Robotic thymectomy

Abstract

Thymectomy is the most frequent surgical operation involving the mediastinum, both for the treatment of thymic tumors and for the multidisciplinary management of myasthenia gravis (MG). Different surgical approaches have been described, either traditional open approaches or minimally invasive ones. Robotic thymectomy represents a further step in the evolution of minimally invasive surgery. Available data show that robotic thymectomy may be considered a safe and feasible operation, with encouraging long-term results in myasthenic patients and promising results in patients with early stage thymoma, both in terms of surgical and oncological outcomes. We present the surgical technique of robotic thymectomy that we apply for patients affected by myasthenia gravis and early stage thymoma.

Keywords: Thymectomy; myasthenia gravis (MG); robot; thymoma.

Figure 1

Patient during a left-side operation; on the right side is positioned the robotic cart.

Figure 2

Components of the robotic system. (A) Surgeon’s master console; (B) cart with vision system and CO₂-supply system; (C) operating cart equipped with robotic arms.

Figure 3

Preoperative patient’s positioning and trocars’ placement. (A) Patient positioned at a 30-degree angle, with marked landmarks and ports’ insertion sites; (B) ports positioned: two ports for the robotic arms laterally and camera-port with CO₂-connecting line in the middle.

Figure 4

Surgical field individuated in a triangle area within the left phrenic nerve (arrow) and the mammary vessels (*).

Figure 5

Surgical technique. (A) Dissection along the phrenic nerve; (B) dissection of the right inferior horn, with opening the right pleura; (C) division of the thymus from the pericardium; (D) dissection towards to the neck between the mammary vessels and the phrenic nerve (*, mammary vessels; ^, left subclavian vein; arrow, phrenic nerve).

Figure 6

Dissection of the left upper horn of the thymus above the left subclavian vein (^).

Figure 7

Dissection and clipping of a thymic vein (^, left subclavian vein; arrow, thymic vein).

Figure 8

Thymic specimen.