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Ann Thorac Surg 2000;70:1423-1424
© 2000 The Society of Thoracic Surgeons

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How to do it

Reversed-T upper mini-sternotomy for extended thymectomy in myasthenic patients

^a Thorax Center, University Hospital of Groningen, Groningen, The Netherlands

Address reprint requests to Dr Grandjean, Thorax Center, University Hospital of Groningen, Hanzeplein, 1, Post Box 30001, 9700 RB Groningen, The Netherlands
e-mail: j.g.grandjean{at}thorax.azg.nl

	Abstract

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A minimally invasive approach for extended thymectomy in myasthenic patients is described. Through an 8- to 10-cm midline skin incision with a reversed-T upper mini-sternotomy, an extended thymectomy was performed. The mediastinal fat was removed beginning from the diaphragm up to the thyroid gland, and to each phrenic nerve, laterally. Extended thymectomy through a reversed-T upper mini-sternotomy warrants complete excision of thymic tissue while allowing a short hospitalization and good cosmetic result.

	Introduction

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Although thymectomy is generally considered the cornerstone of therapy in myasthenic patients with generalized symptoms, controversies still persist regarding the optimal surgical approach [1, 2]. Recently, minimally invasive techniques such as video-assisted thoracoscopic (VATS) thymectomy, performed through a bilateral or unilateral approach, with or without a combined cervicotomy, have been proposed and are currently under evaluation [3].

Recent experiences in minimally invasive approaches for cardiac surgery [4] prompted us to look for a surgical approach that might reduce the operative trauma. The reversed-T upper mini-sternotomy provides an exposure of the mediastinum that allows us to perform a complete resection of the thymus and of all the anterior mediastinal fatty tissue.

	Technique

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The patient is positioned as for the standard sternotomy. An 8- to 10-cm midline skin incision is performed starting about 1 cm under the jugulum, then the sternum is divided up to the third intercostal space. At this level, the sternum is transversely transected by means of an oscillating saw (Fig 1). A Finocchietto-like pediatric retractor is positioned to spread the sternum. The resection starts from the fat of the inferior mediastinum. This step can easily be accomplished putting a hand-held retractor under the sternum and lifting it. The anterior mediastinal fat is removed beginning from the diaphragm going upward. Then, the gland is elevated toward the brachiocephalic trunk, and the draining veins and the thymic branches of internal mammary artery are ligated. Finally, the cervical horns of each lobe are resected by a blunt dissection (Fig 2).

View larger version (87K): [in this window] [in a new window]   Fig 1. The reversed T-upper mini-sternotomy.

View larger version (160K): [in this window] [in a new window]   Fig 2. An en bloc resection of the thymus and mediastinal fat performed through the mini-sternotomy.

In the last year, 4 patients underwent an extended thymectomy through a reversed-T upper mini sternotomy. They were all young women, 21 to 32 years old, with duration of symptoms ranging from 8 to 22 months. The Osserman stage at the diagnosis was IIA in three cases and IIB in one. The symptoms were controlled before surgery in two cases by anticholinesterase and in the remaining two by anticholinesterase plus steroid. The pathological findings consisted of thymic hyperplasia with isles of thymic cells in the mediastinal fat in all the cases. All the patients were extubated in the operating room, the drain was removed the first postoperative day, and they were discharged on the second or third day. Postoperative pain was well controlled with oral medications (diclofenac) in the 2 days after surgery and no patient had chronic pain complaint after discharge. No wound incisions or sternal dehiscence occurred.

With a short follow-up (6 to 16 months), no information about the outcome of the myasthenic symptoms can be provided.

	Comment

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Although several surgical techniques have been proposed in recent years to achieve an extended thymectomy, there is still no conclusive evidence about which can be considered the procedure of choice [5].

The analysis of the results is confusing, and until a uniform classification of severity of symptoms and method of analysis can be achieved, as advocated by Jaretzki [5], comparison of thymectomy techniques will not draw any firm conclusion.

