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Ann Thorac Surg 2001;71:1721-1723
© 2001 The Society of Thoracic Surgeons

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How to do it

Video-assisted extended thymectomy in patients with thymoma by lifting the sternum

^a Department of Thoracic Surgery, Fukuoka, Japan
^b Department of Clinical Research, National Kyushu Medical Center Hospital, Fukuoka, Japan

Accepted for publication November 20, 2000.

^* Address reprint requests to Dr Takeo, Department of Thoracic Surgery, National Kyushu Medical Center Hospital, Jigyohama 1-8-1 Chuo-ku, Fukuoka 810-8563, Japan (Email: sada{at}qmed.hosp.go.jp).

	Abstract

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We present use of minimally invasive video thoracoscopic surgery to perform complete extended thymectomy in patients with thymoma. These procedures were performed using a sternum-elevating method that provides a wide field of vision between the sternum and heart. Indications for this method are Masaoka Stage I, II and some Stage III (invasion to the lung and pericardium). This new method may be useful from the standpoint of minimal access, rapid recovery, less pain, and good cosmetic results.

	Introduction

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All previous reports [1] agree that complete resection should be performed in patients with malignant thymoma whenever possible. Scelsi and colleagues [2] reported that remnants of the thymus may remain in surrounding fatty tissue, and therefore recommended extended thymectomy. When we operate upon patients with thymoma, the resection must extend inward from the bilateral phrenic nerves including the mediastinal pleura, upward from costophrenic areas including fatty tissue, and should include pretracheal fatty tissues including lymph nodes and exfoliation from pericardium. Many authors [3–6] have reported minimally invasive surgery using thoracoscopy in patients with thymoma. Thoracoscopic-assisted extended thymectomy in patients with thymoma is still technically difficult because of the lack of appropriate techniques and the limited space in the anterior mediastinum. We describe a technique for video-assisted complete extended thymectomy using a sternum-elevating method.

	Technique

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Thoracoscopic-assisted extended thymectomy including an anterior mediastinal tumor and bilateral costophrenic fat en bloc was performed with a sternum-elevating method that gives a wide field of vision between the sternum and heart.

After inducing general anesthesia, single-lung ventilation was performed and a double-lumen endobronchial tube was used to provide selective ventilation. The patient was positioned in the supine position and the neck was extended using a pillow under the shoulders. A stainless steel rod was set at the head of the operating table, and a Kent retractor set was placed on the sides of the operating table at thigh level in advance. A collar-shaped cervical incision of about 4 cm was made about a finger-width above the suprasternal notch. After dividing the platysma, the inferior pole of the thyroid gland was exposed. The right and left superior poles of the thymus were exposed separately from the inferior pole of the thyroid gland and moved into the inter-thoracic space anterior to the pretracheal fascia and behind the sternum. After the bilateral superior poles of the thymus were dissected free with a forceps, pretracheal fat tissues including lymph nodes were dissected.

