Robot-assisted thymectomy is superior to transsternal thymectomy

Outcome of Robotic-Assisted Resection of Large Primary Thymic Tumors: A Single High-Volume Institutional Experience

Background

The role of robotic-assisted resection for large primary thymic malignant tumors is uncertain. This study compares outcomes of robotic-assisted resection by tumor size.

Methods

Robotic resections for anterior mediastinal masses were identified from an institutionally maintained database and were retrospectively analyzed. Cases were stratified by tumor size. Data points collected included patient demographics, tumor characteristics, and perioperative outcomes.

Results

From 2014 to 2022, 67 robotic-assisted mediastinal resections were performed for primary thymic malignant tumors. The average tumor size was 5.6 cm (range, 0.7-14.0 cm). The median length of stay was 3 days (range, 1-73 days). The median operative time was 186 minutes (range, 69-644 minutes). Tumors ≤4 cm (n = 21; 31%) vs >4 cm (n = 46; 69%), trended toward a shorter median operative time (157 minutes vs 208 minutes; P = .06), length of stay (2 days vs 3.5 days; P = .18), and lower positive margins (21 [100%] R0 resections in the ≤4-cm group vs 40 [87%] R0 resections in the >4-cm group; P = .09). There was no difference in major complications (2 [9.5%] vs 3 [2.5%]; P = 1.0).

Conclusions

Robotic-assisted resection can be safe and effective for primary thymic malignant tumors. Concern regarding increased rates of positive margins vs an open approach for large tumors remain. Although a robotic approach for larger tumors may spare selected patients the morbidity of an open procedure without compromising outcomes, a low threshold should exist for conversion to open surgery.

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.

National Multicenter Study on the Comparison of Robotic and Open Thymectomy for Thymic Neoplasms in Myasthenic Patients: Surgical, Neurological and Oncological Outcomes

Thymectomy is the gold standard in the treatment of thymic neoplasm and plays a key role in the therapeutic path of myasthenia gravis. For years, sternotomy has been the traditional approach for removing anterior mediastinal lesions, although the robotic thymectomy is now widely performed. The literature is still lacking in papers comparing the two approaches and evaluating long-term oncological and neurological outcomes. This study aims to analyze the postoperative results of open and robotic thymectomy for thymic neoplasms in myasthenic patients. Surgical, oncological and neurological data of myasthenic patients affected by thymic neoplasms and surgically treated with extended thymectomy, both with the open and the robotic approach, in six Italian Thoracic Centers between 2011 and 2021 were evaluated. A total of 213 patients were enrolled in the study: 110 (51.6%) were treated with the open approach, and 103 (48.4%) were treated with robotic surgery. The open surgery, compared with the robotic, presented a shorter operating time (p < 0.001), a higher number of postoperative complications (p = 0.038) and longer postoperative hospitalization (p = 0.006). No other differences were observed in terms of surgical, oncological or neurological outcomes. The robotic approach can be considered safe and feasible, comparable to the open technique, in terms of surgical, oncological and neurological outcomes.

Application of Artificial Intelligence in the Diagnosis, Treatment, and Prognostic Evaluation of Mediastinal Malignant Tumors

Artificial intelligence (AI), also known as machine intelligence, is widely utilized in the medical field, promoting medical advances. Malignant tumors are the critical focus of medical research and improvement of clinical diagnosis and treatment. Mediastinal malignancy is an important tumor that attracts increasing attention today due to the difficulties in treatment. Combined with artificial intelligence, challenges from drug discovery to survival improvement are constantly being overcome. This article reviews the progress of the use of AI in the diagnosis, treatment, and prognostic prospects of mediastinal malignant tumors based on current literature findings.

Robot-assisted thoracoscopic surgery vs. sternotomy for thymectomy: A systematic review and meta-analysis

Introduction

Surgeons have widely regarded sternotomy (ST) as the standard surgical method for thymectomy. Minimally invasive methods for thymectomy, including video-assisted and robot-assisted thoracoscopic surgery (RATS), have been explored. There are some studies have researched and compared the outcomes of patients after robotic and sternotomy procedure.

Methods

We searched the databases of Pubmed, the Cochrane Library, Embase and selected the studies on the efficacy and safety of RATS or ST for thymectomy. Meta-analysis was performed for operation time, operation blood loss, postoperative drainage time, operative complications and hospitalization time.

Results

A total of 16 cohort studies with 1,089 patients were included. Compared to ST, RATS is an appropriate alternative for thymectomy which reduced operation blood loss [standardized mean difference (SMD) = -1.82, 95% confidence interval (95% CI): (-2.64, -0.99), p = 0.000], postoperative drainage time [SMD = -2.47, 95% Cl: (-3.45, -1.48), p = 0.000], operative complications [odds ratio (OR) = 0.31, 95% Cl: (0.18, 0.51), p = 0.000] and hospitalization time [SMD = -1.62, 95% Cl: (-2.16, -1.07), p = 0.000].

Conclusions

This meta-analysis based on cohort studies shows that RATS has more advantages over ST. Therefore, RATS is a more advanced and suitable surgical method for thymectomy.

