1st experience with robotic

Thymectomy in KAUH

Iskender Algithmi, MD
Ragab Shehata, MCs

Cardiothoracic Surgery
Unit - KAUH
2010
 Introduction

 7 case underwent robotic Thymectomy in

KAUH between January 2009 to march
2010.

 Patients characteristics, preoperative

preparation, operative data, postoperative
results will reviewed.
Preoperative Characteristics of
Patients

 Gender Female 7 (100%)

 Mean age (range) 25 years (17–45 years)
 Mean duration of symptoms 18 (6 –64) (months)
 Osserman stage
– I ocular myasthenia 6 (85%)
– IIa mild weakness 2 (28%)
– IIb moderate weakness 3 (44%)
– III acute sever weakness 1 (14%)
– IV late sever weakness 1( 14%)
Preoperative medication therapy:

– Anticholinesterase 7 (100%)
– Steroid 7(100%)
– Azatioprine 2(28%)
– Cyclosporine 1(14%)
Pre operative preparation

 History and physical examination

 Neurological assessment
to establish the diagnosis and degree of
weakness

 Endocrinology assessment required in

3 patient , associated with hypothyroidism
 Complete labs:
CBC, U&E, LFT, INR,PTT, TFT

 Pulmonary function test to asses

respiratory function
Radiology

 Chest x ray PA & Lat. And CT chest.

 To evaluate any Mediastinal masses
 Reveal enlarged thymus in 3 patient
Plasmapheresis

 For all patient 3 sessions to:

- decrease Ab level
- improve symptoms
- decrease incidence of Myasthenic crises

 Anesthesia assessment
 ICU referral
Surgical technique

 Under general anesthesia

 double lumen endotracheal tube for selective

single lung ventilation during the time of
operation

 One patient required bronchial blocker.

patient is positioned left side up at a 30-
degree angle
Surgical technique

 A camera port for the three-dimensional 0-degree

stereo endoscope is introduced through a 15 mm
incision in the fifth intercostal space on the
midaxillary line
 Two additional thoracic ports are inserted; one in
the third intercostal space on the midaxillary
region and another in the fifth intercostal space
on the midclavicular space
Surgical technique

 Two arms of the da Vinci system are then

attached to the two access points and another
arm is attached to the port-inserted endoscope.
 During surgery the hemithorax was inflated
through the camera port with CO2 ranging in
pressure from 6 to 10 mm Hg
Surgical technique
All anterior mediastinal tissue, including fat
between the phrenic nerves, and from innominatet
vein to diaphragm dissected and removed
Surgical technique

 After the hemostasis, a 28F drainage tube is

inserted through the port of the fifth intercostal
space, the lung is reinflated, and the other
wounds are closed.
Thymus specimen
At the end of procedure

 5 patient is extubated in the operating

room and, after an adequate period of
observation, returns to the floor of the
surgical thoracic ward.
 2 patient need ICU admission
Operative Data

 Robotic time:118 minutes

(range 95 to 240 minutes)
 Total operative time: 258 minutes
range (148 - 303 min)
 No major Intraopertaive complications
Post operative

 2 patients requires post op. ventilation for

6, 48 hours and ICU stays 1, 4 days.

 Chest tube drainage: mean 240 ml

 Pots op analgesia: tramadol 50mg po q6h
 Hospital stay: 4 days (3-10)
Complications

 One patient developed post operative

dyspnoa, wheeze and haemoptysis,
 Reintubated, ventilated , bronchoscopy
done showing bronchial injury,
? Bronchial blocker
 frequent suction patient stabilized and
extubated after 2 days
 Histopathology

 Thymic hyperplasia: 3 patient

 Atrophic thymus: 2 patient

 Normal thymic tissue 2 patient

 Follow up

Follow up for 3 to 18 (mean 6)months shows:

