Robotically assisted thymectomy: a review of the literature

The role of minimally invasive surgery in the management of giant mediastinal tumors: a narrative review

BACKGROUND AND OBJECTIVE

Beyond diagnosis, minimally invasive surgery has traditionally not been considered suitable for large tumors, those invading vital structures or high-risk patients. However, with the improvement of multimodality treatments able to reduce tumor size preoperatively, patient evaluation and selection, perioperative care (including both surgical and anesthesiological techniques) and postoperative management, the indications of minimally invasive surgery, even in giant mediastinal tumors, have increased and will continue to broaden in future years. This review aims to summarize the existing literature regarding the role of minimally invasive surgery in the management of giant mediastinal tumors. We have focused in the role minimally invasive surgery has in diagnosis and treatment of these tumors and we have tried to provide an updated perspective to identify future applications and work-directions.

METHODS

Data regarding minimally invasive surgery in giant mediastinal tumors are limited, including a proper definition of them. We performed a PubMed search of English and Spanish written studies until August 2021.

KEY CONTENT AND FINDINGS

There is limited data related to minimally invasive surgery in giant mediastinal tumors and much of the literature review we have performed has yielded isolated case reports, case series with a low number of cases or editorials. Although the role of minimally invasive surgery is well consolidated as a diagnostic approach, adequate patient selection, hospital volume and experience, multidisciplinary discussion of candidates, patient safety and adequate oncological resection remain the most important aspects to be taken into account when considering a minimally invasive approach for a giant mediastinal tumor.

CONCLUSIONS

With careful and multidisciplinary perioperative planning, minimally invasive surgery has shown to be safe and to provide at least similar outcomes when compared to open approaches in well selected cases. Although data is still limited, improved surgical techniques and available technology will pave the way to increased indications of minimally invasive surgery in giant mediastinal tumors.

Learning Curve of Robot-Assisted Thymectomy: Single Surgeon's 7-Year Experience

Background

Robot-assisted thymectomy (RAT) has rapidly emerged as the preferred approach over open trans-sternal or video-assisted thoracoscopy for the surgical treatment of thymomas and non-thymomatous myasthenia gravis (MG). The aim of this study was to describe and discuss the learning curve (LC) of a single surgeon performing 113 consecutive RATs.

Methods

A single-center retrospective analysis of prospectively collected clinical data was performed on all patients who had been operated on by the same surgeon in an RAT setting between October 2013 and February 2020. The cumulative sum (CUSUM) analysis of the operative time was used to define the completion of the learning curve (CLC) in RAT. The CLC was separately calculated for myasthenic patients, non-myasthenic patients, and docking time.

Results

In myasthenic patients, the CLC cut-off was found in 19 patients. Considering the CLC cut-off of 19 patients, the mean operative time in phase 1 (first 19 cases) was 229.79 ± 93.40 min, while it was 167.35 ± 41.63 min in phase 2 (last 51 cases), p≪0.001. In non-myasthenic patients, the CLC cut-off was found in 16 cases. The mean operative time in phase 1 (first 16 cases) was 277.44 ± 90.50 min, while it was 169.63 ± 61.10 min in phase 2 (last 27 cases), p = 0.016. The LC for docking time was reached at 46 cases, recording a significant reduction of time after the first phase (28.09 ± 5.37 min vs. 19.75 ± 5.51 min, p≪0.001). The intraoperative and 30-day mortality were null in all phases of the LC in both myasthenic and non-myasthenic patients. There were no differences between the two phases of the LC in terms of blood loss, duration of postoperative drainage, and postoperative stay in both myasthenic and non-myasthenic groups. However, significantly higher hospital readmission at 30 days post surgery was recorded for myasthenic patients operated on during the first phase of the LC (2 cases vs. 0, p = 0.02).

Conclusions

According to our data, LC in RAT seems to be steep, and RAT confirms to be safe even before reaching CLC.

