Video-Assisted Thoracoscopic Surgery versus Robotic-Assisted Thoracoscopic Surgery Thymectomy

Comparison of transfusion rates between robotic- and video-assisted lobectomy: a propensity score matching analysis

The objective is to compare the perioperative blood transfusion rate and postoperative complications between robot-assisted surgery and thoracoscopic surgery in lung cancer patients. This is a single-center retrospective study. Patients underwent lung cancer minimally invasive resection at Fujian Cancer Hospital from April 1, 2022, to April 30, 2023, were enrolled in this study. Patients were divided into robotic-assisted lobectomy (RAL) and video-assisted lobectomy (VAL) groups according to the surgical methods. Data, including demographics, clinic variables, and endpoint outcomes were collected from the electronic medical record. Propensity score matching (PSM) was performed to analyze the baseline data of patients. The RAL group and the VAL group were matched 1:1. Then, the blood transfusion rates and short-term outcomes of the two groups were compared. A logistic regression was performed to analyze the independent risk factors of perioperative blood transfusion. A total of 558 patients were enrolled in this study. 166 of 558 patients were divided into the RAL group, and 392 patients were into the VAL group. A total of 118 patients were selected and analyzed following propensity score matching. After PSM, there was no difference in perioperative transfusion rates, including RBC transfusion and frozen plasma transfusion, between the VAL and RAL groups (P > 0.05). The RAL group had fewer days of drainage tubes (P = 0.036). There was no difference in other short-term outcomes, including the volume of thoracic drainage, the volume of intraoperative blood loss, the length of hospitalization, and the rate of postoperative pulmonary infection (P > 0.05). Volume of intraoperative blood loss, volume of thoracic drainage, and preoperative hemoglobin were independent risk factors of perioperative red blood cell or frozen plasma transfusion; however, RAL or VAL was not. The study showed that the rates of perioperative blood transfusion were comparable between RAL and VAL. RAL is superior for patient recovery in terms of short-term outcomes.

Robotic-assisted thoracoscopic surgery improves perioperative outcomes in overweight and obese patients with non-small-cell lung cancer undergoing lobectomy: A propensity score matching analysis

Background

The effectiveness of robotic‐assisted lobectomy (RAL) for patients with non–small‐cell lung cancer (NSCLC) has not been fully evaluated.

Methods

This retrospective study compared the perioperative outcomes of NSCLC patients who underwent RAL and video‐assisted lobectomy (VAL) using propensity score matching (PSM) analysis. Subgroup analyses were then performed.

Results

A total of 822 NSCLC patients (359 RAL cases and 463 VAL cases) were included, and there were 292 patients in each group after PSM. Compared with the VAL group, the RAL group had a significantly higher number of lymph nodes (LNs) harvested (10 vs. 8, p < 0.001) and more LN stations examined (6 vs. 5, p < 0.001). The operative duration (95 minutes vs. 115 minutes, p < 0.001) and intraoperative estimated blood loss (65 mL vs. 80 mL, p < 0.001) were significantly reduced, and the drainage volume on postoperative day (POD) 1 (240 mL vs. 200 mL, p < 0.001) and hospitalization costs (¥81084.96 vs. ¥66142.55, p < 0.001) were significantly higher in the RAL group. Subgroup analysis indicated that the incidence of postoperative complications (17.9% vs. 26.7%, p = 0.042) was significantly reduced in the RAL group for overweight and obese patients (body mass index [BMI] ≥24 kg/m²), which became insignificant in the BMI < 24 kg/m² subgroup (31.0% vs. 24.8%, p = 0.307).

Conclusion

RAL might have potential advantages in terms of lymph node assessment, reducing intraoperative blood loss, and shortening operation duration. Overweight and obese patients could benefit more from RAL because of reduced risk of postoperative complications.

Comparison of Early Postoperative Outcomes of Patients Undergoing Robot-Assisted and Transsternal Thymectomy

Objective: Robot-assisted thoracoscopic surgery (RATS) is a minimally invasive technique that has been used in thymectomy operations in recent years. Minimally invasive surgical techniques offer less postoperative pain, a shorter length of hospital stay, and faster recovery compared to conventional surgical techniques. In our study, we aimed to compare the outcomes of robotic and transsternal thymectomies by analyzing the operative and postoperative data of these two approaches. Methods: Twelve robotic thymectomy patients and 16 transsternal thymectomy patients who were operated on in our clinic in 2018 were included in the study. Results: There was no significant difference between the two groups in terms of operative time (p=0.231). The median chest tube duration was 1.5 [range, 1-2] days in robotic thymectomy and 2.5 [range, 1-3.75] days in transsternal thymectomy. However, there was no statistically significant difference between the two groups (p=0.082). The amount of chest tube drainage was significantly lower in the robotic thymectomy group (p=0.006). The length of hospital stay was also significantly shorter in robotic thymectomy patients (p<0.001). Conclusion: The amount of chest tube drainage was lower and the length of hospital stay was shorter in the robotic surgery compared to the transsternal approach. There was no significant difference between the two techniques in terms of operative time. Within today's minimally invasive surgical techniques, robotic thymectomy can be considered a practical, comfortable, and safe technique with better early postoperative outcomes. Keywords: Robot-Assisted Thymectomy, Thymectomy, Transsternal Thymectomy

Robotic assisted minimally invasive thymectomy with simultaneous bilateral thoracoscopy and contralateral phrenic nerve visualization

Background

Thoracoscopic approaches to thymectomy and anterior mediastinal mass resection has become increasingly common due to the potential for decreased blood loss and hospital length of stay. However, contralateral mediastinal and phrenic nerve visualization if often difficult from these unilateral approaches, which may affect the ability to achieve a full phrenic to phrenic dissection Herein, we present our early experience of robotic assisted minimally invasive thymectomy (RAMIT) with simultaneous bilateral thoracoscopy and contralateral phrenic nerve visualization.

