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Ann Thorac Surg 1996;62:1210-1212
© 1996 The Society of Thoracic Surgeons

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How To Do It

Adjuvant Pneumomediastinum in Thoracoscopic Thymectomy for Myasthenia Gravis

Department of Thoracic Surgery, Myasthenia Gravis Unit, Tor Vergata University School of Medicine, Postgraduate Medical School, Rome, Italy

Accepted for publication June 17, 1996.

	Abstract

Top Footnotes Abstract Introduction Technique Patients and Results Comment Acknowledgments References

 
To facilitate initial visualization and subsequent mobilization of the thymus, adjuvant pneumomediastinum was preoperatively induced in 4 patients who underwent video-assisted thoracoscopic thymectomy. Neither mortality nor technique-related morbidity was observed. This experience shows video-assisted thoracoscopic thymectomy to be a safe and reliable procedure. In addition, we believe that adjuvant pneumomediastinum seems to facilitate the dissection maneuvers and could shorten operative time.

	Introduction

Top Footnotes Abstract Introduction Technique Patients and Results Comment Acknowledgments References

 
Thymectomy is presently recognized as effective surgical therapy complementing the medical management of myasthenic patients. On the other hand, the best surgical approach to thymectomy remains controversial. Total and partial sternotomy with or without transverse cervical extension as well as the transcervical approach have been widely used. More recently, video-assisted thoracoscopic thymectomy has been accomplished by left [1], right [2], or combined approaches [3, 4]. We also employed the left thoracoscopic approach to perform thymectomies, which we made easier by using an adjuvant pneumomediastinum.

	Technique

Top Footnotes Abstract Introduction Technique Patients and Results Comment Acknowledgments References

 
Adjuvant pneumomediastinum is performed 24 hours before the operation by introducing a Veress needle, under local anesthesia, at the level of the suprasternal notch, just behind the posterior wall of the sternum. Afterward, 400 to 600 mL of air is insufflated in a sterile way through a syringe at a rate of 25 mL/min. During the procedure, continuous monitoring of the electrocardiogram, artery pressure, pulse rate, and O₂ saturation is accomplished to adequately monitor respiration and circulation.

At the operation, after double-lumen intubation and with the patient lying in a 45-degree off-center position, four thoracoscopic trocars are inserted: the medial port in the fourth intercostal space along the midclavicular line, the camera port in the fifth intercostal space along the anterior axillary line, the lateral port in the fourth intercostal space approximately 2 cm lateral to the anterior axillary line, and the lower port in the sixth intercostal space between the anterior axillary line and the midclavicular line (Fig 1). The entire hemithorax is carefully explored with particular attention to aortic arch, subclavian artery, pericardium, and phrenic nerve. In case of thymoma, if the tumor is judged to be invasive, we convert the operation to an open procedure via a median sternotomy.

View larger version (39K): [in this window] [in a new window]   Fig 1. . Placement of the trocars.

View larger version (53K): [in this window] [in a new window]   Fig 2. . Lateral tomogram showing adjuvant pneumomediastinum, which has partially separated the thymus from the neighboring mediastinal structures (A). Endoscopic visualization of the thymic area is improved by adjuvant pneumomediastinum (B).

View larger version (145K): [in this window] [in a new window]   Fig 3. . Division of thymic veins, which have been isolated and clipped.

	Patients and Results

Top Footnotes Abstract Introduction Technique Patients and Results Comment Acknowledgments References

The first 2 patients were operated on solely by left thoracoscopy, and the mean operative time was 220 minutes. In the subsequent 4 patients, to facilitate the dissection maneuvers and to reduce operative time, we carried out preoperative adjuvant pneumomediastinum, which we had already used in the past for diagnostic purposes. No procedure-related complications were observed, with the exception of cervical transient subcutaneous emphysema, which occurred in 1 patient and resolved spontaneously after 48 hours. Among the last 4 patients operative time ranged from 150 to 180 minutes with a mean of 160 minutes. On the whole, intraoperative blood loss never exceeded 60 mL, and no conversion to a conventional sternotomy procedure was necessary. There was no surgical mortality, whereas morbidity regarded intraoperative ventricular fibrillation requiring electric defibrillation. It occurred in 1 patient with cardiopathy and severe cardiomegaly after careful positioning of an expandable endoscopic retractor on the pericardium. The chest drain was routinely removed 48 hours after the operation. The mean hospital stay was 3 days, ranging from 2 to 4 days. Pathologic examination showed completely encapsulated cortical [7] thymoma (maximum size, 2.5 cm) in 1 patient and thymic hyperplasia in the remaining 5.

	Comment

Top Footnotes Abstract Introduction Technique Patients and Results Comment Acknowledgments References

 
Video-assisted thoracoscopic surgery has provided a new approach to the surgical removal of the thymus for myasthenia gravis. However, to our knowledge, there is only one published series on the subject [2]. Video-assisted thoracoscopic thymectomy has been mainly accomplished in nonthymomatous myasthenic patients, although small, encapsulated thymomas have also been resected in this way [8].

