum in the region posterior and medial to the left subclavian artery. In addition to the subclavian artery, the oesophagus, left vagus nerve and thoracic duct are at risk in performing surgery at this location.

This is a case of a 72 year old man with a history of a large cutaneous squamous cell cancer resected from the anterior chest wall 10 months previously. Bilateral axillary lymph nodes were involved and thus he also had radical axillary nodal clearances and adjuvant radiotherapy to the chest wall. Post treatment surveillance FDG PET showed a FDG avid 15mm soft tissue mass in the superior mediastinum adjacent to the left subclavian artery.

Surgery was performed using the (*brand hidden*) robotic surgical system with 4 8mm ports placed in the 5th and 6th intercostal spaces, and a 12mm Airseal assistant port. The video is sped up x4 times. Following removal of the tumour mass, there appeared to be an injury to the thoracic duct and so the duct was formally identified and clipped with immediate cessation of the chyle leak. He made an uneventful recovery and was discharged 2 days post-operatively. Histopathology confirmed a 21mm lymph node that is entirely replaced by metastatic moderately differentiated squamous cell carcinoma with central necrosis.