Methods

This was a retrospective review of all sequential patients undergoing RAMIT with simultaneous bilateral thoracoscopy from January 2015 to May 2016. This study was approved by our Institutional Review Board (PRO15080367). Individual patient consent was waived.

Results

Twenty-six patients [median age 58 (range, 29-76) years] were included in this study. Sixteen operations were performed for anterior mediastinal mass, 7 for non-thymomatous myasthenia gravis, and 3 for concurrent myasthenia gravis and thymoma. Median blood loss and hospital stay were 25 mL (range, 3-150 mL) and 3 days (range, 2-8 days), respectively. Twenty-one (80.8%) patients experienced an uncomplicated hospital course. The highest graded complication by Clavien Dindo Classification was a grade III due to pleural effusion requiring drainage via pleural catheter. One patient experienced asymptomatic hemidiaphram palsy postoperatively. There were no 90-day postoperative deaths.

Conclusions

RAMIT with simultaneous bilateral thoracoscopy is a feasible approach that may allow for enhanced visualization and more complete thymic resection compared to existing unilateral minimally invasive operations. Comparative studies and long-term follow up are needed to adequately assess the potential benefits of RAMIT.

Median sternotomy versus minimally invasive thymectomy for early-stage thymoma: A systematic review and meta-analysis protocol

BACKGROUND

The completeness of resection is an important prognostic factor for early resectable thymoma. Since its inception 2 decades ago, median sternotomy has been recognized as the gold standard method for the treatment of all types and stages of thyomas. Minimally invasive surgical techniques, including video-assisted and robot-assisted surgery, have been rapidly developed as an alternative to traditional open approach surgery. Compared with traditional open approach surgery, minimally invasive approach has better cosmetic effect, faster improvement of lung function, reduction of surgical trauma, length of stay, and complications. We believe that this is an appropriate time and there is a need for a systematic, comprehensive, and objective assessment of the 2 surgical modalities in order to provide reliable evidence for clinicians to determine the best treatment for patients with early resectable thymoma.

METHODS

Pubmed (Medline), Web of Science, Embase, Cochrane Central Register of Controlled Trials, and Google Scholar will be searched for relevant randomized controlled trials (RCTs), quasi-RCTs, and Hi-Q (high quality) prospective cohort trials published or unpublished in any language before March 1, 2020. Subgroup analysis will be performed in tumor pathological stage and ethnicity. PROSPERO registration number: CRD42019133724.

RESULTS

The results of this study will be published in a peer-reviewed journal.

CONCLUSION

This study will be the first to assess the efficacy and safety of median sternotomy recognized as the gold standard method for the treatment of all types and stages of thyomas and minimally invasive thymectomy for patients with early-stage thymoma. This study will assess whether minimally invasive thoracoscopic and robotic assisted thymectomy can be used as an alternative to traditional median sternotomy for patients with early resectable thymoma and provide high-quality and reliable evidence for clinicians' decision-making.

Surgical approach to the substernal goiter

Surgery for substernal goiters can be technically demanding. Extensive mediastinal extension brings the thyroid gland into close quarters with vital intrathoracic structures. Proper preoperative planning is required to determine the potential need for an extracervical approach. Assessing the risk of requiring an extracervical approach is typically based on findings from cross-sectional imaging of the neck and chest. This article addresses the important anatomical considerations when resecting a large substernal goiter and also reviews various extracervical approaches.

Comparing robotic and trans-sternal thymectomy for early-stage thymoma: a propensity score-matching study

OBJECTIVES

Minimally invasive techniques seem to be promising alternatives to open approaches in the surgical treatment of early-stage thymoma, although there are controversies because of lack of data on long-term results. The aim of the study was to evaluate the surgical and oncological results after robotic thymectomy for early-stage thymoma compared to median sternotomy.

METHODS

Between 1982 and 2017, 164 patients with early-stage thymoma (Masaoka I and II) were operated on by median sternotomy (108 patients) or the robotic approach (56 patients). Duration of surgery, amount of blood loss, complications, duration of chest drainage, postoperative hospital stay, oncological results and total costs were retrospectively evaluated. Data were analysed also after propensity score matching.

RESULTS

Compared to the trans-sternal group, robotic thymectomy had significantly longer average operative times (P < 0.001) but less intraoperative blood loss (P = 0.01), less perioperative complications (P = 0.03), shorter time to chest drainage removal and hospital discharge (P < 0.001). The median expense for the trans-sternal approach was significantly higher than the cost of the robotic procedure (P < 0.001), mainly due to longer hospitalization. From an oncological point of view, there were no differences in thymoma recurrence, although follow-up of the trans-sternal group was significantly longer (P < 0.001). Data were confirmed after propensity score matching.

CONCLUSIONS

Robotic thymectomy for early-stage thymoma is a technically safe and feasible procedure with low complication rate and shorter hospital stay compared to the trans-sternal approach. Cost analysis revealed lower expenses for the robotic procedure due to the reduced hospital stay. The oncological outcomes seemed comparable, but longer follow-up is needed.

Results of Robotic Thymectomy Performed in Myasthenia Gravis Patients Older Than 60 Years at Onset

BACKGROUND

Data are limited on the safety and efficacy of robotic thymectomy in patients with myasthenia gravis (MG) older than 60 years at onset.

METHODS

Patients older than 60 years at MG onset who underwent robotic thymectomy in Charite Universitaetsmedizin Berlin between 2003 and 2017 were potentially eligible for inclusion. The main outcomes were perioperative complications and clinical outcome according to the Myasthenia Gravis Foundation of America Post-Intervention Status.

