Video-Assisted Thoracoscopic Surgery versus Robotic-Assisted Thoracoscopic Surgery Thymectomy

Abstract

The correct treatment of diseases of the thymic gland has remained a matter of debate in thoracic surgery. Indications for thymectomy primarily include suspected thymoma, myasthenia gravis with and without thymoma, and thymic cysts [1Conkle D.M. Adkins R.B. Primary malignant tumors of the mediastinum.Ann Thorac Surg. 1972; 5: 533-567Google Scholar, 2Burkell C.C. Cross J.M. Kent H.P. Nanson E.M. Mass lesions of the mediastinum.Curr Probl Surg. 1969; : 2-57PubMed Google Scholar, 3Wick M.R. Scheithauer B.W. Weiland L.H. Bernatz P.E. Primary thymic carcinomas.Am J Surg Pathol. 1982; 7: 613-630Crossref Scopus (235) Google Scholar, 4Davis R.D. Oldham H.N. Sabiston D.C. Primary cysts and neoplasms of the mediastinum: recent changes in clinical presentation, methods of diagnosis, management, and results.Ann Thorac Surg. 1987; 3: 229-237Abstract Full Text PDF Scopus (317) Google Scholar]. Regardless of the underlying disease indicating thymectomy, complete removal of the entire thymus is always mandatory because of potentially ectopic thymic tissue. This is not uniformly achieved by all the approaches used worldwide. Thus, the optimal surgical approach—combining a high degree of resection of the thymic gland and its perithymic fat tissue with low surgical invasiveness—is still controversial [5Novellino L. Longoni M. Spinelli L. et al.“Extended” thymectomy without sternotomy, performed by cervicotomy and thoracoscopic techniques in the treatment of myasthenia gravis.Int Surg. 1994; 79: 378-381PubMed Google Scholar, 6Zielinski M. Kuzdzal J. Szlubowski A. Soja J. Transcervical-subxiphoid-videothoracoscopic “maximal” thymectomy—operative technique and early results.Ann Thorac Surg. 2004; 78: 404-409Abstract Full Text Full Text PDF PubMed Scopus (91) Google Scholar, 7Jaretzki A. Thymectomy for myasthenia gravis analysis of the controversies regarding technique and results.Neurology. 1997; 48: 52-63Crossref Google Scholar, 8Gellert K. Bottger J. Martin T. Werner J. Mangler C. Martin H. Thoracoscopic thymectomy in the treatment concept for myasthenia gravis.Surg Technol Int. 2005; 14: 99-104PubMed Google Scholar]. The introduction of complete robotic surgical systems in the late 1990s contributed to the field of minimally invasive surgery. It soon became obvious that these devices are most advantageous in tiny and difficult to reach anatomic regions. The mediastinum has thus become a hot spot for thoracic surgeons using robotic assistance, and procedures like thymectomy, thymusectomy, resection of paravertebral tumors or ectopic (para-) thyroidectomy have been shown to be feasible and safe when performed with robotic assistance [9Bodner J. Wykypiel H. Schmid T. Early experience with robot-assisted surgery for mediastinal masses.Ann Thorac Surg. 2004; 78: 259-265Abstract Full Text Full Text PDF PubMed Scopus (118) Google Scholar, 10Ashton R.C. McGinnis K.M. Connery C.P. Swistel D.G. Ewing D.R. DeRose Jr, J.J. Totally endoscopic robotic thymectomy for myasthenia gravis.Ann Thorac Surg. 2003; 75: 569-571Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar, 11Bodner J. Lottersberger C.A. Kirchmayr W. Schmid T. Ectopic mediastinal thyroid adenoma.Eur J Cardiothorac Surg. 2004; 26: 211-212Crossref PubMed Scopus (5) Google Scholar]. Innsbruck Medical University Hospital purchased a 3-arm da Vinci operating robot (Intuitive Surgical Inc, Mountain View, CA) in June 2001; to date, 32 robotic thymectomy procedures have been performed. Written informed consent was obtained from all patients. Use of the da Vinci system was approved by the local ethics committee. A review of the patient charts back to 1999 shows that only four thoracoscopic thymectomies were performed with a conventional video-assisted thoracoscopic surgical approach (VATS); therefore, direct comparison of our results for the two types of thymectomy is not appropriate. A benefit of the robotic-assisted thoracoscopic surgical (RATS) approach to thymectomy compared with the conventional VATS approach has not yet been proven. When