Robotic Thymectomy Research Articles

Experience with the "da Vinci" robotic system for early-stage thymomas: Report of 23 cases.

The aim of this study was to report a single referral center experience in robotic extended thymectomy for clinical early stage thymomas, evaluating its safety, feasibility and efficacy, with special regard to oncological outcomes. Between January 2009 and December 2012, we retrospectively selected patients who underwent robotic extended thymectomy for clinical early stage thymomas. Operative time, morbidity, mortality, duration of hospitalization, and overall and disease-free survival were analyzed. There were 23 patients (15 males, eight females) with a mean age of 49.3 years (range 20-66). There were no intra-operative complications, and no mortality. The mean operative time was 85.2 minutes (range 60-180). No patient underwent conversion to open surgery. All post-operative complications (4.3%) were conservatively treated. The mean post-operative stay was 3.6 days (range two to nine). The pathological analysis revealed Masaoka stage I (21 cases) and II (two cases). No disease recurrence occurred at a mean follow-up of 24.8 months. Robotic thymectomy is a safe and feasible technique, with a short operative time and low morbidity. Even on a small series with short follow-up, robotic extended thymectomy for thymoma appeared to be an effective treatment for early-stage thymomas.

8 Years’ experience with robotic thymectomy for thymomas

The accuracy of a three-dimensional robotic-assisted videothoracoscopic approach may favor a radical resection of thymomas. The aim of this study was to demonstrate the feasibility of the robotic approach by reporting 8 years experience in a single referral center of surgical treatment of thymomas. We retrospectively analyzed all consecutive patients who underwent a thymectomy from April 2004 to April 2012. We analyzed the procedure time, morbidity, mortality, conversions, hospitalization, freedom from recurrence, time to progression, and overall survival. From 2004 until 2012, a total of 138 robotic procedures for mediastinal tumors were performed in our center, of which 37 patients with a mean age of 57.3 years underwent a thymectomy for a thymoma. Histological analysis revealed four type A thymomas (10.8 %), seven type AB thymomas (18.9 %), seven type B1 thymomas (18.9 %), fourteen type B2 thymomas (37.8 %), four type B3 thymomas (10.8 %), and one thymus carcinoma (2.7 %). The Masaoka–Koga stages were as follows: stage I in twenty patients (54 %), stage IIA in five patients (13.5 %), stage IIB in eight patients (21.6 %), stage III in three patients (8.1 %), and stage IVa in one patient (2.7 %). The mean overall procedure time was 149 min (range 88–353). No surgical mortality was reported, and there were no peri-operative complications. No conversions were needed for surgical complications. In three cases, a conversion to sternotomy was preferred by the surgeon because tumor invasion in greater vessels was suspected. Two patients (5.4 %) suffered from a myasthenic crisis postoperatively and required prolonged mechanical ventilation. One patient (2.7 %) underwent a procedure for a thoracic herniation 6 months following thymectomy. The median hospitalization was 3 days. The follow-up analysis showed an overall survival of 100 % and tumor recurrence in one patient (2.7 %). Robotic thymectomies are safe in patients with early-stage thymomas. Robotic surgery may also be feasible for some selected advanced thymomas.

State of the Art of Robotic Thymectomy

Thymectomy is a widely accepted treatment for most cases of myasthenia gravis and essential for the treatment of thymoma. The development of a minimally invasive procedure for thymectomy resulted in a variety of approaches for surgery on the thymic gland. The use of thoracoscopy-based techniques has continued to increase, including the latest advance in this field, robotic thymectomy. We review the rapid development and actual use of this approach by examining published reports, worldwide registries, and personal communications and by analyzing our database, which is the largest single-center experience and contains 317 thymectomies until 12/2012. The technical modifications of robotic thymectomy are also described. Since 2001, approximately 3,500 robotic thymectomies have been registered worldwide. Meanwhile, the results of approximately 500 thymectomy cases have been published. Robotic thymectomy is performed most frequently through a standardized unilateral three-trocar approach. All reports describe promising and satisfactory results for myasthenia gravis. For early-stage thymoma, robotic thymectomy is a technically sound and safe procedure with a very low complication rate and short hospital stay. Oncological outcome without recurrences is promising, but a longer follow-up is needed. The unilateral robotic technique can be considered an adequate approach for thymectomy, even with demanding anatomical configurations. Robotic thymectomy has spread worldwide over the last decade because of the promising results in myasthenia gravis and thymoma patients.

