Background:We present the case of a 38-year-old male with a subaortic, left paratracheal 1.5 cm nodule, concerning for a mediastinal parathyroid adenoma. He was referred the the thoracic surgical service for excision. The procedure was performed via a left transthoracic thoracoscopic robotic-assisted approach with the da Vinci Xi surgical system. Methods:1) Exposing the aortopulmonary (AP) window. This step involves a standard station 5 lymph node dissection to expose the space between the pulmonary artery and aortic arch.2) Posterior mobilization of the pulmonary artery. From the posterior hilum, the tissues between the pulmonary artery and aortic arch are divided. It is important to dissect from the pulmonary artery, leaving it posteriorly with the aorta to protect the left vagus and recurrent laryngeal nerves.3) Entering the pericardium. The left paratracheal space can only be accessed from the left chest by entering the pericardium, therefore, the pericardium must be incised and entered from the AP window that was exposed in step 1.4) Identifying, isolating and dividing the ligamentum arteriosum. The ligamentum arteriosum is the gateway to the paratracheal space from the left chest as the space is medial to this structure. It is important to skeletonize the ligamentum and divide it close to the pulmonary artery to avoid recurrent laryngeal nerve injury.5) Circumferential dissection of the adenoma and excision. Identification of vascular supply to the adenoma is key to this step; if a supplying vessel is not appropriately divided, it may lead to difficult to control bleeding due to retraction into the mediastinum. It is important to avoid fragmentation of the adenoma and seeding of cells in the pleural space.Results:Intraoperative serum PTH monitoring was used with presurgical level at 274.9 pg/ml. Five minutes after resection, it decreased to 68.7 pg/ml. Ten minutes post-resection level was 42.2 pg/nl. Frozen section pathology confirmed the presence of benign parathyroid tissue.Conclusions: By highlighting these steps in this video, we hope to make this procedure reproducible and accessible for the robotic thoracic surgeon.