Post-Operative Outcomes Associated With Open Versus Robotic Thymectomy: A Propensity Matched Analysis

To compare post-operative outcomes associated with thymectomy performed using either open or robotic approaches. Retrospective cohort study from a single-center prospective registry consisting of patients undergoing thymectomy between 2000 and 2020. Patients were grouped according to surgical approach (open vs robotic). A propensity-score matching analysis was performed in a 2:1 open to robotic ratio, and surgical outcomes were evaluated. We analyzed 234 thymectomies (155 open; 79 robotic). Myasthenia gravis was present in 23.2% and 32.9% (P = 0.249) in the open and in the robotic group, respectively. All covariates were balanced in the matched groups (open n = 114; robotic n =5 9), except lesion size. The robotic approach was significantly associated with shorter surgical time (median 95 vs 65 minutes, P < 0.001), lesser clinical (21.1% vs 6.8%, P = 0.016) and surgical (11.4% vs 1.7%, P = 0.036) complications during the same hospitalization, less Clavien-Dindo grade 2 or higher complication rates (28.1 vs 15.3%, P = 0.048), chest tube duration (median: 3 vs 0 days, P < 0.001) and in-hospital length of stay (median: 5 vs 0 days, P < 0.001). Bleeding (P = 0.214), ICU length of stay (P = 0.167), reoperation rate (open, 1.8% vs robotic 0%), 90-day mortality (P = 0.341) and readmission rate post discharge (P = 0.277) were similar between the groups. In the matched population with primary thymic epithelial tumors, the completeness of resection rate was similar (open, 92.1% vs robotic 96.8%, P = 0.66.). Robotic thymectomy is associated with improved post-operative outcomes when compared to open thymectomy, without compromising the goals of oncologic surgery. Longer follow-up is needed to ensure oncologic equivalence.

A universal incision for robot-assisted thoracic surgery

Objective

This paper aimed to design and explore the versatility of the incision for the robot-assisted thoracic surgery.

Methods

The concept of universal incision was designed and put forward. The clinical data of 342 cases of robot-assisted thoracic surgery were summarized, including sex, age, clinical diagnosis, operative method, operative time, conversion to thoracotomy, intraoperative blood loss, number of lymph node dissections, postoperative hospital stays, postoperative pathology, and postoperative complications of the patients.

Results

The 342 cases of robot-assisted surgery included 178 pulmonary surgery cases (94 lobectomy cases, 75 segmentectomy cases, 6 wedge resection cases, and 3 sleeve lobectomy cases), 112 esophageal surgery cases (107 McKeown approach cases and 5 esophageal leiomyoma resection cases), and 52 mediastinal tumor cases (42 anterior mediastinum cases and 10 posterior mediastinum cases). Among these, two cases were converted to thoracotomy (both esophageal cases), and the rest were successful with no massive intraoperative bleeding and no perioperative death.

Conclusion

The universal incision of robot-assisted thoracic surgery is safe and feasible and is suitable for most cases of thoracic surgery.

Deep neuromuscular block for minimally invasive lung surgery: a protocol for a systematic review with meta-analysis and trial sequential analysis

INTRODUCTION

Minimally invasive lung surgery (MILS) gradually became the primary surgical therapy for lung cancer, which remains the leading cause of cancer death. Adequate muscle relaxation by deep neuromuscular block (NMB) is particularly necessary for MILS to provide a satisfactory surgical field. However, deep NMB for MILS remains controversial, as one-lung ventilation may provide an acceptable surgical field. Then, we will perform a protocol for a systematic review and meta-analysis to identify the efficacy of deep NMB for MILS.

METHODS AND ANALYSIS

We will search the PubMed, Cochrane Library, Embase, Ovid Medline, Web of Science, Chinese BioMedical Literature, China National Knowledge Infrastructure, VIP and Wanfang databases from inception to March 2022 to identify randomised controlled trials of adult participants undergoing MILS with deep NMB. Studies published in English or Chinese will be considered. The primary outcome will be the surgical conditions according to the surgeon's perspective. Secondary outcomes will be the incidence of perioperative events and perioperative mortality. Heterogeneity will be assessed by the χ² test and I² statistic. Data will be synthesised by both a fixed-effect and a random-effects meta-analysis, with an intention to present the random-effects result if there is no indication of funnel plot asymmetry. Otherwise, metaregression will be used. The Cochrane risk-of-bias tool, trial sequential analysis and Grading of Recommendations Assessment, Development and Evaluation will be used to assess the evidence quality and control the risks of random errors. Funnel plots and Egger's regression test will be used to assess publication bias.

ETHICS AND DISSEMINATION

Ethical approval was not required for this systematic review protocol. The results will be disseminated through peer-reviewed publications.

PROSPERO REGISTRATION NUMBER

CRD42021254016.

Minimally invasive combined approach robotic thymectomy and transcervical total thyroidectomy

Myasthenia gravis (MG) is the most common autoimmune disorder affecting the neuromuscular junction in the USA. It is not uncommon for these patients to have concomitant autoimmune diseases including autoimmune thyroid disease. We describe here our method of performing a reproducible robotically assisted one-stage thymectomy and thyroidectomy. An African-American woman presented to our institution with a medical history of hypertension, morbid obesity, type 2 diabetes mellitus, symptomatic MG and symptomatic non-toxic substernal multinodular goitre. A one-stage minimally invasive right-sided robotic radical thymectomy and a transcervical total thyroidectomy with excision of the substernal goitre was successfully performed. The treatment of thyroid and thymus pathologies varies drastically from medical observation to surgery. This combined approach surgery clearly benefits the patient by offering similar operative time, fewer operative and postoperative recovery experiences, decreased anaesthesia risks associated with MG patients through fewer intubations, and a faster return to baseline function.