combining our institutional experience with the robotic approach and the recent literature on VATS, we arrive at a critical interim appraisal of RATS vs VATS thymectomy. After general anesthesia is initiated with a volatile anesthetic (sevoflurane), an opioid (remifentanil), and propofol, patients are intubated with a double-lumen tube for selective single-lung ventilation. Standard patient positioning is an incomplete (side up at a 30° angle) left lateral decubitus position. The right arm is positioned at the patient’s side as far back as possible to gain enough space for the robotic arms (Fig 1). Three trocars are placed: the right and the left are the working ports and the trocar in the mid-position is the camera port. An extended thymectomy with en bloc resection of the anterior mediastinal fat tissue, including the thymus, is performed [12Masaoka A. Yamakawa Y. Niwa H. et al.Extended thymectomy for myasthenia gravis a 20-year review.Ann Thorac Surg. 1996; 62: 853-859Abstract Full Text Full Text PDF PubMed Scopus (290) Google Scholar]. The adipose tissue around the upper poles of the thymus, around both brachiocephalic veins and on the pericardium, is meticulously dissected. Dissection limits are the diaphragm caudally, the thyroid gland cranially, and the phrenic nerves laterally [9Bodner J. Wykypiel H. Schmid T. Early experience with robot-assisted surgery for mediastinal masses.Ann Thorac Surg. 2004; 78: 259-265Abstract Full Text Full Text PDF PubMed Scopus (118) Google Scholar]. The port for the robotic endoscope is positioned in the sixth intercostal space in the middle axillary line. The camera is inserted and the 2 robotic instrument ports are visually guided to the third and sixth intercostal spaces, one hand’s breadth left and right of the camera trocar. Dissection is performed with a robotic cautery hook in the right and a Cadiere forceps (Intuitive Surgical Inc, Mountain View, CA) in the left hand, starting medial to the right phrenic nerve from cranial to caudal. Dissection is then continued to the substernal region, and the contralateral pleural cavity is opened. The thymus is dissected free from the pericardium, and preparation proceeds as far as the thymic veins. This is followed by dissection of the right and left upper horns and transection of the thymic vein(s). Larger vessels are clipped, and smaller ones are sealed by electrocautery. The da Vinci system enables the surgeon to also dissect the left thymic lobe accurately from a right-sided access in most patients. The specimen is removed in an Endobag (US Surgical, Norwalk, CT) inserted through the auxiliary port. One chest tube is placed in the right pleural cavity, and patients are extubated while still in the operating room. To locate evidence-based data on RATS and VATS thymectomy, a literature research reviewing the recent literature filed on PubMed (The New York Academy of Sciences) was performed using the key words thymectomy, thoracoscopy, VATS, and robotic. In the 32 institutional robotic thymectomies reported to date, no death and no major intraoperative or postoperative morbidity occurred. One patient (3%) was converted to thoracotomy owing to minor bleeding from the right internal thoracic vein. Minor postoperative complications included a wound infection at a port site and a patient with a peripheral pulmonary embolism. No relevant intraoperative blood loss occurred. Chest tubes were removed on postoperative day 2 (range, 2 to 6 days). Median hospital stay was 6 days (range, 4 to 15 days). In a subgroup of 9 thymoma patients, 6 at Masaoka stage I and 3 at Masaoka stage IIa, histology confirmed the resection margins to be free of tumor (R0). Median size of the thymoma was 30 mm (range, 20 to 50 mm). At a mean follow-up of 25 months (range, 2 to 49 months), no clinical or radiologic sign of tumor recurrence has been noted in any of the thymoma patients. The literature contains 150 published studies and reports demonstrating that the VATS approach for thymectomy is a feasible and technically safe procedure with very low morbidity. Its results in myasthenia gravis are comparable with the