RESULTS

Sixty-eight (25 women, 43 men) of 580 patients with MG who underwent robotic thymectomy were eligible for perioperative analyses (median age at MG onset 67 years, range: 61 to 85 years). The perioperative morbidity rate was 13.2%, and the only perioperative death was due to aortic dissection. Fifty-one patients were available for further analysis with a median follow-up time of 60 months (range: 12 to 263 months). The complete stable remission rate was 7.8%, the improvement rate was 68.6%, and the overall mortality rate was 11.8%. Compared with preoperative use, the mean daily dose of corticosteroid agents was significantly reduced at the last follow-up (17.6 ± 23.6 mg versus 2.6 ± 6.1 mg, p = 0.0001) without increased use of azathioprine (35.9 ± 61.9 mg versus 42.7 ± 59 mg, p = 0.427). After excluding 2 patients seronegative for the anti-acetylcholine receptor antibody, 10 of 49 seropositive patients achieved "good outcome" (including four complete stable remissions, three pharmacologic remissions, and three minimal manifestations 0) which was predicted by being free of concomitant disease (odds ratio 7.307, 95% confidence interval: 1.188 to 44.937, p = 0.032) and Myasthenia Gravis Foundation of America classification I before thymectomy (odds ratio 6.696, 95% confidence interval: 1.259 to 35.620, p = 0.026).

CONCLUSIONS

Robotic thymectomy seems to be safe and effective in patients with MG older than 60 years at onset with a statistically significant steroid-sparing effect.

Video-Assisted Thoracoscopic Versus Robotic-Assisted Thoracoscopic Thymectomy: Systematic Review and Meta-analysis

OBJECTIVE

Minimally invasive thoracic surgical procedures, performed with or without the assistance of a robot, have gained popularity over the last decade. They have increasingly become the choice of intervention for a number of thoracic surgical operations. Minimally invasive surgery decreases postoperative pain, hospital stay and leads to a faster recovery in comparison with conventional open methods. Minimally invasive techniques to perform a thymectomy include video-assisted thoracoscopic surgery (VATS) or robotic-assisted thoracoscopic surgery (RATS). In this study, we aim to systematically review and interrogate the literature on minimally invasive thymectomy and draw a meta-analysis on the outcomes between the two approaches.

METHODS

An extensive electronic health database search was performed on all articles published from inception to May 2015 for studies describing outcomes in VATS and RATS thymectomy.

RESULTS

A total of 350 patients were included in this study, for which 182 and 168 patients underwent RATS and VATS thymectomy, respectively. There were no recorded in-hospital deaths for either procedure. There was no statistical difference in conversion to open, length of hospital stay, or postoperative pneumonia. Operational times for RATS thymectomy were longer.

CONCLUSIONS

The VATS and RATS thymectomy offer good and safe operative and perioperative outcomes. There is little difference between the two groups. However, there is poor evidence basis for the long-term outcomes in minimally invasive procedures for thymectomy. It is imperative that future studies evaluate oncological outcomes both short and long term as well as those related to safety.

Clinical features, diagnosis and thoracoscopic surgical treatment of thymic cysts

Background

Thymic cysts are rare benign developmental anomalies and there is no consensus management for thymic cysts. The aim of this study was to disclose the efficacy of perioperative diagnosis for thymic cysts by chest computerized tomography (CT) and to elucidate the surgical procedure by video-assisted thoracic surgery (VATS) in the management of thymic cysts.

Methods

We retrospectively reviewed 108 consecutive thymic cyst patients who underwent VATS at our institution between April 2001 and August 2015. All patients received chest CT preoperatively and underwent VATS treatment. Clinical characteristics, imaging features and surgical exploration were taken into consideration to determine the surgical extent.

Results

Multivariate logistic regression analysis showed that a diameter ≤3 cm [risk ratio (RR) =4.525; 95% confidence interval (CI), 1.027-20.000; P=0.046] and an unenhanced CT value >20 Hounsfield unit (Hu) (RR =7.043; 95% CI, 1.750-28.345; P=0.006) were independent factors of incorrect diagnosis of chest CT. Three different surgical procedures were performed, which included thymectomy (n=49), cyst resection and partial thymectomy (n=46), and extended thymectomy (n=13). No serious postoperative complications were observed. The median follow-up-time was 60.6 months (range, 12.0-168.0 months) with no late complications or recurrences.

Conclusions

A diameter ≤3 cm and an unenhanced CT value >20 Hu were independent factors of incorrect diagnosis of chest CT. VATS is a reliable approach for the surgical resection of thymic cysts. We think that local resection is adequate for simple thymic cysts. However, thymectomy is necessary when there is suspicion of a thymoma or multilocular thymic cyst, and radical thymectomy is advisable for patients with autoimmune diseases.

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.

Thoracoscopic thymectomy is a feasible and less invasive alternative for the surgical treatment of large thymomas

OBJECTIVES

Thoracoscopic surgery is widely used for the surgical treatment of thymoma. However, large-sized thymomas are typically treated using open surgery. This study evaluated the feasibility of performing thoracoscopic thymectomy (TT) for thymoma ≥50 mm.

METHODS

A retrospective review was conducted on 135 patients who underwent TT or open thymectomy (OT) for Masaoka stage I-IVa thymoma between 1996 and 2014.

RESULTS

Patients were first divided into two groups based on thymoma size: thymoma ≥50 mm and thymoma <50 mm groups. There was no significant difference in the 5-year disease-free survival (DFS) between the groups ( P  = 0.5352). Patients in the thymoma ≥50 mm group were further subdivided into TT and OT groups. The length of postoperative hospital stay was significantly shorter in the TT group than in the OT group (5 vs 14 days, P  < 0.0001), with significantly fewer postoperative complications (6 patients vs 14 patients, P  = 0.0008). There was no significant difference in the 5-year DFS between patients with thymoma ≥50 mm in the TT and OT groups ( P  = 0.3501). Finally, patients undergoing TT were further subdivided into thymoma ≥50 mm and thymoma <50 mm groups and, no significant difference in the 5-year DFS was found between these groups ( P  = 0.6661). Masaoka stages III-IV, but not thymoma size, were an independent prognostic factor for DFS.

