Robotic thymectomy: a review of techniques and results

Abstract

Thymectomy is a well-established therapeutic option in the multidisciplinary treatment of nonthymomatous myasthenia gravis (MG) and in thymoma treatment. Although many surgical procedures for thymectomy have been identified, the transsternal method is still regarded as the gold standard. Minimally invasive procedures, on the other hand, have achieved popularity in the last decades and are now extensively used in this field of surgery. Among them, robotic thymectomy has been the most cutting-edge surgical procedure. Several authors and meta-analyses have shown that a minimally invasive approach to thymectomy is associated with improved surgical results and fewer complications in surgery compared to transsternal open thymectomy, without any substantial changes in myasthenia gravis complete rates of remission. Hence, in the present review of the literature, we aimed to describe and delineate the techniques, advantages, outcomes, and future perspectives of robotic thymectomy. Existing evidence suggests that robotic thymectomy will likely become the gold standard for thymectomy in early stage thymomas and MG subjects. Many of the drawbacks related to other minimally invasive procedures appear to be resolved by robotic thymectomy, and long-term neurological outcomes are satisfactory. In addition, improved vision and high dexterity of instrument movements enable safe and complete thymic tissue dissection, superior to standard thoracoscopic procedures. The access with minimally invasive surgery VATS (video-assisted thoracoscopic surgery) or RATS (robot-assisted thoracic surgery) access in its various variants allows the extent of mediastinal fat resection due to the possibility of ectopic thymic foci in the mediastinum determining the long-term outcome in the group of patients operated on for myasthenia gravis. However, it was recommended to carry out better designed, multi-centre, randomized studies to arrive at definitive conclusions on robotic thymectomy for thymomas and myasthenia gravis treatment.

Thymus Surgery Prospectives and Perspectives in Myasthenia Gravis

“…However, thymectomy may be considered in children with generalized MG with positive acetylcholine receptor anti-receptor serology who do not respond satisfactorily to pyridostigmine therapy or immunosuppressive therapy. There may also be an indication for thymectomy in children for whom it is necessary to prevent possible complications of immunosuppressive therapy [ 34 ].…”

Surgical treatment of myasthenia gravis using a robotic system – a literature review and a description of the first surgery in Poland

“…W analizie największych serii tymektomii wykonywanych przy użyciu robotów wykazano wysoki profil bezpieczeństwa zabiegów RATS oraz mniejszą liczbę powikłań (na poziomie 1,6-7,2%, z których najczęstsze to: chłonkotok, krwawienie i przełom miasteniczny), mniejszą śródoperacyjną utratę krwi i skrócenie czasu hospitalizacji w porównaniu z operacją metodą otwartą. Ponadto tymektomia wykonywana metodami małoinwazyjnymi RATS i VATS jest porównywalna pod względem doszczętności zabiegu, liczby powikłań, czasu hospitalizacji i odsetka konwersji do sternotomii [28]. W 2016 r. Wolfe i wsp.…”

Is RATS Superior to VATS in Thoracic Autonomic Nervous System Surgery?

“…In fact, the robotic platform has enabled increased expertise in dissection and reconstruction of delicate structures. Currently, numerous papers have demonstrated that the use of robotic assistance in thoracic surgery (RATS) can help optimize outcomes and maximize patient benefits in a variety of neoplastic and non-neoplastic diseases [2,3]. The advantages of RATS can be listed as follows: (1) improved vision thanks to the 10 times magnification and the depth perception of its 3D high-definition camera, (2) seven degrees of freedom (7DOF) allowing complex surgical maneuvers to be performed safely, reaching comfortably narrow spaces, (3) tremor filtering (6-Hz motion filter) and motion scaling systems that counteract physiologic hand tremors, allowing the surgeon to perform the finest surgical movements, (4) surgeon ergonomic position reducing fatigue and muscular struggle, (5) Firefly (fluorescence-capable vision system), which offers integrated high-resolution near-infrared fluorescence images in 3-dimensional vision, taking advantage of this technology to identify vascular anatomy.…”