Thoracic Techniques: Robotic Thymectomy for Thymoma

The traditional approach to resection of anterior mediastinal masses has been via sternotomy. This approach has been associated with an average length of stay of 4–5 days, sternal precautions for 6 weeks, a visible scar, and in some cases, long term discomfort. Although some surgeons have attempted VATS resection of thymomas and other anterior mediastinal masses, we have found that a robotic assisted resection, with its enhanced vision (due to the 10× magnification) and endowrist movements, are ideal for the compact space of the anterior mediastinum [1]. Herein, we describe our technique of total thymectomy for thymoma, highlight some adjunctive techniques, discuss the results of robotic thymectomy, and identify the controversies around robotic resection for thymoma.

Surgical and neurologic outcomes after robotic thymectomy in 100 consecutive patients with myasthenia gravis

Thymectomy is a well-defined therapeutic option for patients with myasthenia gravis; however, controversies still exist about the surgical approach, indication, and timing for surgery. We reviewed our experience reporting surgical and neurologic results after robotic thymectomy in patients with myasthenia gravis. Between 2002 and 2010, 100 patients (74 female and 26 male; median age, 37 years) underwent left-sided robotic thymectomy using the da Vinci robotic system (Intuitive Surgical, Inc, Sunnyvale, Calif). The Myasthenia Gravis Foundation of America classification was adopted for pre- and postoperative evaluation. Preoperative Myasthenia Gravis Foundation of America class was I in 10% of patients, II in 35% of patients, III in 39% of patients, and IV in 16% of patients. Median operative time was 120 (60-300) minutes. No death or intraoperative complications occurred. Postoperative complications were observed in 6 patients (6%) (bleeding requiring blood transfusions in 3, chylothorax in 1, fever in 1, and myasthenic crisis in 1). Median hospital stay was 3 days (range, 2-14 days). Histologic analysis revealed 76 patients (76%) with hyperplasia, 7 patients (7%) with atrophy, 8 patients (8%) with small thymomas, and 9 patients (9%) with normal thymus; ectopic thymic tissue was found in 26 patients (26%). Clinical follow-up showed a 5-year probability of complete stable remission and overall improvement of 28.5% and 87.5%. Remission was significantly associated with preoperative I to II Myasthenia Gravis Foundation of America class (P = .02). A significant improvement rate was found in Myasthenia Gravis Foundation of America class I to II (P = .03) and AbAchR+ (P = .04). A high percentage of patients interrupted or reduced their medications. Robotic thymectomy is a safe and effective procedure. We observed a neurologic benefit in a great number of patients. A better clinical outcome was obtained in patients with early Myasthenia Gravis Foundation of America class.

Robot-Assisted Thoracoscopic Thymectomy for Treating Myasthenia Gravis in Children