CONCLUSIONS

These results demonstrate the decreased invasiveness and feasibility of TT for large-sized thymomas.

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.

[Thymomectomy by minimally invasive surgery. Comparative study videosurgery versus robot-assisted surgery]

OBJECTIVES

To report the results of minimally invasive surgery in patients with stage I or II thymoma in the Masaoka classification. The reference technique is partial or complete thymectomy by sternotonomy.

METHODS

A retrospective single-center study of a prospective database including all cases of thymoma operated from April 2009 to February 2015 by minimally invasive techniques: either videosurgery (VATS) or robot-assisted surgery (RATS). The surgical technique, type of resection, length of hospital stay, postoperative complications and recurrences were analysed.

RESULTS

Our series consisted of 22 patients (15 women and 7 men). The average age was 53 years. Myasthenia gravis was present in 12 patients. Eight patients were operated on by VATS and 14 patiens by RATS. There were no conversions to sternotomy and no perioperative deaths. The mean operating time was 92min for VATS and 137min for RATS (P<0.001). The average hospital stay was 5 days. The mean weight of the specimen for the VATS group was 13.2 and 45.7mg for the RATS group. Twelve patients were classified Masaoka stage I and 10 were stage II. According to the WHO classification there were 7 patients type A, 5 type AB, 4 type B1, 4 type B2 4 and 2 type B3. As proposed by the Group ITMIG-IASLC in 2015 all patients corresponded to group I. The mean follow-up period was 36 months. We noted 3 major perioperative complications according to the Clavien-Dindo classification: one pneumonia, one phrenic nerve paralysis and one recurrent laryngeal nerve palsy. We observed one case of local recurrence at 22 months. Following surgery 4 patients were treated with radiotherapy and 2 patients with chemotherapy.

CONCLUSIONS

The minimally invasive route is safe, relatively atraumatic and may be incorporated in the therapeutic arsenal for the treatment of Masaoka stage I and II thymoma as an alternative to conventional sternotomy. RATS and VATS are two minimally invasive techniques and the results in the short and medium term are acceptable. The clinical advantages of one over the other are sifficult to establish. RATS could handle larger and more complex lesions in view of the weight and size of the operating instrument.

Minimally Invasive versus Open Thymectomy for Thymic Malignancies: Systematic Review and Meta-Analysis

Complete resection is the standard of care for treatment of thymic malignancies. The use of minimally invasive surgery remains controversial. We searched online databases and identified studies from 1995 to 2014 that compared minimally invasive to open thymectomy for thymic malignancies. Study end points included operative blood loss, operative time, respiratory complications, cardiac complications, length of hospital stay, R0 resection, and recurrence. We summarized outcomes across studies using random-effects meta-analysis to account for study heterogeneity. We calculated ORs for binary outcomes and standardized mean differences for continuous outcomes. We calculated incidence rate ratios for the number of recurrences, accounting for total person-time observed in each study. Of 516 potential reference studies, 30 with a total of 2038 patients met the inclusion criteria. Patients with Masaoka stage I or II thymic malignancy constituted 94.89% of those in the minimally invasive surgery (MIS) group and 78.62% of those in open thymectomy (open) group. Mean tumor size was 4.09 cm (MIS) versus 4.80 (open). Of the 1355 MIS cases, 32 were converted to open cases. Patients in the MIS group had significantly less blood loss; however, no significant differences in operating time, respiratory complications, cardiac complications, or overall complications were identified. Length of stay was shorter for patients in the MIS group. When patients with Masaoka stage I and II thymic malignancy only were analyzed, there was no difference in rate of R0 resection or overall recurrence rate. One postoperative death occurred in the open group. The results of this unadjusted meta-analysis of published reports comparing minimally invasive with open thymectomy suggest that in selected patients with thymic malignancy, minimally invasive thymectomy is safe and can achieve oncologic outcomes similar to those of open thymectomy.

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.

The clinical features, diagnosis and management of recurrent thymoma

Thymoma is a disease with malignant potential, which has a recurrence rate after complete resection ranging from 5 to 50 %. Multiple studies on the risk factors, treatment or prognosis have been reported. Many of them are controversial, however. In this review, we summarized some accepted risk factors, means of diagnosis and different treatments of recurrent thymoma. The risk factors of recurrent thymoma haven’t been well-studied, and its management remains controversial. We reviewed the literatures and found some key points which should be noticed during the surgery of initial thymoma. Although reoperation should be taken into account preferentially, multimodal treatments are also available. The prognosis are also been discussed.

Robotic thymectomy

Robotic thymectomy is an increasingly used modality. Patients who are candidates for traditional, open thymectomy are typically also candidates for robotic thymectomy, with the exception of patients with invasion of great vessels. Knowledge of and training on the robotic platform is critical for success. Patient and port positioning is described. Critical steps during robotic thymectomy include attention to careful division of the thymus off the innominate vein, and complete retrieval of bilateral superior horns of the gland. Robotic thymectomy may be performed with excellent perioperative and long-term outcomes for both neoplastic and non-neoplastic indications.

