A novel approach: chest wall cyst excised by MIS
A 62-year-old Caucasian male presented with swelling and fullness in the left posterior chest. Mild discomfort of the chest wall had worsened over the preceding 6 months. Pain was associated with sitting or leaning against a wall. His range of motion was normal, and he performed daily activities well. Physical examination revealed a morbidly obese white male with a non-tender fluctuant mass on the left side of the upper back. It extended above and below the left scapula. The right side was without abnormality. There were no surgical scars in the thoracic region. The fluctuant mass was the size of a deflated football. An upper midline scar of the neck was noted. The past surgical history included previous cervical spine surgery. The patient had two motor vehicle accidents that caused a lower right-sided lumbar injury. His past medical history was significant for hypertension, hyperlipidemia, sleep apnea, osteoarthritis, gastroesophageal reflux disease and chronic mild asthma.\nComputed tomography (CT) scan of the chest demonstrated a large cystic mass between the posterior aspect of the thoracic ribs and deep to the muscles of the left back and scapula. There was no obvious connection with the spinal cord or pleural space. No solid or enhancing component was identified.\nChest magnetic resonance imaging delineated a large cystic mass extending from the level of the lower neck to just above the level of the diaphragm measuring 11 cm transversely, 4.5 cm anteroposteriorly and 23 cm craniocaudally (Fig. ).\nThe primary care physician aspirated clear fluid under sterile conditions providing symptomatic relief. Cytologic studies were unremarkable. When the mass returned 2 weeks later, he was referred to our institution for further treatment. Due to symptoms referred to the cyst and the lack of response to aspiration, the decision was made to excise the lesion.\nThe patient underwent general endotracheal anesthesia and was placed in the right lateral decubitus position. A 2.5-cm longitudinal incision was made at a paramedian position on the left mid-back and it was carried through the level of the fascia by cautery. The paraspinous muscle fibers were separated and the bottom of the cyst was bluntly dissected free and the cyst was aspirated of its serous contents. A balloon dissector was inserted ventral to the cyst for additional blunt dissection. The balloon was inflated to grapefruit size and left inflated for 2 min for hemostasis. The balloon dissector created a larger space beneath the cyst and along its lateral margins. The balloon was then replaced with a Hasson trocar, and two additional 5-mm trocars were placed under direct vision to allow access to the CO2-filled cavity (Fig. ). Using a combination of blunt and electrocautery dissection, the cystic lesion was circumferentially freed from the trapezius muscle and cervical structures. Several feeding vessels were clipped and divided. Once freed, the cystic mass was removed in its entirety through the Hasson trocar site. Two 15-French round JP drains were inserted through the 5-mm trocar sites and placed to grenade suction.\nIntraoperatively, the aspirated cystic fluid was clear and devoid of malignant cells. Histologic analysis of the unilocular cyst revealed a primarily fibrous wall with some adipose tissue and associated vasculature. The cyst lacked a true epithelial lining and any malignant features such as hypercellularity, hyperchromasia, cellular pleomorphism or increased mitoses (Fig. ). The final pathologic diagnosis was that of a benign, fibrous-walled cyst.