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

Relevance of robotic surgery for thymoma: a narrative review

Background and Objective

Thymectomy with median sternotomy is the gold standard for thymoma and myasthenia gravis, although minimally invasive procedures such as robot-assisted surgery have recently become more common. However, the superiority of these approaches has not been established, and they are infrequently recommended for localized lesions. The International Thymic Malignancies Interest Group warned that despite the perceived reduction in length of hospital stay and pain, the benefits of these approaches compared to the open approach have not been fully substantiated and that prospective collaborative data collection is critical in defining the value of these techniques. Whether thymectomy is necessary for stage I thymomas in the absence of myasthenia gravis or anti-acetylcholine receptor antibodies is also unclear. This study reviews and discusses the literature on this subject.

Methods

A narrative review was conducted using PubMed and Scopus databases. Original research articles comparing robotic to video-assisted thoracic surgery or to open thymectomy for thymomas were included. A comparison of partial resection and total thymectomy (thymothymectomy) for thymomas was also conducted.

Key Content and Findings

Perioperative outcomes such as blood loss, operative duration, complications, and length of hospital stay were better for robot-assisted resection of early-stage thymomas than for open thymoma surgery. It would be premature to consider partial resection as an appropriate treatment option for thymomas.

Conclusions

Robotic thymothymectomy is safe with effective and promising long-term results and oncological and surgical outcomes in patients with thymoma. Robotic thymectomy can become the standard procedure in patients with early-stage thymomas.

Robotic thymectomy in thymic tumours: a multicentre, nation-wide study

OBJECTIVES

Robotic thymectomy has been suggested and considered technically feasible for thymic tumours. However, because of small-sample series and the lack of data on long-term results, controversies still exist on surgical and oncological results with this approach. We performed a large national multicentre study sought to evaluate the early and long-term outcomes after robot-assisted thoracoscopic thymectomy in thymic epithelial tumours.

METHODS

All patients with thymic epithelial tumours operated through a robotic thoracoscopic approach between 2002 and 2022 from 15 Italian centres were enrolled. Demographic characteristics, clinical, intraoperative, postoperative, pathological and follow-up data were retrospectively collected and reviewed.

RESULTS

There were 669 patients (307 men and 362 women), 312 (46.6%) of whom had associated myasthenia gravis. Complete thymectomy was performed in 657 (98%) cases and in 57 (8.5%) patients resection of other structures was necessary, with a R0 resection in all but 9 patients (98.6%). Twenty-three patients (3.4%) needed open conversion, but no perioperative mortality occurred. Fifty-one patients (7.7%) had postoperative complications. The median diameter of tumour resected was 4 cm (interquartile range 3-5.5 cm), and Masaoka stage was stage I in 39.8% of patients, stage II in 56.1%, stage III in 3.5% and stage IV in 0.6%. Thymoma was observed in 90.2% of patients while thymic carcinoma occurred in 2.8% of cases. At the end of the follow-up, only 2 patients died for tumour-related causes. Five- and ten-year recurrence rates were 7.4% and 8.3%, respectively.

CONCLUSIONS

Through the largest collection of robotic thymectomy for thymic epithelial tumours we demonstrated that robot-enhanced thoracoscopic thymectomy is a technically sound and safe procedure with a low complication rate and optimal oncological outcomes.

Meta-analysis of clinical efficacy of thoracoscopy and robotic surgery in the treatment of mediastinal tumors

OBJECTIVE

Comparing the clinical efficacy of thoracoscopy and robotic surgery in the treatment of mediastinal tumors using meta-analysis.

METHODS

Computer retrieval of PubMed, Embase, The Cochrane Library, and Web of Science databases for literature comparing the clinical effects of video-assisted thoracic surgery (VATS) and robot-assisted thoracic surgery (RATS) in treating mediastinal tumors, with the retrieval time limit from the establishment of the database to September 2023. Two evaluators independently screened the literature, extracted data, and assessed the risk of bias. Meta-analysis was performed using RevMan 5.4.

RESULTS

A total of 19 articles were included, with a total of 3517 patients. The results of the Meta-analysis showed that the RATS group had less intraoperative bleeding [MD =  - 5.20, 95%CI (- 9.28, - 1.12), P = 0.01], lower rate of conversion to thoracotomy [OR = 0.41, 95%CI (0.23, 0.72), P = 0.002], lower rate of total postoperative complications [OR = 0.57, 95%CI (0.34, 0.95), P = 0.03], shorter postoperative drainage time [MD =  - 0.72, 95%CI (- 1.13, - 0.32), P = 0.0004], and shorter postoperative hospital stay [MD =  - 0.90, 95%CI (- 1.16, - 0.65), P < 0.001], in comparison with the VATS group. There was an insignificant difference between the two groups in terms of tumor size [MD =  - 0.02, 95%CI (- 0.33, 0.30), P = 0.91] and operation time [MD = 0.17, 95%CI (- 7.61, 7.94), P = 0.97]. However, in regards to hospitalization costs [MD = 2634.75, 95%CI (991.62, 4277.88), P = 0.002], the RATS group was more expensive than the VATS group.

