Supplement: 2nd International Bi-Annual Minimally Invasive Thoracic Surgery Summit
Section IV: Mediastinum/chest wall
Video-Assisted Thoracic Surgery Thymectomy: The Better Approach

Presented at the 2nd International Bi-Annual Minimally Invasive Thoracic Surgery Summit, Boston, MA, October 9–10, 2009.
https://doi.org/10.1016/j.athoracsur.2010.02.112Get rights and content

Minimally invasive video-assisted thoracic surgery (VATS) thymectomy has evolved significantly over the last decade. The most common indication for VATS thymectomy is the treatment of myasthenia gravis (MG). Video-assisted thoracic surgery thymectomy results in less postoperative pain, better preserved pulmonary function, and improved cosmesis, which can be particularly important to many young female MG patients. Results of VATS thymectomy, in terms of complete stable remission from MG and symptomatic improvement, as well as safety, are comparable with conventional surgical techniques. This more patient-friendly approach would lead to wider acceptance by MG patients and their neurologists for earlier thymectomies and improved outcomes.

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

References (41)

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    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.

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    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

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    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.

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