Thymectomy via a subxiphoid approach: single-port and robot-assisted

Surgical access to the mediastinum-all roads lead to Rome: a literature review

Background and Objective

The mediastinum is a complex, heterogeneous area, which leads vertically across the thoracic cavity between the bilateral mediastinal pleurae, connecting the head and neck region with the thoracic cavity. Different classifications have been published to differentiate between the so-called mediastinal compartments while the most used classification surely is the 4-compartments Gray`s classification, dividing it into the superior, anterior, middle and posterior mediastinum. Mediastinal abnormalities include infections (mediastinitis) and solid or cystic mediastinal masses. These masses can be divided into benign and malignant lesions originating from mediastinal structures/organs or represent manifestations of metastatic disease, often metastatic non-small cell lung cancer (NSCLC). This review aims to explore the different mediastinal pathologies along with indications and surgical approaches.

Methods

We performed literature research in PubMed, MEDLINE, Embase, CENTRAL, and CINAHL databases. Only papers written in English were included.

Key Content and Findings

Depending on the indication for surgical intervention and the localization of the pathology, surgical approach may differ immensely. Mediastinal staging of lung cancer, primary lesions of the mediastinum, mediastinitis and traumatic mediastinal injuries display the most frequent indications for mediastinal surgery. Surgical approaches trend towards minimally invasive, video- or robotic-assisted techniques and are becoming increasingly refined to adapt to the special characteristics of the mediastinum. However, certain indications still require open access for best possible mediastinal exposure or oncological reasons.

Conclusions

To guide optimal surgical approach selection to the mediastinum, the following overview will present all published surgical approaches to the mediastinum and discuss their practical relevance and indications aiming to help surgeons in the management of patients with mediastinal pathologies who should undergo surgery.

Effect of bilateral low serratus anterior plane block on quality of recovery after trans-subxiphoid robotic thymectomy: Results of a randomized placebo-controlled trial

Purpose: This study aimed to investigate the impact of ultrasound-guided, bilateral, low level (T8-T9) deep serratus anterior plane (DSAP) blocks on postoperative recovery quality and postoperative analgesia in patients undergoing trans-subxiphoid robotic thymectomy (TRT). Methods: 39 patients undergoing TRT were randomized to receive either low DSAP block under general anesthesia (Group S) or the sham block (Group C) on each side. The primary outcome was the QoR-40 score at postoperative day (POD) 1. Secondary outcomes included numeric rating scale (NRS) scores over time, postoperative 48 hours opioid consumption, QoR-40 scores at POD 2, 30, and 90. Results: The QoR-40 scores on POD1-2 were higher in Group S than in Group C [179.1 (4.9) vs 167.7 (2.8), P < 0.01; 187.7 (4.6) vs 178.1 (3), P < 0.01, respectively]. Pain scores were significantly lower in Group S, both during resting and motion at postoperative 6h, 12h, and 24h (P < 0.05 for each). The total amount of sufentanil consumed in the first 48 h was lower in Group S than in Group C [61.4 (4.9) vs 78.9 (4.6), P < 0.001]. Conclusion: The bilateral low DSAP blocks enhanced the QoR-40 for 2 days postoperatively, relieved postsurgical pain, and reduced opioid consumption during the early postoperative period in patients undergoing TRT.

Surgical treatment of thymic epithelial tumors: a narrative review

Background and Objective

Thymic epithelial tumors (TETs) are scarce neoplasms of the prevascular mediastinum. Included in this diverse category of lesions are thymomas and thymic carcinomas (TCs). Surgery is the mainstay of treatment of tumors that are deemed resectable. However, up till now, optimal surgical access has been a subject of debate. The advent of new techniques, such as video-assisted thoracoscopic surgery (VATS) and robotic-assisted thoracoscopic surgery (RATS), challenged the median sternotomy which was traditionally considered the access of choice. This review aims to demonstrate the current evidence concerning the surgical treatment of TET and to enlighten other controversial issues about surgery.

Methods

PubMed research was conducted using the terms [surgery] AND [thymic epithelial tumors] OR [thymomas] and [surgical treatment] AND [thymic epithelial tumors] OR [thymomas]. Papers concerning pediatric cases and non-English literature papers were excluded. Individual case reports were also excluded.

Key Content and Findings

Minimally invasive surgical techniques (MIST) such as VATS and RATS are increasingly applied in early-stage TET. Although numerous published studies have demonstrated better perioperative outcomes in early-stage TET, long-term follow-up data are still required to demonstrate the oncological equivalent of MIST to open surgery. Resection of stage III TET is more challenging. Thymectomy can be expanded en bloc to include the major vascular structures, lung, pleura, phrenic, or vagus nerve in these individuals. There is no agreement on the ideal surgical access and traditionally these patients underwent open sternotomy, sometimes combined with a thoracic access. Evidence concerning the treatment of stage IVA disease is mainly derived from retrospective case series which are highly heterogeneous in terms of the number of enrolled patients, histology, degree of pleural involvement, and timing of presentation.

