Supplement: 2nd International Bi-Annual Minimally Invasive Thoracic Surgery SummitSection IV: Mediastinum/chest wallVideo-Assisted Thoracic Surgery Thymectomy: The Better Approach
Section snippets
Patient Selection
For young patients with generalized MG, it is now fairly well accepted that thymectomy should be offered. However, uncertainties remain over the role of thymectomy for patients with purely ocular symptoms and those with late onset of disease. Arguments have been put forward not to operate on ocular symptoms alone because ocular MG is not only less likely to respond to thymectomy, but also carries a better prognosis compared with generalized MG. On the other hand, it has been shown that between
Technical Pearls
We have previously described our technique for VATS thymectomy for MG [12, 13]. Once the lung is collapsed with selective one lung ventilation, there is plenty of room for instrument maneuvering. Therefore, carbon dioxide insufflation and hence valved ports is unnecessary. In fact, there is evidence that thoracic carbon dioxide insufflation during VATS has an adverse effect on the patient's hemodynamics compared with selective one lung ventilation. The use of costal or sternal hooks for
Postoperative Care
Early extubation should be encouraged after surgery. The patient can resume a full diet when fully awake from the general anesthesia, unless impaired by bulbar weakness from MG. A postoperative sitting chest radiograph is taken, and chest physiotherapy as well as incentive spirometry should be provided and encouraged. Oxygen saturation monitoring and bedside spirometry should be performed in the early postoperative period to give warning of respiratory muscle weakness. In particular, a
Limitations of VATS Thymectomy
There are relatively few contraindications to VATS. In addition to the general contraindications such as severe coagulopathy, specific ones include pleural symphysis and patients with severe underlying lung disease or poor lung function who are unable to tolerate the selective one-lung ventilation during general anesthesia. As previously discussed, VATS may not be the ideal approach for very young children. Their small airways are unable to accommodate the smallest double-lumen tube and other
Results
The experience of VATS thymectomy at our institution until 2004 was previously reported [13]. Updating our results from 1992 to the present, we have attempted 64 VATS thymectomies. Two patients required conversion to a small lateral thoracotomy for control of bleeding from a branch of the brachiocephalic vein (conversion rate of 3%), which occurred early in our experience. Four were not related to MG, and there were 8 thymomas. Therefore, 52 VATS thymectomies were successfully performed for
Comment
Considerable uncertainties remain over the optimal treatment of myasthenia gravis. The best surgical approach to thymectomy remains controversial. Regardless of technique, it is generally agreed that thymectomy for MG should be complete. The Columbia-Presbysterian [17] group advocated “maximal” thymectomy involving a combination of median sternotomy with cervical incision to achieve en bloc thymectomy and anterior mediastinal exenteration, which includes mediastinal pleura from the level of the
Conclusion
Video-assisted thoracic surgery thymectomy is a safe operation in experienced hands and represents an increasingly popular alternative approach for patients with MG. The right-sided approach is preferred by us because visualization of the venous anatomy for dissection is essential. Collective evidence so far shows the VATS approach produces results comparable with other conventional surgical techniques for thymectomy. The thoracoscopic approach causes less postoperative pain, shortens hospital
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Cited by (41)
Double sternal elevation subxiphoid versus uniportal thoracoscopic thymectomy associated with superior clearance for stage I–II thymic epithelial tumors: Subxiphoid thymectomy compared with VATS
2022, Surgery (United States)Citation Excerpt :This is the largest cohort addressing this issue to date. Thoracoscopic thymectomy has been used for the treatment of thymic epithelial tumors and has achieved similar outcomes to open surgery.23,24 In 2011, the ITMIG presented the standard terms, definition, and policies for minimally invasive resection of thymoma.
National Use and Short-term Outcomes of Video and Robot-Assisted Thoracoscopic Thymectomies
2022, Annals of Thoracic SurgeryTranscervical Thymectomy Is the Most Cost-Effective Surgical Approach in Myasthenia Gravis
2020, Annals of Thoracic SurgeryCitation Excerpt :Wolfe and colleagues1 showed that patients randomized to extended thymectomy by MS, in combination with prednisone, experienced fewer symptoms and a reduced requirement for steroids at 3 years, as well as dramatically lower hospitalization rates, than those randomized to protocolized steroid therapy alone. Further, several cohort studies have shown that minimally invasive approaches to thymectomy, including the TCT and VATS/RATS approaches, achieve essentially identical MG remission rates to more invasive approaches.4-15 To confirm that identical MG remission rates can indeed be achieved by any operative approach, we reviewed results published for extended thymectomy by MS, TCT, and RATS/VATS in the last 35 years, using what we thought was the highest-quality data available (Table 5).
Surgical techniques for early-stage thymoma: Video-Assisted thoracoscopic thymectomy versus transsternal thymectomy
2014, Journal of Thoracic and Cardiovascular SurgeryCitation Excerpt :In addition to the general contraindications such as severe coagulopathy, the specific contraindications include pleural adhesions and patients with severe underlying lung disease or poor lung function who are unable to tolerate selective single-lung ventilation.1 VATS might not be an ideal approach for very young children because of the difficulty of performing single-lung ventilation in this age group.1 The long-term oncologic outcomes after VATS thymectomy for thymoma remain unclear.
Surgical treatment of myasthenia gravis: Evident benefits and insidious pitfalls of mini-invasive techniques
2013, Annals of Thoracic Surgery