CONCLUSION

Robot-assisted mediastinal tumor resection surgery has more advantages in terms of intraoperative bleeding, conversion to thoracotomy rate, total postoperative complication rate, postoperative drainage time, and postoperative hospital stay, in comparison with thoracoscopic-assisted mediastinal tumor resection surgery. There is an insignificant difference in tumor size and operation time between the two surgeries. However, robot-assisted mediastinal tumor resection surgery increases hospitalization costs.

Robot-assisted surgery outperforms video-assisted thoracoscopic surgery for anterior mediastinal disease: a multi-institutional study

Anterior mediastinal procedures are increasingly being performed using robot-assisted thoracic surgery (RATS) or video-assisted thoracoscopic surgery (VATS). While both approaches have shown superior outcomes compared to open surgery, their comparative benefits are not as distinct. The aim of this retrospective study was to bridge this knowledge gap using a multicenter dataset. Patients who underwent elective minimally invasive surgery for anterior mediastinal disease between 2015 and 2022 were deemed eligible. The study participants were grouped based on whether a robot was used or not, and perioperative outcomes were compared. To mitigate selection bias, inverse probability of treatment weighting (ITPW) was applied using the propensity score. The final analysis included 312 patients (RATS = 120; VATS = 192). Following the application of IPTW, RATS was found to be associated with a longer operating time (215.3 versus 139.31 min, P < 0.001), fewer days with a chest tube (1.96 versus 2.61 days, P = 0.047), and a shorter hospital stay (3.03 versus 3.91 days, P = 0.041) compared to VATS. Subgroup analyses indicated that the benefit of RATS in reducing the length of hospital stay was particularly pronounced in patients with tumors larger than 6 cm (mean difference [MD] =  - 2.28 days, P = 0.033), those diagnosed with myasthenia gravis (MD =  - 3.84 days, P = 0.002), and those who underwent a trans-subxiphoid surgical approach (MD =  - 0.81 days, P = 0.04). Both VATS and RATS are safe and effective approaches for treating anterior mediastinal disease. However, RATS holds distinct advantages over VATS including shorter hospital stays and reduced chest tube drainage periods.

Robot versus video-assisted thoracoscopic thymectomy for large thymic epithelial tumors: a propensity-matched analysis

BACKGROUND

Both video-assisted thoracoscopic surgery (VATS) thymectomy and robot-assisted thoracoscopic surgery (RATS) thymectomy have been suggested as technically sound approaches for early-stage thymic epithelial tumors. However, the choice of VATS or RATS thymectomy for large and advanced thymic epithelial tumors remains controversial. In this study, the perioperative outcomes of VATS and RATS thymectomy were compared in patients with large thymic epithelial tumors (size ≥5.0 cm).

METHODS

A total of 113 patients with large thymic epithelial tumors who underwent minimally invasive surgery were included. Sixty-three patients underwent RATS, and 50 patients underwent VATS. Patient characteristics and perioperative variables were compared.

RESULTS

Compared with the VATS group, the RATS group experienced a shorter operation time (median: 110 min vs.130 min; P < 0.001) and less blood loss (30.00 ml vs. 100.00 ml, P < 0.001). No patients in the RATS group needed conversion to open surgery, but in the VATS series, five patients required conversion to open procedures (0% vs. 14.29%, P = 0.054). The rate of concomitant resection in the RATS group was similar to that in the VATS group (11.43% vs. 5.71%; P = 0.673). There was no significant difference between the two groups in the duration of chest tube (P = 0.587), postoperative complications (P = 1.000), and the duration of postoperative hospital stay (P = 0.141).

CONCLUSION

For large thymic epithelial tumors, RATS thymectomy can be performed safely and effectively in a radical fashion. Due to the advanced optics and precise instrument control, concomitant resections can be easily achieved in larger thymic epithelial tumors using the robotic approach.

A large intrathoracic goiter with tracheal stenosis: Complete resection using a robot-assisted thoracoscopic approach

Growing intrathoracic goiters may compress surrounding organs and deteriorate the cardiopulmonary function. Treating such cases requires carefully considering how to maintain oxygenation and resect the tumor with minimal invasiveness without complications. We herein report a surgically resected case of a large intrathoracic goiter‐compressed trachea extending from the right lower pole of the thyroid gland to the carina. We secured the airway by intubation preparing for extracorporeal membrane oxygenation and successfully performed surgical complete resection using a robot‐assisted thoracoscopic and cervical approach. Intrathoracic goiter is a tumor with abundant neovascularity, and the right vagus nerve is displaced in the thoracic cavity, but a robot‐assisted thoracoscopic approach using CO₂ insufflation improved visualization at the narrow apex area of the thoracic cavity. Robot‐assisted thoracoscopic surgery is a useful surgical procedure enabling safe and minimally invasive surgery without recurrent laryngeal nerve palsy or tracheal injury for intrathoracic giant goiters extending into the thoracic cavity.