Clinical outcomes of CO2-less single-port video-assisted thoracoscopic thymectomy versus open thymectomy: comparative study

BACKGROUND

Although video-assisted thoracoscopic surgery (VATS) for thymic disorders has been introduced, its oncological outcome and benefits over others open approaches remains unclear. Single-port VATS thymectomy using a flexible port and CO₂ has been described. However, VATS thymectomy is possible by a single incision of 3 cm without CO₂ insufflation or special port device avoiding objections related to CO₂ insufflation and allowing instruments to move more freely making procedure easier and cheaper. Our institutional experience in open and CO₂-less VATS single-port thymectomy was retrospectively reviewed to evaluate compared to sternotomy, the clinical and oncological outcomes with this novel approach.

METHODS

A retrospective review consisting of 84 patients who underwent thymectomy because different thymic disorders especially thymoma was performed. Eighteen patients underwent CO₂-less VATS single port thymectomy, while 66 underwent thymectomy through open sternotomy. Many clinical factors associated with the surgical and clinical outcomes, including tumor recurrence and clinical remission, were recorded.

RESULTS

Non major postoperative complications were observed in any group. The median operative time and postoperative hospital stay of CO₂-less VATS single port thymectomy were 95 min and 1 day, respectively and 120 min and 7 days for open sternotomy. The thymoma was the most common thymic disorder with 7 patients (38%) in VATS group and 28 patients (42.4%) for the open approach. The median lesion size was 2.6 cm in the VATS group and 3.2 cm in the open approach. No thymoma recurrence in patients undergoing VATS was observed during the follow-up time, while in the open surgery group 14.28% recurrence was observed, distributed as follows: loco-regional 75% and 25% at distance; free disease period of these patients was 8.3 months. Thymectomy associated with myasthenia gravis (MG) was observed in 6 (33%) patients in the VATS group and 32 (48%) patients for sternotomy; our results regarding thymectomy for the treatment of MG were established by the MG post-intervention status [complete stable remission (CSR), pharmacologic remission, minimal manifestations, improved, unchanged and worse exacerbation, and died of MG] and reflected similar results in both approaches.

CONCLUSIONS

CO₂-less VATS single-port thymectomy is a feasible and safe procedure. Oncologic outcomes are similar to open approaches. Complications, surgical time and hospital stay are shorter compared with sternotomy. This is an initial experience, further work is required to evaluate long-term results.

Feasibility of thoracoscopic thymectomy for treatment of early-stage thymoma

INTRODUCTION

The objective of this study was to evaluate the feasibility of thoracoscopic thymectomy (TT) for treatment of early-stage thymoma and to compare the outcomes with those after open thymectomy (OT).

METHODS

A retrospective review of 98 patients who underwent TT or OT of Masaoka stage I-II thymoma without thymic cancer between 1996 and 2013 was performed.

RESULTS

Thoracoscopic thymectomy was performed in 67 patients, and OT was performed in 31 patients. The intraoperative blood loss amounts differed significantly between the TT group and OT group (100 vs 185 mL, P = 0.0070). The postoperative hospital stay was significantly shorter in the TT group than in the OT group (4 vs 12 days, P < 0.0001). No patient in the TT group underwent conversion to open surgery, and no surgical complications, such as massive bleeding, were observed. Two patients experienced recurrence in the TT group during the median postoperative follow-up period of 65 months. No significant differences were found in the 5-year disease-free survival rates between the two groups. There were no significant differences in disease-free survival as classified by Masaoka stage, World Health Organization type, and the extent of resection of the thymus.

CONCLUSION

Our outcome showed that TT largely reduced the degree of invasiveness. The outcome was not inferior to that of OT. The results primarily demonstrated the feasibility of TT for treatment of early-stage thymoma.

Robotic-Assisted Videothoracoscopic Mediastinal Surgery

BACKGROUND

Tumors of the mediastinum as well as normal thymus glands in patients with myasthenia gravis have traditionally been resected using large and morbid incisions. However, robotic-assisted mediastinal resections are gaining popularity because of the many advantages that the robot provides. However, few comprehensive reviews of the literature on robotic-assisted mediastinal resections exist.

METHODS

A systemic review of the current medical literature was performed, excluding cases related to esophageal pathology. These studies were evaluated and their findings are reported in this comprehensive review. Approximately 48 papers met the inclusion criteria for review.

RESULTS

Robotic-assisted surgical systems are increasingly being used in mediastinal resections. Based on the available literature, robotic-assisted thoracoscopic surgery in the mediastinum is feasible and safe. Robotic-assisted mediastinal surgery appears to be superior to open approaches of the mediastinum and is comparable with videothoracoscopic surgery when patient outcomes are considered.

CONCLUSIONS

Increased robotic experience and more studies, including randomized controlled trials, are needed to validate the findings of the current literature.

State of the art of robotic thymectomy

BACKGROUND

Thymectomy is a widely accepted treatment for most cases of myasthenia gravis and essential for the treatment of thymoma. The development of a minimally invasive procedure for thymectomy resulted in a variety of approaches for surgery on the thymic gland. The use of thoracoscopy-based techniques has continued to increase, including the latest advance in this field, robotic thymectomy.

METHODS

We review the rapid development and actual use of this approach by examining published reports, worldwide registries, and personal communications and by analyzing our database, which is the largest single-center experience and contains 317 thymectomies until 12/2012. The technical modifications of robotic thymectomy are also described.

RESULTS

Since 2001, approximately 3,500 robotic thymectomies have been registered worldwide. Meanwhile, the results of approximately 500 thymectomy cases have been published. Robotic thymectomy is performed most frequently through a standardized unilateral three-trocar approach. All reports describe promising and satisfactory results for myasthenia gravis. For early-stage thymoma, robotic thymectomy is a technically sound and safe procedure with a very low complication rate and short hospital stay. Oncological outcome without recurrences is promising, but a longer follow-up is needed.