Conclusions

New techniques in the field of minimally invasive surgery are gaining acceptance for early-stage TET but longer follow-up periods are warranted to prove their oncological outcomes. On the contrary, these techniques should be used cautiously in case of locally advanced tumors. Surgeons must not forget that the main objective is the complete resection of the lesion, which is one major predictive factor for increased survival.

Meta-analysis of clinical efficacy of thoracoscopy and robotic surgery in the treatment of mediastinal tumors

OBJECTIVE

Comparing the clinical efficacy of thoracoscopy and robotic surgery in the treatment of mediastinal tumors using meta-analysis.

METHODS

Computer retrieval of PubMed, Embase, The Cochrane Library, and Web of Science databases for literature comparing the clinical effects of video-assisted thoracic surgery (VATS) and robot-assisted thoracic surgery (RATS) in treating mediastinal tumors, with the retrieval time limit from the establishment of the database to September 2023. Two evaluators independently screened the literature, extracted data, and assessed the risk of bias. Meta-analysis was performed using RevMan 5.4.

RESULTS

A total of 19 articles were included, with a total of 3517 patients. The results of the Meta-analysis showed that the RATS group had less intraoperative bleeding [MD =  - 5.20, 95%CI (- 9.28, - 1.12), P = 0.01], lower rate of conversion to thoracotomy [OR = 0.41, 95%CI (0.23, 0.72), P = 0.002], lower rate of total postoperative complications [OR = 0.57, 95%CI (0.34, 0.95), P = 0.03], shorter postoperative drainage time [MD =  - 0.72, 95%CI (- 1.13, - 0.32), P = 0.0004], and shorter postoperative hospital stay [MD =  - 0.90, 95%CI (- 1.16, - 0.65), P < 0.001], in comparison with the VATS group. There was an insignificant difference between the two groups in terms of tumor size [MD =  - 0.02, 95%CI (- 0.33, 0.30), P = 0.91] and operation time [MD = 0.17, 95%CI (- 7.61, 7.94), P = 0.97]. However, in regards to hospitalization costs [MD = 2634.75, 95%CI (991.62, 4277.88), P = 0.002], the RATS group was more expensive than the VATS group.

CONCLUSION

Robot-assisted mediastinal tumor resection surgery has more advantages in terms of intraoperative bleeding, conversion to thoracotomy rate, total postoperative complication rate, postoperative drainage time, and postoperative hospital stay, in comparison with thoracoscopic-assisted mediastinal tumor resection surgery. There is an insignificant difference in tumor size and operation time between the two surgeries. However, robot-assisted mediastinal tumor resection surgery increases hospitalization costs.

Perioperative management and postoperative outcomes of locally advanced thymic epithelial tumors: a narrative review

Background and Objective

Thymic epithelial tumors (TETs) are frequently diagnosed at an advanced stage, highlighting the importance of understanding the treatment strategies for these cases. Surgical intervention after chemotherapy or chemoradiotherapy presents specific challenges and underscores the crucial role of perioperative management. This study aimed to explore the perioperative management and postoperative outcomes in patients with locally advanced TETs.

Methods

Relevant studies published between 2000 and 2022 were identified through PubMed searches using a combination of the following terms: "Locally advanced TETs", "Thymoma", "Thymic cancer", "Surgery", "Induction therapy", and "Postoperative outcomes". We analyzed available data to describe the perioperative management and postoperative outcomes of locally advanced TETs.

Key Content and Findings

Surgical outcomes after induction therapy for locally advanced TETs were analyzed for 18 references (total n=646) between 2000 and 2022. The primary objective of induction therapy for locally advanced TETs is complete tumor resection. In recent years, many medical centers have adopted systemic chemotherapy and chemoradiation for the treatment of thymoma and thymic carcinoma, respectively. During surgical intervention, resecting the surrounding organs, such as the lungs, pericardium, and phrenic nerves, is a common practice. Additionally, there may be cases wherein vascular resection of the superior vena cava (SVC) and innominate veins is necessary. Techniques and strategies for revascularization without complications are crucial in these situations. The incidence of postoperative complications varied significantly, ranging from 4.8% to 42%. However, perioperative mortality is typically reported to be approximately 0%, with only two reports showing mortality rates of 1.8% and 9.0%.

Conclusions

The short-term postoperative outcomes of surgical treatment following induction therapy for locally advanced TETs were generally deemed acceptable. However, incomplete resection may occur, particularly when the tumor invades the pulmonary artery or aorta. Hence, careful evaluation the indications for surgery is crucial, considering the patient's overall condition and treatment response.