open approach, with a positive effect on postoperative pulmonary function [13Rückert J.C. Walter M. Müller J.M. Pulmonary function after thoracoscopic thymectomy versus median sternotomy for myasthenia gravis.Ann Thorac Surg. 2000; 70: 1656-1661Abstract Full Text Full Text PDF PubMed Scopus (87) Google Scholar]. However, concerns still surround application of the VATS approach in thymoma patients [14Port J.L. Ginsberg R.J. Surgery for thymoma.Chest Surg Clin N Am. 2001; 11: 421-437PubMed Google Scholar]. The feasibility and safety of RATS thymectomy with the daVinci system have been proven by 10 studies published to date. In this study, we have compared RATS and VATS. Table 1 summarizes a comparison of the recent literature, emphasizing the difference between open and minimally invasive access for thymectomy [15Wagner A.J. Cortes R.A. Strober J. et al.Long-term follow-up after thymectomy for myasthenia gravis: thoracoscopic vs open.J Pediatr Surg. 2006; 41: 50-54Abstract Full Text Full Text PDF PubMed Scopus (39) Google Scholar, 16Iablonskii P.K. Pishchik V.G. Nuraliev S.M. Comparative assessment of the effectiveness of traditional and videothoracoscopic thymectomies in complex treatment of myasthenic thymomas.Vestn Khir Im I I Grek. 2005; 164: 38-42PubMed Google Scholar, 17Hiratsuka M. Iwasaki A. Shirakusa T. et al.Role of video-assisted thoracic surgery for the treatment of myasthenia gravis: extended thymectomy by median sternotomy versus the thoracoscopic approach with sternal lifting.Int Surg. 2006; 91: 44-51PubMed Google Scholar, 18Lin T.S. Tzao C. Lee S.C. et al.Comparison between video-assisted thoracoscopic thymectomy and transternal thymectomy for myasthenia gravis (analysis of 82 cases).Int Surg. 2005; 90: 36-41PubMed Google Scholar, 19Manlulu A. Lee T.W. Wan I. et al.Video-assisted thoracic surgery thymectomy for nonthymomatous myasthenia gravis.Chest. 2005; 128: 3454-3460Crossref PubMed Scopus (64) Google Scholar, 20Tomulescu V. Ion V. Kosa A. Sgarbura O. Popescu I. Thoracoscopic thymectomy mid-term results.Ann Thorac Surg. 2006; 82: 1003-1007Abstract Full Text Full Text PDF PubMed Scopus (81) Google Scholar, 21Toker A. Eroglu O. Ziyade S. et al.Comparison of early postoperative results of thymectomy: partial sternotomy vs. videothoracoscopy.Thorac Cardiovasc Surg. 2005; 53: 110-113Crossref PubMed Scopus (33) Google Scholar, 22Rückert J.C. Sobel H.K. Göhring S. Einhäupl K.M. Müller J.M. Matched-pair comparison of three different approaches for thymectomy in myasthenia gravis.Surg Endosc. 2003; 17: 711-715Crossref PubMed Scopus (32) Google Scholar, 23Cheng Y.J. Kao E.L. Chou S.H. Videothoracoscopic resection of stage II thymoma: prospective comparison of the results between thoracoscopy and open methods.Chest. 2005; 128: 3010-3012Crossref PubMed Scopus (80) Google Scholar, 24Bodner J. Augustin F. Wykypiel H. et al.The da Vinci robotic system for general surgical applications: a critical interim appraisal.Swiss Med Wkly. 2005; 135: 674-678PubMed Google Scholar, 25Augustin F. Schmid T. Bodner J. The robotic approach for mediastinal lesions.Int J Med Robot. 2006; 3: 262-270Google Scholar, 26Savitt M.A. Gao G. Furnary A.P. Swanson J. Gately H.L. Handy J.R. Application of robotic-assisted techniques to the surgical evaluation and treatment of the anterior mediastinum.Ann Thorac Surg. 2005; 79 (discussion 455): 450-455Abstract Full Text Full Text PDF PubMed Scopus (86) Google Scholar, 27Rea F. Marulli G. Bortolotti L. Experience with the ‘da Vinci’ robotic system for thymectomy in patients with myasthenia gravis: report of 33 cases.Ann Thorac Surg. 2006; 81: 455-459Abstract Full Text Full Text PDF PubMed Scopus (111) Google Scholar, 28Mantegazza R. Baggi F. Bernasconi P. et al.Video-assisted thoracoscopic extended thymectomy and extended transsternal thymectomy (T-3b) in non-thymomatous myasthenia gravis patients: remission after 6 years of follow-up.J Neurol Sci. 2003; 212: 31-36Abstract Full Text Full Text PDF PubMed Scopus (103) Google Scholar, 29Cakar F. Augustin F. Bodner J. et al.A comparison of outcomes after robotic open extended thymectomy for myasthenia