The technical aspects of a midline robotic thymectomy

Abstract

Central MessageIn robotic-assisted thymectomy, the midline (subxiphoid) approach is associated with improved visualization of phrenic nerves and facilitates the dissection of the upper poles.See Commentaries on pages 371 and 373. In robotic-assisted thymectomy, the midline (subxiphoid) approach is associated with improved visualization of phrenic nerves and facilitates the dissection of the upper poles. See Commentaries on pages 371 and 373. In the treatment of early-stage thymomas or myasthenia gravis, minimally invasive thymectomy, including robotic approach, has gained popularity. Several approaches are proposed for robotic thymectomy, including the left,1Marulli G. Maessen J. Melfi F. Schmid T.A. Keijzers M. Fanucchi O. et al.Multi-institutional European experience of robotic thymectomy for thymoma.Ann Cardiothorac Surg. 2016; 5: 18-25PubMed Google Scholar right,2Keijzers M. De baets M. Hochstenbag M. Abdul-Hamid M. Zur Hausen A. van der Linden M. et al.Robotic thymectomy in patients with myasthenia gravis: neurological and surgical outcomes.Eur J Cardiothorac Surg. 2015; 48: 40-45Crossref PubMed Scopus (30) Google Scholar bilateral,3Kawaguchi K. Fukui T. Nakamura S. Taniguchi T. Yokoi K. A bilateral approach to extended thymectomy using the da Vinci surgical system for patients with myasthenia gravis.Surg Today. 2018; 48: 195-199Crossref PubMed Scopus (3) Google Scholar and subxiphoid.4Suda T. Tochii D. Tochii S. Takagi Y. Trans-subxiphoid robotic thymectomy.Interact Cardiovasc Thorac Surg. 2015; 20: 669-671Crossref PubMed Scopus (18) Google Scholar The robotic subxiphoid approach was originally described by Suda and colleagues,4Suda T. Tochii D. Tochii S. Takagi Y. Trans-subxiphoid robotic thymectomy.Interact Cardiovasc Thorac Surg. 2015; 20: 669-671Crossref PubMed Scopus (18) Google Scholar who demonstrated its feasibility and safety. We aim to demonstrate the advantages of a subxiphoid approach in robotic thymectomy. This is a single institutional retrospective study. Cases of robotic thymectomy for thymic epithelial malignancies (Masaoka–Koga stage 1 or 2) between October 2018 and November 2019 were included. All procedures (robotic-portal anterior mediastinal operation using 4 arms) were performed with a single operator (K.H.) with the da Vinci Xi surgical system (Intuitive Surgical, Sunnyvale, Calif). The visualization of the bilateral phrenic nerves (Figure 1, A), and the identification of trachea and brachiocephalic artery after dissection of the upper poles (suggesting complete dissection of the poles during procedures; Figure 1, B) by the unilateral approach (Lat group) and the subxiphoid approach (SubX group) were compared. This study was approved by the institutional review board (Ashikaga: No 2019-44) on February 5, 2020, and consent was waived. The procedure is demonstrated in Video 1. To summarize, the patient was positioned supine with arms and legs open. A 3-cm incision was made in the subxiphoid lesion. A single-port device was applied to the subxiphoid incision with CO2 insufflation at 8 mm Hg. Following the opening of the bilateral pleura and the dissection of the thymus off the sternum, 2 ports in the right side and 1 port in the left side were placed at the sixth intercostal space level (Figure 1, C). A 30-degree robotic camera was mounted in the subxiphoid port. The xiphoid process was not removed but was lifted using a robotic camera port to increase the space behind the sternum. An en-bloc complete thymectomy, including adjacent mediastinal fat, was performed (Figure 1, D). For patients with myasthenia gravis, extended thymectomy was performed.5Wolfe G.I. Kaminski H.J. Aban I.B. Minisman G. Kuo H.C. Marx A. et al.Randomized trial of thymectomy in myasthenia gravis.N Engl J Med. 2016; 375: 511-522Crossref PubMed Scopus (167) Google Scholar A single flexible chest tube bridging bilateral chest cavity was placed through the lateral port. A fasciotomy in subxiphoid incision was carefully closed. A tot