Certainly, the thymectomy in the treatment of myasthenia gravis must include all thymic tissue and thymic cells that are present in mediastinal and cervical fat [1, 6]. The transcervical-transsternal maximal thymectomy [1], in which all thymus and cervical-mediastinal fat are resected en bloc, may warrant the removal of the greatest entity of thymic cells. However, most of the authors consider the "extended thymectomy" with the resection of the thymus and all the mediastinal fat through a sternotomy to be a cervicotomy or a thoracoscopy, a less aggressive and reasonable surgical procedure.

Hereby, we suggest an extended thymectomy through a small access performed with conventional surgical instruments and techniques. The reversed-T upper mini-sternotomy is a minimally invasive approach that results in a less operative trauma to the chest structure and function than a full sternotomy.

Considering that myasthenic patients with generalized symptoms may have or develop respiratory muscle weakness leading to impaired lung expansion, saving the integrity of the lower part of the chest may further decrease the incidence of respiratory failure requiring mechanical ventilation. LoCicero has already proposed a combined cervical and partial sternotomy approach for thymectomy [7] with a skin flap, a sternum split down to the second interspace, and a further division of intercostal muscle above the third ribs. Our approach differs in the skin incision, which is on the midline and for the minimal dissection of the subcutaneous tissue. Moreover, in our approach, the sternum is divided to the third intercostal space and there is no need to ligate the internal mammary arteries. Patients who may later require coronary artery bypass in their future will benefit from the presence of the mammary arteries. Last, but not least, in case of thymic tumor or bleeding, the skin as well as the sternum incision can be easily extended to a complete median sternotomy.

The small skin incision warrants good cosmetic results in young women who are the most represented group of patients affected by myasthenia gravis and who usually are concerned about the cosmetic result. An extended thymectomy through a reversed-T upper mini-sternotomy does not discomfort the surgeon and lasts no longer than a complete sternotomy. In conclusion, the reversed-T upper mini-sternotomy is a minimally invasive technique that allows an extended thymectomy while leaving the chest wall largely intact. This technique may improve the operative results of the extended thymectomy for patients with myasthenia gravis in terms of pain control, hospital stay, and cosmetic result.

	References

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1. Jaretzki A., Wolff M. "Maximal" thymectomy for myasthenia gravis. J Thorac Cardiovasc Surg 1988;96:711-716.[Abstract]
2. Cooper J.D., Al-Jilaihawa A.N., Pearson F.G., Humphrey J.G., Humphrey H.E. An improved technique to facilitate transcervical thymectomy for myasthenia gravis. Ann Thorac Surg 1988;45:242-247.[Abstract]
3. Mack M.J., Landreneau R.D., Yim A.P., Hazelrigg S.R., Scruggs G.R. Results of video-assisted thymectomy in patients with myasthenia gravis. J Thor Cardiovasc Surg 1996;112:1352-1360.[Abstract/Free Full Text]
4. Gundry S.R., Shattuck H., Razzouk A.J., Rio M.J., Sardari F.F., Bailey L. Facile minimally invasive cardiac surgery via ministernotomy. Ann Thorac Surg 1998;65:1100-1104.[Abstract/Free Full Text]
5. Jaretzki A., III Thymectomy for myasthenia gravis. Neurology 1997;48(Suppl 5):52-63.
6. Masaoka A., Nagaoka Y., Kotake Y. Distribution of thymic tissue in the anterior mediastinum. J Thorac Cardiovasc Surg 1975;70:747-754.[Abstract]
7. LoCicero J., III The combined cervical and partial sternotomy approach for thymectomy. Chest Surg Clin N Am 1996;6:85-93.[Medline]

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This Article Abstract Full Text (PDF) 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): Massimo A. Mariani Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Grandjean, J. G. Articles by Mariani, M. A. Search for Related Content PubMed PubMed Citation Articles by Grandjean, J. G. Articles by Mariani, M. A. Related Collections Related Article