Thoracic techniques: robotic thymectomy for thymoma

Minimally invasive thymectomy for myasthenia gravis favours left-sided approach and low severity class

OBJECTIVES

Complete thymectomy is a key component of the optimal treatment for myasthenia gravis. Unilateral, minimally invasive approaches are increasingly utilized with debate about the optimal laterality approach. A right-sided approach has a wider field of view, while a left-sided approach accesses potentially more thymic tissue. We aimed to assess the impact of laterality on perioperative and medium-term outcomes, and to identify predictors of a 'good outcome' using standard definitions.

METHODS

We performed a multicentre review of 123 patients who underwent a minimally invasive thymectomy for myasthenia gravis between January 2000 and August 2015, with at least 1-year follow-up. The Myasthenia Gravis Foundation of America standards were followed. A 'good outcome' was defined by complete stable remission/pharmacological remission/minimal manifestations 0, and a 'poor outcome' by minimal manifestations 1-3. Univariate and multivariable logistic regression analyses were performed to assess factors associated with a 'good outcome'.

RESULTS

Ninety-two percent of thymectomies (113/123) were robotic-assisted. The left-sided approach had a shorter median operating time than a right-sided: 143 (interquartile range, IQR 110-196) vs 184 (IQR 133-228) min, P = 0.012. At a median of 44 (IQR 27-75) months, the left-sided approach achieved a 'good outcome' (46%, 31/68) more frequently than the right-sided (22%, 12/55); P = 0.011. Multivariable analysis identified a left-sided approach and Myasthenia Gravis Foundation of America class I/II to be associated with a 'good outcome'.

CONCLUSIONS

A left-sided thymectomy may be preferred over a right-sided approach in patients with myasthenia gravis given the shorter operating times and potential for superior medium-term symptomatic outcomes. A lower severity class is also associated with a 'good outcome'.

The evolution of robotic thoracic surgery

Robotic surgery has the features to represent the future of surgery, considering the rapid evolution of its technology and the resulting in the surgical field. In the last years, the robotic technique in thoracic surgery has progressively become widespread in the word, particularly for the treatment of the mediastinal and pulmonary lesions. The development of technology in the robotic system has been associated with the improvement of intraoperative and postoperative results. Due to the satisfying results and increasing experience and confidence with the robotic technique, surgeons are consequently enlarging the surgical indication, moving to increasingly challenging cases. Thoracic robotic surgery is being affirmed as a safe technique also for those complex cases, which in the past were considered a matter solely for open surgery. In fact, robotic surgery is increasingly associated with positive surgical results and guarantees less traumatism and a fast recovery to the patients. These positive results have resulted from the evolution of the technique, which has developed in parallel with the evolution of the technology, exploiting to its best the latest features of the robotic system. These features, such as the fluorescence-detection tool or the robotic stapler, have been aiding the surgeon to maximise the safety and feasibility of the application of the robotic technique to thoracic surgery.

Robot-assisted en bloc anterior mediastinal mass excision with pericardium and adjacent lung for locally advanced thymic carcinoma

Robot-assisted surgery for anterior mediastinal mass resection has been increasingly adopted as an alternative method to open sternotomy and conventional video-assisted thoracic surgery. However, more evidence is needed to expand the indication of this technique to more complicated cases. We present a case of robot-assisted en bloc resection of a 7-cm anterior mediastinal mass with pericardium and adjacent lung for thymic squamous cell carcinoma, accompanied by reconstruction of pericardium with polytetrafluoroethylene patch. In conclusion, complex anterior mediastinal mass excision is feasible with robotic thoracic surgery.

Robotic-assisted thoracoscopic surgery thymectomy

In recent decades, mediastinal surgery has undergone radical innovations. In fact, introduction of minimally invasive methods, such as video-assisted thoracoscopic surgery (VATS), showed several clinical benefits over median sternotomy. Recently the introduction of robotic-assisted thoracoscopic surgery (RATS) has added more technological advantages in mediastinal dissection such as 3-dimensional (3D) vision and multi-articulated instruments. We agree with many authors about the advantages of RATS for the treatment of patients with thymomas and patients with myasthenia gravis (MG) resistant to medical treatment, but actually we express concerns about the high costs of this procedure. Furthermore we are waiting for long term clinical and oncological outcomes compared with trans-sternal or VATS approach. Here we report our series experience.

