Video-Assisted Thymectomy—Video 25

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CHAPTER 25 Video-Assisted Thymectomy—Video 25

Scott J. Swanson

Introduction

Thymectomy using a video-assisted thoracic surgical (VATS) approach is an excellent technique for patients with myasthenia gravis and small (<4 cm) thymomas that do not appear to invade other structures. It usually requires three right-sided ports, but if it is difficult to see the left phrenic nerve, a fourth left medial port may be needed.

Approach to Video-Assisted Thymectomy

Order of Operative Steps

The order of the steps of the operation is as follows: pericardial fat pad, pleura along phrenic nerve, right lower pole of thymus, open left pleura and left thymic pole, and left and right cervical poles.

Key Points

♦ Work from right to left and from inferior to superior.
♦ No manipulation of lung necessary.

image Video-Assisted Thymectomy (Video 25)

Step 1. Placement of Three Ports

♦ Position the patient supine with the arms over the head and an I-roll behind the patient (i.e., vertically behind the spine, horizontally behind the shoulders, and horizontally behind the hips) (Figure 25-1)
♦ Make the incisions.

image Incision 1, made in the eighth intercostal space and along the mid-clavicular line, is for the camera.
image Incision 2, made in the fourth intercostal space and medial to the breast (anterior clavicular line), is a working port.
image Incision 3, made in the fifth intercostal space and medial to the breast (anterior clavicular line), is a working port.
image Incision 4 (optional) is made in the left seventh intercostal space and anterior to the clavicular line.

image

Figure 25-1 Incisions for a thymectomy performed as video-assisted thoracic surgery.

Step 2. Initial Dissection

♦ Exposure: Gravity makes the lung fall posteriorly, out of the way.
♦ Aim the thoracoscope superiorly, and point the lens toward the mediastinum.
♦ A grasper through incision 3 lifts the pleura anterior to the phrenic nerve. The Harmonic scalpel opens the mediastinal pleura parallel to the right phrenic nerve pedicle and approximately 2 mm anterior to it (Figure 25-2A).
♦ Carry this dissection superiorly to the origin of the superior vena cava, where the left innominate vein and right innominate vein join (Figure 25-2B).
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