The main method of treatment of benign neurogenic tumors is surgical. The development of medicine has made it possible to remove neurogenic tumors using minimally invasive methods (thoracoscopy), since previously removal was performed through a traumatic thoracotomy approach (Figure b).
But not all neurogenic tumors can be removed by thoracoscopic access. In the case of tumor invasion, it is necessary to perform combined operations with resection or removal of the structures involved in the tumor process, which can improve the resectability from 60-75 % to 85 % . In this case, a thoracotomy (Figure b) or a sternotomy (Figure a) is clearly used, less often a combined sternotomy-thoracotomy approach.
In tumors of the "dumbbell" type, a combined approach can be used: the intra-thoracic component of the tumor is isolated by thoracoscopic access, and hemilaminectomy is used to mobilize the spinal component.
At the moment, there is a debate about the advantages and disadvantages of using the thoracoscopic method of removing neurogenic tumors . Despite the great popularity of the thoracoscopic method, there are many opponents of this approach. Many authors believe that thoracoscopic interventions do not fully comply with the basic principle of surgical removal of tumors – the radicalism of surgical intervention. Observing all the principles of ablasty, the thoracoscopic method is not inferior in radicalism to the open method.
Advantages of the thoracoscopic method.
Taking into account the variability of the location of neurogenic tumors in the mediastinum, the use of the thoracoscopic method in comparison with the open method has a number of advantages, since there is a possibility of simultaneous 2-way access to the tumor, providing less trauma, high resolution of the camera, which allows you to visualize individual structures on the screen with multiple magnification, faster recovery of functional indicators in the postoperative period, reduced hospital stay, better cosmetic effect.
The trauma caused by the use of open access is greater than the trauma of the very stage of tumor removal. Large injuries (dissection of the intercostal muscles, the broadest back muscle, sternum, rib fractures) during open operations leads to a pronounced pain syndrome, the result of all this is a restriction of the excursion of the chest, their ventilation, especially the lower parts, as a result – the development of pneumonia; there is also hypodynamia as a result of a pronounced pain syndrome, increasing the risk of developing thrombosis of the veins of the lower extremities.
Complications after thoracotomy occur in 11-12 % of cases. As a result, minimally invasive surgical interventions are widely used in oncological practice, due to the relative safety of the method, as well as the minimum number of complications (6.5 %) . Complications that occur after sternotomy are associated with the divergence of the edges of the sternum, which leads to a violation of the healing of the postoperative wound with the reproduction of microbial flora.
Thus, according to other authors, the thoracoscopic method is the method of choice for small neurogenic tumors and the absence of invasion into neighboring structures.
Complications also occur after thoracoscopic surgery. The most common complications are: bleeding from the intercostal vessels as a result of their damage during the installation of a thoracoport; damage to the lung parenchyma, with untimely restoration of integrity in the postoperative period, pneumothorax may occur.
The main disadvantage of thoracoscopic methods is the high cost of equipment.
The method of thoracoscopic removal of neurogenic tumors.
Thoracoscopic removal of neurogenic tumors is performed by a number of surgeons using three ports: one port for insertion into the thoracic cavity of the endoscope and two working ports for instruments. The ports are installed in such a way that a triangle is formed and the "swing" effect is not created (Figure 2).
Neurogenic tumors are the most common tumors of the posterior mediastinum. This type of tumor is formed either from the actual nervous tissue-nerve cells and nerve membranes, or from the membranes of the nerves. Benign neurogenic tumors are encapsulated, have a " leg " that goes to the spine. The main method of treatment is surgical. For the removal of neurogenic tumors, the following methods are used: thoracoscopic and open access. Indications for thoracoscopy are the following criteria: small tumor size (up to 12 cm), no invasion of neighboring structures. In compliance with the principles of ablasty, the thoracoscopic method is not inferior to the open one. The frequency of postoperative complications after thoracoscopic removal of mediastinal tumors is 6.5 %, after the use of open access 11-12 %. The main disadvantage of thoracoscopy is the high cost of equipment.