An Overview of Surgical Treatment of Thymic Epithelial Tumors in Korea: A Retrospective Multicenter Analysis

Background

Thymic epithelial tumors (TETs) are rare, and information regarding their surgical outcomes and prognostic factors has rapidly changed in the past few decades. We analyzed surgical treatment practices for TETs and outcomes in terms of overall survival (OS) and freedom from recurrence (FFR) during a 13-year period in Korea.

Methods

In total, 1,298 patients with surgically resected TETs between 2000 and 2013 were enrolled retrospectively. OS and FFR were calculated using the Kaplan-Meier method and evaluated with the log-rank test. Prognostic factors for OS and FFR were analyzed with multivariable Cox regression.

Results

A total of 1,098 patients were diagnosed with thymoma, and 200 patients were diagnosed with thymic carcinoma. Over the study period, the total number of patients with surgically treated TETs and the proportion of patients who underwent minimally invasive thymic surgery (MITS) increased annually. The 5-year and 10-year survival rates of surgically treated TETs were 91.0% and 82.1%, respectively. The 5-year and 10-year recurrence rates were 86.3% and 80.0%, respectively. The outcomes of surgically treated TETs improved over time. Multivariable Cox hazards analysis for OS, age, tumor size, and Masaoka-Koga stage were independent predictors of prognosis. The World Health Organization classification and tumor-node-metastasis (TNM) staging were also related to the prognosis of TETs.

Conclusion

Surgical treatment of TETs achieved a good prognosis with a recent increase in MITS. The M-K stage was the most important prognostic factor for OS and FFR. The new TNM stage could also be an effective predictor of the outcomes of TETs.

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

Meta-Analysis of Limited Thymectomy versus Total Thymectomy for Masaoka Stage I and II Thymoma

Background

This meta-analysis aimed to evaluate the incidence of tumor recurrence, postoperative myasthenia gravis, postoperative complications, and overall survival after limited versus total thymectomy for Masaoka stage I and II thymoma.

Methods

A systematic search of the literature was conducted using the PubMed, Embase, MEDLINE, and Cochrane databases to identify relevant studies that compared limited and total thymectomy in Masaoka stage I-II patients. The quality of the included observational studies was assessed using the Newcastle-Ottawa Scale. The results of the meta- analysis were expressed as log-transformed odds ratios (log ORs), with 95% confidence intervals (CIs).

Results

Seven observational studies with a total of 2,310 patients were included in the meta-analysis. There was an overall non-significant difference in favor of total thymectomy in terms of tumor recurrence (pooled log OR, 0.40; 95% CI, -0.07 to 0.87; p=0.10; I²=0%) and postoperative myasthenia gravis (pooled log OR, 0.12; 95% CI, -1.08 to 1.32; p=0.85; I²=22.6%). However, an overall non-significant difference was found in favor of limited thymectomy with respect to postoperative complications (pooled log OR, -0.21; 95% CI, -1.08 to 0.66; p=0.64; I²=36.1%) and overall survival (pooled log OR, -0.01; 95% CI, -0.68 to 0.66; p=0.98; I²=47.8%).

Conclusion

Based on the results of this systematic review and meta-analysis, limited thymectomy as a treatment for stage I and II thymoma shows similar oncologic outcomes to total thymectomy.

Midterm Results for Robotic Thymectomy for Malignant Disease

BACKGROUND

There are limited reports on robotic thymectomy for malignant disease. Our objectives are to review our experience and midterm outcomes.

METHODS

We reviewed a single-surgeon prospective database for patients who underwent planned robotic resection for malignancy from January 2010 to June 2019.

RESULTS

Two hundred thirteen patients underwent resection of an anterior mediastinal mass, all of which were planned for a robotic approach. Of these, 84 (39%) underwent robotic thymectomy for malignant disease. Thymoma was the most common pathology resected (68%). Median tumor size was 4.7 cm (interquartile range, 2.9-6.3), and median operative time was 81.5 minutes (interquartile range, 64-104). All except 1 patient had a complete (R0) resection (98.8%). There were 2 (2.3%) unplanned but elective conversions to open surgery, 1 of which required cardiopulmonary bypass. Median length of stay was 1 day (range, 0-9) with 1 readmission (1.2%). Major morbidity occurred in 3 patients (3.5%), and there were no 30- or 90-day mortalities. In patients with thymoma, follow-up was complete at a median of 32 months (range, 1-98), and 1 patient (1.8%) had an ipsilateral chest recurrence. To date there have been no patient deaths.

CONCLUSIONS

Robotic thymectomy for patients with malignant disease is safe with excellent perioperative outcomes. A robotic approach achieves a high rate of complete R0 resection, even for larger tumors. For patients with thymoma local recurrence is low after midterm follow-up, but longer-term analysis is needed to determine oncologic durability.

