Robotic Thymectomy for B3 Thymoma Infiltrating the Left Phrenic Nerve

Robotic surgery is characterized by a progressive enhancement of its application in the thoracic field, notably regarding the management of mediastinal lesions. The most common robotic mediastinal procedure reported in scientific literature is thymectomy, which is indicated in this case, of Myasthenia gravis or thymoma (1).

Thymoma is a rare thymic tumor with a heterogenous behavior. It requires a high level of accuracy given the significant risk of neoplastic cell dissemination during surgical manipulation (2). 

Radical oncologic treatment may be achieved by robotic surgery thanks to the excellent three-dimensional magnified vision and wide maneuverability, guaranteeing a minimally invasive approach (3). In addition, the application of the firefly after endovenous indocyanine green injection allows the detection of phrenic nerves and periphrenic vessels by near-infrared fluorescence during the robotic procedure (4).

The Patient

The video above shows the case of a forty-one-year-old woman affected by Myasthenia gravis (Osserman class IIIB) exhibiting dyspnea, hyposthenia, and occasional dysarthria. The patient was treated with high dose corticosteroids and intravenous immunoglobulin therapy.

A CT scan of the thorax revealed an anterior mediastinal mass (36 x 11 mm), suspicious of thymoma. After tumor board evaluation, the patient was determined to be a candidate for extended thymectomy by robotic approach.

The Surgery

After double-lumen tube intubation for selective single-lung ventilation, the patient was placed in a supine position with the left arm in a flexed and lower position. The port mapping required three incisions along the submammary line. The first incision was made in the fifth intercostal space at the anterior axillary line for the camera port, the second in the third intercostal space at the anterior middle axillary line, and the last in the fifth intercostal space at the midclavicular line. CO2 insufflation (P=5 mmHg) was used to obtain a wider field of view and more space for maneuverability.

After the introduction of the 30-degree 3D camera, an anterior mediastinal round-shaped lesion was detected as part of the thymic tissue. It was adherent to the pericardium and partially invading the left phrenic nerve. An extended thymectomy was performed with meticulous skeletonization of the left phrenic nerve using bipolar instruments (Fenestrated bipolar forceps and Maryland), after its near-infrared identification.

Given the young age of the patient, the surgeon decided to attempt to preserve the phrenic nerve, having the confirmation of the absence of periphrenic neoplastic tissue during the dissection.

The histological examination of the specimen resulted in a B3 thymoma with R0 resection.

The patient didn’t present any postoperative complications. She was discharged after three days, and diaphragmatic mobility appeared preserved.

References

1. Lane T. A short history of robotic surgery. Ann R Coll Surg Engl 2018;100:5-7.
2. Romano G, Zirafa CC, Ceccarelli I, Guida M, Davini F, Maestri M, Morganti R, Ricciardi R, Hung Key T, Melfi F. Robotic thymectomy for thymoma in patients with myasthenia gravis: neurological and oncological outcomes. Eur J Cardiothorac Surg. 2021 Oct 22;60(4):890-895. doi: 10.1093/ejcts/ezab253. PMID: 34263301.
3. Valero R, Ko YH, Chauhan S, et al. Robotic surgery: history and teaching impact. Actas Urol Esp 2011;35:540-5.
4. Okusanya OT, Hess NR, Luketich JD, et al. Infrared intraoperative fluorescence imaging using indocyanine green in thoracic surgery. Eur J Cardiothorac Surg 2018;53:512-8.

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