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Fukui M, Hayashi T, Matsunaga T, Hattori A, Takamochi K, Oh S, Suzuki K. Distribution of Ectopic Thymus Tissue Present Within Extended Thymectomy. Indian J Surg 2023. [DOI: 10.1007/s12262-023-03682-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
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Anesthetic Management during Robotic-Assisted Minimal Invasive Thymectomy Using the Da Vinci System: A Single Center Experience. J Clin Med 2022; 11:jcm11154274. [PMID: 35893373 PMCID: PMC9332370 DOI: 10.3390/jcm11154274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 07/14/2022] [Accepted: 07/20/2022] [Indexed: 11/23/2022] Open
Abstract
Background: Robotic-assisted surgery is gaining more adaption in different surgical specialties. The number of patients undergoing robotic-assisted thymectomy is continuously increasing. Such procedures are accompanied by new challenges for anesthesiologists. We are presenting our primary anesthesiologic experience in such patients. Methods: This is a retrospective single center study, evaluating 28 patients who presented with thymoma or myasthenia gravis (MG) and undergone minimal invasive robotic-assisted thoracic thymectomy between 01/2020−01/2022. We present our fast-track anesthesia management as a component of the enhanced recovery program and its primary results. Results: Mean patient’s age was 46.8 ± 18.1 years, and the mean height was 173.1 ± 9.3 cm. Two-thirds of patients were female (n = 18, 64.3%). The preoperative mean forced expiratory volume in the first second (FEV1) was 3.8 ± 0.7 L, forced vital capacity (FVC) was 4.7 ± 1.1 L, and the FEV1/FVC ratio was 80.4 ± 5.3%. After the creation of capnomediastinum, central venous pressure and airway pressure have been significantly increased from the baseline values (16.5 ± 4.9 mmHg versus 13.4 ± 5.1 mmHg, p < 0.001 and 23.4 ± 4.4 cmH2O versus 19.3 ± 3.9 cmH2O, p < 0.001, respectively). Most patients (n = 21, 75%) developed transient arrhythmias episodes with hypotension. All patients were extubated at the end of surgery and discharged awake to the recovery room. The first 16 (57.1%) patients were admitted to the intensive care unit and the last 12 patients were only observed in intermediate care. Postoperatively, one patient developed atelectasis and was treated with non-invasive ventilation therapy. Pneumonia or reintubation was not observed. Finally, no significant difference was observed between MG and thymoma patients regarding analgesics consumption or incidence of complications. Conclusions: Robotic-assisted surgery is a rapidly growing technology with increased adoption in different specialties. Fast-track anesthesia is an important factor in an enhanced recovery program and the anesthetist should be familiar with challenges in this kind of operation to achieve optimal results. So far, our anesthetic management of patients undergoing robotic-assisted thymectomy reports safe and feasible procedures.
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Cata JP, Lasala JD, Williams W, Mena GE. Myasthenia Gravis and Thymoma Surgery: A Clinical Update for the Cardiothoracic Anesthesiologist. J Cardiothorac Vasc Anesth 2018; 33:2537-2545. [PMID: 30219643 DOI: 10.1053/j.jvca.2018.07.036] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Indexed: 12/17/2022]
Abstract
Myasthenia gravis (MG) is a rare neuromuscular disorder characterized by skeletal muscle weakness. Patients with MG who have thymoma and thymic hyperplasia have indications for thymectomy. The perioperative care of patients with MG scheduled for thymus resection should be focused on optimizing their neuromuscular function, identifying factors related to postoperative mechanical ventilation, and avoiding of triggers associated with myasthenic or cholinergic crisis. Minimally invasive surgical techniques, use of regional analgesia, and avoidance or judicious administration of neuromuscular blocking drugs (NMBs) is recommended during the perioperative period. If NMBs are used, sugammadex appears to be the drug of choice to restore adequately the neuromuscular transmission. In patients with postoperative myasthenic crisis, plasma exchange or intravenous immune globulin and mechanical support is recommended.
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Affiliation(s)
- Juan P Cata
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX; Anesthesiology and Surgical Oncology Research Group, Houston, TX.
| | - Javier D Lasala
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX; Anesthesiology and Surgical Oncology Research Group, Houston, TX
| | - Wendell Williams
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX; Anesthesiology and Surgical Oncology Research Group, Houston, TX
| | - Gabriel E Mena
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX; Anesthesiology and Surgical Oncology Research Group, Houston, TX
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Abstract
Over the past decade there has been an exponential increase in the number of robotic-assisted surgical procedures performed in Australia and internationally. Despite this growth, there are no level I or II studies examining the anaesthetic implications of these procedures. Available observational studies provide insight into the significant challenges for the anaesthetist. Most anaesthetic considerations overlap with those of non-robotic surgery. However, issues with limited patient access and extremes of positioning resulting in physiological disturbances and risk of injury are consistently demonstrated concerns specific to robotic-assisted procedures.
