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Robotic video-assisted thoracoscopic thymectomy

Federico Rea*, Giuseppe Marulli, Luigi Bortolotti
Division of Thoracic Surgery, University of Padua, via Giustiniani 2, 35128 Padua, Italy
Presentation of a minimally invasive surgical technique for thymectomy in patients affected
by myasthenia gravis (MG): robotic video-assisted thoracic surgery (VATS) is a surgical technique applied to perform thymectomy and remove the entire mediastinal fat through a left
transpleural approach.

Keywords: Thymectomy, myasthenia gravis, robotic surgery

Introduction and history
Myasthenia gravis (MG) is an autoimmune disease
that affects neuromuscular transmission and determines chronic weakness and fatigue at various levels
of striated muscles.
Since 1941, when Blalock w1x first reported results of
transsternal thymectomy in patients affected by MG,
thymectomy has played a significant role constituting
a widely accepted therapeutic option in the integrated
management of MG.
Multiple techniques are described to remove the thymus in MG: transcervical thymectomy (basic or extended) w2x, video assisted thoracoscopic thymectomy
(VATS) w35x (classic or extended), transsternal thymectomy w6x (standard, extended or maximal), infrasternal mediastinoscopic thymectomy w7x.
Basic techniques for thymectomy enable a radical
resection of the thymic gland through a single surgical
approach; extended techniques associate more than
one access (i.e. transcervical plus transsternal incision
for maximal thymectomy proposed by Jaretzki w8x):
the rationale of extended techniques is to obtain a
complete resection of the visible thymus, the suspected thymus and cervical-mediastinal fat tissue (in
Authors declare to have no conflict of interest and to be
responsible for any falsehoods or omissions.

* Corresponding author: Tel.: q39-049 821 2237, fax: q39-049 821

2005 European Association for Cardio-thoracic Surgery

which microscopic foci of thymic tissue may be contained) using a wide exposure.
In the last decade growing interest in minimally invasive surgical techniques has developed and recently
robotic surgery has affirmed itself as an evolution of
The first surgical application of robotic technique was
described by Loulmet and Reichenspurner in 1999:
they performed a coronary by-pass w910x.
Subsequently robotic instruments were applied in other fields too and, in 2001, Yoshino w11x described the
first robotic thymectomy in the treatment of small
In 2003, Ashton w12x and Rea w13x published a case
report on robotic thymectomy in MG using two different approaches: the former surgeon from Columbia
University adopted a right-sided approach with completion of the operation through a left-sided approach,
the latter from the University in Padua used a leftsided approach only.

Surgical technique
After neurological assessment, preoperative evaluation includes: a radiogram and computed tomography
of the chest (Photo 1) to verify feasibility of the surgical procedure. Surgery is performed in the following
manner: the patient is under general anaesthesia and
has a double-lumen endotracheal tube for selective
single lung ventilation during the time of operation. In

F. Rea et al. / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2004.000422

Photo 1. The CT-scan shows hyperplasia of the thymus and

excludes any neoplastic pathologies.

Video 1. The surgeon sits at the console containing a display showing the images obtained with the endoscopic camera and any
manipulators the surgeon uses to control the movements of surgical
endoscopic instruments. This system is equipped with an intuitive
3-dimensional vision, a scale motion with tremor filtering and the
EndoWrists with articulated movements permitting a full seven
degree of freedom.

Video 2. The mediastinal surface of the left pleural space is

explored and the anatomic structures are identified: the pericardium, the phrenic nerve and the mammary vessels.

Schematic 1. Schematic planning in the surgical room: the patient

is positioned on the surgical table, the Da Vinci robotic system
with the surgical cart and the surgeons console are displaced.

Video 3. The operation starts with the removal of all the pericardiophrenic angle fat tissue.

Photo 2. The thoracic ports are placed after the identification of the
5th and 3rd intercostal space and the arms of the Da Vinci surgical
system are attached to the ports and are operative.

the surgical room (Schematic 1) the patient is positioned left side up, 30 degrees on a bean bag. The
arms of the Da Vinci surgical system (MMCTSLink
17) are placed as follows: a camera port for the 3dimensional 0 degree stereo endoscope is introduced
through a 15 mm incision in the 5th intercostal space
in the anterior portion of the midaxillary region; two

additional thoracic ports are inserted through two

additional 5 mm incisions in the 5th intercostal space
on the midclavicular line and in the 3rd intercostal
space on the anterior portion of the midaxillary region
(Photo 2).
The left arm has an EndoWrist instrument that grasps
the thymus; the right arm is an Endo-Dissector device
with electric cautery function used to perform the dissection (Video 1).
During surgery the hemithorax is inflated through the
camera port with CO2 ranging in pressure from 6 to
10 mmHg. CO2 inflation is very useful to obtain a clear
view within the chest and to allow an easier dissection
as it extends the mediastinal space.

F. Rea et al. / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2004.000422

Video 4. Following the removal of the pericardio-phrenic angle fat

tissue, an incision is made from the bottom to the top of the retrosternal part of the mediastinal pleura.

Video 5. The thymic tissue is dissected from the retrosternal space.

Video 6. Isolation of the thymus from the pericardial surface is also

performed from the bottom to the top.

Video 8. Mobilization and dissection of the thymus gland is performed from the aorto-pulmonary surface.

Video 9. The thymic gland is divided from the right mediastinal pleura and the right inferior horn is dissected.