gravis.Eur J Cardiothorac Surg. 2007; 3 (discussion 504–5): 501-504Crossref Scopus (60) Google Scholar, 30Chang P.C. Chou S.H. Kao E.L. et al.Bilateral video-assisted thoracoscopic thymectomy vs. extended transsternal thymectomy in myasthenia gravis: a prospective study.Eur Surg Res. 2005; 37: 199-203Crossref PubMed Scopus (24) Google Scholar]. Because many VATS studies compare thoracoscopic and open procedures, the results for the transsternal operation are also shown.Table 1Comparison of Video-Assisted and Robotic-Assisted Thoracoscopic Thymectomy From the LiteratureVariable, First AuthorVATSRATSTranssternalp ValueBlood loss (mL) Wagner [15Wagner A.J. Cortes R.A. Strober J. et al.Long-term follow-up after thymectomy for myasthenia gravis: thoracoscopic vs open.J Pediatr Surg. 2006; 41: 50-54Abstract Full Text Full Text PDF PubMed Scopus (39) Google Scholar]7.552.50.02 Iablonskii [16Iablonskii P.K. Pishchik V.G. Nuraliev S.M. Comparative assessment of the effectiveness of traditional and videothoracoscopic thymectomies in complex treatment of myasthenic thymomas.Vestn Khir Im I I Grek. 2005; 164: 38-42PubMed Google Scholar]82.5557.1<0.05 Hiratsuka [17Hiratsuka M. Iwasaki A. Shirakusa T. et al.Role of video-assisted thoracic surgery for the treatment of myasthenia gravis: extended thymectomy by median sternotomy versus the thoracoscopic approach with sternal lifting.Int Surg. 2006; 91: 44-51PubMed Google Scholar]68.6154.1<0.05OR times (min) Wagner [15Wagner A.J. Cortes R.A. Strober J. et al.Long-term follow-up after thymectomy for myasthenia gravis: thoracoscopic vs open.J Pediatr Surg. 2006; 41: 50-54Abstract Full Text Full Text PDF PubMed Scopus (39) Google Scholar]138.8139.8NS Hiratsuka [17Hiratsuka M. Iwasaki A. Shirakusa T. et al.Role of video-assisted thoracic surgery for the treatment of myasthenia gravis: extended thymectomy by median sternotomy versus the thoracoscopic approach with sternal lifting.Int Surg. 2006; 91: 44-51PubMed Google Scholar]268.3177.3<0.05 Lin [18Lin T.S. Tzao C. Lee S.C. et al.Comparison between video-assisted thoracoscopic thymectomy and transternal thymectomy for myasthenia gravis (analysis of 82 cases).Int Surg. 2005; 90: 36-41PubMed Google Scholar]180.0248.20.0004 Manlulu [19Manlulu A. Lee T.W. Wan I. et al.Video-assisted thoracic surgery thymectomy for nonthymomatous myasthenia gravis.Chest. 2005; 128: 3454-3460Crossref PubMed Scopus (64) Google Scholar]107 Tomulescu [20Tomulescu V. Ion V. Kosa A. Sgarbura O. Popescu I. Thoracoscopic thymectomy mid-term results.Ann Thorac Surg. 2006; 82: 1003-1007Abstract Full Text Full Text PDF PubMed Scopus (81) Google Scholar]90 Toker [21Toker A. Eroglu O. Ziyade S. et al.Comparison of early postoperative results of thymectomy: partial sternotomy vs. videothoracoscopy.Thorac Cardiovasc Surg. 2005; 53: 110-113Crossref PubMed Scopus (33) Google Scholar]101.782.7NS Rueckert [22Rückert J.C. Sobel H.K. Göhring S. Einhäupl K.M. Müller J.M. Matched-pair comparison of three different approaches for thymectomy in myasthenia gravis.Surg Endosc. 2003; 17: 711-715Crossref PubMed Scopus (32) Google Scholar]197113<0.001 Cheng [23Cheng Y.J. Kao E.L. Chou S.H. Videothoracoscopic resection of stage II thymoma: prospective comparison of the results between thoracoscopy and open methods.Chest. 2005; 128: 3010-3012Crossref PubMed Scopus (80) Google Scholar]193.3207.5NS Bodner [24Bodner J. Augustin F. Wykypiel H. et al.The da Vinci robotic system for general surgical applications: a critical interim appraisal.Swiss Med Wkly. 2005; 135: 674-678PubMed Google Scholar]150 Augustin [25Augustin F. Schmid T. Bodner J. The robotic approach for mediastinal lesions.Int J Med Robot. 