Comparison of the progression-free survival between robot-assisted thymectomy and video-assisted thymectomy for thymic epithelial tumors: a propensity score matching study

Background

Robotic system was recently introduced to assist surgeons in performing thymectomy. However, whether robot-assisted thoracoscopic thymectomy (RATT) could replace video-assisted thoracoscopic thymectomy (VATT) and be considered as a superior treatment for thymic epithelial tumors is still controversial. The aim of this study was to evaluate the progression-free survival (PFS) and short-term clinical outcomes in patients undergoing RATT or VATT by comparing the matched two groups after performing propensity score analysis.

Methods

We retrospectively reviewed the clinical data of 295 patients diagnosed with thymic epithelial tumors. There were 60 patients in RATT group and 235 in VATT group. Propensity score matching was done between two groups with variables of age, gender, tumor size, organization histologic classification, original Masaoka stages, presence of myasthenia gravis (MG) and adjuvant therapy. Sixty patients from the RATT group and 60 from the VATT group were matched, fitting the model. The PFS and short-term clinical outcomes of matched groups were compared.

Results

After matching, the surgical time in RATT groups was significant shorter than that in VATT groups (P=0.042). Loco-regional recurrence and distal metastasis were detected in 4 patients with thymoma and 1 patient with thymic carcinoma in RATT group and in 25 patients with thymoma and 3 patients with thymic carcinoma in VATT group before matching. PFS were estimated in only thymoma cases. The PFS in RATT group (n=55) intended to be longer than that in VATT group (n=58) after matching (5-year PFS rate: 81.5% and 75.4%, respectively; log-rank P=0.095).

Conclusions

RATT has the superiorities over VATT on short-term outcomes due to enabling surgeons to operate in a stable and comfortable environment. Meanwhile, RATT yielded a longer PFS compared with VATT, although the difference was not significant. Therefore, RATT could be considered as a standard approach for the treatment of thymic epithelial tumors.

Robotic assisted transaxillary thymectomy: Novel approach to thymic surgery

BACKGROUND

We present a video case with a novel, minimally invasive approach to the thymus, which does not require a sternotomy, thoracic incision, or entry into the pleural space.

METHODS

A 14-year-old girl was referred to our clinic with dysphagia and left sided thymic mass. A detailed video shows the operative techniques used to perform a thymectomy with robotic assistance via a transaxillary approach.

RESULTS

The procedure was tolerated well and without complication. The patient was discharged the day after surgery and was symptom free at her 2-week follow-up appointment.

CONCLUSION

We present a novel approach to thymic surgery that does not require a neck incision, sternotomy, or entry into the pleural space. There could be several benefits from this minimally invasive approach; however, concerns related to exposure and adequacy of resection need further research prior to recommending this technique for myasthenia or malignancy.

Robotic-Extended Rethymectomy for Refractory Myasthenia Gravis: A Case Series

To assess the safety and efficacy of robotic-extended rethymectomy in selected refractory myasthenia gravis (MG) patients with suspected residual thymic tissue. Robotic-extended rethymectomy was performed in 6 MG patients with seropositive acetylcholine receptors (AChR) antibody who had undergone a previous thymectomy (1 cervicotomy, 2 video-assisted thoracoscopic surgeries, and 3 sternotomies). The median observation time before robotic rethymectomy was 108 (24-171) months. The main outcomes were perioperative morbidity, mortality, conversion to open surgery, and clinical outcomes according to the Myasthenia Gravis Foundation of America Post-Intervention Status (MGFA-PIS). Before rethymectomy, all patients required immunosuppressants and 5 patients (83.3%) required intravenous immune globulin and/or plasma exchange to control the symptoms. The median specimen weight was 24.5 (14-144) g after rethymectomy, and residual thymic tissue was found in 5 patients (83.3%). No conversion to open surgery or perioperative morbidity and mortality was observed. With a median follow-up time of 46.5 (13-155) months, 3 patients (50%) achieved "improved" and 3 (50%) were "unchanged" according to the MGFA-PIS. Compared with preoperative use, the median daily dose of corticosteroids statistically decreased (25 [7.5-60] vs 0 [0-5] mg, P = 0.002) without significant change in azathioprine use (100 [0-200] vs 50 [0-150] mg, P = 0.360). AChR antibody positive MG patients with a treatment refractory long-term course after thymectomy might have remaining thymic tissue with the 2 commonly associated thymus pathologies, thymoma, and follicular hyperplasia. Robotic-extended rethymectomy might be considered as a safe and beneficial treatment option in these patients.

Comparing robotic and trans-sternal thymectomy for early-stage thymoma: a propensity score-matching study

OBJECTIVES

Minimally invasive techniques seem to be promising alternatives to open approaches in the surgical treatment of early-stage thymoma, although there are controversies because of lack of data on long-term results. The aim of the study was to evaluate the surgical and oncological results after robotic thymectomy for early-stage thymoma compared to median sternotomy.

METHODS

Between 1982 and 2017, 164 patients with early-stage thymoma (Masaoka I and II) were operated on by median sternotomy (108 patients) or the robotic approach (56 patients). Duration of surgery, amount of blood loss, complications, duration of chest drainage, postoperative hospital stay, oncological results and total costs were retrospectively evaluated. Data were analysed also after propensity score matching.