Video 10. The cervical fat is dissected from the retrosternal and
jugular region to identify the upper horns of the thymus.

At the top of the mediastinum, the pleura is incised

in the area delimited by the mammary vessels in the
anterior limit and by the phrenic nerve in the posterior
limit (Video 7). At this point the lower part of the thymus is mobilized upwards and thymic tissue is dissected from the plane of the aorto-pulmonary window
(Video 8). The dissection continues in the right side
with the visualization of the right mediastinal pleura
and the right inferior horn (Video 9).
Video 7. At the apical level the pleural incision is made to reach the
area that comprises the mammary vessels and the phrenic nerve.

After careful exploration of the mediastinal pleural

space (Video 2), the dissection of the fat tissue starts
inferiorly at the left pericardiophrenic angle (Video 3).
The thymic gland is then divided from the retrosternal
area (Videos 4, 5) and the left inferior horn of the thymus is subsequently isolated and dissected from the
pericardium (Video 6).

The isolation proceeds up to into the neck until the

superior horns are identified and divided from the inferior portion of the thyroid gland (Videos 10, 11, 12).
The innominate vein is identified and the dissection
continues along the border of the innominate vein up
to the point where the thymic veins are identified,
clipped and divided (Video 13).
The dissection finishes in the lower right side (Video

F. Rea et al. / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2004.000422

Video 11. The cervical left horn of the thymus is identified in the
neck region. In this particular step it is important to carefully locate
the innominate vein.

Video 15. The entire specimen is finally mobilized and an Endo-Bag

is introduced in the pleural space through the inferior port. The thymus is placed in the Endo-Bag and taken out. A chest tube is
placed and the lung is inflated under optical view.

Video 12. When the innominate vein is isolated, the cervical horns
with an apical traction are dissected.

Video 13. The thymic veins are visualized, doubly clipped and cut.
Photo 3. Surgical specimen: the thymic gland and mediastinal fat
are removed en-bloc.

The patient is extubated in the operating room and,

subsequent to an adequate period of observation,
returns to the floor of surgical thoracic ward.
The chest drainage tube is removed 24 h after surgery
and, if neurological evaluation is satisfactory, the
patient is discharged 4872 h after surgery.
Video 14. Dissection of the thymic tissue from the right mediastinal
pleura is completed to remove the fatty tissue of the right pericardio-phrenic angle.

The thymus gland, the anterior mediastinal and the

necks fatty tissue are radically resected and the
specimen is placed in an Endo-Bag so it can be
removed by trocar incision. After the haemostasis, a
28F drainage tube is inserted through the wound of
the 5th intercostal space, the lung is reinflated and the
other wounds are closed (Video 15, Photo 3).

Thymectomy in MG is an effective therapy that produces good clinical results.
In literature the remission rate is comparable for the
various surgical techniques proposed (Table 1).
The transsternal approach is a widespread surgical
technique for thymectomy. The main advantages

F. Rea et al. / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2004.000422

Table 1. Comparison of clinical results after thymectomy using different approaches.



Masaoka w6x, 1996

Papatestas w15x, 1987


Calhoun w2x, 1999

Mineo w3x, 2000
Mack w4x, 1996
Mantegazza w5x, 1998
Personal experience


VAT extended
Robotic VATS

Followup (years)

rate (%)






ments permitting a full seven degree of freedom.

These characteristics allow an accurate dissection,
easier than classic VATS, particularly in the neck
where the dissection is more difficult. The disadvantages of this approach include the initial high
costs of the robotic system, the early increased
operative time and the learning curves associated
with robotic technology.
Photo 4. The cosmetic results can be seen from the frontal view
and the lateral view.

are: an optimal exposition and dissection of the thymus and perithymic fat tissue and lower risks of
vascular and nervous injuries. Some disadvantages
include invasiveness of the approach and a longer
The transcervical thymectomy, popularized by Cooper et al. w14x, is a minimally invasive technique that
is easily accepted by young patients and neurologists. The advantages are a short hospitalization,
fewer complications and lower costs. The main criticism to this approach is related to the small space
of access causing a crowding of instruments thus
making surgical manoeuvres difficult and impossible to perform a thymectomy that extends to the
perithymic fat tissue.
VATS thymectomy through the left- or right-sided
approach is a minimally invasive technique that permits a good visualization of the anterior mediastinum, achieving an extended thymectomy. The
disadvantages are the 2-dimensional view of the
operative field and the limited manoeuvrability of
the endoscopic instruments.
The robotic approach combines the advantages of
minimally invasive techniques (fewer complications,
minimal thoracic trauma, decreased postoperative
pain, early improved pulmonary function, shorter
recovery period and optimal cosmetic results wPhoto 4x) and the specific advantages as an intuitive 3dimensional vision, a scale motion with tremor
filtering and the endo-wrists with articulated move-

Between April 2002 and October 2003, 24 patients

underwent thoracoscopic thymectomy with the Da
Vinci surgical system at the Division of Thoracic
Surgery of Padua. The operative time was 129 min
(ranging from 60 to 240 min), no intraoperative mortality or complications were experienced; no conversion to median sternotomy and no more
accesses were required. Post-operative complications occurred in two cases (8.3%): one patient had
a chylothorax, another patient had a haemothorax
caused by bleeding from one access and both were
treated conservatively. Mean time of hospitalization after surgery was 2.7 days (ranging from 2 to
14 days).

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