Minimally invasive thoracic surgery: robot-assisted versus video-assisted thoracoscopic surgery

Minimally invasive techniques have been widely applied in general thoracic surgery. Compared with video-assisted thoracoscopic surgery (VATS), due to its theoretic superiority, robotic surgery is challenging the traditional position of VATS. With its unique advantages, including 3D vision and a high-freedom endowrist, it leads to easier lymph node dissection, more convenient blood vessel dissection, a shorter learning curve and competence for the completion of complex surgery. However, as a new surgical technology, the safety and efficacy of robotic-assisted thoracoscopic surgery (RATS) still need to be further verified. Thus, in this article, we review and summarize the application of RATS versus VATS in general thoracic surgery.

Robot-assisted thoracic surgery versus video-assisted thoracic surgery for mediastinal lesions

BACKGROUND

Robot-assisted thoracic surgery (RATS) has become widely used for mediastinal procedures since 2018 when it was included in insurance coverage in Japan. Few studies have compared the surgical outcomes of RATS with the more established video-assisted thoracic surgery (VATS) approach to mediastinal surgery. We aimed to compare the perioperative outcomes of VATS and RATS to examine the advantages of the RATS approach in a single institutional cohort.

METHODS

A total of 144 patients who underwent VATS and 46 who underwent RATS mediastinal surgery between 2014 and 2022 were enrolled. We compared clinicopathological features such as age, sex, smoking history, respiratory function, surgical field, laterality, surgical procedure, board certification of the surgeon, and histology between the two groups. Perioperative outcomes including operation time, volume of blood lost, number of conversion cases to open surgery, duration of chest drainage, postoperative hospital stay, and postoperative complications were also reviewed.

RESULTS

The comparison of patient characteristics between the groups showed significant differences in median age (VATS, 52.5 years; RATS, 67.0 years; P=0.001), combined resection of surrounding tissues of the tumor (VATS, 2.1%; RATS, 10.9%; P=0.02), board certification of the surgeon (VATS, 53.5%; RATS, 100.0%; P<0.001), and histology (RATS group had a higher percentage of thymic epithelial tumors, P=0.01). Regarding perioperative outcomes, the median operation time was 120 min in the VATS group and 88 min in the RATS group, showing a significant difference (P=0.03). There were no significant differences in the volume of blood lost, incidence of conversion to open chest surgery, duration of chest drainage, postoperative length of stay in hospital, and incidence of perioperative complications. In the perioperative outcomes of cases operated on by board-certified surgeons, the median operation time (VATS, 117 min; RATS, 88 min; P=0.02) and median postoperative length of stay in hospital (VATS, 7 days; RATS, 6 days; P=0.001) showed significant differences, while other postoperative outcomes were not significantly different.

CONCLUSIONS

RATS for mediastinal surgery is as safe as the VATS approach and may result in a shorter operative time and postoperative hospital stay. Further analysis of RATS for mediastinal surgery in a larger cohort is warranted.

Anterior mediastinal tumor surgery applying single-port thoracoscopy using the subxiphoid approach

Background

This study aims to investigate the effectiveness of application of single-port thoracoscopy using the subxiphoid approach in anterior mediastinal tumor surgery.

Methods

Between June 2014 and June 2016, a total of 108 patients (59 males, 49 females; mean age: 64.9±7.5 years; range, 45 to 79 years) with anterior mediastinal tumors were randomized into subxiphoid (experimental) or right chest (control) groups. Single-port thoracoscopy using the subxiphoid approach was performed in the subxiphoid group, while thoracoscopy using the right thoracic approach was performed in the control group. Preand postoperative pain stress indicators, Visual Analog Scale scores, quality of life scores, postoperative tumor recurrence, and five-year survival rates were compared between the groups.

Results

There were no mortality or serious complications in either group. The mean Visual Analog Scale pain scores on postoperative Days 1 and 7 were 6.5±0.8 and 2.9±0.8 in the subxiphoid group, respectively, compared to 7.2±0.8 and 3.4±0.8 in the control group (p<0.05 for all), respectively. The mean quality of life scores on postoperative Days 1 and 7 were 81.5±5.0 and 79.3±7.7, respectively, in the subxiphoid group compared to 72.4±4.3 and 71.3±4.8 in the control group, respectively (p<0.05 for all). Postoperative pain and pain mediator indexes were lower in the subxiphoid group (p<0.05 for all). The postoperative tumor recurrence rates were 3.70% and 20.37% in the subxiphoid and control groups, respectively (p=0.008). The five-year survival rates were 85.2% and 63.0% in the subxiphoid and control groups, respectively (p=0.008).

Conclusion

Single-port thoracoscopy using the subxiphoid approach is technically feasible, safe, and effective in performing surgery for anterior mediastinal tumors with an intact capsule and a tumor diameter of ≤5 cm.

A uniport subxiphoid approach with a modified sternum retractor is safe and feasible for anterior mediastinal tumors

Background

Minimally invasive surgery has been used to treat anterior mediastinal tumors. This study sought to describe a single team's experience of uniport subxiphoid mediastinal surgery using a modified sternum retractor.

