Ann Thorac Surg 2003;76:1310-1311
© 2003 The Society of Thoracic Surgeons
How to do it
Thoracoscopic thymectomy using anterior chest wall lifting method
Mitsunori Ohta, MDa*,
Hirohisa Hirabayasi, MDa,
Meinoshin Okumura, MDa,
Masato Minami, MDa,
Hikaru Matsuda, MDa
a Department of General Thoracic Surgery, Osaka University, Graduate School of Medicine, Osaka, Japan
Accepted for publication February 15, 2003.
* Address reprint requests to Dr Ohta, Department of General Thoracic Surgery, Osaka University Graduate School of Medicine, E1-2-2, Yamadaoka, Suita, Osaka 565-0871, Japan
e-mail: ohta{at}surg1.med.osaka-u.ac.jp
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Abstract
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We performed a thoracoscopic resection of thymus and thymoma using a novel method whereby the chest wall was lifted by costal hooks placed on the bilateral third ribs. Since the thymus and fat tissue were also elevated, the mediastinal dissection was started at the underlying vessels and pericardium. This technique conforms to the purpose of endoscopic surgery, as it maximizes the operative field and minimizes chest wall trauma. We have applied this approach to benign mediastinal tumor and stage I thymoma with satisfactory results.
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Introduction
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Video-assisted thoracoscopic resection of anterior mediastinal masses offers the advantages of minimal chest wall disruption and improved cosmetic results. The common procedure involves a bilateral intrathoracic approach [1–3]. However, Kido and coworkers [4] reported another procedure by which thymic clearance was achieved through an infrasternal wound and not the pleural cavity. By whichever route is taken, a wide view of the mediastinum allows for easy resection of all thymic tissue with thoracoscope. Herein we describe our technique for bilateral thoracoscopic surgery using an anterior chest wall lifting method to attain a wide view. One of the features of our method is that the wounds from the chest wall lifting were minimal. Another is that the dissection between the anterior mediastinum and the sternum is performed during the last stage of the operation.
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Technique
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Under general anesthesia with selective one lung ventilation, the patient was placed in a supine position. Three trocars were introduced into the right pleural cavity through the third, fourth, and fifth intercostal spaces at the anterior axillary line and then similarly into the left pleural cavity (Fig 1).
A vertical skin incision of approximately 5 mm was made 2 cm lateral of the sternum at the upper edge of the third rib on both sides. A costal hook, as shown in Figure 1, was inserted into the pleural cavity through this wound to lift the third rib. The anterior chest wall was then lifted by connecting the costal hook to an abdominal wall lifting system (Mizuho Co, Ltd, Tokyo, Japan), which was placed on the both sides of the operating table at head level. The position of the hook could be changed easily from the third to the fourth or fifth rib for dissection of the lower pericardial fat portion.
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Fig 1. In a supine position, trocars are introduced into the bilateral pleural cavity through the third, fourth, and fifth intercostal spaces. Short skin incisions are made approximately 2 cm lateral of the sternum at the third intercostal space on both sides. The hooks are inserted into the pleural cavity through this wound and then used to lift the chest wall. When the thymus and adherent fat were free from mediastinum, they were placed in a plastic bag and then removed through the trocar wound of the fifth intercostal space.
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First, the right mediastinal pleura was incised using endoscopic scissors or a Harmonic scalpel (Ethicon Endo-surgery, Inc, Cincinnati, OH) just in front of the phrenic nerve. The thymus and mediastinal fat were then gently moved from the superior vena cava and right brachiocephalic vein until the left brachiocephalic vein was exposed (Fig 2).