RESULTS

Compared to the trans-sternal group, robotic thymectomy had significantly longer average operative times (P < 0.001) but less intraoperative blood loss (P = 0.01), less perioperative complications (P = 0.03), shorter time to chest drainage removal and hospital discharge (P < 0.001). The median expense for the trans-sternal approach was significantly higher than the cost of the robotic procedure (P < 0.001), mainly due to longer hospitalization. From an oncological point of view, there were no differences in thymoma recurrence, although follow-up of the trans-sternal group was significantly longer (P < 0.001). Data were confirmed after propensity score matching.

CONCLUSIONS

Robotic thymectomy for early-stage thymoma is a technically safe and feasible procedure with low complication rate and shorter hospital stay compared to the trans-sternal approach. Cost analysis revealed lower expenses for the robotic procedure due to the reduced hospital stay. The oncological outcomes seemed comparable, but longer follow-up is needed.

Robot-assisted thoracic surgery in Colombia: a multi-institutional initial experience

Background

Robotic assisted videothoracoscopic surgery (RVATS) adoption has increased worldwide from 3.4% in 2010 to 17.5% in 2015. However, in Latin America, the literature is limited to a report of a series of 10 patients who underwent RVATS lobectomy and one case report of an RVATS thymectomy from Brazil.

Methods

This is a retrospective review of all RVATS performed in Bogotá Colombia since 2012. A single thoracic surgeon (RB) performed all the operations at three institutions: Clínica de Marly, Fundación Clínica Shaio and Instituto Nacional de Cancerología. Preoperative, intraoperative, postoperative and pathology report variables were included. Patients were analyzed in three groups: robotic RVATS pulmonary resections, RVATS mediastinal surgeries and other RVATS procedures. Descriptive statistics were used to report the median and interquartile range (IQR) of the continuous variables, and number and percentage were used to describe categorical variables. The association between total operative time and the year the surgery was analyzed using a linear regression model.

Results

Forty-seven patients underwent RVATS pulmonary resections; 72.3% (n=34) of these patients underwent a RVATS lobectomy. The median total operative time was 220 (IQR: 200 to 250) minutes, 6.4% (n=3) had intraoperative complications, and the most frequent histologic diagnosis was adenocarcinoma (n=24, 51.1%). Of 18 patients who underwent RVATS mediastinal surgeries, 50.0% (n=9) had RVATS thymectomy, the median total operative time was 195.5 (IQR: 131 to 221) minutes and two patients (11.1%) had intraoperative complications. The linear regression model of the association between total operative time and the year the surgery showed a 10.3 minute reduction per year (P=0.006).

Conclusions

This is the second series of RVATS published in Latin America and the first published in Colombia, with comparable perioperative results to other reports.

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.

Robotic-assisted mediastinal surgery: the first Chinese series of 167 consecutive cases

Background

To report the first and largest series of robotic-assisted mediastinal surgeries performed in a single center by the same surgical team in mainland China.

Methods

From May 2009 to June 2017, 167 patients (100 males, 67 females), with a mean age of 50.2 years (range, 12-78 years), underwent robotic surgery for the treatment of a mediastinal mass. Data regarding the operation time, docking time, blood loss, conversion rate, morbidity, mortality and survival follow-up were collected and analyzed.

Results

The mean operation time and docking time were 70.01±29.49 and 10.12±2.77 min. There were 56 thymomas, 52 cysts, 17 schwannomas, 9 bronchogenic cysts, 6 thymic hyperplasias, 6 foregut cysts, 4 squamous carcinomas and 17 others. The mean drainage on the first day after operation was 122.83±107.58 mL, and the mean post-operative drainage duration and post-operative hospital stay were 2.95 days, ranging from 1-7 days, and 4.09 days, ranging from 2-10 days, respectively. The post-operative complication rate was 3%, and the conversion rate was 1.8%. No perioperative mortality occurred. One patient died due to tumor recurrence.

Conclusions

Our experience indicates that this robotic surgical system is a safe and established technique for mediastinal mass resection.

Robotic Thymectomy Is Feasible for Large Thymomas: A Propensity-Matched Comparison

BACKGROUND

Robotic-assisted thymectomy (RAT) is increasingly performed for resection of thymomas. Its application for large tumors remains controversial. In this study, we evaluated the safety and feasibility of RAT for large thymomas in comparison with transsternal thymectomy (ST).

METHODS

A single institution database was reviewed for patients who underwent RAT for thymoma of 4 cm or larger between 2004 and 2016. Propensity scores were applied to match RAT with ST patients, based on age, sex, tumor size, and Masaoka stage. Perioperative outcomes were compared.

RESULTS

Twenty patients (15 women and 5 men, median age 59 years) underwent RAT for a large thymoma (median size 6.0 cm). A right-sided approach was used in 14 patients (70%). A control group of 34 ST patients (median size 6.7 cm) had similar Masaoka staging (p = 0.64). Combined resection of adjacent structures, including pericardium, lung, and phrenic nerve, were frequently performed in both groups (50% RAT versus 47% ST, p = 0.83). RAT patients had lower blood loss (25 mL versus 150 mL, p = 0.001), were more frequently managed with a single chest tube (85% versus 56%, p = 0.027), and had a shorter median length of stay (3 days versus 4 days, p = 0.034). There were no perioperative deaths and no major vascular injuries. Three RAT patients (15%) were converted to open approach. Overall complication rates were similar between RAT and ST patients (15% versus 24%, p = 0.45). No difference was seen in R0 resection rates (90% versus 85%, p = 0.62).

