Uniportal Robotic-Assisted Extended Thymectomy

Robotic-assisted thoracic surgery (RATS) offers superior three-dimensional visualization and maneuverability compared to traditional video-assisted thoracoscopic surgery (VATS) (1). However, RATS is traditionally performed via at least one access incision with two or three additional ports (2). In the era of uniportal VATS, which is associated with less pain and improved postoperative recovery while feasibility, safety, and oncological principles are preserved, uniportal RATS (U-RATS) is a promising alternative to the traditional approach (3). A multicenter retrospective study found that U-RATS was associated with shorter operative times and reduced length of hospital stay, while maintaining comparable R0 resection rates, number of resected lymph nodes, and risk of conversion to thoracotomy compared to multiportal RATS (4). 

The feasibility of thymectomy via subxiphoid U-RATS in patients with and without thymoma has been reported in multiple case series (5-7). However, to the best of the authors’ knowledge, the intercostal approach of U-RATS for thymectomy in patients with thymoma has not yet been reported. 

Case and Surgical Technique 

A 66-year-old male with a 30 pack per year smoking history was admitted to the thoracic surgery clinic after being diagnosed with myasthenia gravis three months prior. His blood test for anti-acetylcholine receptor antibodies was positive. A positron emission tomography/computed tomography (PET/CT) scan revealed an 80 mm diameter lobulated, calcified mass in the anterior mediastinum with poorly defined borders with the pericardium and maximum standardized uptake value (SUVmax) of 6.8. An extended thymectomy via U-RATS was planned. 

The patient was positioned in the right semi-lateral decubitus position, and a 5 cm incision was made in the sixth intercostal space along the anterior axillary line. After placement of the wound retractor, the robotic arms were inserted, with the camera arm positioned at the top. The robotic arms were defined as follows: the first arm for the left hand, using prograsper forceps; the second arm for the camera; and the third arm for the right hand, using Maryland Bipolar Forceps. The fourth arm was not used.  

Dissection began from the inferior part of the mediastinum, and the plane between the mass and the pericardium was dissected with Maryland Bipolar Forceps. Dissection continued between the borders of the bilateral phrenic nerves with safe margins. The thymic veins were detected, encircled, and ligated using Maryland Bipolar Forceps or a bipolar energy device. The thyrothymic ligaments were pulled and divided. The thymectomy was completed, and the specimen was removed from the thoracic cavity using an endobag. Paratracheal lymph nodes were biopsied. A 24 French chest tube was placed through the mediastinum, and the operation was concluded. 
The chest tube was removed on postoperative day (POD) one, and the patient was discharged on POD two. Pathologic examination confirmed the diagnosis of thymoma, type B2 + B3, with extracapsular invasion (T1bN0, Masaoka IIa). 

Conclusion 

Extended thymectomy for anterior mediastinal masses via U-RATS is safe and feasible. However, its impact on postoperative and oncological outcomes warrants further studies.

References

1. Gonzalez-Rivas D, Manolache V, Bosinceanu ML, Gallego-Poveda J, Garcia-Perez A, de la Torre M, Turna A, Motas N. Uniportal pure robotic-assisted thoracic surgery-technical aspects, tips and tricks. Ann Transl Med. 2023 Aug 30;11(10):362.
2. Oh DS, Tisol WB, Cesnik L, Crosby A, Cerfolio RJ. Port Strategies for Robot-Assisted Lobectomy by High-Volume Thoracic Surgeons: A Nationwide Survey. Innovations (Phila). 2019 Nov/Dec;14(6):545-552./span>
3. Mercadante E, Martucci N, De Luca G, La Rocca A, La Manna C. Early experience with uniportal robotic thoracic surgery lobectomy. Front Surg. 2022 Sep 23;9:1005860.
4. Manolache V, Motas N, Bosinceanu ML, de la Torre M, Gallego-Poveda J, Dunning J, Ismail M, Turna A, Paradela M, Decker G, Ramos R, Bodner J, Espinosa Jimenez D, Zardo P, Garcia-Perez A, Ureña Lluveras A, Pantile D, Gonzalez-Rivas D. Comparison of uniportal robotic-assisted thoracic surgery pulmonary anatomic resections with multiport robotic-assisted thoracic surgery: a multicenter study of the European experience. Ann Cardiothorac Surg. 2023 Mar 31;12(2):102-109.
5. Park SY, Han KN, Hong JI, Kim HK, Kim DJ, Choi YH. Subxiphoid approach for robotic single-site-assisted thymectomy. Eur J Cardiothorac Surg. 2020 Aug 1;58(Suppl_1):i34-i38.
6. Kim IH, Kim YH, Yun JK, Kim HR. Initial experience with the da Vinci single-port system in patients with an anterior mediastinal mass. Eur J Cardiothorac Surg. 2024 Sep 2;66(3):ezae325.
7. Suda T, Tochii D, Tochii S, Takagi Y. Trans-subxiphoid robotic thymectomy. Interact Cardiovasc Thorac Surg. 2015 May;20(5):669-71.

Disclaimer

The information and views presented on CTSNet.org represent the views of the authors and contributors of the material and not of CTSNet. Please review our full disclaimer page here.