Comparison of two-lung and one-lung ventilation in bilateral video-assisted thoracoscopic extended thymectomy in myasthenia gravis: a retrospective study

Background

Myasthenia gravis (MG) is an autoimmune disease, and early thymectomy is recommended. Since the introduction of video-assisted thoracoscopic surgery, the safety and effectiveness of carbon dioxide insufflation in the thoracic cavity (capnothorax) has been controversial. This study aimed to compare the safety and effectiveness of ventilation methods in bilateral video-assisted thoracoscopic extended thymectomy (BVET) with capnothorax.

Methods

We retrospectively investigated the medical records of patients with MG who underwent BVET between August 2016 and January 2018. Patients were divided into two groups: group D (n = 26) for one-lung ventilation and group S (n = 28) for two-lung ventilation. We set nine anesthesia time points (T0–T8) and collected respiratory and hemodynamic variables, including arterial O₂ index (PaO₂/FiO₂).

Results

SpO₂ at T1–T3 and T8 was significantly lower in group D than in group S. The FiO₂ in group S was lower than that in group D at all time points. The number of PaO₂/FiO₂ ≤ 300 and PaO₂/FiO₂ ≤ 200 events was significantly higher in group D than in group S. Hemodynamic variables were not significantly different between the two groups at any time point. The duration of surgery and anesthesia was shorter in group S than in group D.

Conclusions

This retrospective study suggests that anesthesia using two-lung ventilation during BVET with capnothorax is a safe and effective method to improve lung oxygenation and reduce anesthesia time.

Robot-assisted thoracic surgery versus video-assisted thoracic surgery for treatment of patients with thymoma: A systematic review and meta-analysis

Background

Surgical resection of the thymus is indicated in the presence of primary thymic diseases such as thymoma. Video‐assisted thoracoscopic surgery (VATS) and robot‐assisted thoracic surgery (RATS) offer a minimally invasive approach to thymectomy. However, there is no clear conclusion whether RATS can achieve an equal or even better surgical effect when compared with VATS in treatment of thymoma. We performed this meta‐analysis to explore and compare the outcomes of RATS versus VATS for thymectomy in patients with thymoma.

Methods

PubMed, Cochrane Library, EMBASE, China National Knowledge Infrastructure (CNKI), Medline, and Web of Science databases were searched for full‐text literature citations. The quality of the articles was evaluated using the Newcastle–Ottawa Scale and the data analyzed using Review Manager 5.3 software. Fixed or random effect models were applied according to heterogeneity. Subgroup analysis was conducted.

Results

A total of 11 studies with 1418 patients, of whom 688 patients were in the RATS group and 730 in the VATS group, were involved in the analysis. Compared with VATS, RATS was associated with less blood loss in operation, lower volume of drainage, fewer postoperative pleural drainage days, shorter postoperative hospital stay, and fewer postoperative complications. There was no significant difference in operative time and patients with or without myasthenia gravis between the two groups.

Conclusions

RATS has more advantages over VATS, indicating that RATS is better than VATS in terms of postoperative recovery. We look forward to more large‐sample, high‐quality randomized controlled studies published in the future.

Artificial pneumothorax suppresses postoperative inflammatory reaction in mediastinal tumor surgery

OBJECTIVE

The induction of artificial pneumothorax has many intraoperative advantages. However, few reports on the postoperative effects of artificial pneumothorax induction are available. In this study, we investigated the effect of artificial pneumothorax on postoperative clinical course in patients with mediastinal tumors.

METHODS

We retrospectively investigated the clinical courses of 89 patients who had undergone mediastinal tumor resection between January 2010 and December 2020. Sixty-five patients had undergone resection with artificial pneumothorax.

RESULTS

The tumor location significantly varied across patients. The proportion of patients in whom artificial pneumothorax was induced was higher among those having anterior mediastinal tumors. The number of ports and the total skin incision length were significantly higher in patients without artificial pneumothorax. The C-reactive protein level elevation on postoperative day 2 and pleural effusion at 24 h after surgery were significantly higher in patients without artificial pneumothorax. Furthermore, the albumin level reduction and hospital stay after surgery were significantly lower in patients with artificial pneumothorax. Multiple regression analysis showed that the use of artificial pneumothorax was an independent predictive factor of the C-reactive protein level elevation on postoperative day 2 and pleural effusion at 24 h after surgery. In patients without artificial pneumothorax, the operation time positively correlated with the C-reactive protein level (r = 0.646, P < 0.001).

CONCLUSIONS

Artificial pneumothorax suppressed the postoperative inflammatory response, pleural effusion, and albumin reduction, and shortened the hospital stay in patients undergoing mediastinal tumor surgery.