Robotic approach in case of thymoma involving the left anonymous vein: a case report

The robotic system has several technical advantages over the manual video thoracoscopic approach. It offers a high definition three-dimensional view and robotic arms are more comfortable to use, because they allow more precise, flexible, and intuitive movements. This case report describes a locally advanced thymoma in a 75-year-old male patient, excised through a robotic-assisted thymectomy with atypical resection of the infiltrated left upper lobe, the preservation of the left phrenic nerve and partial resection of the left anonymous vein involved, without necessity of reconstruction. Clinical staging was thymoma T3 B1-2, while the postoperative histological classification and radiation was thymoma T3, B3, Masaoka-Koga stage IIB. The postoperative course was uneventful and the patient was discharged in second postoperative day. This case remarks that robotic devices are of great help in the intraoperative recognition and precise management of infiltrated structure, like important vessels and nerves, avoiding conversion to an open approach, which until now was the main surgical indication in these situations.

Robotically assisted thymectomy: a review of the literature

The aim of this literature review is to see where the robotic thymectomy stands nowadays. A thorough search of the PubMed revealed eighty-two related articles which reviewed comprehensively. The zero intraoperative mortality, the minimal intraoperative morbidity, as well as the recorded recurrence rate of 0-11.1% and complete stable remission rate of 0-40% suggests that the robotic-assisted thymectomy is a feasible, safe and an upcoming procedure. However, the lack of prospective randomized controlled trials prevents this technique to become the standard approach for the nonce.

Robotic Resection of 3 cm and Larger Thymomas Is Associated With Low Perioperative Morbidity and Mortality

OBJECTIVE

The approach to thymoma resection has usually been determined by tumor size, although established guidelines do not exist. Minimally invasive approaches have been limited to tumors smaller than 5 cm, although 3 cm has been the suggested cutoff for performing an adequate oncologic procedure. No study has compared the perioperative outcomes of patients with 3 cm or larger tumors resected robotically versus sternotomy.

METHODS

We reviewed patients who underwent resection of 3 cm or larger thymomas from 2004 to 2014. Patients were divided based on approach: robotic and open thymectomy/thymomectomy.

RESULTS

Forty patients with tumors ranging from 3 to 13 cm were evaluated, 23 robotic and 17 open. Patient and tumor characteristics were similar. An R0 resection was primarily achieved: robotic, 91% (21/23); and open, 88% (15/17); P = 0.832. Adjuvant radiation rates were statistically equivalent: robotic, 17% (4/23) versus open, 41% (7/17); P = 0.191. Major postoperative complications were comparable: robotic, 4% (1/23) versus open, 29% (4/17); P = 0.184. Median chest tube duration was shorter for robotic (1 day) versus open (3 days); P = 0.001. The robotic approach had a shorter median intensive care unit stay compared to open (0 days vs 1 day); P = 0.024. The median hospital stay was shorter for robotic (2 days) versus open (5 days); P < 0.001.

CONCLUSIONS

In 3 cm or larger thymomas, robotic thymectomy is feasible based on the ability to achieve a complete resection with similar adjuvant radiation therapy rates. Perioperatively, robotic thymectomy is associated with lower morbidity; and shorter chest tube duration, intensive care unit stay, and hospital stay compared to open. However, oncologic outcomes are immature and require prolonged surveillance.

Robotic thymectomy

Thymectomy is the most frequent surgical operation involving the mediastinum, both for the treatment of thymic tumors and for the multidisciplinary management of myasthenia gravis (MG). Different surgical approaches have been described, either traditional open approaches or minimally invasive ones. Robotic thymectomy represents a further step in the evolution of minimally invasive surgery. Available data show that robotic thymectomy may be considered a safe and feasible operation, with encouraging long-term results in myasthenic patients and promising results in patients with early stage thymoma, both in terms of surgical and oncological outcomes. We present the surgical technique of robotic thymectomy that we apply for patients affected by myasthenia gravis and early stage thymoma.

Robotic-assisted thymectomy: current perspectives

Thymectomy is the cornerstone in the treatment of thymic tumors and an accepted option for the management of myasthenia gravis. Different surgical approaches have been described, but the gold standard is represented by median sternotomy. In the last two decades, the development of minimally invasive surgery has led to an increased acceptance of thymectomy, especially for benign diseases. Robotic thymectomy seems a further step in the development and evolution of minimally invasive approaches. Since its introduction, different authors described their experience with robotic thymectomy, both for nonthymomatous myasthenia gravis and for thymic tumors. Available data show that robotic thymectomy may be considered a safe and feasible operation. In patients with nonthymomatous myasthenia, robotic thymectomy is effective and the long-term results are encouraging. The role of robotic thymectomy in patients affected by thymoma is still under evaluation, but the intermediate results seem promising both in terms of surgical and oncologic outcomes.