Robotic subxiphoid thymectomy

Abstract

When endoscopic surgery is indicated for myasthenia gravis and thymomas, most institutions use a lateral thoracic approach that includes robot-assisted surgery. However, with the unilateral thoracic approach, it can be difficult to ensure the operative field in the neck and difficult to identify the location of the contralateral phrenic nerve. In 2015, we reported on a robotic subxiphoid thymectomy (RST) in which the camera is inserted from the subxiphoid incision and robotic forceps are inserted from the bilateral intercostal spaces. With this approach, a camera is inserted into a subxiphoid incision which is the midline of the body and a surgical field comparable to that in a median sternotomy can be achieved. This makes it easier to identify the location of the bilateral phrenic nerves and offer the good visualization in the neck area. Here we report on our RST techniques. For a thymectomy without suturing, a subxiphoid, single-port thymectomy is performed because it is minimally invasive. In patients who require suturing, such as with a pericardial patch closure, RST is selected. The RST has excellent operability when performed with a robot, making it suitable for more difficult procedures. In the future, we believe that a robot-assisted thymectomy might become the standard method.

Keywords: Thymectomy; robot; subxiphoid; thoracoscopy/VATS.

Figure 1

Robotic subxiphoid thymectomy (RST). A pericardial resection and substitution with an artificial pericardial sheet are very easy with an articulated robotic system.

Figure 2

With the approach from the lateral thoracic side, the neck portion of the thymus is not between the left and right arms (A). In contrast, with the subxiphoid approach, the entire thymus is between the left and right arms, thereby enabling good robotic operability (B) (9).

Figure 3

When the tumor is close to the brachiocephalic vein, the approach from the lateral chest cannot identify the contralateral brachiocephalic vein beyond the tumor (Lateral approach). In contrast, with the subxiphoid approach, the left brachiocephalic vein may be identified at proximal and distal ends to the tumor (Subxiphoid approach).

Figure 4

Equipment configuration with the da Vinci SI surgical system.

Figure 5

Pre-docking procedure (11). Available online: http://www.asvide.com/articles/1039

Figure 6

Robotic subxiphoid thymectomy (RST) (12). Available online: http://www.asvide.com/articles/1040

Figure 7

Robotic pericardial patch closure by the subxiphoid approach (13). Available online: http://www.asvide.com/articles/1041