2006; 3: 262-270Google Scholar]127 Savitt [26Savitt M.A. Gao G. Furnary A.P. Swanson J. Gately H.L. Handy J.R. Application of robotic-assisted techniques to the surgical evaluation and treatment of the anterior mediastinum.Ann Thorac Surg. 2005; 79 (discussion 455): 450-455Abstract Full Text Full Text PDF PubMed Scopus (86) Google Scholar]96 Rea [27Rea F. Marulli G. Bortolotti L. Experience with the ‘da Vinci’ robotic system for thymectomy in patients with myasthenia gravis: report of 33 cases.Ann Thorac Surg. 2006; 81: 455-459Abstract Full Text Full Text PDF PubMed Scopus (111) Google Scholar]120Median159.4123158.55Length of hospital stay (d) Wagner [15Wagner A.J. Cortes R.A. Strober J. et al.Long-term follow-up after thymectomy for myasthenia gravis: thoracoscopic vs open.J Pediatr Surg. 2006; 41: 50-54Abstract Full Text Full Text PDF PubMed Scopus (39) Google Scholar]1.510.60.13 Lin [18Lin T.S. Tzao C. Lee S.C. et al.Comparison between video-assisted thoracoscopic thymectomy and transternal thymectomy for myasthenia gravis (analysis of 82 cases).Int Surg. 2005; 90: 36-41PubMed Google Scholar]6.126.90.001 Manlulu [19Manlulu A. Lee T.W. Wan I. et al.Video-assisted thoracic surgery thymectomy for nonthymomatous myasthenia gravis.Chest. 2005; 128: 3454-3460Crossref PubMed Scopus (64) Google Scholar]3 Tomulescu [20Tomulescu V. Ion V. Kosa A. Sgarbura O. Popescu I. Thoracoscopic thymectomy mid-term results.Ann Thorac Surg. 2006; 82: 1003-1007Abstract Full Text Full Text PDF PubMed Scopus (81) Google Scholar]2.3 Toker [21Toker A. Eroglu O. Ziyade S. et al.Comparison of early postoperative results of thymectomy: partial sternotomy vs. videothoracoscopy.Thorac Cardiovasc Surg. 2005; 53: 110-113Crossref PubMed Scopus (33) Google Scholar]2.35.6<0.001 Mantegazza [28Mantegazza R. Baggi F. Bernasconi P. et al.Video-assisted thoracoscopic extended thymectomy and extended transsternal thymectomy (T-3b) in non-thymomatous myasthenia gravis patients: remission after 6 years of follow-up.J Neurol Sci. 2003; 212: 31-36Abstract Full Text Full Text PDF PubMed Scopus (103) Google Scholar]5 Savitt [26Savitt M.A. Gao G. Furnary A.P. Swanson J. Gately H.L. Handy J.R. Application of robotic-assisted techniques to the surgical evaluation and treatment of the anterior mediastinum.Ann Thorac Surg. 2005; 79 (discussion 455): 450-455Abstract Full Text Full Text PDF PubMed Scopus (86) Google Scholar]2 Rea [27Rea F. Marulli G. Bortolotti L. Experience with the ‘da Vinci’ robotic system for thymectomy in patients with myasthenia gravis: report of 33 cases.Ann Thorac Surg. 2006; 81: 455-459Abstract Full Text Full Text PDF PubMed Scopus (111) Google Scholar]2.6 Cakar [29Cakar F. Augustin F. Bodner J. et al.A comparison of outcomes after robotic open extended thymectomy for myasthenia gravis.Eur J Cardiothorac Surg. 2007; 3 (discussion 504–5): 501-504Crossref Scopus (60) Google Scholar]510<0.05Median2.652.610.3Myasthenia improvement/remission Wagner [15Wagner A.J. Cortes R.A. Strober J. et al.Long-term follow-up after thymectomy for myasthenia gravis: thoracoscopic vs open.J Pediatr Surg. 2006; 41: 50-54Abstract Full Text Full Text PDF PubMed Scopus (39) Google Scholar]83.383.3NS Iablonskii [16Iablonskii P.K. Pishchik V.G. Nuraliev S.M. Comparative assessment of the effectiveness of traditional and videothoracoscopic thymectomies in complex treatment of myasthenic thymomas.Vestn Khir Im I I Grek. 2005; 164: 38-42PubMed Google Scholar]NANANS Hiratsuka [17Hiratsuka M. Iwasaki A. Shirakusa T. et al.Role of video-assisted thoracic surgery for the treatment of myasthenia gravis: extended thymectomy by median sternotomy versus the thoracoscopic approach with sternal lifting.Int Surg. 2006; 91: 44-51PubMed Google Scholar]NANANS Lin [18Lin T.S. Tzao C. Lee S.C. et al.Comparison between video-assisted thoracoscopic thymectomy and transternal thymectomy for myasthenia gravis (analysis of 82 cases).Int Surg. 2005; 90: 36-41PubMed Google Scholar]NANA0.574 Chang [30Chang P.C. Chou S.H. Kao E.L. et al.Bilateral video-assisted thoracoscopic thymectomy vs. extended transsternal thymectomy in myasthenia gravis: a prospective study.Eur Surg Res. 2005; 37: 199-203Crossref PubMed Scopus (24) Google Scholar]NANANS Mantegazza [28Mantegazza R. Baggi F. Bernasconi P. et al.Video-assisted thoracoscopic extended thymectomy and extended transsternal thymectomy (T-3b) in non-thymomatous myasthenia gravis patients: remission after 6 years of follow-up.J Neurol Sci. 2003; 212: 31-36Abstract Full Text Full Text PDF PubMed Scopus (103) Google Scholar]aOnly complete remissions were mentioned.50.648.7NS Manlulu [19Manlulu A. Lee T.W. Wan I. et al.Video-assisted thoracic surgery thymectomy for nonthymomatous myasthenia gravis.Chest. 