CONCLUSIONS

RAT can be performed safely and effectively in a radical fashion for large thymomas. Future studies are necessary to determine long-term oncologic 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.

Robot-assisted thoracic surgery for complex procedures

Background

As an option for minimally invasive thoracic surgery, robot-assisted thoracic surgery (RATS) has shown comparable perioperative outcomes to those achieved by traditional video-assisted thoracic surgery (VATS). It is unknown whether RATS might have any potential benefits in more complex thoracic surgical procedures, which usually require open surgery instead of VATS. The current study presents a preliminary result regarding the use of RATS in complex thoracic operations in an attempt to address this unresolved question.

Methods

Data from a prospectively collected and maintained surgical database were collected on patients who underwent RATS between February 2012 and August 2014. We defined complex RATS as those operations involving difficult dissections, complex sutures or excision of very large tumors (>8 cm) which would have required open surgery in our hospital before the introduction of RATS. The characteristics and peri-operative outcomes of patients receiving complex RATS were reviewed.

Results

Of the 120 patients undergoing RATS, 30 of them were classified as having undergone complex RATS, 21 to remove lung tumors and 9 to remove mediastinal tumors. The indications for complex RATS included 21 difficult dissections, 10 complex sutures, and 7 very large tumors (8 patients had two indications). There are three conversions to thoracotomy for pulmonary arterial bleeding. There was one mortality resulted from post-pneumonectomy pulmonary hypertension and sepsis. Patients with difficult dissection had longer operative time and hospital stay, and more bleeding and postoperative morbidity.

Conclusions

RATS for complex thoracic procedures is feasible, especially for complex suturing and excision of very large mediastinal tumors, but more attention is needed for patients needing difficult dissections. Advanced preparation for conversion is necessary during this difficult operation.

Robotic trans-subxiphoid extended thymectomy in a patient with thymoma-associated pemphigus

We herein firstly reported that a patient with thymoma-associated pemphigus (TAP) underwent a robotic-assisted trans-subxiphoid thoracoscopic extended thymectomy and then achieved stable resolution. The patient, a 47-year-old male, was first admitted to our hospital owing to stomatitis and bullae of the trunk after four months' prednisone treatment. On admission, chest computed tomography (CT) revealed an anterior-mediastinal mass and it was initially diagnosed as a thymoma. He was positive for anti-BP (bullous pemphigoid)-180 antibody and anti-desmoglein 3 antibody. Then, a robotic-assisted thymectomy was performed, following which, the anti-BP-180 and anti-desmoglein 3 antibody titres have declined. The patient's mucocutaneous lesions improved, and the steroid dose was gradually decreased from 60 to 40 mg/day. According to previous reports, and the experience of the presented case, we therefore believe that early extended thymectomy is an effective therapeutic intervention for TAP.

A bilateral approach to extended thymectomy using the da Vinci Surgical System for patients with myasthenia gravis

PURPOSE

We adopted a bilateral approach to complete robotic extended thymectomy with the excision of the pericardial fat tissue from both sides and analyzed the initial outcomes.

METHODS

The patient cart was docked first from the left shoulder side. After dissection of the thymus and right pericardial fat tissue, the cart was temporarily rolled out, and the bed was rotated approximately 90° clockwise. The cart was then re-docked from the right-side shoulder, and extended thymectomy was performed via the left-side approach. The outcomes were compared with four cases of unilateral approach performed for mediastinal tumor in the same term.

RESULTS

Four patients with myasthenia gravis (two of whom had stage I thymoma) underwent extended thymectomy by the bilateral approach. The mean operative time was 288 min, and the console time was 146 min in the right side and 67 min in the left side. The resected thymus and surrounding adipose tissue were almost symmetrical, in contrast with those obtained via the unilateral approach. No remarkable events were noted.

CONCLUSION

Bilateral extended thymectomy for myasthenia gravis patients was safe and reasonable based on the initial outcomes.

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.

Thymectomy via open surgery or robotic video assisted thoracic surgery: Can a recommendation already be made?

BACKGROUND

Robot-assisted minimally invasive surgery (RVATS) is a relatively new technique applied for thymectomies. Only few studies directly compare RVATS to the mainstay therapy, open surgery (sternotomy).

METHODS

A systematic search of the literature was performed in October 2016. The meta-analysis includes studies comparing robotassisted and open thymectomy regarding operation time, length of hospitalization, intraoperative blood loss, and chest-in-tube days, postoperative complications, reoperation, arrhythmic events, pleural effusion, and postoperative bleeding.

