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000422
which microscopic foci of thymic tissue may be contained) using a wide exposure.
In the last decade growing interest in minimally invasive surgical techniques has developed and recently
robotic surgery has affirmed itself as an evolution of
VATS.
The first surgical application of robotic technique was
described by Loulmet and Reichenspurner in 1999:
they performed a coronary by-pass w910x.
Subsequently robotic instruments were applied in other fields too and, in 2001, Yoshino w11x described the
first robotic thymectomy in the treatment of small
thymoma.
In 2003, Ashton w12x and Rea w13x published a case
report on robotic thymectomy in MG using two different approaches: the former surgeon from Columbia
University adopted a right-sided approach with completion of the operation through a left-sided approach,
the latter from the University in Padua used a leftsided approach only.
Surgical technique
After neurological assessment, preoperative evaluation includes: a radiogram and computed tomography
of the chest (Photo 1) to verify feasibility of the surgical procedure. Surgery is performed in the following
manner: the patient is under general anaesthesia and
has a double-lumen endotracheal tube for selective
single lung ventilation during the time of operation. In
1
Video 1. The surgeon sits at the console containing a display showing the images obtained with the endoscopic camera and any
manipulators the surgeon uses to control the movements of surgical
endoscopic instruments. This system is equipped with an intuitive
3-dimensional vision, a scale motion with tremor filtering and the
EndoWrists with articulated movements permitting a full seven
degree of freedom.
Video 3. The operation starts with the removal of all the pericardiophrenic angle fat tissue.
Photo 2. The thoracic ports are placed after the identification of the
5th and 3rd intercostal space and the arms of the Da Vinci surgical
system are attached to the ports and are operative.
the surgical room (Schematic 1) the patient is positioned left side up, 30 degrees on a bean bag. The
arms of the Da Vinci surgical system (MMCTSLink
17) are placed as follows: a camera port for the 3dimensional 0 degree stereo endoscope is introduced
through a 15 mm incision in the 5th intercostal space
in the anterior portion of the midaxillary region; two
2
Video 8. Mobilization and dissection of the thymus gland is performed from the aorto-pulmonary surface.
Video 9. The thymic gland is divided from the right mediastinal pleura and the right inferior horn is dissected.
Video 10. The cervical fat is dissected from the retrosternal and
jugular region to identify the upper horns of the thymus.
Video 11. The cervical left horn of the thymus is identified in the
neck region. In this particular step it is important to carefully locate
the innominate vein.
Video 12. When the innominate vein is isolated, the cervical horns
with an apical traction are dissected.
Video 13. The thymic veins are visualized, doubly clipped and cut.
Photo 3. Surgical specimen: the thymic gland and mediastinal fat
are removed en-bloc.
Results
Thymectomy in MG is an effective therapy that produces good clinical results.
In literature the remission rate is comparable for the
various surgical techniques proposed (Table 1).
The transsternal approach is a widespread surgical
technique for thymectomy. The main advantages
No
patients
Approach
375
962
100
31
33
104
24
Transsternal
Transcervical
Transsternal
Transcervical
VATS
VATS
VAT extended
Robotic VATS
Followup (years)
7.9
10.0
5.0
3.3
1.9
3.7
1.5
Remission
rate (%)
Improvement
(%)
47
32
42
35
36
18
26.7
12.5
50
60
70
43
66.7
are: an optimal exposition and dissection of the thymus and perithymic fat tissue and lower risks of
vascular and nervous injuries. Some disadvantages
include invasiveness of the approach and a longer
hospitalization.
The transcervical thymectomy, popularized by Cooper et al. w14x, is a minimally invasive technique that
is easily accepted by young patients and neurologists. The advantages are a short hospitalization,
fewer complications and lower costs. The main criticism to this approach is related to the small space
of access causing a crowding of instruments thus
making surgical manoeuvres difficult and impossible to perform a thymectomy that extends to the
perithymic fat tissue.
VATS thymectomy through the left- or right-sided
approach is a minimally invasive technique that permits a good visualization of the anterior mediastinum, achieving an extended thymectomy. The
disadvantages are the 2-dimensional view of the
operative field and the limited manoeuvrability of
the endoscopic instruments.
The robotic approach combines the advantages of
minimally invasive techniques (fewer complications,
minimal thoracic trauma, decreased postoperative
pain, early improved pulmonary function, shorter
recovery period and optimal cosmetic results wPhoto 4x) and the specific advantages as an intuitive 3dimensional vision, a scale motion with tremor
filtering and the endo-wrists with articulated move-
References
w1x Blalock A, McGehee HA, Ford FR. The treatment
of myasthenia gravis by removal of the thymus
gland. JAMA 1941;117:1529
w2x Calhoun R, Ritter J, Guthrie T, Pestronk A, Meyers
B, Patterson A, Pohl M, Cooper J. Results of
transcervical thymectomy for myasthenia gravis in
100 consecutive patients. Ann Surg 1999;
230:555561
w3x Mineo TC, Pompeo E, Lerut T, Bernardi G,
Coosemans W, Nofroni I. Thoracoscopic
thymectomy in autoimmune myasthenia: results
of left-sided approach. Ann Thorac Surg
2000;69:15371541
w4x Mack M, Landreneau R, Yim A, Halzelrigg S,
Scruggs G. Results of video-assisted thymectomy
in patients with myasthenia gravis. J Thorac
Cardiovasc Surg 1996;112:13521360
5
w11x
w12x
w13x
w14x
w15x