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Ann Thorac Surg 2003;75:569-571
© 2003 The Society of Thoracic Surgeons
a St. Luke’s Roosevelt Hospital Center, College of Physicians and Surgeons, Columbia University, New York, New York, USA
Accepted for publication August 14, 2002.
* Address reprint requests to Dr Ashton, St. Luke’s Roosevelt Hospital Center, 1000 Tenth Ave, Suite 2B07, New York, NY 10019, USA
e-mail: rashton{at}chpnet.org
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Abstract |
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Introduction |
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The patient is a 28-year-old woman with a 2-year history of generalized weakness. Her medical management included mestinon and corticosteroids for controlling her symptoms. A computed tomography (CT) scan of the chest demonstrated thymic hyperplasia without evidence of thymoma.
The procedure was performed under general anesthesia with a double-lumen endotracheal tube for single-lung ventilation during the procedure. The patient was positioned right side up at a 30-degree angle with a shoulder roll and bean bag. The right arm was positioned at her side. The right side was approached first owing to increased space in the right pleural space and better visualization of the superior vena cava and inominate vein. A 12-mm incision was made lateral to the breast in the fifth intercostals space for the camera port. A superior 7-mm incision was made in the third intercostal space in the midclavicular line and a 7-mm submammary incision was made in the seventh intercostal space in the anterior axillary line. A separate working 12-mm accessory port was made lateral to the camera port.
With the right lung deflated and insufflation to a pressure of 10 mm Hg the dissection was performed using Caudier forceps, ultrasonic coagulating shears, cautery blade, and a 0-degree scope. Starting inferiorly at the pericardiophrenic angle dissection along the phrenic nerve was performed, inferiorly to superiorly and laterally to medially, to the level of the superior vena cava. Ultrasonic coagulating shears were used along the phrenic nerve to prevent injury to it. A cautery blade was used for the all other parts of the dissection. Dissection along the superior vena cava with identification of the inominate vein proceeded. Next the mediastinum was dissected free from the restrosternal area to the left internal thoracic artery. The dissection continued into the neck teasing out the upper poles of the cervical thymus. A fan retractor was utilized to provide traction of the thymus inferiorly. After mobilization of the cervical poles the inominate vein and its thymic vein branches were visualized. The thymic veins were doubly clipped and transected with the ultrasonic coagulating scalpel. The dissection along the anterior pericardium was performed from right to left. A 30-degree scope was used at this point to evaluate the left phrenic nerve. The left phrenic nerve was not safely visualized despite retraction of the thymus to the right pleural space. The ports were then removed and the incisions closed.
The da Vinci cart was then positioned on the left side and the patient repositioned for a left-sided approach. Mirror incisions of the right side were made with the exception of the accessory port. The dissection along the phrenic nerve was completed inferiorly to superiorly. Only minimal dissection was needed on this side as the majority had been performed from the right side. Once the thymus was completely mobilized it was placed in an endoscopy bag and removed through the inferior submammary incision (Fig 1). Chest tubes were placed bilaterally through the inferior incisions. The patient was discharged on postoperative day 3 without complications. Pathology revealed thymic hyperplasia and no thymoma.
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Comment |
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This newest approach for complete thymectomy uses the da Vinci Surgical System. This robotic system has enhanced optics that include three-dimensional visualization and x12 magnification. The surgical arms have distal "endowrists" that simulate normal wrist movement, have scaled motion, and remove hand tremors. With the maneuverability of the endowrists and enhanced visualization, precise dissection of tissue and control of small vessels are obtainable.
The disadvantages with this approach include the initial fixed cost of the system, early increased operative time, and learning curves associated with robotic technology. The variable costs of reusable instruments are comparable with those of disposable thoracoscopic instruments. No studies have documented the number of procedures necessary to develop proficiency using this system. As with the advent of laparoscopy and thoracoscopy, learning curves are part of any new technology and need to be studied.
This initial case demonstrated limitations compared with other published approaches. Transcervical thymectomy includes only one neck incision and minimal pain and patients are able to be discharged the same day. Thoracoscopic thymectomy has been performed from one side only whereas our approach is bilateral. A bilateral approach depends on body habitus and a learning curve. Refinements in this procedure, including the surgeons’ learning curve, should make this comparable with the thoracoscopic approach.
Minimally invasive approaches in general have demonstrated shorter recovery times and less pain compared with sternotomies. Lack of sternal and neck incisions are cosmetically appealing to patients. With improved cosmetic results young patients may opt for thymectomy earlier in the course of their disease. That is significant, as some results suggest improved beneficial effects of thymectomy for patients who are younger and who are treated earlier in the course of their disease [5].
It is our intention to continue to refine this robotic approach to provide maximal surgical benefit to patients with myasthenia gravis undergoing thymectomy. We intend to prospectively observe these patients using the guidelines set forth by Jaretski and colleagues [6]. Long-term analysis by standard guidelines is necessary to properly assess all methods of surgical thymectomy. Ultimately thymectomy for myasthenia gravis will be judged on clinical improvement and remissions rates, which increase over time after surgery. Presently surgeons should perform thymectomies using the methods that they find most comfortable and that provide the best clinical outcomes.
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