Robotic thymectomy for autoimmune myasthenia gravis

We present the case of a 27-year-old woman who has had an autoimmune myasthenia gravis for 6 months. The current treatment essentially includes anticholinesterasics, but no use of corticosteroids. Thymectomy is indicated in the presence of thymic hyperplasia visible on a thorax CT-scan with contrast injection. The use of the da Vinci robot for this type of intervention has been recognized many years ago now with the work of Federico Rea and Jens Ruckert amongst others. The advantage of this technique is the possibility to proceed with a radical thymectomy enlarged to the mediastinal fat exactly in the same way as for a median sternotomy which is the standard technique. When compared with thoracoscopy, the advantage stems from 3D vision, segmentation of the operator’s movements and exceptional maneuverability of the instruments which have 7 degrees of freedom. These instruments allow for an access to the lower cervical area without the use of a cervicotomy. The choice of the left side is explained by the need to identify the phrenic nerve’s position, which is more difficult to predict than the right nerve’s position, which can be easily identified on the right lateral aspect of the superior vena cava. The video is followed by an interview with Professor Marescaux (MD, FACS, Hon FRCS, Hon JSES) and Doctor Santelmo (MD, FETCS) about robotic thymectomy, comparing it with Novellino's procedure and discussing the ways in which this technique pushes robotic surgery forward.

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Robotic thymectomy for autoimmune myasthenia gravis

Authors

N Santelmo, S Renaud, J Marescaux

Abstract

We present the case of a 27-year-old woman who has had an autoimmune myasthenia gravis for 6 months. The current treatment essentially includes anticholinesterasics, but no use of corticosteroids. Thymectomy is indicated in the presence of thymic hyperplasia visible on a thorax CT-scan with contrast injection. The use of the da Vinci robot for this type of intervention has been recognized many years ago now with the work of Federico Rea and Jens Ruckert amongst others. The advantage of this technique is the possibility to proceed with a radical thymectomy enlarged to the mediastinal fat exactly in the same way as for a median sternotomy which is the standard technique. When compared with thoracoscopy, the advantage stems from 3D vision, segmentation of the operator’s movements and exceptional maneuverability of the instruments which have 7 degrees of freedom. These instruments allow for an access to the lower cervical area without the use of a cervicotomy. The choice of the left side is explained by the need to identify the phrenic nerve’s position, which is more difficult to predict than the right nerve’s position, which can be easily identified on the right lateral aspect of the superior vena cava.
The video is followed by an interview with Professor Marescaux (MD, FACS, Hon FRCS, Hon JSES) and Doctor Santelmo (MD, FETCS) about robotic thymectomy, comparing it with Novellino's procedure and discussing the ways in which this technique pushes robotic surgery forward.

Classification

robotic

Keywords

Robotic thymectomy, autoimmune myasthenia gravis

Media type

Surgical video

Duration

12'14''

Publication

2011-12

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E-publication

WeBSurg.com, Dec 2011;11(12).
URL: http://www.websurg.com/doi-vd01en3515.htm

Robotic thymectomy for autoimmune myasthenia gravis

1. Patient position 00'09''

The thymectomy is carried out through a left thoracoscopy with the assistance of the da Vinci II robot. The patient is in a supine position with a cushion placed under the left hemithorax, which lifts the patient up while allowing for the arm to be freed caudally.

2. Trocar placement 00'25''

The left trocar is placed at the 5th left intercostal space on the parasternal line in order to accommodate the grasper. The optical trocar is placed at the 5th left intercostal space on the anterior axillary line to achieve a 0-degree vision. The right trocar is placed at the 3rd intercostal space on the anterior axillary line to accommodate the cautery spatula.

3. Opening of mediastinal pleura 00'46''

The pneumothorax is created by a CO2 injection under 10cm H2O pressure. The dissection begins with the use of the cautery spatula on the anterior edge of the left phrenic nerve, caudally to cranially. The dissection then continues medially to the mammary pedicle in order to delimitate the resection triangle. The thymus is lifted from caudal to cranial until the left innominate vein is reached.