Limited resection for early-stage thymoma: minimally invasive resection does not mean limited resection

Standard resection for patients with thymoma is resection of thymoma with total thymectomy (TTx) via median sternotomy. Hence, limited resection for thymoma means a lesser extent of resection of normal thymus compared with a standard procedure, i.e. resection of thymoma with partial thymectomy (PTx). In contrast, minimally invasive resection has been defined as resection of thymoma with TTx via a less-invasive approach. However, to date, few studies have precisely evaluated the differences in surgical and oncological outcomes among these three procedures. This report summarizes the differences among these three procedures with a review of studies (January 2000 to December 2020) focusing on the difference in surgical and oncological outcomes and presents current issues in the surgical management of thymoma. In this report, 16 studies were identified; 5 compared standard resection to limited resection, 9 compared standard resection to minimally invasive resection and 2 compared limited resection to minimally invasive resection. Most studies reported that the surgical and oncological outcomes of limited resection or minimally invasive resection were similar to those of standard resection in patients with early-stage thymoma. However, they did not include a sufficient follow-up period. Both limited resection and minimally invasive resection for early-stage thymoma might be reasonable treatment options. However, they are still promising modes of resection. Further studies with a long follow-up period are needed.

Robotic approach has improved outcomes for minimally invasive resection of mediastinal tumors

BACKGROUND

The optimal minimally invasive surgical (MIS) approach to mediastinal tumors is unknown. There are limited reports comparing the outcomes of resection with robotic-assisted and video-assisted thoracoscopy (RATS vs VATS). We hypothesized that patients who underwent RATS would have improved outcomes.

METHODS

The National Cancer Database was queried for all patients who underwent MIS for any mediastinal tumor from 2010-2016. Patients were determined to have an adverse composite outcome if they had any of the adverse perioperative outcomes; conversion to open procedure, 90-day mortality, 30-day readmission, and positive pathologic margins. Secondary outcomes of interest were length-of-stay (LOS) and overall survival. Multivariable logistic regression was used to assess likelihood of having a composite adverse outcome based on surgical approach.

RESULTS

856 patients were included: 402 (47%) underwent VATS and 454 (53%) underwent RATS. RATS resections were associated with fewer conversions (4.9% vs 14.7%, p<0.001), fewer positive margins (24.3% vs 31.6%, p=0.02), shorter LOS (3.8d vs 4.3d, p=0.01) and less composite adverse events (36.7% vs 51.3%, p<0.001). Multivariate analysis showed RATS (OR 0.44, p<0.001) was independently associated with decreased likelihood of composite adverse outcome, even among tumors >4 cm (OR 0.45, p=0.001). Overall survival was similar between the two groups.

CONCLUSIONS

Among patients who underwent MIS for a mediastinal tumor, RATS had fewer adverse outcomes than VATS, even for tumors ≥4 cm. These data suggests that RATS may be the preferred technique for patients who are candidates for minimally invasive resection of mediastinal tumors.

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

Does robotic-assisted thymectomy have advantages over video-assisted thymectomy in short-term outcomes? A systematic view and meta-analysis

OBJECTIVES

A thymic epithelial tumour is the most common primary tumour in the anterior mediastinum of adults. A few retrospective studies compared the short-term outcomes between robotic-assisted thymectomy (RAT) and video-assisted thymectomy (VAT). So, it is necessary to conduct a meta-analysis to further compare these 2 surgical techniques.

METHODS

EMBASE, Medline and Web of Science were used. Thesaurus terms and medical subject headings were used in Medline and EMBASE, respectively. The Newcastle-Ottawa scale was used for grading because the included studies were all case-control studies.

RESULTS

Nine studies were included in the meta-analysis with a total of 723 patients, including 315 patients in the RAT group and 408 patients in the VAT group. The meta-analysis [odds ratio (OR) 0.24, 95% confidence interval (CI) 0.06-0.94; P = 0.041], indicating that RAT yielded a significantly lower rate of conversion compared with VAT. Duration of drainage with RAT was significantly less than that with VAT (weighted mean difference = -1.10; 95% CI -1.98 to -0.22; P = 0.014). The pooled analysis (weighted mean difference = -103.6; 95% CI -199.21 to -7.98; P = 0.034) suggested that patients in the RAT group had less drainage than those in the VAT group. The recurrence rates in both groups were comparable (OR 0.19, 95% CI 0.03-1.20; P = 0.078).

CONCLUSIONS

RAT has advantages over VAT in terms of short-term outcomes such as shorter duration of drainage, less total drainage and a lower rate of conversion. The recurrence rate was comparable between the 2 techniques. Therefore, RAT could be considered as an alternative treatment for diseases of the thymus.

National Use and Short-term Outcomes of Video and Robot-Assisted Thoracoscopic Thymectomies

BACKGROUND

Transsternal open thymectomy has long been the most widely used approach for thymectomy, but recent decades have seen the introduction of minimally invasive surgery (MIS), such as video-assisted thoracoscopic surgery (VATS) and robot-assisted thoracoscopic surgery (RATS) thymectomy. This retrospective cohort study provides a national comparison of trends, outcomes, and resource utilization of open, VATS, and RATS thymectomy.

METHODS

Admissions for thymectomies from 2008 to 2014 were identified in the National Inpatient Sample. Patients were identified as undergoing open, VATS, or RATS thymectomy. Propensity score-matched analyses were used to compare overall complication rates, length of stay (LOS), and cost of VATS and RATS thymectomies.