In the United States, the prevalence of myasthenia gravis (MG) is approximately 14-20 per 100,000. One treatment option involves a thymectomy, which can lead to remission of symptoms. The amount of thymic tissue removed is correlated with a better outcome for patients. Thus, it is critical that the procedure used when performing a thymectomy maximize the resection of thymic tissue. Robotic-assisted thoracoscopic thymectomy provides a minimally invasive platform that avoids the mortality and morbidity of a median sternotomy while providing better visualization and a more delicate dissection than is available in a standard thoracoscopic procedure. Following Institutional Review Board approval, in total, 9 patients who underwent robotic thymectomy were reviewed. Intraoperative statistics such as operative time and blood loss were reviewed from operative records. Postoperative outcomes such as hospital stay, discharge medications, and complications were reviewed from hospital charts. Lastly, disease response was evaluated in consultation with a pediatric neurologist who specializes in MG. Age at operation ranged from 2 to 15 years of age (average, 9.4 years). A majority of patients had an MGFA classification of II or greater (n=5). All patients were on pyridostigmine preoperatively, and 7 of 9 (77%) were taking prednisone. Mean operative time was 160.1±6.1 minutes. Average postoperative hospital stay was 1.1±0.3 days. One patient had a documented persistent pneumothorax on postoperative Day 1, which was treated with nasal cannula oxygen for an additional day. There were no additional operative complications, and all patients were discharged home on acetaminophen with codeine for pain control. Eight of 9 patients had improvement in MG symptoms after the procedure. Robotic-assisted thoracoscopic thymectomy is a safe and effective operation for children with MG. Robotic assistance allows for articulating instruments, three-dimensional visualization, and minimal blood loss. These factors may allow for a more complete resection compared with a standard thoracoscopic thymectomy.

First experience of robotic extended thymectomy in Japan for myasthenia gravis with thymoma

We performed robot (da Vinci)-assisted thoracoscopic extended thymectomy (rThx) for myasthenia gravis with thymoma. The patient was a 66-year-old woman who complained of palpebral heaviness. Robotic operation was performed in the supine position by placing four ports in the right chest wall under 10 mmHg CO(2) insufflation using three arms and one assist port. Compared with conventional video-assisted thoracic surgery (VATS), the bilateral upper horns, fat around the diaphragm, and aortopulmonary window could be resected more easily. The tumor measured 41 mm maximum diameter and was diagnosed as type AB noninvasive thymoma. The operating time was 298 min, console operating time was 203 min, and the amount of bleeding was small. The postoperative course was uneventful with no complications. This is a report of the first Japanese case of rThx for myasthenia gravis. rThx is a promising technique, and further improvement in the procedure is expected.

Robotic extended thymectomy for early-stage thymomas

The aim of this study was to report a single referral centre experience in robotic extended thymectomy for clinical early-stage thymomas, evaluating its safety, feasibility and efficacy, with special regard to oncological outcomes. Between April 2002 and February 2011, we retrospectively selected all those patients who underwent robotic thymectomy for clinical early-stage thymomas. Operative time, morbidity, mortality, duration of hospitalization and overall and disease-free survival were analysed. There were 14 patients (8 males, 6 females) with a mean age of 65.2 years (range 23-81). One patient suffered from myasthenia gravis. The WHO classifications were: A in two cases, AB in four cases, B1 in three cases, B2 in two cases and B3 in three cases. The Masaoka stages were: I in seven cases, IIA in four cases, IIB in two cases and III in one case. The mean operative time was 139 min. No intra-operative complication or death occurred. Conversion to open surgery was required in two cases. Minor complications occurred in two patients (14.2%) due to pleural effusion. The mean hospitalization was 4.0 days. Five patients underwent adjuvant radiotherapy. All patients were alive with no disease recurrence, with a median follow-up of 14.5 months (range 1-98). Robotic thymectomy is a safe and feasible technique, with a short operative time and low morbidity. Even on a small series with short follow-up, robotic extended thymectomy for thymoma appeared to be an effective treatment for early-stage thymomas.

Mediastinal neoplasms in patients with Graves disease: a possible link between sustained hyperthyroidism and thymic neoplasia?