Methods

Patients who underwent uniport subxiphoid video-assisted thoracoscopic surgery (USVATS) or unilateral video-assisted thoracoscopic surgery (LVATS) from September 2018 to December 2021 were retrospectively enrolled in this study. A 5-cm vertical incision approximately 1-cm caudal to the xiphoid process was usually made followed by the installment of a modified retractor, which was able to raise the sternum by 6-8 cm. Next, the USVATS was performed. In the unilateral group, 3 1-cm incisions were usually made, among which, 2 are made in the 2nd or 3rd and 5th intercostal anterior axillary line, and the 3rd was made in the 5th intercostal midclavicular line. In some instances, an additional subxiphoid incision was made to remove the large tumors. All the clinical and perioperative data, including the prospectively recorded visual analogue scale (VAS) score, were analyzed.

Results

In total, 16 patients who underwent USVATS and 28 patients who underwent LVATS were enrolled in this study. With the exception of tumor size (USVATS 7.9±1.6 cm vs. LVATS 5.1±2.4 cm, P<0.001), the baseline data of the patients in the 2 groups were comparative. Blood loss in surgery, conversion, draining duration, postoperative stay, postoperative complications, pathology and tumor invasion were similar between the 2 groups. Although the operation time was significantly longer in the USVATS group than the LVATS group (115±19 vs. 83±30 min, P<0.001), the VAS score at 1st postoperative day (1.9±1.1 vs. 3.1±1.1, P<0.001) and moderate pain level (a VAS score >3) (6.3% vs. 32.1%, P=0.049) were better in the USVATS group than the LVATS group.

Conclusions

Uniport subxiphoid mediastinal surgery is a feasible and safe procedure, especially for large tumors. Our modified sternum retractor is especially helpful during uniport subxiphoid surgery. Compared to lateral thoracic surgery, this approach has the advantages of less injury and lower postoperative pain, which may lead to a faster recovery. However, its long-term follow-up outcomes need to be observed.

Clinical efficacy of robot-assisted subxiphoid versus lateral thoracic approach in the treatment of anterior mediastinal tumors

BACKGROUND

The purpose of this study was to compare the perioperative efficacy and safety of da Vinci robot-assisted thoracoscopic surgery (RATS) for treating anterior mediastinal tumors through the subxiphoid and lateral thoracic approaches under the anesthesia of nontracheal intubation (i.e., laryngeal mask airway).

METHODS

We retrospectively analyzed the clinical data of 116 patients with anterior mediastinal tumors treated by RATS under laryngeal mask anesthesia completed by the same operator in the Department of Thoracic Surgery, Gansu Provincial People's Hospital, from October 2016 to October 2022. There were a total of 52 patients including 24 males and 28 females, with an average age of 45.40±4.94 years, in the subxiphoid approach (subxiphoid group). On the other hand, there were a total of 64 patients including 34 males and 30 females, with a mean age of 46.86±5.46 years in the lateral thoracic approach (lateral thoracic group). Furthermore, we have detailedly compared and analyzed the operating time, intraoperative bleeding, and total postoperative drainage in the two groups.

RESULTS

All patients in both groups successfully completed resection of the anterior mediastinal tumor without occurring perioperative death. Compared with the lateral thoracic group, the subxiphoid group has more advantages in terms of total postoperative drainage (P=0.035), postoperative drainage time (P=0.015), postoperative hospital stay (P=0.030), and visual analog scale (VAS) pain on postoperative days 2 (P=0.006) and 3 (P=0.002). However, the lateral thoracic group has more advantages in the aspect of docking time (P=0.020). There was no statistically significant difference between the two groups in terms of operative time (P=0.517), total operative time (P=0.187), postoperative day 1 VAS pain score (P=0.084), and postoperative complications (P=0.715).

CONCLUSION

The subxiphoid approach of RATS under laryngeal mask anesthesia is safe and feasible for resecting anterior mediastinal tumors. Compared with the lateral thoracic approach, the subxiphoid approach has advantages in terms of rapid postoperative recovery and postoperative patient pain, and patient acceptance is also higher and thus is worth promoting in hospitals where it is available.

Comparison of the Perioperative Outcomes for Thoracoscopic Thymectomy Between the Subxiphoid Approach and the Lateral Intercostal Approach for Masaoka-Koga I-II Thymoma: A Propensity Score-Matching Analysis

BACKGROUND

The appropriate approach for video-assisted thoracic surgery for early-stage thymoma remains debatable. The current study compared the safety and feasibility between subxiphoid-approach thoracoscopic thymectomy (SATT) and lateral intercostal-approach thoracoscopic thymectomy (LATT) for Masaoka-Koga stages 1 and 2 thymoma.