RESULTS

An estimated 23,087 patients underwent thymectomy during the study period: open in 16,025 (69%) and MIS in 7217 (31%). Of the MIS cohort, 4119 (18%) underwent VATS and 3097 (13%) underwent RATS. Performance of RATS and VATS thymectomy increased while that of open thymectomy declined. Baseline characteristics between VATS and RATS were similar, except more women underwent VATS thymectomy. No differences in LOS or overall complication rates were appreciable in this study. VATS was associated with the lowest cost of the 3 approaches.

CONCLUSIONS

Our findings demonstrate the increasing adoption of MIS and declining use of the open surgical approach for thymectomy. There are no differences in overall complication rates between RATS and VATS thymectomy, but RATS is associated with greater cost and lower cardiac complication rates.

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.

Robotic Thoracic Surgery

Minimally invasive surgery for diseases of the chest offsets the morbidity of painful thoracic incisions while allowing for meticulous dissection of major anatomic structures. This benefit translates to improved outcomes and recovery following the surgical management of benign and malignant esophageal pathologic condition, mediastinal tumors, and lung resections. This anatomic region is particularly amenable to a robotic approach given the fixed space and need for complex intracorporeal dissection. As robotic platforms continue to evolve, more complex thoracic surgical interventions will be facilitated, translating to improved outcomes for our patients.

A national analysis of open versus minimally invasive thymectomy for stage I to III thymoma

OBJECTIVE

The oncologic efficacy of minimally invasive thymectomy for thymoma is not well characterized. We compared short-term outcomes and overall survival between open and minimally invasive (video-assisted thoracoscopic and robotic) approaches using the National Cancer Data Base.

METHODS

Perioperative outcomes and survival of patients who underwent open versus minimally invasive thymectomy for clinical stage I to III thymoma from 2010 to 2014 in the National Cancer Data Base were evaluated using multivariable Cox proportional hazards modeling and propensity score-matched analysis. Predictors of minimally invasive use were evaluated using multivariable logistic regression. Outcomes of surgical approach were evaluated using an intent-to-treat analysis.

RESULTS

Of the 1223 thymectomies that were evaluated, 317 (26%) were performed minimally invasively (141 video-assisted thoracoscopic and 176 robotic). The minimally invasive group had a shorter median length of stay when compared with the open group (3 [2-4] days vs 4 [3-6] days, P < .001). In a propensity score-matched analysis of 185 open and 185 minimally invasive (video-assisted thoracoscopic + robotic) thymectomy, the minimally invasive group continued to have a shorter median length of stay (3 vs 4 days, P < .01) but did not have significant differences in margin positivity (P = .84), 30-day readmission (P = .28), 30-day mortality (P = .60), and 5-year survival (89.4% vs 81.6%, P = .20) when compared with the open group.

CONCLUSIONS

In this national analysis, minimally invasive thymectomy was associated with shorter length of stay and was not associated with increased margin positivity, perioperative mortality, 30-day readmission rate, or reduced overall survival when compared with open thymectomy.

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.

Resource implications of robotic thoracic surgery: what are the wider issues?

The benefits of minimally invasive thoracic surgery are well documented when compared to the use of standard thoracotomy. Much controversy exists, however, regarding the resource implications when using robot-assisted thoracic surgery (RATS), especially when compared to video-assisted thoracoscopic surgery (VATS). Much of the costs attributed to a particular approach center around the frequency and severity of the complications that may arise. Little exists in the literature to appropriately compare and contrast the complication rate following either of the minimally invasive approaches. There is a suggestion that many conventional open surgeons are more readily persuaded to adopt a minimally invasive approach through the use of the robotic platform, therefore reducing the complication-related costs of standard thoracotomy by an increase in minimally invasive resection rates. Further gains may be made in the ability to perform more complex minimally invasive procedures via a RATS approach without recourse to open conversion when compared to VATS. As opportunities and competition increase in the commercial market place, it is reasonable to assume costs will fall and further savings will be made.

A systematic review of robotic versus open and video assisted thoracoscopic surgery (VATS) approaches for thymectomy

Background

Median sternotomy has been the most commonly used approach for thymectomy to date. Recent advances in video-assisted thoracoscopic surgery (VATS) and robotic access with CO₂ insufflation techniques have allowed more minimally invasive approaches. However, prior reviews have not compared robotic to both open and VATS thymectomy.

Methods

A systematic review was conducted in accordance with the PRISMA guidelines using PubMed, Embase and Scopus databases. Original research articles comparing robotic to VATS or to open thymectomy for myasthenia gravis, anterior mediastinal masses, or thymomas were included. Meta-analyses were performed for mortality, operative time, blood loss, transfusions, length of stay, conversion to open, intraoperative and postoperative complication rates, and positive/negative margin rates.

Results

Robotic thymectomy is a valid alternative to the open approach; advantages include: reduced blood loss [weighted mean difference (WMD): -173.03, 95% confidence interval (95% CI): -305.90, -40.17, P=0.01], fewer postoperative complications (odds ratio: 0.37, 95% CI: 0.22, 0.60, P<0.00001), a shorter hospital stay (WMD: -2.78, 95% CI: -3.22, -2.33, P<0.00001), and a lower positive margin rate (relative difference: -0.04, 95% CI: -0.07, -0.01, P=0.01), with comparable operative times (WMD: 6.73, 95% CI: -21.20, 34.66, P=0.64). Robotic thymectomy was comparable with the VATS approach; both have the advantage of avoiding median sternotomy.