Thymic veins and artery could be identified and then divided, using an Endoclip (Autosuture, USSC). Next, the right inferior pole of the thymus was separated from the underlying pericardium extending onto the aorta, while lifting the bilateral fifth ribs. Dissection was then carried out behind the sternum over the endothoracic fascia toward the contralateral side. The left brachiocephalic vein was used as the landmark of the superior border of the left anterior mediastinum, and the thymus and fat were dissected from the left mediastinum. When the mediastinal pleura was dissected behind the sternum on the left side, the thymus and fat tissue, except for the superior thymic poles, were free from the mediastinum.
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Fig 2. Intraoperative photograph of the right mediastinum (top) and interpretation (bottom) of patient with thymoma show aortic arch (Ao-arch), left brachiocephalic vein (LBCV), superior vena cava (SVC), phrenic nerve (Phrenic N), and anterior chest wall clearly.
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In all patients, the superior poles could be pulled down into the pleural cavity with gentle inferior traction on the thymus when the head of the patient was bent forward to move the poles into the mediastinum. After removal of the thymus and adherent fat in a plastic bag through the inferior trocar wound, the thymic bed was explored to ensure hemostasis and complete resection. Chest tubes were then placed in the bilateral pleural cavity and layered closure of wounds completed the operation. We have used this method for 4 patients without morbidity. One patient had a thymic hyperplasia 1.5 cm in diameter, 1 had a cyst, and 2 had a Masaoka stage I thymoma with diameters of 3 and 4 cm, respectively.
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Comment
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We performed a thoracoscopic resection of thymus and thymoma using a novel method of anterior chest wall lifting. Two Masaoka stage 1 thymomas were removed completely along with the upper poles of the thymus without using a cervical approach. Many authors reported that the entire resection of stage 1 and 2 thymoma by thoracoscopic operation is technically feasible [2, 3].
A thoracoscopic approach is less invasive compared with a transsternal approach, resulting in a patient’s improved acceptance of surgery [2]. However, whether a thoracoscopic thymectomy has the same operative quality as a median sternotomy, that is, complete clearance of all pathologic tissue, is still controversial. For patients with a thymoma, the standard therapeutic approach is complete removal of thymic tissue from the underlying vessels and pretracheal area through a median sternotomy. It is often difficult for an endoscopic operation to achieve complete removal of the thymus from such complex anatomies, because of poor visualization [5, 6]. However, our method for lifting the anterior chest wall and such mediastinal structures as the thymus and mediastinal fat obtained an excellent view of the mediastinal space. Then we were able to skeletonize the bilateral brachiocephalic veins and superior vena cava (Fig 2). By careful inspection and additional resection of remnants from the thymic bed, we achieved a complete thymectomy. Moreover, because dissection of the thymus was started at the underlying vessels and pericardium, unexpected advanced lesions of thymoma invading these anatomies could be detected and conversion to a formal median sternotomy in the early stage of the operation was possible.
We concluded that, in selected cases, an endoscopic approach for thymic disease using an anterior chest wall lifting method was an effective alternative to a conventional transsternal approach, minimizing patient’s anxieties about thoracic trauma.
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References
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- Sugarbaker D.J. Thoracoscopy in the management of anterior mediastinal masses. Ann Thorac Surg 1993;56:653-656.[Abstract]
- Yim A.P.C. Video-assisted thoracoscopic resection of mediastinal masses. Int Surg 1996;81:350-353.[Medline]
- Takeo S., Sakada T., Yano T. Video-assisted extended thymectomy in patients with thymoma by lifting the sternum. Ann Thorac Surg 2001;71:1721-1723.[Abstract/Free Full Text]
- Kido T., Hazama K., Inoue Y., et al. Resection of anterior mediastinal masses through an infrasternal approach. Ann Thorac Surg 1999;67:263-265.[Abstract/Free Full Text]
- Scelsi R., Ferro M.T., 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]
- Uchiyama A., Shimizu S., Murai H., et al. Infrasternal mediastinoscopic thymectomy in myasthenia gravis: surgical results in 23 patients. Ann Thorac Surg 2001;72:1902-1905.[Abstract/Free Full Text]
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Abstract
Introduction