METHODS

The study retrospectively enrolled 461 patients without myasthenia gravis who underwent SATT or LATT at the Zhongshan Hospital of Fudan University between 2016 and 2020. A 1:1 propensity score-matching (PSM) analysis was performed to control for selection bias. A series of perioperative outcomes, including surgical outcomes, inflammatory factors, morbidity and mortality, pain assessment, and quality of life, were compared.

RESULTS

Each group consisted of 144 patients after PSM. The results showed that the SATT group had a significantly higher rate of exposure to the bilateral phrenic nerves (SATT [98.6 %] vs. LATT [77.1 %]; p < 0.001) as well as a larger maximum length (9.20 ± 3.08 vs. 7.52 ± 3.44 cm; p < 0.001) and width (6.13 ± 1.81 vs. 5.04 ± 1.77 cm; p < 0.001) of resected tissue than the LATT group. In addition, the SATT group had lower postoperative high-sensitivity C-reactive protein (hs-CRP) levels (9.37 ± 2.17 vs. 12.69 ± 2.13 mg/L; p < 0.001), better postoperative days 1, 3, and 7 visual analog pain scale (VAS) scores (p < 0.001), and better postoperative days 30 and 90 quality of life (p < 0.05). However, the two groups showed no significant increase in surgical time, estimated blood loss, total drainage time, postoperative total drainage volume, complications, or postoperative hospital stays.

CONCLUSIONS

The study results suggest that the SATT is feasible and safe for Masaoka-Koga stages 1 and 2 thymoma.

Can the Ratio SUVmax of the Lesion/SUVmax of Mediastinal Tissues Guide the Choice of Surgical Access for the Resection of Thymic Epithelial Tumors?

Background

There are studies showing the utility of the 18-fluorodeoxyglucose positron emission tomography (18FDG PET) scan in the management of patients with thymic epithelial tumors. It seems to be a correlation between the standard uptake value (SUVmax) of thymic epithelial tumors and the histological type and the stage. This study aims to use the ratio of the SUVmax of the lesion to the SUVmax of the adjacent mediastinal tissues in order to guide the choice of the surgical access.

Methods

All patients who presented an anterior mediastinal lesion with a high suspicion of being of thymic origin were included in a prospective database. A ratio inferior to 1 could predict a benign nature and less aggressive behavior, and a minimally invasive approach was performed. A ratio superior to 1 suggested a malignant and aggressive behavior, and a median sternotomy (or a thoracotomy) was performed.

Results

There were 15 male (mean age 44.6 ± 16.26 years, range 25–73) and 15 female patients (mean age 50.1 ± 16.94 years, range 25–76). When the ratio is inferior to 1, it predicts benign disease in 80% of cases. When it is superior to 1, it predicts in half of cases advanced histological types (high risk thymomas and thymic carcinomas). On the contrary, it can quite accurately predict advanced Masaoka–Koga stages.

Conclusions

The protocol of this study is in accordance with the current literature showing the utility of 18FDG PET scan in the treatment of thymic epithelial tumors. This study goes one step further since the choice of surgical access is based on the SUVmax values. The ratio SUVmax of the lesion/SUVmax of the mediastinal tissues could be a new marker, more pertinent than absolute SUVmax values.

Robot-Assisted Thoracic Surgery Thymectomy

Robotic thymectomy has been adopted recently and has been shown to be safe and feasible in treating thymic tumors and myasthenia gravis. The surgical indications of robotic technology are expanding, with advantages including an excellent surgical view and sophisticated manipulation. Herein, we describe technical aspects, considerations, and outcomes of robotic thymectomy.

Surgical management of thymic epithelial tumors

Resection is the mainstay of treatment for thymic epithelial tumors (TETs), with complete removal of the tumor and involved organs being the ultimate aim. The choice of surgical approach plays a major role in defining treatment success, and the optimal choice of method should thus provide an adequate surgical view to achieve complete tumor resection. While median sternotomy is considered the gold standard for access to the mediastinum, several minimally invasive approaches to thymectomy have been described, including video-assisted robotic-assisted thymectomy, although the oncological outcomes of that procedure remain unclear. A multimodal approach incorporating chemotherapy or chemoradiotherapy followed by extended surgery may improve resectability and outcomes for patients with advanced TETs. Surgical debulking is also reportedly acceptable for invasive thymoma because of its potential for achieving favorable outcomes. Re-resection is an acceptable option for patients with recurrent thymoma after initial resection, and repeat resection for recurrent pleural dissemination seems effective. Here, the literature on current clinical practices in the surgical management and treatment of TETs is reviewed.

Trans-subxiphoid robotic surgery for anterior mediastinal disease: an initial case series

Background

Video-assisted thoracoscopic trans-subxiphoid surgery is an ideal technique for removing anterior mediastinal lesions. The diffusion of this method, however, has been limited by the complexity of surgical maneuvers to be performed in the narrow retrosternal space. Robotic surgery holds promise to overcome the technical limitations of the thoracoscopic trans-subxiphoid approach. Here, we describe a case series of patients who had undergone trans-subxiphoid robotic surgery-with a special focus on short-term outcomes.