RESULTS

Of 626 studies preliminary screened, 7 articles were included. There were no significant differences in comparison of operation time (-3.19 minutes [95% confidence interval, 95% CI -112.43 to 106.05]; P = .94), but patients undergoing RVATS spent significantly less time in hospital (-4.06 days [95% CI -7.98 to -0.13], P = .046). There were fewer chests-in-tube days (-2.50 days [95% CI -15.01 to 10.01]; P = .24) and less intraoperative blood loss (-256.84 mL [95% CI -627.47 to 113.80]; P = .10) observed in the RVATS group; due to a small number of studies, these results were not statistically significant. There were also less post-operative complications in the RVATS group (12 complications in 209 patients vs 51 complications in 259 patients); however, this difference was not statistical significant (odds ratio 0.27, 95% CI 0.07-1.12; P = .06).

CONCLUSIONS

Patients undergoing RVATS spent less time in hospital than patients treated by open surgery (sternotomy). These patients tended to have less postoperative complications, less intraoperative blood loss, and fewer chest-in-tube days. We found evidence for the safety and feasibility of RVATS compared with open surgery, which has to be further confirmed in randomised controlled trials.

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.

Robotic video-assisted thoracoscopy: minimally invasive approach for management of mediastinal tumors

In spite of difficult anatomic access for tumors of mediastinum, surgical resection remains the best diagnostic and therapeutic approach. Widespread acceptance of video-assisted thoracoscopy (VATS) is restricted by the limiting nature of instruments and suboptimal visualization. Robotic assisted minimally invasive surgery seems to hold most promise in remote, narrow anatomical regions. After obtaining approval from Institutional Review Board (IRB), a retrospective review of prospectively collected database on patients that underwent Robotic VATS between 2009 and 2013 was conducted. Forty-eight patients underwent RVATS resection of mediastinal tumor. One procedure (2.1%) was converted to open. The size of the mass ranged from 0.6 to 12.5 cm in greatest dimension (mean 5.16 cm). The mean duration of procedure was 127.96 min (60-240 min). Five patients (10.4%) had early postoperative complications including chylothorax (1 patient), new onset atrial fibrillation (1 patient), pleural effusion (1 patient), empyema (1 patient), and bleeding (1 patient). Mean follow-up time was 186 days (10-1300 days). Two patients (4%) with invasive thymoma developed local recurrence. The present study documents the feasibility of RVATS in the management of mediastinal tumors irrespective of the location in various mediastinal compartments. The role for careful and complete excision of the tumor, and surveillance afterward on invasive thymoma, was noted in our study, as in literature.

Robotic lung resections: video-assisted thoracic surgery based approach

Advances in technology cause major developments in minimally invasive thoracic surgery practice. The expected benefits of minimally invasive pulmonary surgery are clear and mostly as follows; shorter hospital stay, fast recovery, less pain, and decreased morbidity and mortality. Robotic surgery with improved visualization and instrumental technical capabilities has become an attractive tool for surgeons who are performing lung resections. However, robotic surgery still seems far away from standardization even in the basic fundamental which is "the best approach for docking". In this article, we would like to share our experience in robotic surgery with video-assisted thoracic surgery (VATS) based or in other terms "robotic-assisted" approach, and discuss its advantages and disadvantages. We speculate that, especially at early experience, VATS based approach or "robotic-assisted approach" may provide a smooth start up with the support of the experienced table surgeon.

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 Surgery for Thoracic Disease

Robotic surgeries have developed in the general thoracic field over the past decade, and publications on robotic surgery outcomes have accumulated. However, controversy remains about the application of robotic surgery, with a lack of well-established evidence. Robotic surgery has several advantages such as natural movement of the surgeon's hands when manipulating the robotic arms and instruments controlled by computer-assisted systems. Most studies have reported the feasibility and safety of robotic surgery based on acceptable morbidity and mortality compared to open or video-assisted thoracic surgery (VATS). Furthermore, there are accumulated data to indicate longer operation times and shorter hospital stay in robotic surgery. However, randomized controlled trials between robotic and open or VATS procedures are needed to clarify the advantage of robotic surgery. In this review, we focused the literature about robotic surgery used to treat lung cancer and mediastinal tumor.

Thymic pathologies in myasthenia gravis: a preoperative assessment of CAT scan and nuclear based imaging

Precise diagnostic work up of a suspected thymic pathology in patients with myasthenia gravis (MG) is very important for potential surgical implications and further disease course. In this study the diagnostic value of combined preoperative radiological (CAT scan) and nuclear based imaging (octreotide and thallium scintigraphy) in patients with MG was evaluated. Twenty four patients were included. Histopathology revealed thymoma in nine patients, thymic carcinoma (TC) in one patient, lymphofollicular hyperplasia in seven patients, and involuted thymus in another seven patients. Diagnostic sensitivity for detecting thymoma/TC was 80 % in CAT scan as well as in somatostatin scintigraphy; the combination of both procedures reached 90 %. However, the diagnostic specifity to exclude thymoma in CAT scan was 100 % and in octreotide scintigraphy 85.7 %. Semiquantitative octreotide uptake significantly correlated with histological grading of thymoma/TC (r = 0.764) and histological proliferation rate Ki67 (r = 0.894). Thallium scintigraphy was positive only in one out of four thymoma cases. In this study, somatostatin scintigraphy has been shown to be a useful additional diagnostic technique in detecting thymic malignancies in patients with MG. These results might be especially helpful in patients with late onset MG as these patients are in general no candidates for thymectomy.