Conclusions

While randomized controlled studies are required to make definitive conclusions, current data suggests that robotic thymectomy is superior to open surgery and comparable to a VATS approach. Long-term follow-up is required to further delineate oncological outcomes.

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.

Independent long-term result of robotic thymectomy for myasthenia gravis, a single center experience

Background

Robotic thymectomy has been suggested a feasible and safe approach for myasthenia gravis (MG). Few investigations have revealed the independent effect of robotic thymectomy without the confounding impact of immunosuppressive (IM) therapy.

Methods

Between May 2009 and December 2012, robotic extended thymectomy was carried out for patients with diagnosis of MG. The clinical data, subsequent neurological therapy and postintervention status were collected.

Results

Data of 37 cases was available for analysis. The mean follow-up was 70.0±13.3 months. The median age was 40 years. Twelve (32.4%) patients kept free of IM therapy, and 25 (67.6%) patients accepted postoperatively. The overall 5-year complete stable remission (CSR) rate was 40.6% and improvement rate was 81.6%. The young (age ≤40) displayed a significant better CSR rate (P=0.015) and a trend of better improvement rate (P=0.050) compared to the old (age >40). Patients without usage of IM therapy showed significant higher CSR rate (P=0.014) and improvement rate (P=0.024) compared to those with usage of IM therapy. Patients with Myasthenia Gravis Foundation of America (MGFA) classes I showed a trend of higher remission rate by multivariate analysis. No significant differences were found for the remission rate according to gender, pathology, and the duration of symptoms.

Conclusions

The mono-therapy of robotic thymectomy may bring with a satisfactory long-term result for part of MG patients. Precision selection and individualized therapy are of the most importance.

Antero mediastinal retrosternal goiter: surgical excision by combined cervical and hybrid robot-assisted approach

Most intrathoracic goiters are located in the anterior mediastinum. Surgical resection is usually recommended in case of morbidity associated with the goiter's mass effect or for suspicion of malignancy difficult to diagnose without resection. Intrathoracic goiters are usually resected through a cervical approach, with sternotomy needed in selected cases. We report a case of antero mediastinal retrosternal goiter in old age patient undergoing surgical excision by combined cervical and hybrid robot-assisted approach. All steps of the thoracic procedure were completely performed using the da Vinci robot system with final extension of a port-site incision to extract the specimen. This approach provides more advantages than sternotomy regarding post operative clinical benefits and allows a more accurate surgical resection in the antero-superior mediastinum than conventional thoracoscopy.

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.

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 versus thoracoscopic lung resection: A systematic review and meta-analysis

BACKGROUND

Robotic video-assisted surgery (RVATS) has been reported to be equally effective to video-assisted surgery (VATS) in lung resection (pneumonectomy, lobectomy, and segmentectomy). Operation time, mortality, drainage duration, and length of hospitalization of patients undergoing either RVATS or VATS are compared in this meta-analysis.

METHODS

A systematic research for articles meeting our inclusion criteria was performed using the PubMed database. Articles published from January 2011 to January 2016 were included. We used results of reported mortality, operation time, drainage duration, and hospitalization length for performing this meta-analysis. Mean difference and logarithmic odds ratio were used as summary statistics.

RESULTS

Ten studies eligible were included into this analysis (5 studies for operation time, 3 studies for chest in tube days, 4 studies for length of hospitalization, and 6 studies for mortality). We were able to include 3375 subjects for RVATS and 58,683 subjects for VATS. Patients were mainly treated for lung cancer, metastatic foci, and benign lesions. We could not detect any difference between operation time; however, we found 2 trends showing that drainage duration and length of hospitalization are shorter for following RVATS than for following VATS. Mortality also is lower in patients undergoing RVATS.

CONCLUSIONS

Therefore, we conclude that RVATS is a suitable minimal-invasive procedure for lung resection and suitable alternative to VATS. RVATS is as time-efficient as VATS and shows a trend to reduced hospital stay and drainage duration. More and better studies are required to provide reliable, unbiased evidence regarding the relative benefits of both methods.

A comparison of three approaches for the treatment of early-stage thymomas: robot-assisted thoracic surgery, video-assisted thoracic surgery, and median sternotomy

BACKGROUND

This aim of this study was to compare three approaches of extended thymectomy for the treatment of early-stage thymomas, which included robot-assisted thoracic surgery (RATS), video-assisted thoracic surgery (VATS), and median sternotomy (MS) perioperative parameters.

METHODS

A retrospective study was conducted on 123 patients with early stage thymomas at Shanghai Chest Hospital who underwent extended thymectomy between February 2009 and August 2014. Among them, MS was performed on 37 patients, VATS was performed on 35 patients, and RATS was performed on 51 patients. A series of outcome measures were compared between these three approaches, including operative time, intra-operative blood loss volume, occurrence of intra-operative complications, post-operative pleural drainage duration, post-operative pleural drainage volume, duration of hospital stay, and the incidence of post-operative complications.

