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Taje R, Peer M, Gallina FT, Ambrogi V, Sharbel A, Melis E, Elia S, Idit M, Facciolo F, Patirelis A, Sorge R, Pompeo E. Ergonomic Assessment of Robotic versus Thoracoscopic Thymectomy. J Clin Med 2024; 13:1841. [PMID: 38610606 PMCID: PMC11012820 DOI: 10.3390/jcm13071841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 03/13/2024] [Accepted: 03/20/2024] [Indexed: 04/14/2024] Open
Abstract
Introduction: Robotic and thoracoscopic surgery are being increasingly adopted as minimally invasive alternatives to open sternotomy for complete thymectomy. The superior maneuverability range and three-dimensional magnified vision are potential ergonomical advantages of robotic surgery. To compare the ergonomic characteristics of robotic versus thoracoscopic thymectomy, a previously developed scoring system based on impartial findings was employed. The relationship between ergonomic scores and perioperative endpoints was also analyzed. Methods: Perioperative data of patients undergoing robotic or thoracoscopic complete thymectomy between January 2014 and December 2022 at three institutions were retrospectively retrieved. Surgical procedures were divided into four standardized surgical steps: lower-horns, upper-horns, thymic veins and peri-thymic fat dissection. Three ergonomic domains including maneuverability, exposure and instrumentation were scored as excellent(score-3), satisfactory(score-2) and unsatisfactory(score-1) by three independent reviewers. Propensity score matching (2:1) was performed, including anterior mediastinal tumors only. The primary endpoint was the total maneuverability score. Secondary endpoints included the other ergonomic domain scores, intraoperative adverse events, conversion to sternotomy, operative time, post-operative complications and residual disease. Results: A total of 68 robotic and 34 thoracoscopic thymectomies were included after propensity score matching. The robotic group had a higher total maneuverability score (p = 0.039), particularly in the peri-thymic fat dissection (p = 0.003) and peri-thymic fat exposure score (p = 0.027). Moreover, the robotic group had lower intraoperative adverse events (p = 0.02). No differences were found in residual disease. Conclusions: Robotic thymectomy has shown better ergonomic maneuverability compared to thoracoscopy, leading to fewer intraoperative adverse events and comparable early oncological results.
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Affiliation(s)
- Riccardo Taje
- Department of Thoracic Surgery, University of Rome “Tor Vergata”, 00133 Rome, Italy; (R.T.); (V.A.); (A.P.)
- Doctoral School of Microbiology, Immunology, Infectious Diseases and Transplants, MIMIT, University of Rome “Tor Vergata”, 00133 Rome, Italy
| | - Michael Peer
- Department of Thoracic Surgery, Ichilov Medical Center, Tel Aviv 6423906, Israel; (M.P.); (A.S.)
| | - Filippo Tommaso Gallina
- Department of Thoracic Surgery, IRCCS National Cancer Institute Regina Elena, 00144 Rome, Italy; (F.T.G.); (E.M.); (F.F.)
| | - Vincenzo Ambrogi
- Department of Thoracic Surgery, University of Rome “Tor Vergata”, 00133 Rome, Italy; (R.T.); (V.A.); (A.P.)
| | - Azzam Sharbel
- Department of Thoracic Surgery, Ichilov Medical Center, Tel Aviv 6423906, Israel; (M.P.); (A.S.)
| | - Enrico Melis
- Department of Thoracic Surgery, IRCCS National Cancer Institute Regina Elena, 00144 Rome, Italy; (F.T.G.); (E.M.); (F.F.)
| | - Stefano Elia
- Department of Medicine and Health Sciences “V. Tiberio”, University of Molise, 86100 Campobasso, Italy;
| | - Matot Idit
- Department of Anaesthesia and Intensive Care, Ichilov Medical Center, Tel Aviv 6423906, Israel;
| | - Francesco Facciolo
- Department of Thoracic Surgery, IRCCS National Cancer Institute Regina Elena, 00144 Rome, Italy; (F.T.G.); (E.M.); (F.F.)
| | - Alexandro Patirelis
- Department of Thoracic Surgery, University of Rome “Tor Vergata”, 00133 Rome, Italy; (R.T.); (V.A.); (A.P.)
| | - Roberto Sorge
- Department of Biostatistics, University of Rome “Tor Vergata”, 00133 Rome, Italy;
| | - Eugenio Pompeo
- Department of Thoracic Surgery, University of Rome “Tor Vergata”, 00133 Rome, Italy; (R.T.); (V.A.); (A.P.)