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.

Minimally invasive versus open thymectomy: a systematic review of surgical techniques, patient demographics, and perioperative outcomes

BACKGROUND

Thymectomy is the mainstay of treatment for thymoma and other anterior mediastinal tumors, and is often utilized in the management of patients with myasthenia gravis (MG). While traditionally approached through a median sternotomy, minimally invasive approaches to thymectomy have increasingly emerged. The present systematic review was conducted to compare perioperative and clinical outcomes following minimally invasive thymectomy (MIT) and open thymectomy (OT).

METHODS

Articles were obtained through a PubMed literature search. Comparative studies reporting clinical outcomes following MIT and OT were eligible for inclusion. We selected studies with full text availability, written in the English language, published after 2005 and with at least 15 patients in each arm. A descriptive analysis was performed.

RESULTS

Twenty studies were included, involving a total of 2,068 patients undergoing either MIT (n=838) or OT (n=1,230). Within individual studies, MIT and OT cohorts were well matched with regards to patient age and gender, but there was considerable variation across studies. Resected thymomas were consistently larger in OT groups, with mean diameter significantly larger in five studies (MIT, 29-52 mm; OT, 31-77 mm). MIT was consistently associated with a lower estimated blood loss (MIT, 20-200 mL; OT, 86-466 mL), chest tube duration (MIT, 1.3-4.1 days; OT, 2.4-5.3 days), and hospital length of stay (MIT, 1-10.6 days; OT, 4-14.6 days). There were no consistent differences in rates of perioperative complications, thymoma recurrence, MG complete stable remission, or 5-year survival.

CONCLUSIONS

In appropriately selected patients, MIT may reduce blood loss, chest tube duration, and hospital length of stay, with comparable clinical outcomes compared to OT via median sternotomy.

Current Trend of Robotic Thoracic and Cardiovascular Surgeries in Korea: Analysis of Seven-Year National Data

Background

Robotic surgery is an alternative to minimally invasive surgery. The aim of this study was to report on current trends in robotic thoracic and cardiovascular surgical techniques in Korea.

Methods

Data from the National Evidence-based Healthcare Collaborating Agency (NECA) between January 2006 and June 2012 were used in this study, including a total of 932 cases of robotic surgeries reported to NECA. The annual trends in the case volume, indications for robotic surgery, and distribution by hospitals and surgeons were analyzed in this study.

Results

Of the 932 cases, 591 (63%) were thoracic operations and 340 (37%) were cardiac operations. The case number increased explosively in 2007 and 2008. However, the rate of increase regained a steady state after 2011. The main indications for robotic thoracic surgery were pulmonary disease (n=271, 46%), esophageal disease (n=199, 34%), and mediastinal disease (n=117, 20%). The main indications for robotic cardiac surgery were valvular heart disease (n=228, 67%), atrial septal defect (n=79, 23%), and cardiac myxoma (n=27, 8%). Robotic thoracic and cardiovascular surgeries were performed in 19 hospitals. Three large volume hospitals performed 94% of the case volume of robotic cardiac surgery and 74% of robotic thoracic surgery. Centralization of robotic operation was significantly (p<0.0001) more common in cardiac surgery than in thoracic surgery. A total of 39 surgeons performed robotic surgeries. However, only 27% of cardiac surgeons and 23% of thoracic surgeons performed more than 10 cases of robotic surgery.

Conclusion

Trend analysis of robotic and cardiovascular operations demonstrated a gradual increase in the surgical volume in Korea. Meanwhile, centralization of surgical cases toward specific surgeons in specific hospitals was observed.

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.

Experience with the "da Vinci" robotic system for early-stage thymomas: Report of 23 cases

BACKGROUND

The aim of this study was to report a single referral center experience in robotic extended thymectomy for clinical early stage thymomas, evaluating its safety, feasibility and efficacy, with special regard to oncological outcomes.

METHODS

Between January 2009 and December 2012, we retrospectively selected patients who underwent robotic extended thymectomy for clinical early stage thymomas. Operative time, morbidity, mortality, duration of hospitalization, and overall and disease-free survival were analyzed.

RESULTS

There were 23 patients (15 males, eight females) with a mean age of 49.3 years (range 20-66). There were no intra-operative complications, and no mortality. The mean operative time was 85.2 minutes (range 60-180). No patient underwent conversion to open surgery. All post-operative complications (4.3%) were conservatively treated. The mean post-operative stay was 3.6 days (range two to nine). The pathological analysis revealed Masaoka stage I (21 cases) and II (two cases). No disease recurrence occurred at a mean follow-up of 24.8 months.

CONCLUSIONS

Robotic thymectomy is a safe and feasible technique, with a short operative time and low morbidity. Even on a small series with short follow-up, robotic extended thymectomy for thymoma appeared to be an effective treatment for early-stage thymomas.

Robotic-assisted thoracoscopic resection of a benign anterior mediastinal teratoma

There is an emerging body of evidence to support robotic-assisted mediastinal surgery, particularly for thymectomy. We describe the case of a 42-year-old woman with a benign anterior mediastinal teratoma resected by robotic-assisted thoracoscopy. This case illustrates the use of robotic-assisted surgery in a less commonly encountered mass of the anterior mediastinum.