CONCLUSION

The unilateral robotic technique can be considered an adequate approach for thymectomy, even with demanding anatomical configurations. Robotic thymectomy has spread worldwide over the last decade because of the promising results in myasthenia gravis and thymoma patients.

Robotic thoracic surgery: The state of the art

Minimally invasive thoracic surgery has come a long way. It has rapidly progressed to complex procedures such as lobectomy, pneumonectomy, esophagectomy, and resection of mediastinal tumors. Video-assisted thoracic surgery (VATS) offered perceptible benefits over thoracotomy in terms of less postoperative pain and narcotic utilization, shorter ICU and hospital stay, decreased incidence of postoperative complications combined with quicker return to work, and better cosmesis. However, despite its obvious advantages, the General Thoracic Surgical Community has been relatively slow in adapting VATS more widely.

The introduction of da Vinci surgical system has helped overcome certain inherent limitations of VATS such as two-dimensional (2D) vision and counter intuitive movement using long rigid instruments allowing thoracic surgeons to perform a plethora of minimally invasive thoracic procedures more efficiently.

Although the cumulative experience worldwide is still limited and evolving, Robotic Thoracic Surgery is an evolution over VATS. There is however a lot of concern among established high-volume VATS centers regarding the superiority of the robotic technique. We have over 7 years experience and believe that any new technology designed to make minimal invasive surgery easier and more comfortable for the surgeon is most likely to have better and safer outcomes in the long run. Our only concern is its cost effectiveness and we believe that if the cost factor is removed more and more surgeons will use the technology and it will increase the spectrum and the reach of minimally invasive thoracic surgery.

This article reviews worldwide experience with robotic thoracic surgery and addresses the potential benefits and limitations of using the robotic platform for the performance of thoracic surgical procedures.

Experience with the "da Vinci" robotic system for early-stage thymomas: Report of 23 cases

BACKGROUND

The aim of this study was to report a single referral center experience in robotic extended thymectomy for clinical early stage thymomas, evaluating its safety, feasibility and efficacy, with special regard to oncological outcomes.

METHODS

Between January 2009 and December 2012, we retrospectively selected patients who underwent robotic extended thymectomy for clinical early stage thymomas. Operative time, morbidity, mortality, duration of hospitalization, and overall and disease-free survival were analyzed.

RESULTS

There were 23 patients (15 males, eight females) with a mean age of 49.3 years (range 20-66). There were no intra-operative complications, and no mortality. The mean operative time was 85.2 minutes (range 60-180). No patient underwent conversion to open surgery. All post-operative complications (4.3%) were conservatively treated. The mean post-operative stay was 3.6 days (range two to nine). The pathological analysis revealed Masaoka stage I (21 cases) and II (two cases). No disease recurrence occurred at a mean follow-up of 24.8 months.

CONCLUSIONS

Robotic thymectomy is a safe and feasible technique, with a short operative time and low morbidity. Even on a small series with short follow-up, robotic extended thymectomy for thymoma appeared to be an effective treatment for early-stage thymomas.

Comparative study of video-assisted thoracic surgery versus open thymectomy for thymoma in one single center

BACKGROUND

Due to the popularity of video-assisted thoracic surgery (VATS) techniques in clinical, thymoma patients via VATS thymectomy are increasing rapidly. However, compared with open thymectomy, the potential superiorities and defects of VATS thymectomy remain controversial.

METHODS

A number of 129 patients who underwent thymectomy of early stage thymoma (Masaoka stage I and stage II) in one single center from January 2007 to September 2013 were selected in this retrospective study. Of those patients, 38 thymoma patients underwent VATS thymectomy (VATS group) and 91 underwent open thymectomy (open group) via either transsternal [44] or transthoracic approach [47] in the same period. The postoperative variables, which included postoperative hospital length of stay (LOS), the intensive care unit (ICU) LOS, the entire resection ratio, the number of thoracic drainage tubes, the quantity of output and duration of drainage, were analyzed. Meanwhile, the operation time and blood loss were considered as intraoperative variables.

RESULTS

All thymoma patients in the analysis included 19 thymoma patients with myasthenia gravis, among which five patients via VATS thymectomy and 14 patients via open thymectomy respectively. There was no death or morbidity due to the surgical procedures perioperatively. The ICU LOS, operation time, entire resection ratio, and the number of chest tubes were not significantly different in two groups. The postoperative hospital LOS of VATS thymectomy was shorter than that of open thymectomy (5.26 versus 8.32 days, P<0.001). The blood loss of VATS thymectomy was less than open thymectomy (114.74 versus 194.51 mL, P=0.002). Postoperatively, the quantity of chest tubes output in VATS group was less than that in open thymectomy group (617.86 versus 850.08 mL, P=0.007) and duration of drainage in VATS group was shorter than that in open thymectomy group (3.87 versus 5.22 days, P<0.001).

CONCLUSIONS

VATS thymectomy is a safe and practicable treatment for early-stage thymoma patients. Thymoma according with Masaoka staging I-II without evident invading seems to be performed through VATS approach appropriately, which has shorter postoperative hospital LOS, less blood loss and less restrictions to activities, hence patients will recover sooner.

Thoracoscopic versus robotic approaches: advantages and disadvantages

The overall advantages of thoracoscopy over thoracotomy in terms of patient recovery have been fairly well established. The use of robotics, however, is a newer and less proven modality in the realm of thoracic surgery. Robotics offers distinct advantages and disadvantages in comparison with video-assisted thoracoscopic surgery. Robotic technology is now used for a variety of complex cardiac, urologic, and gynecologic procedures including mitral valve repair and microsurgical treatment of male infertility. This article addresses the potential benefits and limitations of using the robotic platform for the performance of a variety of thoracic operations.

