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Ann Thorac Surg 1997;64:584-585
© 1997 The Society of Thoracic Surgeons

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Correspondence

Thoracoscopic Thymectomy: Which Side to Approach?

Division of Cardiothoracic Surgery, Department of Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong, e-mail:yimap{at}cuhk.edu.hk

To the Editor:

I read with great interest the well-written publication by Mineo and associates on thoracoscopic thymectomy for myasthenia gravis [1]. They advocated the left-sided approach with adjuvant pneumomediastinum.

Although the thymus could be approached from either side thoracoscopically, my colleagues and I favor a right-sided approach [2, 3] because the venous anatomy (the confluence of the two brachiocephalic veins to form the superior vena cava) is more clearly visualized from the right, and we believe this is essential when the thoracoscopic approach is used. I recently performed a demonstration case in Bangkok in which three quarters of the enlarged thymus was in the left side of the chest. I persevered with the right approach and was glad I did so. There were numerous venous tributaries including one arising from the confluence of the two brachiocephalic veins, which would have been very difficult to deal with from the left. With gentle and deliberate traction on the thymus anteriorly and laterally, a space was opened up between the thymus and the great vein for careful blunt dissection of the tributaries.

I have no experience with pneumomediastinum and have not found this adjuvant maneuver to be necessary. The potential risk of venous laceration and air embolism with fatal outcome is real in inexperienced hands.

References

1. Mineo TC, Pompeo E, Ambrogi V, et al. Adjuvant pneumomediastinum in thoracoscopic thymectomy for myasthenia gravis. Ann Thorac Surg 1996;62:1210–2.[Abstract/Free Full Text]
2. Yim APC, Kay RLC, Ho JKS. Video-assisted thoracoscopic thymectomy for myasthenia gravis. Chest 1995;108:1440–3.[Abstract/Free Full Text]
3. Mack MJ, Landreneau RJ, Yim APC, Hazelrigg SR, Scruggs GR. Results of VATS thymectomy in patients with myasthenia gravis. J Thorac Cardiovasc Surg 1996;112:1352–60.[Abstract/Free Full Text]

Myasthenia Gravis Unit, Department of Thoracic Surgery, Tor Vergata University School of Medicine, Postgraduate Medical School, Ospedale S. Eugenio, lo p.le Umanesimo, 00144 Rome, Italy, e-mail:mineo{at}utovrm.it

Reply To the Editor:

It has always been our firm conviction that the thymus can be safely approached by thoracoscopy from either side. This conviction was reinforced after reading the interesting report by Yim and associates [1]. Nevertheless, we have favored the left access as routine approach, and this choice has a rationale.

We agree with Dr Yim when he points out that the confluence of the two brachiocephalic veins is more clearly visualized from the right thoracoscopic approach. However, because the thymic veins drain into the left innominate vein, it is essential to have a wider exposure of this vessel rather than of the confluence of the two brachiocephalic veins. This represents the main reason that convinced us to prefer the left approach. In addition, tributary veins arising from the confluence are not so common to induce us per se to prefer the right approach.

Furthermore, it is our impression that the left approach may allow a more extended removal of the perithymic fatty tissue, which is prevalent in the left pericardiophrenic angle and in the aortopulmonary window. We routinely perform this step in our procedures, considering it essential in achieving intentional extended thymectomy.

The routine use of adjuvant pneumomediastinum considerably facilitates the dissection maneuvers, and we consider it worthwhile. One of us (Dr Mineo) achieved familiarity with this technique in employing it for diagnostic purposes in the era before computed tomography and never had any complications. We are thus confident that this technique may be safely performed even by inexperienced hands by simply following the fundamental rules for its execution.

To date, from the beginning of our experience, 12 video-assisted thymectomies, including one massive thymic hyperplasia, were completed through the left-sided approach with excellent results. Further experience on video-assisted thymectomy performed either through the right or the left approach will help us clarify the best access for this operation.

We thank Dr Yim for the interest shown in our article and for his constructive criticisms.

Reference

1. Yim APC, Kay RLC, Ho JKS. Video-assisted thoracoscopic thymectomy for myasthenia gravis. Chest 1995;108:1440–3.[Abstract/Free Full Text]

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This Article 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): Anthony P. C. Yim Tommaso Claudio Mineo Vincenzo Ambrogi Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Yim, A. P. C. Articles by Ambrogi, V. Search for Related Content PubMed PubMed Citation Articles by Yim, A. P. C. Articles by Ambrogi, V.