Methods

Between January 2018 and January 2019, a total of 20 patients underwent trans-subxiphoid robotic surgery for maximal thymectomy or removal of anterior mediastinal masses. A 3-cm longitudinal incision was performed below the xiphoid process, through which carbon dioxide was insufflated and a camera port was inserted. Subsequently, the lower sections of the mediastinal pleura were detached bilaterally-followed by the creation of two bilateral 1-cm skin incisions on the anterior axillary line in the sixth intercostal space for the insertion of robotic arms. Upon completion of port positioning, the surgical robot was docked.

Results

All robotic surgery procedures were successfully completed. Neither conversion to open surgery nor the creation of additional ports was required. The median operating time and console time were 118 min [interquartile range (IQR): 84-147 min] and 92.5 min (IQR: 78.5-133.5 min), respectively. Drainage tube positioning was not required in 11 (55%) patients. There were no operative deaths, and the median length of postoperative hospital stay was 2.5 days (IQR: 2-3 days). One patient had postoperative chylothorax and received conservative treatment.

Conclusions

The results of this case series provide initial support to the clinical feasibility, safety, and short-term positive outcomes of trans-subxiphoid robot-assisted surgery for anterior mediastinal disease.

Robotic thymectomy for advanced thymic epithelial tumor: indications and technical aspects

Robotic thymectomy is widely accepted as a valuable treatment option for surgical resection of thymic epithelial tumor as minimally invasive surgery has shown better early clinical outcomes than open surgery. Technical advances in robotic surgery have expanded the indications for robotic thymectomy, and the technique can be used to perform complete resection of advanced thymic epithelial tumor requiring concomitant resection of adjacent structures. To ensure complete resection, a multi-disciplinary approach, with thorough preoperative evaluation, must be adopted to determine whether a patient shows surgical indications for advanced thymic epithelial tumor. The early clinical outcomes after robotic thymectomy to treat advanced thymic epithelial tumor are promising; however, the long-term oncologic outcomes should be evaluated in the further studies.

Subxiphoid robotic extended thymectomy - The first Indian report

Background

Minimally invasive thymectomy is fast becoming the preferred approach for myasthenia gravis and non-invasive thymoma. The most commonly employed approach for minimally invasive thymectomy is the lateral thoracic approach. Safe achievement of radical resection requires adequate visualisation of both the phrenic nerves along their entire course. In our experience, such visualisation is rather difficult with unilateral transthoracic approaches. We herein describe our technique and initial experience of 25 cases with subxiphoid robotic thymectomy (SRT) for myasthenia gravis with or without thymoma. To the best of our knowledge, this is the first such report from India.

Subjects and Methods

We retrospectively analysed data of patients who underwent SRT at our centre from June 2017 to September 2018. Twenty-five consecutive patients were analysed, and demographic data, total duration of the procedure, console time, blood transfusion requirement, duration of chest drainage, length of hospital stay, pain score on post-operative day (POD) 1 and day of discharge and post-operative morbidity and mortality within 90 days were recorded.

Results

A total of 25 patients underwent SRT. All our patients had myasthenia gravis with 4 of them having thymoma. There were 11 males and 14 females with mean age of 29.30 years (range 23-48). The mean console time was 102.85 min (range 88-120) while the mean total operative time was 199.14 (range 180-220). On first POD 1, visual analogue scale score average was 5, and at discharge, it was 2. There was no 30-day or 90-day mortality. All cases of thymoma had a complete R0 resection.

Conclusion

Our experience suggests that subxiphoid approach offers a good operative view of the thymus in cervical region along with easy identification of bilateral phrenic nerves. Thus, SRT can be performed safely with comparable results.

Subxiphoid thymectomy with a double sternum retractor: a pilot study

Background

Our study aims to describe the experience of a single team in terms of the potential and benefits of subxiphoid thymectomy using a double sternum hook retractor.

Methods

From November 2016 to July 2018, 34 patients have been undergone subxiphoid thymectomy at our Department. Twenty patients were diagnosed with Masaoka Stage I-III thymomas, 12 with thymic hyperplasia or cysts of the thymus, 2 with thymic tumors. All patients underwent a chest computed tomography (CT) with enhancement. 18-Fludeoxyglucose positron emission tomography (¹⁸FDG-PET) was performed when recurrence was suspected. Neurological examinations were set. Patients underwent video-assisted thoracoscopic surgery (VATS) subxiphoid thymectomy with a double sternum retractor. A retrospective analysis of clinical, perioperative data, and follow-up was performed. Incidence rates for death or recurrence were calculated. Average pain score (NRS scale), average mental health, and physical health scores (SF-12) were analyzed.