BackgroundAnterior mediastinal masses are a rare but well documented finding in Graves disease. The vast majority of these lesions represents benign thymic hypertrophy and regress after treatment of the hyperthyroidism. A small percentage of these cases however represent neoplastic/malignant diseases which require further treatment.Cases12 year old boy with one year history of refractory Graves disease was found to have an anterior mediastinal mass and underwent curative thyroidectomy for sustained hyperthyroidism. Cervical lymphadenopathy was detected during the procedure and biopsy was obtained. A 23 year old woman who presented with a one month history of hyperthyroid symptoms, was diagnosed with Graves disease and also was found to have an anterior mediastinal mass on imaging. Biopsy of the anterior mediastinal mass was obtained and subsequently the patient underwent robotic thymectomy. Histologic examination and immunophenotyping of the cervical lymph node in a 12 year old boy revealed neoplastic proliferation of T lymphoblasts diagnostic of T lymphoblastic leukemia/lymphoma. Examination of the anterior mediastinal mass biopsy in the 23 year old woman revealed type B1 thymoma which was confirmed after examination of the subsequent robotic thymectomy specimen.ConclusionThis is the first reported case of T cell lymphoblastic lymphoma and the third reported case of thymoma associated with sustained hyperthyroidism due to Graves disease. These cases indicate that an anterior mediastinal mass in a patient with active Graves disease may be due to a neoplastic cause, which may require definitive treatment. Caution should be exercised when dismissing a mediastinal mass as benign thymic hyperplasia in patients with active Graves disease.

Invited Commentary

We read with interest the study by Liu and associates [1Liu Z. Feng H. Yeung S.-C.J. et al.Extended transsternal thymectomy for the treatment of ocular myasthenia gravis.Ann Thorac Surg. 2011; 92: 1993-1999Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar]. Optimal treatment of ocular myasthenia gravis (MG) is still a controversial issue with no agreement among surgeons and neurologists. There is no doubt that patients with thymoma should undergo surgery, whatever the MG stage is; however, many doubts still persist regarding the indication for surgery for those with pure ocular MG. This dilemma is related to several factors. At this stage, some natural remissions (approximately 30% of cases) occur without surgery. In addition, most of the patients with ocular MG remain at this stage with symptoms easily controlled by medical treatment. Furthermore, the variability in diagnosis, type of medical treatment, length of time before referral for surgery, preparation for surgery, and type of surgical approach has made MG (in particular ocular MG) difficult to study. In the last two decades, an increasing number of reports have sustained the potential role of surgery, even at the early stage of MG. The results are even more crucial in the era of thoracoscopic and robotic thymectomy. Proponents of thymectomy generally agree that the duration of symptoms before surgery is a predictor for outcome, with better results in patients reporting symptoms for less than 1 year. However, this does not match with the guidelines proposed by neurologists: they suggest a period of medical treatment not shorter than 1 year in the absence of thymoma. The results of surgical treatment of ocular MG should be popularized among neurologists to encourage the debate and eventually increase referrals to thoracic surgery units. It could also help to alleviate neurologists' historical reluctance to withdraw medications after surgery in patients without symptom; this is usually reported as one of the factors contributing to lower cure rates. We must admit that phase II studies are interesting and encouraging, but they are not persuasive from the scientific point of view. We now need phase III studies in patients with ocular MG involving surgeons and neurologists; this will be the only way to identify the best treatment for ocular MG. Extended Transsternal Thymectomy for the Treatment of Ocular Myasthenia GravisThe Annals of Thoracic SurgeryVol. 92Issue 6PreviewThe optimal treatment for ocular myasthenia gravis (OMG) remains controversial. We conducted a review of the long-term clinical outcomes of Chinese patients with OMG after extended transsternal thymectomy (ETT) to determine the efficacy of this procedure as a treatment for OMG. Full-Text PDF

Long-Term Follow-Up After Robotic Thymectomy for Nonthymomatous Myasthenia Gravis

Thymectomy is recognized as a significant component in the treatment of myasthenia gravis. However, controversy exists as to the optimal surgical approach. This investigation summarizes our experience performing extended thymectomy using a robotic technique in a large group of patients with significant follow-up. Data collection for patients undergoing robotic thymectomy for nonthymomatous myasthenia gravis over a 6-year period was prospectively performed. Patients were assessed using the Myasthenia Gravis Foundation of America's quantitative disease severity score and the post intervention status classification. During the study period, 75 patients underwent thymectomy by this method. Mean preoperative myasthenia gravis severity score was 2.7. Mean operative time was 113±46 minutes. Extubation in the operating room occurred in 73 (98%) patients. Mean intensive care stay and total hospital length of stay were 0.9 and 2.2 days respectively. Mean interval between surgery and return to work (or prethymectomy activities of daily living) was 15±6 days. Significant improvement of myasthenia gravis symptoms occurred in 65 (87%) patients with a mean follow-up of 45±14 months. Robotic-assisted thymectomy is a safe and effective technique for patients with symptomatic myasthenia gravis. It allowed an extended thymectomy to be performed without the associated length of stay or recovery period of a transsternal approach while producing comparable rates of symptom improvement.

