Left Robotic Approach for Extended Thymectomy

Over the past 10 years, video-assisted thoracoscopic approaches (and more recently robot-assisted surgery) have replaced median sternotomy for resectable anterior mediastinal masses, including thymoma.

Numerous studies confirmed that a minimally invasive approach for thymectomy, when compared to a standard sternotomy, results in less post-operative pain, better preservation of pulmonary function, and improved cosmetic outcomes (which can be particularly important to many young female myasthenia gravis patients). It is also oncologically feasible for non-invasive thymomas, as long as en bloc resection of the tumor is achieved. In this video, the authors demonstrate a left 3-arm robotic approach for extended thymectomy.

Patient: female, 46-years-old, non-smoker, no comorbidity
Diagnosis: 4 cm thymoma

Patient Positioning and Port Placement

Under general anesthesia with double lumen intubation, the patient was placed in a 30-degree semi-supine position, left side up, with a roll placed under the left shoulder for better left chest exposure. The right arm was right-extended on a padded board. This approach allowed access to the right side, when necessary.

The first incision (camera port) was made in the fifth intercostal space in the anterior axillary line. The two “operative” ports were made in the anterior axillary line in the third intercostal space and in the fifth intercostal space in the mid-clavicular line.

The surgeon worked from the master console. The bedside assistant and the scrub nurse stood on the same side of the bed.

Operative Steps

After making the first incision (camera port), the endoscope (12 mm in diameter, 30° lens) was inserted to explore the chest cavity and confirm that the lesion was resectable.

Under thoracoscopic view, the two operative ports were made. The daVinci^TM Robotic System (Surgical Intuitive, Sunnyvale, CA, USA) was introduced in the surgical field and docked. The right robotic arm has a hook with electric cautery function to perform dissection. The left arm has Cadiere forceps (EndoWrist; Intuitive Surgical) for grasping fat tissue around the thymus. The authors routinely use Ultracision (Ethicon) for dissection and for small vessel division. There is usually no need for any lung retraction.

Before proceeding with dissection, carbon dioxide (CO2) was insufflated with a 6l/min flow and 8 mmHg pressure. CO2 insufflation was used to help collapse the lung and to aid in dissection of fat planes, effectively creating a pneumomediastinum. Carbon dioxide insufflation was continued throughout the procedure as an aid to dissection.

The left phrenic nerve was seen coursing across the superior pericardium and the ascending aorta, and medial to the left pulmonary hilum. The internal mammary artery and innominate vein were the superior extent of dissection. The authors proceeded by dissecting the mediastinal tissue from the pericardium, going up cranially to expose and isolate the innominate vein.

Usually the dissection is started from the inferior border at the pericardial reflection, proceeding lateral to medial across the midline. When the right pleura and the right phrenic nerve are reached, the dissection is directed to the cephalad parallel to the nerve. Once the pleural dissection has been completed in a circumferential nature, the thymus is mobilized and retracted laterally and dissected off of the underlying pericardium. The bilateral upper poles are then stripped down from the neck in order to reveal the thymic vein branches to the innominate vein. The removed thymus and fat tissue are placed in a specimen bag and taken out.

At the end of the procedure, the surgeon introduced a 24 or 28Fr chest tube trough the operative port at the fifth intercostal space. The postoperative outcome was uneventful. The patient completely recovered and was discharged on the second post-operative day.