Results

Thirty-four patients (mean age 54; 12 men and 22 women) with thymic neoformation (from 1.0 cm × 1.0 cm × 1.0 cm to 14.0 cm × 9.0 cm × 4.5 cm) were enrolled. All patients underwent subxiphoid thymectomy. No mortality or recurrence was observed. Median follow-up time was 17.9 months (range, 2.2-23.3 months). The morbidity rate was 9.7 events per 100 person-years. Average pain scores after surgery and after follow-up were 1.7±0.4 and 0.1±0.4, respectively; average mental health and physical health scores on the SF-12 scale were 45.6±2.4 and 33.6±2.4, respectively.

Conclusions

Subxiphoid thymectomy is a high satisfaction approach with positive aesthetic outcomes and low pain. Double sternum retractors are especially useful for creating space during thymectomy. However, the qualified experience is needed.

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.

Tips and tricks for success in subxiphoid video-assisted thoracic surgery

The subxiphoid approach to video-assisted thoracic surgery (VATS) has been introduced as an alternative to intercostal VATS. There is some evidence that avoiding intercostal incision and instrumentation leads to reduced pain and facilitates early mobilisation and enhanced recovery. Access of the pleural cavities and anterior mediastinal space through a subxiphoid incision presents some challenges, particularly when accessing posterior pulmonary lesions. With increasing experience, a large range of thoracic surgical operations performed through the subxiphoid approach have been reported including anatomical segmentectomies, thymectomies. Another attraction is that bilateral procedures can be performed through a single incision. The experience of several surgeons passing through the learning curve of subxiphoid VATS surgery has resulted in overcoming many of the early challenges faced. In this paper, a series of tips and tricks are presented to enable surgeons considering adopting this technique into their practice to do so safely and with an appreciation of the difficulties that they may face.

Subxiphoid approach for video-assisted thoracoscopic surgery: an update

The transthoracic video-assisted thoracoscopic surgery (VATS) is considered as standard operation for various thoracic diseases. With the development of single-incision VATS, the thoracic surgery becomes less traumatic. However, chronic chest wound pain still an issue despite the less invasive approach. Therefore, subxiphoid VATS was proposed to overcome this problem. In this article, we review current applications, pros and cons, and potential developments of VATS through subxiphoid approach.

Feasible and promising modified trans-subxiphoid thoracoscopic extended thymectomy for patients with myasthenia gravis

Background

We have used a promising, minimally invasive thoracoscopic technique of extended thymectomy for patients with myasthenia gravis (MG). The aim of this study was to report our promising technique, a modified single-port trans-subxiphoid approach (MTXA) and to compare perioperative outcomes and effects on MG between our approach and sternotomy.

Methods

We retrospectively reviewed records of all patients undergoing extended thymectomy for MG and/or thymoma between January 1, 2010 and December 31, 2016. The patients were divided into the MTXA group and Sternotomy group.

Results

Of the 50 consecutive patients undergoing extended thymectomy for MG, finally, 13 patients undergoing our MTXA extended thymectomy technique were compared with 20 patients undergoing extended thymectomy via sternotomy. Intraoperative blood loss, postoperative length of stay, and C-reactive protein value on postoperative day 1 were significantly more favorable in the MTXA group than the Sternotomy group (P<0.0001, P=0.0040 and P=0.0073, respectively). Furthermore, no significant differences in the frequency of patients with improvement of their Quantitative Myasthenia Gravis score and/or MG-Activities of Daily Living scale, decrease in the serum level of acetylcholine receptor antibody, and dose reduction of oral prednisone were seen between the two groups.

Conclusions

Our approach to extended thymectomy might be more favorable than sternotomy in patients with MG.

Subxiphoid uniportal VATS thymectomy

Background

To present the technique of minimally invasive extended thymectomy performed through the uniportal subxiphoid approach, with double elevation of the sternum for nonthymomatous myasthenia gravis (MG).

Methods

Operative technique: the whole dissection was performed through the 4-7 cm transverse or longitudinal subxiphoid incision with use of videothoracoscope. The sternum was elevated with two hooks connected to the sternal frame (Rochard bar, Aesculap-Chifa, Nowy Tomysl, Poland). The lower hook was inserted through the subxiphoid incision and the superior hook was inserted percutaneously, after the mediastinal tissue including the major mediastinal vessels were dissected from the inner surface of the sternum. The fatty tissue of the anterior mediastinum and the aorta-pulmonary window was completely removed.

Results

There were four patients in the period 1.1.2017-30.4.2017. There was no mortality and morbidity.

Conclusions

The uniportal subxiphoid approach combined with double elevation of the sternum enabled very extensive thymectomy in case of thymoma.

VATS thymectomy for early stage thymoma and myasthenia gravis: combined right-sided uniportal and left-sided three-portal approach

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.

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.