 Significant improvement and decrease

medication in 3 patient .
 Mid to moderate improvement in 2 case
 No improvement in 2 cases
Brief review of Thymectomy in

myasthenia gravis
MYASTHENIA

 Autoimmune disease
 Affects neuromuscular junction receptors
 Characterized by:
– Localized or generalized weakness that improves
with rest
– Inability to sustain or repeat muscle contractions
MYASTHENIA

– 3:100,000
– 10- 40 YEARS
– Women more often than men
– Onset May be abrupt /Insidious
– May have spontaneous remissions
CLASSIFICATIONS

 Osserman
– Group I ocular disease
– Group IIA mild, general symptoms
– Group IIB mod, general symptoms
– Group III acute, severe; lasts weeks-
months; severe bulbar S.
– Group IV late; severe, marked bulbar S.
and general severe weakness
MYASTHENIA

 BULBAR WEAKNESS
– Oropharyngeal weakness, dysphagia
– Difficulty breathing
– Difficulty clearing secretions
MYASTHENIA
 85% have antibodies to ACh receptors in skeletal
muscle
 Antibody binds close to receptor sites 
destruction of sites
 Thymus thought to be involved:
– 30-50% pts with thymoma have MG
– After Thymectomy
 25% remission
 70-80% improve over weeks to months
DIAGNOSIS

 Clinical symptoms
 EMG
 Improvement after Edrophonium
 Bulbar symptoms = poor prognostic sign
TREATMENT

 GOAL:

Improving neuromuscular
function
 TREATMENT (medical)

 Cholinesterase inhibitors
– Inhibit hydrolysis ACh increase its concentration
– Successful in mild disease
– Pyridostigmine (longer duration, less side effects)
 60 mg po Q6h
TREATMENT (medical)

 Corticosteroids
– Dec AChR antibodies
 80% remission
 Limited by long term Side Effect
– GI bleed
– HTN, hyperglycemia
– Osteoporosis
– susceptibility to infection
TREATMENT (medical)

 Immunosuppressive
– Interferes with formation AChR antibodies
– Side effects
 Bone marrow suppression
 Susceptibility to infections
 malignancy
– Cyclophosphamide, azathioprine,
cyclosporine
TREATMENT

 Plasmapheresis
– Short term improvement
– significant decease postop. complications
 IV Immunoglobulin
– Short term
– May be given pre op
TREATMENT (surgical)

Thymectomy:
 Major source antibody production
 Arrests/reverses disease
 Indicated in:
– Adults with generalized disease
– Thymoma
– Thymic hyperplasia
– Drug resistant MG
Thymectomy (approach)

 The transsternal approach:

 widespread surgical technique for Thymectomy.
 The main advantages are: an optimal exposition and
dissection of the thymus and perithymic fat tissue
 Lower risks of vascular and nervous injuries.
 Disadvantages include invasiveness of the approach
and a longer hospitalization.
Thymectomy

 The transcervical thymectomy:

 minimally invasive technique that is easily accepted
by young patients and neurologists.
 The advantages are a short hospitalization, fewer
complications and lower costs.
 Disadvantage: small space of access making surgical
manoeuvres difficult
 Impossible to perform a thymectomy that extends to
the perithymic fat tissue.
Thymectomy

 VATS thymectomy:
 minimally invasive technique
 through the left- or right-sided approach
 good visualization of the anterior mediastinum,
 achieving an extended thymectomy.
 The disadvantages are the 2-dimensional view of the
operative field and the limited manipulation of the
endoscopic instruments.
Thymectomy

 The robotic Thymectomy:

 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
 the specific advantages is 3-dimensional vision, a
scale motion with tremor filtering and articulated
movements.
Results
Conclusion

 In patients with MG, robot-assisted thymectomy can

be performed safely and efficiently.
 The improved visualization and instrument and its
advanced technology may facilitate the minimally
invasive approach to the thymus.
 We prefer to use the left-sided approach because it
provides an enhanced visualization of the aortic
window and it reduces the probability of phrenic
nerves injury.
 A longer follow-up is necessary to verify long-term
clinical results.
Thank you