2005; 128: 3454-3460Crossref PubMed Scopus (64) Google Scholar]91.6 Rea [27Rea F. Marulli G. Bortolotti L. Experience with the ‘da Vinci’ robotic system for thymectomy in patients with myasthenia gravis: report of 33 cases.Ann Thorac Surg. 2006; 81: 455-459Abstract Full Text Full Text PDF PubMed Scopus (111) Google Scholar]91.7 Cakar [29Cakar F. Augustin F. Bodner J. et al.A comparison of outcomes after robotic open extended thymectomy for myasthenia gravis.Eur J Cardiothorac Surg. 2007; 3 (discussion 504–5): 501-504Crossref Scopus (60) Google Scholar]10078NSNA = not applicable; NS = not significant; RATS = robotic-assisted thoracoscopic surgery; VATS = video-assisted thoracoscopic surgery.a Only complete remissions were mentioned. Open table in a new tab NA = not applicable; NS = not significant; RATS = robotic-assisted thoracoscopic surgery; VATS = video-assisted thoracoscopic surgery. Thymectomy is indicated in various diseases, including thymoma, thymic cysts, and thymus carcinoma, and is also a therapeutic option in adjunct to medical management in myasthenia gravis. The surgical approach to thymectomy remains controversial, and a variety of different techniques have been introduced in recent decades, each with its advantages and disadvantages. Common characteristics of any kind of minimally invasive approach are reduced patient morbidity, mortality, and postoperative pain; shorter postoperative hospital stay and recovery; and lower wound infection rates. These obvious advantages of minimally invasive surgery have induced greater acceptability, especially among patients with myasthenia gravis and the physicians who treat them, and have thus increased the total number of thymectomies being performed. The VATS approach combines the advantages of minimally invasive techniques with an excellent view of the anterior mediastinum. This permits an extended thymectomy to be performed, similar to the one in the transsternal approach. The most evident benefits of a VATS approach are decreased estimated blood loss (7.5 to 82.5 mL vs 52.5 to 557.1 mL) [15Wagner A.J. Cortes R.A. Strober J. et al.Long-term follow-up after thymectomy for myasthenia gravis: thoracoscopic vs open.J Pediatr Surg. 2006; 41: 50-54Abstract Full Text Full Text PDF PubMed Scopus (39) Google Scholar, 16Iablonskii P.K. Pishchik V.G. Nuraliev S.M. Comparative assessment of the effectiveness of traditional and videothoracoscopic thymectomies in complex treatment of myasthenic thymomas.Vestn Khir Im I I Grek. 2005; 164: 38-42PubMed Google Scholar, 17Hiratsuka M. Iwasaki A. Shirakusa T. et al.Role of video-assisted thoracic surgery for the treatment of myasthenia gravis: extended thymectomy by median sternotomy versus the thoracoscopic approach with sternal lifting.Int Surg. 2006; 91: 44-51PubMed Google Scholar], decreased length of hospital stay (1.5 to 6.1 days vs 5.6 to 26.9 days) [15Wagner A.J. Cortes R.A. Strober J. et al.Long-term follow-up after thymectomy for myasthenia gravis: thoracoscopic vs open.J Pediatr Surg. 2006; 41: 50-54Abstract Full Text Full Text PDF PubMed Scopus (39) Google Scholar, 18Lin T.S. Tzao C. Lee S.C. et al.Comparison between video-assisted thoracoscopic thymectomy and transternal thymectomy for myasthenia gravis (analysis of 82 cases).Int Surg. 2005; 90: 36-41PubMed Google Scholar, 19Manlulu A. Lee T.W. Wan I. et al.Video-assisted thoracic surgery thymectomy for nonthymomatous myasthenia gravis.Chest. 