RESULTS

A series of intra- and post-operative parameters showed significant differences in intra-operative blood loss volume, mean post-operative pleural drainage duration, pleural drainage volume and mean duration of hospital stay. For these parameters, during further analysis, significant differences were also demonstrated for comparisons between any two groups. RATS reduces the post-operative drainage duration and volume (2.88 vs. 3.77 and 4.41 days, P<0.05; 352.2 vs. 613.9 and 980 mL, P<0.05) and the hospital stay versus the MS and VATS groups (4.3 vs. 5.5 and 6.6 days). Three patients experienced post-operative complications in the MS group, and no post-operative complications occurred in the RATS or VATS group.

CONCLUSIONS

RATS and VATS both appear feasible and safe for the resection of early-stage thymomas as compared to MS. RATS is less invasive than VATS with a shorter post-operative pleural drainage duration time, a reduced drainage volume, and a shorter hospital stay.

Robotic versus thoracoscopic thymectomy: The current evidence

BACKGROUND

The purpose of this study was to analyze all relevant comparative studies comparing robot-assisted minimally invasive thymectomy (RATS) and video-assisted thoracic surgery thymectomy (VATS) in terms of surgical and short-term outcomes.

METHODS

A systematic search for articles describing robot-assisted and video-assisted thymectomy and addressing surgical outcomes, operation time, length of hospitalization, intra-operative blood loss, conversion to sternotomy and post-operative complications was performed using the medical databases.

RESULTS

Of the 478 studies from preliminary screening, five articles were included. By pooling these studies, we found no significant differences between the RATS and VATS (odds ratio 1.24 (95% CI 0.51, 3.03; p = 0.63)).There were no significant differences in comparison of conversion rates, operation time (26.29 min (95% CI -2.57, 55.35; p = 0.07)) and length of hospitalization (-1.58 days (95% CI -4.78, 1.62; p = 0.33)). There was a slightly higher blood loss in the RATS group.

CONCLUSION

Our meta-analysis did not detect any statistically significant differences in surgery outcomes between the two groups.

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.

Video-assisted and minimally-invasive open chest surgery for the treatment of mediastinal tumors and masses

This article reviews the anatomy of the mediastinum as well as indications, limitations, techniques, and results of video-assisted thoracic surgery (VATS) and other minimally-invasive open-chest surgery approaches currently used for the surgical management of mediastinal tumors and masses. It is written by two surgeons with vastly different backgrounds and thoracic surgical experience. One of them is young and very familiar with VATS approaches and technologies while the other is a senior surgeon relatively unfamiliar with minimally-invasive techniques. This combination of authorship is ideal to analyze the pros and cons of the use of minimally-invasive approaches for the surgical management of mediastinal lesions such as thymic epithelial tumors (TETs) or neurogenic tumors. This is important because several thoracic surgeons have expressed concerns about the ability of thoracoscopic procedures to maintain adherence to sound oncological principles.

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.

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.

[Perioperative Outcomes and Long-term Survival in Clinically Early-stage Thymic Malignancies: Video-assisted Thoracoscopic Thymectomy versus Open Approaches]

背景与目的

胸腔镜胸腺切除术相比开放手术治疗早期（Masaoka-Koga Ⅰ期或Ⅱ期）胸腺恶性肿瘤在理论上具有优势，然而尚未有研究报道其在长期生存率方面的差异。本研究基于中国胸腺肿瘤研究协作组（Chinese Alliance for Research in Thymomas, ChART）的数据库对此进行了研究。

方法

以数据库中1994年到2012年间的1, 117例早期（Masaoka-Koga Ⅰ期或Ⅱ期）胸腺恶性肿瘤患者为研究对象。其中241例行胸腔镜胸腺切除术，876例行开放手术。采用单因素分析比较两组的临床资料与围手术期结果方面的差异。采用多因素分析明确影响长期预后的相关因素。

结果

与开放手术组相比，胸腔镜组的全胸腺切除比例更高（80.5% vs 73.9%, P=0.028），根治性切除率更高（98.8% vs 88.7%, P < 0.000），而复发率更低（2.9% vs 16.0%, P < 0.001），5年无瘤生存率更高（92% vs 83%, P=0.011），而两组的5年生存率接近（92% vs 92%, P=0.15）。Cox比例风险模型分析显示WHO分型、Masaoka-Koga分期和术后辅助治疗是影响胸腺恶性肿瘤长期生存的独立因素。

结论

胸腔镜胸腺切除术是治疗早期胸腺恶性肿瘤安全有效的方法，与开放手术相比其围手术期效果更好，肿瘤学疗效一致。

Perioperative outcomes and long-term survival in clinically early-stage thymic malignancies: video-assisted thoracoscopic thymectomy versus open approaches

BACKGROUND

Video-assisted thoracoscopic surgery (VATS) theoretically offers advantages over open thymectomy for clinically early-stage (Masaoka-Koga stage I and II) thymic malignancies. However, long-term outcomes have not been well studied. We compared the postoperative outcomes and survival from a cohort study based on the database of the Chinese Alliance for Research in Thymomas (ChART).

