Retroperitoneal transdiaphragmatic robotic-assisted laparoscopic resection of a left thoracolumbar neurofibroma

Abstract

Objective: Robotic technology has been used in a variety of surgical procedures for its 3D magnification and precision. Minimally invasive techniques have already become common in neurosurgery; however, robotic-assisted procedures in neurosurgery are still a relatively new frontier. This report describes the first use of robotic technology to resect a left thoracolumbar neurofibroma.

Case report: A 19-year-old male with a family history of neurofibromatosis was diagnosed with a suspected 3-cm x 4-cm neurofibroma in the T12-L1 left paraspinal area. His only complaint was back pain requiring narcotic analgesics. He had no other findings on physical examination or laboratory/radiologic workup.

Methods: After consulting urologic robotic surgeons, it was agreed to use the da Vinci robot (Intuitive Surgical, Sunnyvale, CA) for the resection of this mass. Following retroperitoneal laparoscopic access, the urologic surgeons opened the diaphragm and began the initial mobilization of the mass laparoscopically. The robot was docked, and the neurosurgeon operated the robot at the console to resect the mass from its nerve origin. There were no complications, and the mass, a confirmed neurofibroma, was completely removed. The patient was discharged on postoperative day 2; his back pain resolved, requiring no analgesia by the end of the first postoperative week.

Conclusion: This case provides early evidence that robotic assistance can be successfully used for the resection of a paraspinal neurofibroma.

Figure 1.

Abdominal CT scan revealing paravertebral mass (black arrow) adjacent to the upper pole of the left kidney, posterior to the inferior left hemidiaphragm (white curve and arrow).

Figure 2.

T1-weighted MRI of mass originating at T12-L1 neural foramen.

Figure 3.

Docked robot, with 2 working arms, one arm attached to the endoscope, and 2 additional assistant's ports.

Figure 4.

Initial view of tumor through robotic endoscope with bipolar serrated graspers in the left robotic hand, monopolar electrosurgical scissors in the right robotic hand, and assistant operated irrigation/suction inferiorly.

Figure 5.

Retraction of tumor anteromedially after resection, showing tumor bed and nerve root.

Figure 6.

Neurofibroma histology, showing the presence of stout collagen strands within the tumor. This has been referred to as a “shredded carrot” appearance.