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Gkouma A. Robotically assisted thymectomy: a review of the literature. J Robot Surg 2017; 12:3-10. [PMID: 28905304 DOI: 10.1007/s11701-017-0748-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Accepted: 09/04/2017] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Antonia Gkouma
- Cardiothoracic Surgery Department, St. Thomas' Hospital, Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH, UK.
- 251 General Airforce Hospital, Panagioti Kanellopoulou 3, Athens, 11525, Greece.
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Difficult Management of a Double-Lumen Endotracheal Tube and Difficult Ventilation during Robotic Thymectomy with Carbon Dioxide Insufflation. Case Rep Surg 2017; 2017:3403045. [PMID: 28529813 PMCID: PMC5424183 DOI: 10.1155/2017/3403045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Revised: 04/02/2017] [Accepted: 04/11/2017] [Indexed: 11/18/2022] Open
Abstract
Robotic surgery with carbon dioxide (CO2) insufflation to the thorax is frequently performed to gain a better operative field of view, although its intraoperative complications have not yet been discussed in detail. We treated two patients with difficult ventilation caused by distal migration of a double-lumen endotracheal tube (DLT) during robotic thymectomy. In the first case, migration of the DLT during one-lung ventilation (OLV) occurred after CO2 insufflation to the bilateral thoraxes was started. Oxygenation rapidly deteriorated because dependent lung expansion was restricted by CO2 insufflation. In the second case, migration of the DLT during OLV occurred while CO2 insufflation to a unilateral thorax and mediastinum was performed. In both cases, once migration of the DLT during OLV occurred with CO2 insufflation, readjusting the DLT became very difficult because our manipulation of bronchofiberscopy was prevented by the robot arms located above the patient's head and because deformation of the trachea/bronchus induced by CO2 insufflation caused a poor image of the bronchofiberscopic view. Thus, during robotic-assisted thoracoscopic surgery with CO2 insufflation, since there is a potential risk of difficult ventilation with a DLT and since readjustment of the DLT is very difficult, discontinuing CO2 insufflation and switching to double-lung ventilation are needed in such a situation.
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Challenges in the Anesthetic Management for a Robotic Thymectomy in a Patient With Myasthenia Gravis. ACTA ACUST UNITED AC 2017; 8:222-225. [DOI: 10.1213/xaa.0000000000000471] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Kamel MK, Rahouma M, Stiles BM, Nasar A, Altorki NK, Port JL. Robotic Thymectomy: Learning Curve and Associated Perioperative Outcomes. J Laparoendosc Adv Surg Tech A 2017; 27:685-690. [PMID: 28121481 DOI: 10.1089/lap.2016.0553] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Recently, robotic-assisted thymectomy (RAT) has emerged as an alternative to either, an open transsternal approach or to a video-assisted thoracoscopic approach, for both thymic tumors and benign lesions. We have reviewed our early experience with RAT to assess the associated learning curve as well as the short-term perioperative outcomes. METHODS A prospectively collected database was reviewed for patients who underwent RAT for all causes in the period 2012-2016. Robotic thymectomy cases were stratified and compared according to the number of cases performed by each surgeon (≤15 versus >15 cases). A propensity score matching was done to compare perioperative outcomes in patients undergoing robotic and transsternal resection of thymomas. RESULTS Seventy patients (47 females) with a median age of 52, underwent RAT. The median operative time was 102 min with 5 conversions to an open approach for local invasion (n = 3) or for complete pleural symphysis (n = 2). There were 2 rib fractures and 1 recurrent laryngeal nerve palsy. Median length of chest tube drainage and length of stay were 1 and 3 days, respectively. Operative time and estimated blood loss plateaued after surgeon's initial 15-20 cases, which may reflect the initial learning curve. A comparison between early and late robotic cases showed that with the growing experience, the operative time becomes shorter (94 versus 107 min, P = .018). Propensity score analysis between robotic and transsternal resection of thymoma (n = 22 in each group) showed no significant differences in operative time (P = .79), intraoperative complications (P = .99), or postoperative complications (P = .99). CONCLUSIONS Robotic thymectomy is feasible and safe, and is associated with comparable perioperative outcomes to the traditional transsternal approach in patients undergoing thymomectomy. An initial learning curve of 15-20 robotic thymectomy cases may be required by the surgeons to adequately perform this relatively novel technique.