4. Dissection of first thymic vein and left superior horn 01'45''

A first thymic vein is dissected, the left superior horn is then dissected. The right hand’s movements of the robot allow to reach the superior thymic horn until the cervical region. Such movements are difficult to perform through conventional thoracoscopy. The right phrenic nerve is identified. Its fixed position on the right lateral edge of the superior vena cava makes its identification easier and safer.

5. Dissection of right inferior horn 04'17''

The right inferior horn is dissected and the right mediastinal pleura is opened. This step can bring about ventilation problems within the right lung hence requiring the anesthesiologist to increase insufflation pressures. A second thymic vein is clipped.

6. Dissection of right superior thymic horn 05'19''

The right superior thymic horn can now be dissected. The specimen falls into the left pleural cavity. The aortopulmonary window, seat of frequent ectopias, is dissected and resected.

7. Specimen extraction and end of procedure 06'50''

The specimen is extracted in an Endobag. A central drain only is placed and the patient is reventilated.

8. Interview between Professor Marescaux and Doctor Santelmo 07'29''

“Dr. Nicolas Santelmo, let me first congratulate you for your video on “robotic thymectomy”. I have two questions. Until now the reference for me was Novellino in Italy, who has the most experience and who operated a patient here at the IRCAD. He performed a neck incision and used an axillary access on one side, as well as on the contralateral side. What I liked was that it is even less invasive because it is a unilateral axillary access thymectomy, and to me it is a good example of a surgical technique that cannot be carried out without the robot, and that is quite rare. So my question is simple: is it true? And why did you use a left approach, and what are the advantages of robotic surgery as compared to laparoscopy or standard thoracoscopy?” “The robot is an exceptional instrument that allows for movements, which are not possible with standard thoracoscopy, for example the rotation of an instrument’s head, which has 7 degrees of freedom, which is undoubtedly superior to any other instrument, even to the surgeon’s hand. The main advantage is that with only three approaches, the thorax can be entered with no scarring, and then the thymus can be reached all the way to the cervical area”. “Which point would one usually reach? I remember seeing that with Novellino’s procedures, how far and cephalad into the thymus can you go with a rigid instrument?” “Novellino needs to carry out a cervicotomy in order to be more radical. With the use of the robot, we can get to the superior horn of thymus, at the junction with the thyroid’s inferior pole. This can be done very easily thanks to the rotating heads. That is the main advantage. Why only at the top left, because the difficulty of this operation lies in the finding of the phrenic nerve. The left phrenic nerve’s position is much less predictable, so the advantage of going through the left side is to see the phrenic nerve’s exact position, as it can be seen in the operative field. We can position ourselves anterior to the phrenic nerve, and detach the entire thymus from caudally to cranially by lifting the horn of the thymus. The brachiocephalic or innominate vein is reached, and by following the innominate vein to the right, towards the right thoracic cavity, the vena cava is reached, and the right phrenic nerve is on the lateral aspect of the vena cava. At that point, the phrenic nerve can be identified by deduction, due to its position, which is always very specific.” “Could you summarize two or three obvious advantages of your technique as compared to the techniques you have used in the past or Novellino’s technique and what you’re doing now in robotics using a left unilateral axillary approach? What are the advantages of using a unilateral axillary approach?” “The advantage is that the intervention is even less invasive that Novellino’s, and it is thus put forward by neurologists much earlier than other interventions as a way to treat the illness, as it is also very well tolerated by patients.” “And the earlier the patient is treated, the greater the chance of success for this intervention”. “Indeed. A radical thymectomy can also be performed by removing the entire thyroid’s mediastinal anterior fat until the diaphragm, and also by dissecting out the aortopulmonary window, which is fundamental as there is 35% of ectopic islets at that level.” “This technique is a major improvement. I have one last question – up to now plunging goiters necessitated a sternotomy, which is an extremely invasive procedure. Could we imagine that your technique could cover part of the dissection using the robotic axillary approach, or do you think that would be too dangerous?” “It could without a doubt be considered, although it is very rare to see plunging goiters that are not resectable through a cervical route”.