Robotic thymectomy: The Hong Kong experience.

Thymectomy is widely employed as part of the management for generalized myasthenia gravis. The surgical approach has evolved over the years, and although there is no consensus regarding the optimal surgical approach, minimally invasive techniques such as video-assisted thoracoscopic thymectomy have gained popularity. Robotic-assisted surgical systems have been employed in recent years to perform thymectomies as the robotic arm allows extra wrist action of the instruments which provide seven degrees of movement, giving improved dexterity compared to the conventional thoracoscopic approach. Here we describe our early experience with the da Vinci system in thymectomy. Between April 2006 and November 2009, 12 robotic-assisted complete thymectomy procedures were performed with no need for conversion to open procedures. Operation times ranged from 100 minutes to 200 minutes (mean time 140 minutes). There were no intraoperative or postoperative complications. Nearly all chest drains were removed on postoperative day 1 and the mean hospital stay was 4 days. The follow-up period ranged from 2 to 44 months. Early postoperative evaluations showed one patient had complete remission of symptoms (DeFilippi class 1) and 11 patients became asymptomatic or less symptomatic with a decreased medication requirement (DeFilippi class 2 and 3). Our early experience suggests that robotic thymectomy is comparable to video-assisted thoracic surgery thymectomy, and our results appear to be comparable to those reported in the literature. A larger number of cases and more extended follow up is needed to fully evaluate the merits of robotic thymectomy.

Starting a Robotic Program in General Thoracic Surgery: Why, How, and Lessons Learned

We report our experience in starting a robotic program in thoracic surgery. We retrospectively reviewed our experience in starting a robotic program in general thoracic surgery on a consecutive series of patients. Between February 2009 and September 2010, 150 patients underwent robotic operations. Types of procedures were lobectomy in 62, thymectomy in 30, and benign esophageal procedures in 6. No thymectomy or esophageal procedures required conversion. One conversion was needed for suspected bleeding for a mediastinal mass. Twelve patients were converted for lobectomy (none for bleeding, 1 in the last 24). Median operative time for robotic thymectomy was 119 minutes, and median length of stay was 1 day. The median time for robotic lobectomy was 185 minutes, and median length of stay was 2 days. There were no operative deaths. Morbidity occurred in 23 patients (15%). All patients with cancer had R0 resections and resection of all visible mediastinal and hilar lymph nodes. Robotic surgery is safe and oncologically sound. It requires training of the entire operating room team. The learning curve is steep, involving port placement, availability of the proper instrumentation, use of the correct robotic arms, and proper patient positioning. The robot provides an ideal surgical approach for thymectomy and other mediastinal tumors. Its advantage over thoracoscopy for pulmonary resection is unproven; however, we believe complete thoracic lymph node dissection and teaching is easier. Importantly, defined credentialing for surgeons and cost analysis studies are needed.

Assessment of Robotic Thymectomy Using the Myasthenia Gravis Foundation of America Guidelines