2005; 128: 3454-3460Crossref PubMed Scopus (64) Google Scholar, 20Tomulescu V. Ion V. Kosa A. Sgarbura O. Popescu I. Thoracoscopic thymectomy mid-term results.Ann Thorac Surg. 2006; 82: 1003-1007Abstract Full Text Full Text PDF PubMed Scopus (81) Google Scholar, 21Toker A. Eroglu O. Ziyade S. et al.Comparison of early postoperative results of thymectomy: partial sternotomy vs. videothoracoscopy.Thorac Cardiovasc Surg. 2005; 53: 110-113Crossref PubMed Scopus (33) Google Scholar], improved cosmetic results, and faster recovery and social reintegration with lower pain scores (median visual analog scale score, 1.9 to 3.1 vs 4.8 to 6.1) [16Iablonskii P.K. Pishchik V.G. Nuraliev S.M. Comparative assessment of the effectiveness of traditional and videothoracoscopic thymectomies in complex treatment of myasthenic thymomas.Vestn Khir Im I I Grek. 2005; 164: 38-42PubMed Google Scholar, 21Toker A. Eroglu O. Ziyade S. et al.Comparison of early postoperative results of thymectomy: partial sternotomy vs. videothoracoscopy.Thorac Cardiovasc Surg. 2005; 53: 110-113Crossref PubMed Scopus (33) Google Scholar, 30Chang P.C. Chou S.H. Kao E.L. et al.Bilateral video-assisted thoracoscopic thymectomy vs. extended transsternal thymectomy in myasthenia gravis: a prospective study.Eur Surg Res. 2005; 37: 199-203Crossref PubMed Scopus (24) Google Scholar]. Moreover, the results obtained with the minimally invasive transcervical, VATS, or combined approach have been proven to be comparable with the significantly more invasive transsternal approach in terms of remission or clinical improvement of myasthenic symptoms, thus suggesting that any approach is effective if thymectomy is radical and extended to the perithymic tissue [15Wagner A.J. Cortes R.A. Strober J. et al.Long-term follow-up after thymectomy for myasthenia gravis: thoracoscopic vs open.J Pediatr Surg. 2006; 41: 50-54Abstract Full Text Full Text PDF PubMed Scopus (39) Google Scholar, 16Iablonskii P.K. Pishchik V.G. Nuraliev S.M. Comparative assessment of the effectiveness of traditional and videothoracoscopic thymectomies in complex treatment of myasthenic thymomas.Vestn Khir Im I I Grek. 2005; 164: 38-42PubMed Google Scholar, 17Hiratsuka M. Iwasaki A. Shirakusa T. et al.Role of video-assisted thoracic surgery for the treatment of myasthenia gravis: extended thymectomy by median sternotomy versus the thoracoscopic approach with sternal lifting.Int Surg. 2006; 91: 44-51PubMed Google Scholar, 18Lin T.S. Tzao C. Lee S.C. et al.Comparison between video-assisted thoracoscopic thymectomy and transternal thymectomy for myasthenia gravis (analysis of 82 cases).Int Surg. 2005; 90: 36-41PubMed Google Scholar, 30Chang P.C. Chou S.H. Kao E.L. et al.Bilateral video-assisted thoracoscopic thymectomy vs. extended transsternal thymectomy in myasthenia gravis: a prospective study.Eur Surg Res. 2005; 37: 199-203Crossref PubMed Scopus (24) Google Scholar]. Compared with VATS, RATS thymectomy has a similar median length of hospital stay of 2 to 5 days. To date, no data on intraoperative blood loss or postoperative pain scores are available for the robotic approach. Published operative times for VATS thymectomy range from a median 90 minutes to 268.3 minutes. This wide range may be caused by learning curves, different frequencies among various institutions, and differences in patients and diseases enrolled. In 2005, Savitt and colleagues [26Savitt M.A. Gao G. Furnary A.P. Swanson J. Gately H.L. Handy J.R. Application of robotic-assisted techniques to the surgical evaluation and treatment of the anterior mediastinum.Ann Thorac Surg. 2005; 79 (discussion 455): 450-455Abstract Full Text Full Text PDF PubMed Scopus (86) Google Scholar] reported 15 successful RATS thymectomies with a mean operative time of 96 minutes (range, 62 to 132 minutes). In a series of patients with myasthenia gravis operated on robotically, Rea and colleagues [27Rea F. Marulli G. Bortolotti L. Experience with the ‘da Vinci’ robotic system for thymectomy in patients with myasthenia gravis: report of 33 cases.Ann Thorac Surg. 2006; 81: 455-459Abstract Full Text Full Text PDF PubMed Scopus (111) Google Scholar] reported a mean operative time of 120 minutes (range, 60 to 240 minutes). The median operative time in our own first series of extended thymectomies was 150 minutes (range, 104 to 223 minutes) [24Bodner J. Augustin F. Wykypiel H. et al.The da Vinci robotic system for general surgical applications: a critical interim appraisal.Swiss Med Wkly. 2005; 135: 674-678PubMed Google Scholar], but dropped with increasing experience to 127 minutes (range, 54 to 314 minutes in 2006 [25Augustin F. Schmid T. Bodner J. The robotic approach for mediastinal lesions.Int J Med Robot. 