Thoracoscopic Extended Thymothymectomy For Myasthenia Gravis And Thymic Malignancies: A Bilateral Minimally Invasive Approach
Mitsuhiro Kamiyoshihara, Takashi Ibe, Natsuko Kawatani, Fumi Ohsawa, Ryohei Yoshikawa.
Maebashi Red Cross Hospital, Maebashi, Japan.
OBJECTIVE: Studies of the usefulness of thoracoscopic extended thymothymectomy for myasthenia gravis and thymic malignancies have reported equivalent early and mid-term outcomes, shorter lengths of stay, and low rates of postoperative complications. We performed thoracoscopic extended thymothymectomies on four patients. Here, we present surgical tips for maximizing the operative field and minimizing chest wall trauma using a bilateral minimally invasive approach based on our experience.
METHODS: The patient is placed in a left semi-lateral position under general anesthesia using a double-lumen tube. Then, using a 5-mm flexible thoracoscope and a bipolar sealing device, the thymic tumor is removed to avoid tumor implantation, and the thymic tissue is detached from the anterior mediastinum and inferior pole of the thymus on the right side via three-port thoracoscopic surgery in the right chest wall. Next, the thymic tissue is detached from both inferior poles of the thyroid gland to the superior mediastinum by pushing the upper mediastinal organs using cotton swabs. After turning the patient over, we then detach the left-side thymic tissue through three ports. Finally, the thymus, including the anterior mediastinal fat, is removed under thoracoscopic view.
RESULTS: The surgical procedure was completed in all patients, with operating times ranging from 270 to 300 min, and with less than 50 g hemorrhage. There was little postoperative pain due to the port sites. The postoperative courses were uneventful; all four patients were discharged 3 to 5 days after surgery, and have had no recurrence for between 1 and 28 months.
CONCLUSIONS: Using a bilateral minimally invasive approach, we excised sufficient fat from around the left brachiocephalic vein and excised the thymoma in one piece with the mediastinal parietal pleura. For safe manipulation, we think that the use of a 5-mm flexible thoracoscope is effective for decreasing the invisible areas, particularly the space behind the sternum.
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