Subxiphoid approach for a combined right upper lobectomy and thymectomy through a single incision

The subxiphoid uniportal video assisted thoracoscopic surgery (VATS) is a new interesting approach for the resection of anterior mediastinal masses and lung resections. For this reason in cases with both pathologies is an ideal approach to perform both procedures at the same time without multiple incisions. The evolution in the surgery of thymoma is getting less invasive, from the transsternal thymectomy to the minimally invasive Thoracic surgery improving the recovery of the patients and with satisfactory postoperative results, otherwise the anatomical view of the main structures and the recognition of the vascular anatomy, and his variants is feasible. In those cases with synchronic masses, the Subxiphoid approach is an ideal option in hands of experienced surgeons. In this video, we present the case of a right upper lobectomy and a thymectomy by subxiphoid approach in which the anatomical variations of the thymic artery are well recognized, and both procedures were completed without complications.

Minimally invasive surgical procedures for thymic disease in Asia

Video-assisted thoracic surgery (VATS) procedures for thymic tumors and myasthenia gravis were introduced in Asia in the middle 1990s in at least two regions, Hong Kong and Japan. To overcome difficulties in obtaining a wide view of the anterior mediastinum, several methods for lifting the sternum or anterior chest wall have been presented, mainly by Japanese surgeons. More recently, single port VATS through a subxiphoid incision was also introduced in Japan. The long-term outcome of a VATS extended thymectomy for myasthenia gravis has been shown to be comparable to that of a trans-sternal extended thymectomy, while the long-term outcome of a VATS thymectomy for thymic epithelial tumors remains to be elucidated. Nevertheless, its indication for tumors in an early stage is now widely accepted, and the number of VATS procedures is steadily increasing in Japan and China. Single-port VATS through a subxiphoid incision was developed in Japan and might become accepted as a useful approach in the near future when combined with robot-assisted thoracoscopic surgery. In addition, robot-assisted thoracoscopic surgery for the thymus has also been introduced in some areas in Asia. Although few of those surgical procedures for the thymus have been performed, results obtained thus far indicate that it might be preferable to lung resection. Several novel minimally invasive thymectomy techniques have been invented and developed in Asia, and further advancements in this field by Asian surgeons are anticipated.

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.

Video-assisted and minimally-invasive open chest surgery for the treatment of mediastinal tumors and masses

This article reviews the anatomy of the mediastinum as well as indications, limitations, techniques, and results of video-assisted thoracic surgery (VATS) and other minimally-invasive open-chest surgery approaches currently used for the surgical management of mediastinal tumors and masses. It is written by two surgeons with vastly different backgrounds and thoracic surgical experience. One of them is young and very familiar with VATS approaches and technologies while the other is a senior surgeon relatively unfamiliar with minimally-invasive techniques. This combination of authorship is ideal to analyze the pros and cons of the use of minimally-invasive approaches for the surgical management of mediastinal lesions such as thymic epithelial tumors (TETs) or neurogenic tumors. This is important because several thoracic surgeons have expressed concerns about the ability of thoracoscopic procedures to maintain adherence to sound oncological principles.

A case of anterior mediastinitis and bilateral multiple lung abscesses occurring after trans-subxiphoid video-assisted thoracoscopic extended thymectomy for thymoma with myasthenia gravis

A 68-year-old female was admitted to our hospital with an acute episode of chest pain, progressive cough and fever. She underwent trans-subxiphoid video-assisted thoracoscopic extended thymectomy (TsVATET) for thymoma with myasthenia gravis (MG) 9 days ago. Chest computed tomography (CT) showed anterior mediastinal oedema, and infiltrative findings involved bilateral lung. Physical examination revealed the subxiphoid wound suppuration. We diagnosed subxiphoid incision infection, anterior mediastinitis and concomitant bilateral pneumonia. Using antibiotics intravenously combined with anterior mediastinum irrigation and drainage, she felt well but bilateral multiple lung abscesses were discovered on the 12^th day of hospitalisation. After conservative treatment with antibiotics and wound care, the recovery was satisfactory and she discharged home. In our experience, because the subxiphoid incision, the anterior mediastinum and the bilateral thoracic cavity communicated directly after TsVATET, we should be aware of the risk of anterior mediastinitis, the infection of bilateral pleural cavity, pneumonia and multiple lung abscesses following subxiphoid incision infection.

Video-assisted thoracoscopic extended thymectomy using the subxiphoid approach

Minimally invasive thoracoscopic surgery has become an inevitable trend in the treatment of anterior mediastinal tumors and other thoracic diseases. Many surgical approaches may be used for video-assisted thoracoscopic surgery (VATS) thymectomy. Some researchers have proven that that VATS thymectomy using the subxiphoid approach is technically safe and feasible. Compared with the transthoracic approach, the subxiphoid approach is considered to provide a better view of the bilateral pleural cavities and to cause relatively less pain; it is thus considered a less invasive surgical approach. In this article, we summarize our experience with various incision designs, specific surgical procedures, and key operative manipulations that are crucial for successful performance of subxiphoid VATS extended thymectomy.