Robotic thymectomy is an emerging treatment for myasthenia gravis. However, the Myasthenia Gravis Foundation of America clinical research standards have been infrequently adopted in the surgical literature. Twenty-six patients underwent robotic thymectomy for myasthenia gravis between 2003 and 2008, performed by a single surgeon using the da Vinci system (Intuitive Surgical; Sunnyvale, CA) through a four-port right-sided approach. Mean operative times were 68+/-25 minutes of robotic system activation and 127+/-35 minutes from incision to closure. There were no intraoperative or postoperative mortalities; the most common intraoperative complication was desaturation after single-lung ventilation, for which four procedures were converted to open. On histologic examination, there were five thymomas. The average follow-up after surgery was 26 months. Median preoperative and postoperative Myasthenia Gravis Foundation of America disease classifications were 2 and 0, respectively, reflecting a statistically significant decrease in symptoms (p<0.01). Additionally, the average daily dose of cholinesterase inhibitor decreased by 63% postoperatively. Overall, 82% of patients improved and 18% were unchanged; no worsening disease was observed. Robotic thymectomy is a safe and efficacious treatment option for myasthenia gravis. There were no notable differences in patient demographics compared with previously published reports of open thymectomies. Furthermore, surgical and neurologic outcomes in this series compare favorably with conventional approaches in the literature. Of those with follow-up greater than 6 months, 82% of patients undergoing robotic thymectomy demonstrated significant clinical improvement postoperatively, indicating that this approach in concert with optimized medical management is an effective treatment for myasthenia gravis.

Extended videoscopic robotic thymectomy with the da Vinci telemanipulator for the treatment of myasthenia gravis: the Vienna experience

Surgical treatment of myasthenia gravis should include the complete resection of the thymus with the whole fatty tissue adherent to the pericardium for immunologic as well as oncologic reasons. The aim of the current study was to investigate the efficacy and safety of robotic approach. A total of 18 patients with myasthenia gravis (mean age 44 years) have been operated robotically via a left-sided approach. Preoperative MGFA (Myasthenia Gravis Foundation of America) classification was: Class I n=4, Class IIa n=4, Class IIb n=5, and Class IIIa n=3, IIIb n=2. Total endoscopic resection was feasible in 17/18 patients. One patient had to be converted due to bleeding. In the remaining patients, operative time was 175 min, intensive care unit (ICU) one day, hospital stay four days. In all patients it was possible to perform an extended thymic resection. MGFA post-intervention status after a mean of 18 months follow-up showed complete stable remission n=5, pharmacologic remission n=4, minimal manifestations n=5, unchanged n=1. Complete endoscopic thymus surgery with the da Vinci surgical system enables a complete and extended resection of all thymic tissue in the mediastinum. Due to the minimal trauma, patients can return to full activity within a short time.

Robotic-Assisted Thymectomy

Thymectomy is an established therapy for myasthenia gravis. Minimally invasive surgery for thymectomy has been reported, but not clearly shown to be equivalent to open resection. Robotic-assisted thymectomy may provide the benefit of a full resection of thymic tissue and anterior mediastinal tissue for the treatment of myasthenia gravis by a minimally invasive approach. We present a review of the experience of robotic thymectomy.

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

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

Three-Year Experience with Totally Endoscopic Robotic Thymectomy

: Robotic technology has facilitated the evaluation and treatment of anterior mediastinal pathology. We describe a 3-year experience using the da Vinci Robotic Surgical System to perform thymectomies for a range of diseases. : From March 2002 to November 2004, 9 patients (3 myasthenia gravis, 3 mediastinal mass, 2 myasthenia gravis plus thymoma, 1 hyperparathyroidism) underwent totally endoscopic robotic thymectomy. Medical records and operative databases were reviewed. The cohort was divided into an early experience (group A) and a later experience (group B). Data were analyzed with the Fisher exact test and Mann-Whitney test. : Complete robotic resection of the thymus was accomplished in all 9 patients. The mean age for the entire cohort was 40 ± 12 years (range 28-66 years) and 78% of the patients were women. No significant differences in age, gender, or operative conversions were detected between the groups. Patients in group A were more likely to have a bilateral approach. Group B demonstrated statistically significant reductions in operating room and operation time and a trend toward decreased chest tube days and length of stay. No morbidity or mortality associated with the procedure was noted in either group. : Robotic thymectomy is a safe and effective procedure. Its steep learning curve promises to allow more surgeons to adopt minimally invasive approaches to the mediastinum safely and efficiently.

Three-Year Experience with Totally Endoscopic Robotic Thymectomy

Three-Year Experience with Totally Endoscopic Robotic Thymectomy