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Abstract
Kido and colleagues in 1999 used for the first time the subxiphoid approach. Recently, video-assisted thoracoscopic surgery (VATS) thymectomy has been improved for the advancement of surgical materials and new instruments. The most important aspect regarding the subxiphoid approach is the possibility to avoid the intercostal nerve damage with the consequence of a decreased use of postoperative analgesics, quite short surgical duration, fast discharge from hospital and a guarantee of successful cosmetics results.
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Hamouri S, Hatamleh M, Alaydi J, Alhadidi H, Alomari M, Aldaoud N, Darayseh B. Intra-thymic bronchogenic cyst an extremely rare tumor of anterior mediastinum in adults. J Cardiothorac Surg 2018; 13:120. [PMID: 30458821 PMCID: PMC6247636 DOI: 10.1186/s13019-018-0809-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Accepted: 11/11/2018] [Indexed: 12/30/2022] Open
Abstract
Background Intra-thymic bronchogenic cysts are a rare entity but should be considered in the differential of all non-invasive thymic masses. Case presentation We describe a 50-year-old patient who was found to have an incidental thymic mass on computer tomography of the chest. Non-invasive thymoma was suspected and a thoracoscopic thymectomy was performed. Final pathology revealed a bronchogenic cyst. Conclusion Intra-thymic bronchogenic cysts are extremely rare tumors of the anterior mediastinum. It should be considered in differential diagnosis of anterior mediastinal masses.
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Affiliation(s)
- Shadi Hamouri
- Department of General Surgery and Urology, Faculty of Medicine, Jordan University of Science and Technology, Irbid, 22110, Jordan.
| | - Muad Hatamleh
- Department of General Surgery and Urology, Faculty of Medicine, Jordan University of Science and Technology, Irbid, 22110, Jordan
| | - Jamal Alaydi
- Division of Thoracic Surgery, Department of Surgery, King Hussein Medical Center, Jordanian Royal Medical Services, Amman, Jordan
| | - Hani Alhadidi
- Division of Thoracic Surgery, Department of Surgery, King Hussein Medical Center, Jordanian Royal Medical Services, Amman, Jordan
| | - Mazen Alomari
- Division of Thoracic Surgery, Department of Surgery, King Hussein Medical Center, Jordanian Royal Medical Services, Amman, Jordan
| | - Najla Aldaoud
- Department of Pathology and Microbiology, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Bashar Darayseh
- Department of Pathology and Microbiology, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
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Elsayed HH, Gamal M, Raslan S, Abdel Hamid H. Video-assisted thoracoscopic thymectomy for non-thymomatous myasthenia gravis: a right-sided or left-sided approach? Interact Cardiovasc Thorac Surg 2017; 25:651-653. [PMID: 28591868 DOI: 10.1093/icvts/ivx136] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2016] [Accepted: 04/03/2017] [Indexed: 11/14/2022] Open
Abstract
A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was in [patients undergoing video-assisted thoracoscopic thymectomy for myasthenia gravis (MG)] is a [left-sided approach] superior to a [right-sided approach] in terms of [clinical outcome]? Two hundred and fifty-nine papers were found using the reported search. In looking at both procedures, we selected studies with a sizeable number of patients performing or studying both procedures and comparing their outcome. Hence, only 4 studies represented the best evidence to answer the clinical question. The authors, journal, date, country, study type, patient group, relevant outcomes and results of these papers are tabulated. Two studies compared their clinical experience with a right-sided versus a left-sided video assisted thoracoscopic surgery thymectomy approach, while 1 study compared using a bilateral versus a unilateral right-sided approach in patients with non-thymomatous MG. The number of patients studied included 31, 107 and 103 patients, respectively. All 3 studies demonstrated no difference regarding surgical time, intraoperative blood loss, postoperative hospital stay, postoperative complications and therapeutic effects (the last study compared the 5-year complete stable remission rate). All 3 studies concluded that both approaches are feasible, effective and comparable in operative and long-term results for the treatment of non-thymomatous MG. One anatomical study compared both approaches in 10 cadavers, 5 in each group. They studied the size of the specimen resected and visualization of different anatomic sites via each approach. Visualization was superior using the left-sided approach, while a right-sided approach resulted in slightly higher chances of an incomplete resection. The study concluded that a left-sided approach achieves a better chance of radical thoracoscopic thymectomy due to anatomic considerations. In conclusion, despite 1 cadaveric study suggesting that a left-sided approach may achieve more complete resection, possibly due to anatomical considerations, there are no differences in outcomes with either unilateral approach in terms of complications, hospital stay or long-term symptom relief.