2006; 3: 262-270Google Scholar]. In sum, overall operating time seems to be shorter in the RATS group. Because the high costs are one of the main points of criticism voiced in connection with robotic-assisted operations, we recently evaluated the procedural costs of thymectomy for various minimally invasive approaches. Use of the robot is significantly more expensive; we demonstrated additional costs of about 91% compared with conventional VATS (Fig 2). These extra costs are primarily caused by the expensive robotic instruments, which can be reused only a limited number of times [24Bodner J. Augustin F. Wykypiel H. et al.The da Vinci robotic system for general surgical applications: a critical interim appraisal.Swiss Med Wkly. 2005; 135: 674-678PubMed Google Scholar]. Because all published results do not favor any of the minimally invasive techniques and no prospective randomized trials are available, only general statements can be made about why we prefer the robotic approach. The upper mediastinum is an anatomic area that is difficult to reach when approached by conventional thoracoscopy. Working thoracoscopically in an anatomic region with vulnerable large vessels and nerves certainly poses a potential risk: the image of the operating field on the monitor is only two-dimensional with a loss of depth perception, the surgeon’s hand movements have to be executed counteractively to the direction the instruments are intended to take inside the pleural cavity, and the surgeon’s hand tremor is increased by thoracoscopic instruments. This makes it particularly difficult to dissect the thymus in the neck region and to reach the perithymic fat in the contralateral hemithorax [27Rea F. Marulli G. Bortolotti L. Experience with the ‘da Vinci’ robotic system for thymectomy in patients with myasthenia gravis: report of 33 cases.Ann Thorac Surg. 2006; 81: 455-459Abstract Full Text Full Text PDF PubMed Scopus (111) Google Scholar]. Needless to say, advanced surgical skills are required. Robotic technology was introduced into surgical medicine to overcome these obvious limitations of conventional minimally invasive surgery. The da Vinci surgical robotic system offers advanced visual control and superior maneuverability of the surgical instruments, and hand movements in the grips of the console are naturally and intuitively transmitted to the robot’s instruments. With 7° of freedom in movement of the instrument tip and a possible rotation of 360°, it is superior to a surgeon’s hand in open surgery, thus improving maneuverability around anatomic structures [31Hashizume M. Konishi K. Tsutsumi N. Yamaguchi S. Shimabukuro R. A new era of robotic surgery assisted by a computer-enhanced surgical system.Surgery. 2002; 131: 330-333Abstract Full Text Full Text PDF Scopus (67) Google Scholar]. This facilitates gentle and precise dissection within a small, fixed three-dimensional and remote area. To date, no prospective randomized trials comparing outcomes after VATS and RATS thymectomy have been published; thus at this stage, reliance on impressions and personal feelings may still be tolerable. Because of the improved maneuverability found with RATS, Savitt and colleagues [26Savitt M.A. Gao G. Furnary A.P. Swanson J. Gately H.L. Handy J.R. Application of robotic-assisted techniques to the surgical evaluation and treatment of the anterior mediastinum.Ann Thorac Surg. 2005; 79 (discussion 455): 450-455Abstract Full Text Full Text PDF PubMed Scopus (86) Google Scholar] stated that robotic surgery is more suitable than VATS for an extended thymectomy. Further definite pros for the robotic approach seem to be the easier dissection of the upper horns, the controlled ligation of the thymic veins, and the excellent access to the entire anterior mediastinum from a single-sided approach. This appraisal remains to be verified. But even then, why use a cumbersome robotic system at significantly higher costs if VATS thymectomy is feasible and safe and yields excellent long-term results? Only when randomized trials are performed, will we learn the answer.