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Affiliation(s)
- Mohamed K Kamel
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, New York Presbyterian Hospital - Weill Cornell Medical College , New York, New York
| | - Mohamed Rahouma
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, New York Presbyterian Hospital - Weill Cornell Medical College , New York, New York
| | - Brendon M Stiles
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, New York Presbyterian Hospital - Weill Cornell Medical College , New York, New York
| | - Abu Nasar
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, New York Presbyterian Hospital - Weill Cornell Medical College , New York, New York
| | - Nasser K Altorki
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, New York Presbyterian Hospital - Weill Cornell Medical College , New York, New York
| | - Jeffrey L Port
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, New York Presbyterian Hospital - Weill Cornell Medical College , New York, New York
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Karlekar A, Dutta D, Saxena R, Sharma KK. Anesthetic management of robot-assisted thoracoscopic thymectomy. J Anaesthesiol Clin Pharmacol 2016; 32:389-91. [PMID: 27625494 PMCID: PMC5009852 DOI: 10.4103/0970-9185.168207] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Myasthenia gravis (MG) is a rare disorder involving neuromuscular junction. In conjunction with medical therapy, thymectomy is a known modality of treatment of MG and has shown to increase the probability of remission and overall symptomatic improvement. For minimally invasive thymectomy, video-.assisted thoracoscopic surgery has been the preferred surgical approach till recently. The robotic surgical procedure must necessarily bring new challenges to the anesthesiologists to effectively meet the specific requirements of the technique. At present, there is a paucity of literature regarding the anesthetic concerns of robotic assisted thymectomy, patient in question specifically posed a challenge since different maneuvers and techniques had to be tried to obtain optimum surgical conditions with stable ventilatory and hemodynamic parameters. Concerns of patient positioning and hemodynamic monitoring have also been discussed.
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Affiliation(s)
- Anil Karlekar
- Department of Anaesthesiology and Intensive Care, Fortis Escorts Heart Institute, New Delhi, India
| | - Devesh Dutta
- Department of Anaesthesiology and Intensive Care, Fortis Escorts Heart Institute, New Delhi, India
| | - Ravindra Saxena
- Department of Anaesthesiology and Intensive Care, Fortis Escorts Heart Institute, New Delhi, India
| | - Krishna Kant Sharma
- Department of Anaesthesiology and Intensive Care, Fortis Escorts Heart Institute, New Delhi, India
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Abstract
Robotic cardiac surgery with the da Vinci robotic surgical system offers the benefits of a minimally invasive procedure, including a smaller incision and scar, reduced risk of infection, less pain and trauma, less bleeding and blood transfusion requirements, shorter hospital stay and decreased recovery time. Robotic cardiac surgery includes extracardiac and intracardiac procedures. Extracardiac procedures are often performed on a beating heart. Intracardiac procedures require the aid of peripheral cardiopulmonary bypass via a minithoracotomy. Robotic cardiac surgery, however, poses challenges to the anaesthetist, as the obligatory one-lung ventilation (OLV) and CO2 insufflation may reduce cardiac output and increase pulmonary vascular resistance, potentially resulting in hypoxaemia and haemodynamic compromise. In addition, surgery requires appropriate positioning of specialised cannulae such as an endopulmonary vent, endocoronary sinus catheter, and endoaortic clamp catheter under the guidance of transoesophageal echocardiography. Therefore, cardiac anaesthetists should have a working knowledge of these systems, OLV and haemodynamic support.
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Affiliation(s)
- Gang Wang
- Department of Cardiovascular Anesthesiology, PLA Institute of Cardiac Surgery, PLA General Hospital, Beijing, China
| | - Changqing Gao
- Department of Cardiovascular Anesthesiology, PLA Institute of Cardiac Surgery, PLA General Hospital, Beijing, China
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Jun Y, Hao L, Demin L, Guohua D, Hua J, Yi S. Da Vinci robot-assisted system for thymectomy: experience of 55 patients in China. Int J Med Robot 2014; 10:294-9. [PMID: 24573969 DOI: 10.1002/rcs.1577] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2012] [Revised: 10/16/2013] [Accepted: 01/02/2014] [Indexed: 11/07/2022]
Abstract
BACKGROUND Da Vinci robot-assisted thymectomy has been used in the past several years in China, however, practical experience in performing this approach in China remains limited. Thus, the study aimed to evaluate the experience of da Vinci robot-assisted thymectomy in China. METHODS From June 2010 to December 2012, 55 patients with diseases of the thymus underwent thymectomy using the da Vinci surgical HD robotic system. The clinical data of the da Vinci robot-assisted thymectomies were compared with the data of video-assisted thoracoscopic thymectomies in the same period. RESULTS All da Vinci robot operations were successful. This is a retrospective analysis which demonstrated that compared with video-assisted thoracoscopic thymectomy in the same period, the clinical outcomes of da Vinci robot-assisted thymectomy were not significantly different. CONCLUSION The da Vinci robot-assisted thymectomy is a safe, minimally invasive, and convenient operation, and shows promise for general thoracic surgery in China.
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Affiliation(s)
- Yi Jun
- Department of Cardiothoracic Surgery, Jinling Hospital, Clinical Medicine School of Nanjing University, Nanjing, China
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