Minimally invasive thymectomy: the Mayo Clinic experience

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.

Mediastinal cystic teratoma misdiagnosed as pleural tuberculosis: A case report and review of 53 cases revealed by pleural effusion

Mediastinal teratoma (MT) can be misdiagnosed for a long period and revealed by fatal pleural effusion at any age. In high burden tuberculosis settings, it is important to consider MT for extra-pulmonary tuberculosis not responding to medical treatment.

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.

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.

A pitfall of thoracoscopic thymectomy: a case with intraoperative and postoperative complications

We have reported the usefulness of the subxiphoid approach in thymectomy. However, such a new operation method may have unknown complications that rarely occur. Surgeons cannot completely avoid intraoperative and postoperative complications. We report a case of intraoperative injury of the orifice of the left internal thoracic vein flowing to the left brachiocephalic vein and postoperative pericarditis following video-assisted thoracic surgery (VATS) thymectomy. The innominate vein has been considered to be the vessel that is most frequently injured especially at the orifice of the thymic veins. We also suggest that the orifice of the left internal thoracic vein is the second dangerous location that requires special care. In addition, postoperative pericarditis occurred in this patient. Pericardial drainage was necessary. No additional complications have been found in the 9 months since the operation. Though VATS thymectomy using the subxiphoid approach is a safe and less-invasive operation, intraoperative and postoperative complications were possible to be occurred.

Surgical approach in thymectomy: Our experience and review of the literature

Aim

Thymectomy is the main treatment for thymoma and patients with myasthenia gravis (MG). The traditional approach is through a median sternotomy, but, recently, thymectomy through minimally invasive approaches is increasingly performed. Our purpose is an analysis and discussion of the clinical presentation, the diagnostic procedures and the surgical technique. We also consider post-operative complications and results, over a period of 5 years (May 2011–June 2016), in thymic masses admitted in our Thoracic Surgery Unit.

Methods

We analyzed 8 patients who underwent surgical treatment for thymic masses over a period of 5 years. 6 patients (75%) had thymoma, 2 patients (25%) had thymic carcinomas. 2 patients with thymoma (33%) had myasthenia gravis. We performed a complete surgical resection with median sternotomy as standard approach.

Results

One patient (12%) died in the postoperative period. The histological study revealed 6 (75%) thymoma and 2 (25%) thymic carcinomas. Post-operative morbidity occurred in 2 patients (25%) and were: pneumonia in 1 case (12%), atrial fibrillation and pleural effusion in 2 patients (25%). One patient with thymoma type A recurred at skeletal muscle 2-years after surgery.

Conclusions

Thymic malignancies are rare tumors. Surgical resection is the main treatment, but a multimodal approach is useful for many patients. Radical thymectomy is completed removing all the soft tissue in the anterior mediastinum between the two phrenic nerves and this is the most important factor in controlling myasthenia and influencing survival in patients with thymoma. Open (median sternotomy) approach has been the standard approach for thymectomy for the better visualization of the anatomical structures. Actually, video-assisted thoracoscopic surgery (VATS) thymectomy and robotic video-assisted thoracoscopic (R-VATS) approach versus open surgery has an equal if not superior oncological efficacy, better perioperative complications and survival outcomes.

Uniportal video assisted thoracoscopic surgery thymectomy (right approach)

BACKGROUND

Video assisted thoracoscopic surgery (VATS) thymectomy for the management of myasthenia gravis and thymoma has been described and routinely performed. With the advent of single port surgery, uniportal thymectomy has gained popularity as it has the advantages in terms of improved cosmesis, less surgical trauma and financial savings in particularly over robotic thymectomy. The approach demonstrated in this video also negates the problems of sub-xiphoid route in patient with obesity, cardiomegaly, and limitations of instruments manoeuvrability.

METHODS

Patient positioned semi-supine with right sided propped up and the ipsilateral arm placed naturally and secured by the side and below the chest wall. Cleaned and draped as for sterile procedure. General anaesthesia and lung isolation achieved with a double lumen endotracheal intubation. A 2.5 cm incision was made at 5^th intercostal space, anterior axillary line (lateral to nipple line). Extra small size wound protector was used and CO₂ insufflation was not needed. Instruments utilised in this case were "not new" and used for laparoscopic surgery 2 decades ago. This video demonstrates the simple technique of right uniportal approach to total thymectomy. Safe en bloc dissection of thymus and thymic tumour with surrounding fatty tissue were performed by combination of careful pleura dissection using diathermy, traction and blunt dissection of thymus. Extra caution when dividing thymic vein branches from innominate vein is prudent in all thymic dissection and prevent intra-operative haemorrhage and subsequent conversion to sternotomy or thoracotomy.

RESULTS

In this video, total thymectomy was performed without complication. The specimen was removed through the port and a single chest tube was placed at end of procedure for 1 day. Patient went home uneventfully on day 2.

CONCLUSIONS

Right uniportal VATS thymectomy is feasible, and this simple approach should be encouraged and performed by all enthusiastic VATS thoracic surgeons.

Uniportal video assisted thoracoscopic surgery thymectomy (left approach)

BACKGROUND

Video assisted thoracoscopic surgery (VATS) thymectomy for the management of myasthenia gravis and thymoma has been described and routinely performed. With the advent of single port surgery, uniportal thymectomy has gained popularity and left side approach is preferred only if the suspecting tumour is situated on the left mediastinum. However, many doubt or dislike the left side VATS approach to anterior mediastinum as the ventricular apex renders maneuverer of instruments difficult. This is certainly not the case as shown in this video and to date, there is no published manuscript on left uniportal thymectomy.

METHODS

Patient positioned semi-supine with left sided propped up and the ipsilateral arm placed naturally and secured by the side and below the chest wall. Cleaned and draped as for sterile procedure. General anaesthesia and lung isolation achieved with a double lumen endotracheal intubation. A 2.5 cm incision was made at 4^th intercostal space, anterior axillary line (lateral to nipple line). Extra small size wound protector was used and CO₂ insufflation was not needed. Instruments utilised in this case were "not new" and used for laparoscopic surgery 2 decades ago. This video demonstrates the simple technique of left uniportal approach to total thymectomy. Safe en bloc resection of thymus and thymic tumour with surrounding fatty tissue were performed, by combination of careful pleura dissection using diathermy, traction and blunt dissection of thymus. Extra caution when dividing thymic vein branches from innominate vein is prudent in order to prevent intra-operative haemorrhage and subsequent conversion to sternotomy or thoracotomy.

RESULTS

In this video, total thymectomy was performed without complication. The specimen was removed through the port and a single chest tube was placed at end of procedure for 1 day. Patient went home uneventfully on day 2.

CONCLUSIONS

Left uniportal VATS thymectomy is feasible, and preferred for left sided thymoma. This simple approach should be encouraged and performed by all enthusiastic VATS thoracic surgeons.