METHODS

Between 1994 and 2012, data of 1,117 patients having surgery for clinically early-stage (Masaoka-Koga stage I and II) tumors were enrolled for the study. Among them, 241 cases underwent VATS thymectomy (VATS group), while 876 cases underwent open thymectomy (Open group). Univariate analyses were used to compare the clinical character and perioperative outcomes between the two groups. And multivariate analysis was performed to determine the independent predictive factors for long-term survival.

RESULTS

Compared with the Open group, the VATS group had higher percentage of total thymectomy (80.5% vs. 73.9%, P=0.028), resection rate (98.8% vs. 88.7%, P=0.000) and less recurrence (2.9% vs. 16.0%, P=0.000). Five-year overall survival was 92% after VATS and 92% after open thymectomy, with no significant difference between the two groups (P=0.15). However, 5-year disease free survival were 92% in VATS group and 83% in Open group (P=0.011). Cox proportional hazards model revealed that WHO classification, Masaoka-Koga stage and adjuvant therapy were independent predictive factors for overall survival, while surgical approach had no significant impact on long-term outcome.

CONCLUSIONS

This study suggests that VATS thymectomy is an effective approach for clinically early-stage thymic malignancies. And it may offer better perioperative outcomes, as well as equal oncological survival.

Minimally invasive mediastinal surgery

In the past, mediastinal surgery was associated with the necessity of a maximum exposure, which was accomplished through various approaches. In the early 1990s, many surgical fields, including thoracic surgery, observed the development of minimally invasive techniques. These included video-assisted thoracic surgery (VATS), which confers clear advantages over an open approach, such as less trauma, short hospital stay, increased cosmetic results and preservation of lung function. However, VATS is associated with several disadvantages. For this reason, it is not routinely performed for resection of mediastinal mass lesions, especially those located in the anterior mediastinum, a tiny and remote space that contains vital structures at risk of injury. Robotic systems can overcome the limits of VATS, offering three-dimensional (3D) vision and wristed instrumentations, and are being increasingly used. With regards to thymectomy for myasthenia gravis (MG), unilateral and bilateral VATS approaches have demonstrated good long-term neurologic results with low complication rates. Nevertheless, some authors still advocate the necessity of maximum exposure, especially when considering the distribution of normal and ectopic thymic tissue. In recent studies, the robotic approach has shown to provide similar neurological outcomes when compared to transsternal and VATS approaches, and is associated with a low morbidity. Importantly, through a unilateral robotic technique, it is possible to dissect and remove at least the same amount of mediastinal fat tissue. Preliminary results on early-stage thymomatous disease indicated that minimally invasive approaches are safe and feasible, with a low rate of pleural recurrence, underlining the necessity of a "no-touch" technique. However, especially for thymomatous disease characterized by an indolent nature, further studies with long follow-up period are necessary in order to assess oncologic and neurologic results through minimally invasive approaches. Furthermore, increased robotic experience and studies, including randomized controlled trials, are needed to validate the findings of the current literature.

Thymoma and thymic carcinomas

Thymomas (Ts) and thymic carcinomas (TCs) are rare tumours of the mediastinum with an incidence rate of 1.7/million per year in Europe. Histological classification is based on rate of non-malignant-appearing thymic epithelial cells and proportions of lymphocytes (A, AB, B1, B2, B3, and C), while staging system concerns localisation of the involved areas. Surgery is the mainstay of treatment with a 10-year survival of 80%, 78%, 75%, and 42% for stages I, II, III and IV, respectively, with an R0 resection. Radiotherapy has a role in selected cases (stage III patients or R1-2 residual) and platinum-based chemotherapy remains the standard of care for patients with advanced disease. A multimodality approach would be advisable when surgery is not recommended. Since molecular aberrations are poorly understood and few responses are reported, targeted therapies are yet being studied. In this review, we describe key aspects of clinical management for Ts and TCs.

Standardized definitions and policies of minimally invasive thymoma resection

A wide range of technical approaches for the minimally invasive resection of thymus have been described. Most of the time, the benefits are superior cosmetic outcome and shorter duration of postoperative stay. Other demonstrable differences that have been reported include shorter duration of surgery, less intraoperative blood loss and less postoperative pleural drainage. Robotic surgery and video-assisted surgery (VATS) may become routinely used procedures in the treatment of stage I and II thymomas.

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.

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.

Synchronous thymoma and lung adenocarcinoma treated with a single mini-invasive approach

A 75 year-old man with a lesion in the middle lobe of the lung was discovered to also have, during the follow-up period, a mass in the mediastinum, diagnosed as a multi-thymic cyst. Both pathologies were successfully treated with a single surgical approach by video-assisted thoracoscopy. We performed a middle VATS lobectomy with complete lymphadenectomy followed by radical thymectomy without additional incision. The postoperative course was uneventful.

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.