Robotic thymectomy for myasthenia gravis

Robotic thymectomy with the da Vinci robotic system is the latest development in the surgery of thymic gland. Thymectomy for myasthenia gravis is best offered to patients with seropositive acetylcholine receptor antibodies and who are seronegative for muscle-specific kinase protein. The robotic operation technique is indicated in all patients with myasthenia gravis in association with a resectable thymoma, typically Masaoka-Koga stages I and II.

Robotic-assisted thoracoscopic resection of a benign anterior mediastinal teratoma

There is an emerging body of evidence to support robotic-assisted mediastinal surgery, particularly for thymectomy. We describe the case of a 42-year-old woman with a benign anterior mediastinal teratoma resected by robotic-assisted thoracoscopy. This case illustrates the use of robotic-assisted surgery in a less commonly encountered mass of the anterior mediastinum.

Surgical treatment of early-stage thymomas: robot-assisted thoracoscopic surgery versus transsternal thymectomy

BACKGROUND

This study aimed to compare the perioperative outcomes for patients who underwent transsternal or robot-assisted thymectomy and to determine the feasibility of robot-assisted thymectomy for the treatment of Masaoka stages 1 and 2 thymomas.

METHODS

The study evaluated the short-term outcomes for 74 patients undergoing surgery for Masaoka stages 1 and 2 thymomas without myasthenia gravis between January 2009 and December 2012. Of these 74 patients, 23 underwent thymoma resection using unilateral robot-assisted thoracoscopic surgery (RATS group), and 51 underwent transsternal thymectomy (TST group). Duration of surgery, amount of intraoperative blood loss, duration of chest drainage, duration of postoperative hospital stay, and postoperative complications were evaluated.

RESULTS

The intraoperative blood loss was significantly less in the RATS groups (61.3 ml) than in the TST group (466.1 ml) (p < 0.01). The postoperative hospital stay was significantly shorter in the RATS group (3.7 vs 11.6 days; p < 0.01). No patients in the RATS group underwent conversion to open surgery. No severe surgical complications (e.g., bleeding caused by injury to the left brachiocephalic vein) and only one case of pulmonary atelectasis (appearing in a male patient 2 days after surgery) were detected in this series.

CONCLUSION

Robot-assisted thoracoscopic thymectomy for early-stage thymomas is technically feasible, safe, and less invasive for the patient.

Video-assisted thoracoscopic surgery versus robotic-assisted thoracoscopic surgery in the surgical treatment of Masaoka stage I thymoma

Background

The purpose of this study was to compare perioperative outcomes in patients who underwent video-assisted thoracoscopic surgery or robot-assisted thoracoscopic surgery and assess the feasibility of robotic-assisted thymectomy for the treatment of Masaoka stage I.

Methods

We evaluated the short-term outcomes of 46 patients who underwent surgery for Masaoka stage I thymoma without myasthenia gravis between January 2009 and June 2012. Of these patients, 25 received unilateral video-assisted thoracoscopic surgery (VATS group) and the rest 21 recieved unilateral robotic-assisted thoracoscopic surgery (RATS group). We evaluated the duration of surgery, amount of intraoperative blood loss, duration of chest drainage, duration of postoperative hospital stay, hospitalization costs, postoperative complications and oncological outcomes.

Results

The duration of surgery was not significantly different between the two groups. Intraoperative blood loss volumes did not differ significantly between the VATS and RATS groups (86.8 mL and 58.6 mL, respectively; P=0.168). The postoperative hospital stay was significantly shorter in the RATS group (3.7 days vs. 6.7 days; P <0.01), and the postoperative pleural drainage volume of the RATS group was significantly less than VATS group (1.1 days vs. 3.6 days; P <0.01). No patients in the RATS group needed conversion to open surgery. However, in the VATS series, one patient had conversion to an open procedure. No surgical complications were observed except that one case had pulmonary atelectasis in the RATS group and one case developed pneumonia after surgery. Use of robot is much more expensive than video. No early recurrence was observed in both groups.

Conclusions

Robotic thymectomy is feasible and safe for Masaoka stage I thymoma. RATS is equally minimally invasive as VATS and results in a shorter drainage period and reduced hospital stay compared with the VATS approach.

Video-assisted thymectomy with contralateral surveillance camera: a means to minimize the risk of contralateral phrenic nerve injury

OBJECTIVE

Thymectomy for thymoma has traditionally been performed through midsternotomy that provides excellent exposure for a complete and safe resection. Minimally invasive alternatives have not been extensively evaluated for this disease process because data regarding the long-term oncologic effectiveness of these techniques remain to be established. Furthermore, video-assisted surgery as a unilateral approach may compromise the extension of the resection and could cause irreversible damage to the phrenic nerve of the opposite side. We evaluated the clinical feasibility and safety of a bilateral concomitant video-assisted approach with contralateral surveillance camera in patients undergoing thymectomy for thymoma.

METHODS

Four patients (3 females, 1 male) with thymoma causing myasthenia gravis (MG) were operated thoracoscopically at our institute under general anesthesia with double-lumen endotracheal intubation. The patients were placed in a supine position, and a 5-mm 30-degree lens thoracoscope was introduced into the left pleural space. Two other 10-mm working channels were applied. En bloc thymectomy was then performed, including mediastinal and pericardial fat pads, other tissue, and pleura from the level of the thoracic inlet to the diaphragm. A second 5-mm thoracoscope was inserted into the right hemithorax, and it was kept inside during the entire procedure to allow lateral surveillance of the extension and safety of the resection. Carbon dioxide insufflation and valved ports were used.

RESULTS

The duration of the operation was 90 ± 72 minutes. Complete resection was achieved in all patients without any nerve injury. There were no perioperative adverse events. Gradual remission from extremity and ocular weakness was achieved after recovery.