Thymic Epithelial Tumors as a Model of Networking: Development of a Synergistic Strategy for Clinical and Translational Research Purposes

Among the group of thymic epithelial tumors (TET), thymomas often show either uncertain or explicit malignant biological behavior, local invasiveness, and intrathoracic relapse and are often difficult to manage. From the initial stages, thymic carcinomas tend to show aggressive behavior and extrathoracic spread. Moreover, the interplay of epithelial cells and thymocytes in thymomas causes complex immune derangement and related systemic autoimmune diseases. Due to their rare occurrence and to the limited funding opportunities available for rare tumors, it is challenging to make advances in clinical and translational research in TET. The authors of this paper are all members of a multidisciplinary clinical and research thoracic tumor team. Strong input was given to the team by long-standing expertise in TET in the Pathology Department. In addition, thanks to the collaboration between research units at our Institute as well as to national collaborations, over the last 10 years we were able to perform several tissue-based research studies. The most recent studies focused on microRNA and on functional studies on the thymic carcinoma cell line 1889c. The recent implementation of our biobank now provides us with a new tool for networking collaborative research activities. Moreover, the participation in a worldwide community such as ITMIG (International Thymic Malignancy Interest Group) has allowed us to significantly contribute toward fundamental projects/research both in tissue-based studies (The Cancer Genome Atlas) and in clinical studies (TNM staging of TET). Our achievements derive from constant commitment and long-standing experience in diagnosis and research in TET. New perspectives opened up due to the establishment of national [the Italian Collaborative Group for ThYmic MalignanciEs (TYME)] and European reference networks such as EURACAN, for an empowered joint clinical action in adult solid rare tumors. The challenge we face still lies in the advancement of clinical and basic science in thymic epithelial malignancies.

Robotic assisted transaxillary thymectomy: Novel approach to thymic surgery

BACKGROUND

We present a video case with a novel, minimally invasive approach to the thymus, which does not require a sternotomy, thoracic incision, or entry into the pleural space.

METHODS

A 14-year-old girl was referred to our clinic with dysphagia and left sided thymic mass. A detailed video shows the operative techniques used to perform a thymectomy with robotic assistance via a transaxillary approach.

RESULTS

The procedure was tolerated well and without complication. The patient was discharged the day after surgery and was symptom free at her 2-week follow-up appointment.

CONCLUSION

We present a novel approach to thymic surgery that does not require a neck incision, sternotomy, or entry into the pleural space. There could be several benefits from this minimally invasive approach; however, concerns related to exposure and adequacy of resection need further research prior to recommending this technique for myasthenia or malignancy.

Robotic-assisted thymectomy for early-stage thymoma: a propensity-score matched analysis

The aim of this study was to analyse the feasibility and safety of robotic-assisted thymectomy (RoT) in patients with clinically early stage thymoma, investigating clinical and early oncological results. Between 1998 and 2017, we retrospectively reviewed 76 (42.2%) patients who underwent radical thymectomy for clinically early stage thymoma (Masaoka-Koga I and II), identifying all patients who underwent RoT (n = 28) or open thymectomy (OT) with eligibility criteria for robotic surgery (n = 48). Using a propensity-score matched for tumor size (3.9 ± 1.8 cm) and stage (35% stage I, 42% stage IIA, 23% stage IIB), we paired 24 patients who had RoT with 24 patients undergoing OT. RoT was left-sided in 19 (79.2%) patients. None of the patients required conversion to open surgery. OT was via sternotomy in 21 (87.5%) patients and thoracotomy in 3 (12.5%). Mean operating time was shorter in the RoT group (117 ± 40 min) than in the OT (141 ± 46 min) (p = 0.06), even if not statistically significant. Length of stay was significantly shorter in the RoT group (mean 4.0 ± 1.9 days) than in the OT (mean 5.9 ± 1.7 days) (p = 0.0009). No significant difference between the two groups regarding post-operative complications. Five patients died in the OT group after a median follow-up of 6.1 years (only one for recurrence). After a median follow-up of 1.3 years, all patients in the RoT group were alive without disease. RoT is feasible and safe for early stage thymoma with clear advantage compared to OT in term of short term outcomes. A longer follow-up is needed to better evaluate the oncological results.