Minimal chest wall trauma, short hospitalization, and better patient acceptance of the operation, which were all considered advantages of the transcervical over the transsternal approach, can be likewise considered for the thoracoscopic approach. However, video-assisted thoracoscopic thymectomy shows additional advantages over the transcervical approach in that the visualization is superior, crowding of instruments through a single access site is avoided [2], and a more accurate dissection of all the perithymic tissue is allowed. Our early experience with video-assisted thoracoscopic thymectomy showed that although the operation could always be accomplished, the dissection was sometimes tedious and time-consuming. This fact prompted us to add pneumomediastinum, which resulted in the last 4 patients in facilitated dissection of the gland from the neighboring structures, and in shortened operative time. However, to date, we cannot differentiate how much operative time gain in the last 4 patients depended on the use of pneumomediastinum or mainly reflected our learning curve in performing the operation. In the past, pneumomediastinum had been widely used in the pre-computed tomography era for diagnostic purposes, particularly in cases of thymic gland pathology [9]. This technique is safe, easy to accomplish, and well tolerated even in myasthenic patients. Nevertheless, potential complications may include vascular injuries, air embolism, and subcutaneous emphysema. We performed pneumomediastinum 24 hours preoperatively to allow uniform distribution of the air within the anterior mediastinum, and the ungluing of the thymus from perithymic tissues. By adding pneumomediastinum, we also found the resection of mediastinal and cervical fatty tissue, which is a potential site of ectopic thymic tissue, to be simpler and quicker.

Although complications are rare, we recommend video-assisted thoracoscopic thymectomy be performed by teams with specific expertise in advanced thoracoscopy as well as with traditional mediastinal approaches. Difficulties can be encountered in obese patients due to exuberant mediastinal fat, and in patients with cardiopathy and severe cardiomegaly, as reported in our series.

From our initial experience, we conclude that video-assisted thoracoscopic thymectomy is a technically safe and reliable procedure. We have found adjuvant pneumomediastinum to have great utility in the initial visualization and subsequent mobilization of the thymus. As a result, the dissection maneuvers seem to be facilitated and operative time is shortened. Video-assisted thoracoscopic thymectomy still needs confirmation by larger surgical experiences with long-term follow-up. However, we believe that its role is evolving and that this operation will undoubtedly have increasing use in the setting of myasthenia gravis.

	Acknowledgments

Top Footnotes Abstract Introduction Technique Patients and Results Comment Acknowledgments References

 
This work was supported by a grant from MURST 60%.

	Footnotes

Top Footnotes Abstract Introduction Technique Patients and Results Comment Acknowledgments References

 
Address reprint requests to Dr Mineo, Cattedra di Chirurgia Toracica, Ospedale S. Eugenio, P.le Umanesimo, 10, 00144 Rome, Italy.

	References

Top Footnotes Abstract Introduction Technique Patients and Results Comment Acknowledgments References

 

1. Mack M. Thoracoscopy. In: Pearson FG, Deslauriers J, Ginsberg RJ, Hiebert CA, McKneally MF, Urschel HC, eds. Thoracic surgery. New York: Churchill Livingstone, 1995:1488–509.
2. Yim APC, Kay RLC, Ho JKS. Video-assisted thoracoscopic thymectomy for myasthenia gravis. Chest 1995;108:1440–3.[Abstract/Free Full Text]
3. Sugarbaker DJ. Thoracoscopy in the management of anterior mediastinal masses. Ann Thorac Surg 1993;56:653–6.[Abstract]
4. Novellino L, Longoni M, Spinelli L, et al. "Extended" thymectomy, without sternotomy, performed by cervicotomy and thoracoscopic technique in the treatment of myasthenia gravis. Int Surg 1994;79:378–81.[Medline]
5. Mineo TC. Terapia chirurgica della miastenia grave. Atti Accad Lancisiana Roma 1978;23:1–12.
6. Osserman KE. Myasthenia gravis. New York: Grune & Stratton, 1958:80–1.
7. Muller-Hermelink HK, Marino M, Palestro G, Schumacher U, Kirchner T. Immunohistological evidence of cortical and medullary differentiation in thymoma. Virchows Arch (A) 1985;408:143–61.
8. Landreneau RJ, Dowling RD, Castillo WM, Ferson PF. Thoracoscopic resection of an anterior mediastinal tumor. Ann Thorac Surg 1992;54:142–4.[Abstract]
9. Kreel L. Pneumomediastinography in myasthenia gravis. Proceedings of the 11th International Congress of Radiology. Excerpta Medica International Congress Series. 1965;105:55–6.

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Tommaso Claudio Mineo Vincenzo Ambrogi Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Mineo, T. C. Articles by Casciani, C. U. Search for Related Content PubMed PubMed Citation Articles by Mineo, T. C. Articles by Casciani, C. U.