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Affiliation(s)
- Hany Hasan Elsayed
- Department of Thoracic Surgery, Ain Shams University Hospital, Cairo, Egypt
| | - Mahmoud Gamal
- Department of Cardiac Surgery, Nasser Institute for Research and Treatment, Cairo, Egypt
| | - Saleh Raslan
- Department of Cardiothoracic Surgery, Al Azhar University, Cairo, Egypt
| | - Hossam Abdel Hamid
- Department of Cardiothoracic Surgery, Ain Shams University Hospital, Cairo, Egypt
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Infante M, Benato C, Giovannetti R, Bonadiman C, Canneto B, Falezza G, Lonardoni A, Gandini P. VATS thymectomy for early stage thymoma and myasthenia gravis: combined right-sided uniportal and left-sided three-portal approach. J Vis Surg 2017; 3:144. [PMID: 29302420 DOI: 10.21037/jovs.2017.09.01] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Accepted: 08/28/2017] [Indexed: 01/10/2023]
Abstract
The traditional approach to thymectomy requires median sternotomy based on the assumption that it is the best means to achieve adequate resection margins, complete removal of the thymus and clearance of the anterior mediastinal fat. However, in recent years, VATS thymectomy has been gaining acceptance as a means to achieve adequate oncologic results and symptomatic improvement of myasthenic symptoms with less impact on the patient. We have adopted a flexible approach based on the location of the tumor and on whether the patient has myasthenia gravis (MG) or not when planning minimally invasive VATS thymectomy. A preferential approach from the left side is chosen for clinical stage I-II thymomas located on the left side or on the midline in patients without MG, and a bilateral approach (uniportal VATS on the right side and three-portal VATS on the left side) for MG patients with or without thymoma in order to achieve complete clearance of the anterior mediastinal fat on both sides. Such techniques are herewith clearly illustrated in hope that surgeons wishing to endeavor in such an effort will be facilitated.
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Affiliation(s)
- Maurizio Infante
- Department of Thoracic Surgery, University and Hospital Trust of Verona, Verona, Italy
| | - Cristiano Benato
- Department of Thoracic Surgery, University and Hospital Trust of Verona, Verona, Italy
| | - Riccardo Giovannetti
- Department of Thoracic Surgery, University and Hospital Trust of Verona, Verona, Italy
| | - Cinzia Bonadiman
- Department of Thoracic Surgery, University and Hospital Trust of Verona, Verona, Italy
| | - Barbara Canneto
- Department of Thoracic Surgery, University and Hospital Trust of Verona, Verona, Italy
| | - Giovanni Falezza
- Department of Thoracic Surgery, University and Hospital Trust of Verona, Verona, Italy
| | - Alessandro Lonardoni
- Department of Thoracic Surgery, University and Hospital Trust of Verona, Verona, Italy
| | - Paola Gandini
- Department of Thoracic Surgery, University and Hospital Trust of Verona, Verona, Italy
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Siwachat S, Tantraworasin A, Lapisatepun W, Ruengorn C, Taioli E, Saeteng S. Comparative clinical outcomes after thymectomy for myasthenia gravis: Thoracoscopic versus trans-sternal approach. Asian J Surg 2016; 41:77-85. [PMID: 27810167 DOI: 10.1016/j.asjsur.2016.09.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Revised: 09/08/2016] [Accepted: 09/21/2016] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND Thymectomy is an effective treatment option for long-term remission of myasthenia gravis. The superiority of the trans-sternal and thoracoscopic surgical approaches is still being debated. The aims of this study are to compare postoperative outcomes and neurologic outcomes between the two approaches and to identify prognostic factors for complete stable remission (CSR). METHODS Myasthenia gravis patients who underwent thymectomy with trans-sternal or thoracoscopic approach in MahaRaj Nakorn Chiang Mai Hospital, Chiang Mai, Thailand between January1, 2006 and December 31, 2013 were retrospectively reviewed. The endpoints were postoperative outcomes and cumulative incidence function for CSR. The analysis was performed using multilevel model, Cox's proportional hazard model, and propensity score. RESULTS Ninety-eight patients were enrolled in this study: 53 in the thoracoscopic group and 45 in the trans-sternal group. There were no significant differences between groups in composite postoperative complications, surgical time, ventilator support days, and length of intensive care unit stay. Intraoperative blood loss and length of hospital stay were significant less in the thoracoscopic group. The CSR and median time to remission were not significantly different between the two approaches. Prognostic factors for CSR were nonthymoma (hazard ratio: 3.5, 95% confidence interval: 1.01-12.22) and presence of pharmacological remission (hazard ratio: 24.3, 95% confidence interval: 3.27-180.41). CONCLUSION Thoracoscopic thymectomy is safe and provides good neurologic outcomes in comparison to the trans-sternal approach. Two predictive factors should be considered for CSR. Further prospective studies with a larger sample size and longer follow-up period are warranted to confirm these results.
