Efficacy and Safety of Trap-Door Procedure in Mediastinal Tumor Resection

Abstract

A safe approach is required for tumor resection at the thoracic outlet area, where blood vessels, nerves, muscles, and bones are concentrated. The trap-door procedure, also known as the Hemi-clamshell procedure, is reported as such an approach and can also be applied to cases requiring the careful dissection of mediastinal blood vessels. There are limited reports on the use of this technique in children. We present our experience with this technique.

We retrospectively reviewed the medical records of five patients who underwent tumor resection by the trap-door procedure between 2012 and 2023. The median age at surgery was 13 (3–16) years. The trap-door procedure involved an L-shaped incision connecting the cranial partial median sternotomy incision to an intercostal thoracotomy, and the unilateral chest wall was elevated by traction threads to obtain an operative field. Of the five patients, three had tumors in the thoracic outlet (desmoplastic small round cell tumors, neuroblastoma, and mixed germ cell tumor), one required careful dissection from mediastinal vessels (choriocarcinoma), and one required open-heart surgery with simultaneous mediastinal tumor resection and lung lobectomy (BCOR-related sarcoma). In one patient, resection was performed utilizing intraoperative neuromonitoring. All patients underwent complete tumor resection, and no complications, including brachial neuropathy, Horner’s syndrome, and wound infection, were observed, except for transient diaphragmatic paralysis in one patient. The trap-door procedure is a safe approach for tumor resection at the thoracic outlet and in cases where the dissection of the mediastinal vessels is required because of the excellent field of view it provides.