Exposure of the left innominate vein and the thymic veins was not necessary. Next, a transverse abdominal incision of about 6 to 8 cm was made about one finger-width below the xiphoid process. A stainless steel retractor (2 cm wide, 30 cm long) was then inserted behind the sternum from the abdomen side. This retractor was made to slide behind the sternum, and to be removed from the collar-shaped incision above the suprasternal notch. Naruke’s 5-mm thoraco-cotton (Wyeth Lederle, Tokyo, Japan) can be slipped between the retractor and the space behind the sternum, and led to the collar-shaped incision. Cotton string (10 mm wide, about 2 m long) was doubled-up, tied to the end of Naruke’s 5-mm thoraco-cotton, and withdrawn from the abdomen. The cotton string (10 mm) was caught on the stainless steel rod at the head of the table and tied to the hook of the Kent retractor, and the sternum was lifted after the stainless retractor was removed (Fig 1). A 5-mm Hopkins telescope for adults was introduced through a 5.5-mm thoraco-port inserted in the sixth intercostal space in the anterior axillary line from the side that the tumor originates. Two more 5.5-mm thoraco-ports were then placed to introduce the endoscopic instruments: one in the third and one in the fourth intercostal space in the anterior axillary line. With our patients, tumors were found anterior to the pericardium, and the tumor diameters were 3 to 8 cm. The phrenic nerve was freed from the mediastinal pleura using Autosonix System Ultrashears instruments (US Surgical Corporation, Norwalk, CT), 5 mm ultrasonic cutting shears (Autosonix). The resection also extended from the phrenic nerve including the mediastinal pleura, upward from costophrenic areas including fatty tissue, and included dissection from pericardium. The latter was dissected with a 5-mm grasper and 5-mm Autosonix. For this procedure, a 10-mm Endopath short Straight Grasper (Ethicon Endo-surgery, Inc, Cincinnati, OH) was inserted through the abdominal incision, and pulled to the inferior pole of the thymus and mediastinal fat tissue. This is useful for dissection of these structures. Using this technique, the costophrenic region including fatty tissue to the isthmus of the thymus with thymoma can be freed from the pericardium by using Autosonix and a 5-mm Endopath short Straight Curved Dissector (SCD32; Ethicon Endosurgery Inc, Cincinnati, OH). Two to three thymic veins draining into the left innominate vein were coagulated and cut with an Autosonix without clipping. The thymic artery from the internal mammary artery was also coagulated and cut with an Autosonix without clipping. The superior pole of the thymus on the side with the tumor was then pulled into the thoracic cavity and dissected from the isthmus to the superior pole of the thymus including pretracheal fatty tissue. When dissection extended to the central portion from the pericardium, the10-mm cotton string became a good landmark. Three ports were used with a 5-mm endoscope, a 5-mm Autosonix, and an 55 mm Endopath short Straight Grasper (SSG22; Ethicon Endo-surgery, Cincinnati, OH) in the procedures. If the tumor had invaded the lung, then a combined resection was needed, and a 11.5-mm thoraco-port was inserted in one port lesion and an End GIA II (United States Surgical Corporation, Norwalk, CT) single-use stapler was inserted through the port and used in the resection. If the tumor had invaded to the pericardium, then a combined resection of the invaded pericardium was needed, and a 5-mm Autosonix was used in the resection.

View larger version (3K): [in this window] [in a new window]   Fig 1. A stainless steel rod is set at the head of the operating table in advance, and a Kent retractor system is set at thigh level. Ten-mm cotton string is caught in the stainless steel rod and tied to the hook of the Kent retractor. The sternum is lifted after a stainless retractor is removed. Three 5.5-mm thoraco-ports are inserted in the third, fourth and sixth intercostal spaces in the anterior axillary line.

	Comment

Top Abstract Introduction Technique Comment Acknowledgments References

 
We have reported the complete successful extended resection of thymus with thymoma. This method makes it possible to perform a safe and effective extended thymectomy. The anterior mediastinum becomes wider as the sternum is lifted. The 10-mm cotton string is a good landmark when it exfoliates from the pericardium, since it is on the proper side. Since the operation can be performed through three 5.5-mm ports, there are few wounds and little pain after the operation. There is little bleeding because of the Autosonix. Endoscopic clips are not needed to ligate thymic veins and thymic arteries. One drawback is the slightly longer operating time in comparison with a trans-sternal incision. This can be overcome to a certain extent by familiarity with the procedure. This method may be indicated in patients with thymoma Stages I, II, and some Stage III (invasion to the lung and pericardium). On the other hand, this method is not indicated for patients with thymoma with mediastinal lymph node swelling and invasion to the vessels. The functional and cosmetic advantages for the patient are unquestionable (Fig 2).

View larger version (5K): [in this window] [in a new window]   Fig 2. A postoperative picture of a patient shows the incisions.

	Acknowledgments

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The authors thank Noriyuki Koga and Atsuhiro Nakashima.

	References

Top Abstract Introduction Technique Comment Acknowledgments References

 

1. Wilkins KB, Sheikh E, Green R, et al. Clinical and pathologic predictors of survival in patients with thymoma Ann Surg 1999;230:562-574.[Medline]
2. Scelsi R, Ferro MT, Scelsi L, et al. Detection and morphology of thymic remnants after video-assisted thoracoscopic extended thymectomy (VATET) in patients with myasthenia gravis Int Surg 1996;81:14-17.[Medline]
3. Yim AP. Video-assisted thoracoscopic resection of anterior mediastinal masses Int Surg 1996;81:350-353.[Medline]
4. Yellin A. Video-assisted thoracoscopic surgery. thymectomy. Chest 1996;110:578-579.[Free Full Text]
5. Landreneau RJ, Dowling RD, Castillo WM, Ferson PF. Thoracoscopic resection of an anterior mediastinal tumor Ann Thorac Surg 1992;54:142-144.[Abstract/Free Full Text]
6. Acuff TE, Mack MJ, Ryan WH, Bowman RT, Douthit MB. Thoracoscopic thymoma resection Ann Thorac Surg 1993;55:561-568.[Free Full Text]

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