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Affiliation(s)
- Sophon Siwachat
- Thoracic Surgery Unit, Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Apichat Tantraworasin
- Thoracic Surgery Unit, Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand.
| | - Worakitti Lapisatepun
- Thoracic Surgery Unit, Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Chidchanok Ruengorn
- Department of Pharmaceutical Care, Faculty of Pharmacy, Chiang Mai University, Chiang Mai, Thailand
| | - Emanuela Taioli
- Department of Population Health Science and Policy and Institute for Translational Epidemiology, Icahn Medical School at Mount Sinai, New York, NY, USA
| | - Somcharoen Saeteng
- Thoracic Surgery Unit, Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
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Bedetti B, Solli P, Lawrence D, Panagiotopoulos N, Hayward M, Scarci M. Single port video-assisted thoracoscopic thymectomy. J Vis Surg 2016; 2:149. [PMID: 29078536 DOI: 10.21037/jovs.2016.08.07] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Accepted: 08/22/2016] [Indexed: 11/06/2022]
Abstract
Over the past decade, video-assisted thoracic surgery (VATS) has started to replace median sternotomy for the resection of non-invasive anterior mediastinal masses, including thymoma. In fact, many studies confirmed that, compared to standard sternotomy, VATS thymectomy results in less post-operative pain, better preserved pulmonary function, improved cosmesis (which can be particularly important to many young female myasthenia gravis patients) and is oncologically feasible for non-invasive thymomas as long as en bloc resection of the tumour is achieved. Classically three ports are used, but the current trend is to reduce the number of ports and minimize the length of incisions to further decrease postoperative pain, chest wall paraesthesia, and length of hospitalization. Uniportal VATS thymectomy for non-invasive mediastinal tumour resection is proven to be a safe and reliable method. In this paper we describe and illustrate our technique for single port VATS thymectomy.
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Affiliation(s)
- Benedetta Bedetti
- Department of Thoracic Surgery, University College of London Hospitals, London, UK
| | - Pierfiorgio Solli
- Department of Thoracic Surgery, Morgagni-Pierantoni Hospital, Forli, Italy
| | - David Lawrence
- Department of Thoracic Surgery, University College of London Hospitals, London, UK
| | | | - Martin Hayward
- Department of Thoracic Surgery, University College of London Hospitals, London, UK
| | - Marco Scarci
- Department of Thoracic Surgery, University College of London Hospitals, London, UK
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Abstract
The continuous development and refinement of minimally invasive approaches to thymectomy over the last two decades has potential benefits for patients in terms of better cosmesis, less postoperative pain, shorter length of stay, earlier return to daily activities, less bleeding and fewer complications overall with similar outcomes regarding survival, recurrence of thymoma and complete remission (CR) for myasthenia gravis patients. A variety of different approaches have been described previously. This is a detailed description of video-assisted thoracoscopic thymectomy using three 5 mm ports, carbon dioxide (CO2) insufflation and bipolar electrocoagulation (LigaSure).
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Affiliation(s)
- René Horsleben Petersen
- Department of Cardiothoracic Surgery, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
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