CONCLUSIONS

The ultimate surgical goal of thymectomy is to completely remove the gland and anterior mediastinal tissue without nerve injury. Bilateral concomitant video-assisted thoracic thymectomy with a contralateral surveillance camera was found feasible and safe. Given the capability of our technique to perform a complete and extensive thymectomy associated with less invasiveness and beneficial effects, there seems to be a role for minimally invasive thymectomy in the treatment of thymoma.

Minimally invasive thoracic surgery in pediatric patients: the Taiwan experience

Minimally invasive technology or laparoscopic surgery underwent a major breakthrough over the past two decades. The first experience of thoracoscopy in children was reported around 1980 for diagnosis of intrathoracic pathology and neoplasia. Up until the middle of the 1990s, the surgical community in Taiwan was still not well prepared to accept the coming era of minimally invasive surgery. In the beginning, laparoscopy was performed in only a few specialties and only relatively short or simple surgeries were considered. But now, the Taiwan's experiences over the several different clinical scenarios were dramatically increased. Therefore, we elaborated on the experience about pectus excavatum: Nuss procedure, primary spontaneous hemopneumothorax, thoracoscopic thymectomy, and empyema in Taiwan.

Oncological outcomes of thoracoscopic thymectomy for the treatment of stages I-III thymomas

OBJECTIVES

Thoracoscopic thymectomy has gradually replaced conventional sternotomy for resection of thymoma; however, a thoracoscopic approach for thymoma remains controversial. We evaluated the oncological outcomes of thoracoscopic thymectomy for the treatment of stages I-III thymomas.

METHODS

Sixty-two patients who underwent thoracoscopic thymectomy for the treatment of thymoma were retrospectively reviewed between July 2005 and September 2011 at Jikei University Hospital. Surgical outcomes and pathological results between stages I+II and stage III were compared.

RESULTS

Twenty-nine patients had Masaoka stage I, 28 had stage II and 5 had stage III. Three stage III patients needed conversions to open surgery. Masaoka stage III comprised pathological type B3 in 3 patients and thymic carcinoma in 2. For all patients, the 5-year overall survival rate was 100%. Three recurrences, diagnosed as thymic carcinoma, were observed in the Masaoka stage II or III patients. The 5-year disease-free survival rate was 94.2% for all patients, 100% for Masaoka stage I, 96.1% for stage II and 37.5% (55 months) for stage III (P=0.002). The 5-year disease-free survival rate was 100% for the World Health Organization classification types A, AB and B1-3 and 0% for thymic carcinoma (P<0.0001). Significant differences were found in the 5-year disease-free survival stratified by the Masaoka stage or WHO classification, but not by surgical procedures.

CONCLUSIONS

Thoracoscopic thymectomy for Masaoka stages I and II thymomas presented acceptable oncological outcomes. Further investigation in a large series with longer follow-up is required. Masaoka stage III thymoma requires careful consideration of the approaches, including median sternotomy.

Robot-assisted thoracoscopic surgery: current status and prospects

The most favorable advantage of robotic surgery is the markedly free movement of joint-equipped robotic forceps under 3-dimensional high-vision. Accurate operation makes complex procedures straightforward, and may overcome weak points of the previous thoracoscopic surgery. The efficiency and safety improves with acquiring skills. However, the spread of robotic surgery in the general thoracic surgery field has been delayed compared to those in other fields. The surgical indications include primary lung cancer, thymic diseases, and mediastinal tumors, but it is unclear whether the technical advantages felt by operators are directly connected to merits for patients. Moreover, problems concerning the cost and education have not been solved. Although evidence is insufficient for robotic thoracic surgery, it may be an extension of thoracoscopic surgery, and reports showing its usefulness for primary lung cancer, myasthenia gravis, and thymoma have been accumulating. Advancing robot technology has a possibility to markedly change general thoracic surgery.

Robotic-assisted thymectomy with Da Vinci II versus sternotomy in the surgical treatment of non-thymomatous myasthenia gravis: early results

BACKGROUND

The role of thymectomy in myasthenia gravis remains controversial. The remission rate 5years after surgery varies from 13 to 51% in the literature. Sternotomy is the standard technique, though unacceptable by patients because of significant esthetic sequelae. Our objective was to demonstrate that the robot-assisted technique using the Da Vinci Surgical Robot II is at least as efficient and leaves fewer scars than the standard surgical technique.

METHODS

We retrospectively reviewed the data of 31 consecutive patients suffering from myasthenia gravis who underwent surgery in our center from January 1998 to March 2010. Ten patients with thymoma were excluded from this study. Two groups were formed: group 1 corresponding to patients treated with sternotomy, group 2 patients with robot-assisted technique. The duration of the hospital stay, the pain on D1, the degree of improvement at 1year according to Myasthenia Gravis Foundation of America (MGFA) classification, the frequency of relapses, and perioperative treatment were studied.

RESULTS

Our sample consisted of 14 women and seven men. The mean age was 31.3years. The mean delay before surgery was 24months. Group 1 included 15 patients and group 2 had six patients. The complete remission rate at 1year was 9.5% (n=2). Surgery decreased the frequency of relapses after surgery (P=0.08) equally in the two groups. The duration of hospital stay and the pain level on D1 in group 2 were significantly lower than those in group 1 (P=0.02 and P<0.001). The degree of postoperative improvement was not significantly different between the two groups (P=0.31).

CONCLUSION

The results at 1year are fully comparable for sternotomy and the robot-assisted technique. The robot provides additional benefits of minimally invasive techniques: minimal esthetic sequelae in often young patients, less parietal morbidity (including pain), shorter hospital stays. Our complete remission rate, lower than those in the literature, must be considered taking into account the early nature of these results. The surgical robot, because of its many advantages, appears to be a promising technique and should facilitate the early management of these patients.