Video-Assisted Thymectomy—Video 25

Published on 13/02/2015 by admin

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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).
image

Figure 25-2 A, The Harmonic scalpel starts the dissection anterior to the phrenic nerve. B, The thymus is dissected off the surface of the pericardium.

Step 3. Dissection of the Right Lower Pole of the Thymus

♦ Exposure: Gravity makes the lung fall posteriorly, out of the way.
♦ Aim the thoracoscope superiorly, and point the lens toward the mediastinum.
♦ A ring forceps through incision 2 holds the thymus as the Endokittner (Ethicon Endosurgery, Cincinnati, Ohio) bluntly sweeps the right pole of the thymus from the pericardium (Figure 25-3A).
♦ If vascular adhesions are encountered, use the Harmonic scalpel (Ethicon Endosurgery) to control them (Figure 25-3B).
♦ Take diaphragmatic fat with the inferior aspect of the right thymic pole by dividing attachments to the diaphragm with the Harmonic scalpel or by sweeping them off bluntly with the Ethicon Endokittner.
♦ Carry this dissection to the midline (i.e., level of sternum) (Figure 25-3C).
image

Figure 25-3 A, Endokittner bluntly dissects the thymus away from the pericardium. B, The Harmonic scalpel transects small vessels. C, Blunt dissection of the thymus off the surface of the pericardium.

Step 4. Dissection of the Left Lower Pole of the Thymus

♦ Exposure: Gravity makes the lung fall posteriorly, out of the way.
♦ Aim the thoracoscope superiorly, and point the lens toward the mediastinum.
♦ At level of sternum, bluntly create the plane between peristernal tissue (including the mammary pedicle) and the left-sided mediastinal pleura.
♦ When mediastinal pleura is clearly identified over the left lung, open the pleura with the Harmonic scalpel (Figure 25-4A and B).
♦ After the left thymic pole is clearly identified, begin dissection along medial left diaphragmatic surface, including the diaphragmatic fat, to ensure that the entire thymus is resected.
♦ Use Harmonic scalpel to open the mediastinal pleura 2 mm anterior to the left phrenic pedicle (i.e., similar to dissection on right side) (Figure 25-4C).
♦ Carry the dissection up to the level of the left innominate vein (Figure 25-4D).
♦ If there is any issue regarding visualization of the left phrenic pedicle add 4th port in left 7th intercostal space in anterior clavicular line. Put camera in this port and ask anesthesiologists to intermittently hold ventilation to visualize structures (this is necessary <20% of the time) (Figure 25-4E).
image

Figure 25-4 A, Opening the contralateral pleura. B, The Harmonic scalpel resects the left pericardial fat pad. C, The Harmonic scalpel dissects just anteriorly to the left phrenic nerve. D, Dissection proceeds along the surface of the innominate vein. E, Placement of a trocar into the left pleural space facilitates visualization of the left phrenic nerve.

Step 5. Identification of the Cervical Thymic Poles Superficial and Superior to the Left Innominate Vein

♦ Exposure: Gravity makes the lung fall posteriorly, out of the way.
♦ Aim the thoracoscope medially, and point the lens superiorly.
♦ Open the fascial layer over the left and right cervical thymic poles, and begin blunt dissection with the Endokittner (Figure 25-5A).
♦ Divide any draining vessels with the Harmonic scalpel.
♦ When the poles have been brought down to the level of the innominate vein, identify the draining veins of the body of the thymus into the innominate, and divide these veins with the Harmonic scalpel, or clip and cut them (depending on the surgeon’s preference) (Figure 25-5B and C).
♦ Occasionally, the right internal mammary vein at the juncture with the innominate vein prevents visualization of the cervical thymic poles. It can be clipped and divided to open up the space into the neck.
♦ After the vascular supply to the cervical poles has been controlled, each pole can be teased out of the neck (Figure 25-5D and E).
image

Figure 25-5 A, Opening the fascia over the thymic poles. B, The thymic veins are divided between clips using scissors. C, Thymic veins have been clipped. D, Mobilization of the right thymic pole from the neck. E, Mobilization of the left thymic pole from the neck.

Step 6. Thymus Retrieval

♦ Exposure: Gravity makes the lung fall posteriorly, out of the way.
♦ Aim the thoracoscope inferiorly, and point the lens toward the mediastinum.
♦ At this point, the entire thymus should be freed, along with the surrounding mediastinal and diaphragmatic fat. Place the specimen in a retrieval bag, and remove it from the chest through incision 2 (Figure 25-6).
image

Figure 25-6 The thymus is removed and placed in a bag.

Step 7. Chest Tube

♦ Exposure: Gravity makes the lung fall posteriorly, out of the way.
♦ Aim the thoracoscope inferiorly, and point the lens toward the mediastinum.
♦ Inspect the thymic bed for hemostasis and completeness of dissection (Figure 25-7A).
♦ Place a 19-French Blake drain into the chest through the camera port, and drape in a large C shape so that the pleural spaces and mediastinum are well drained (Figure 25-7B).
image

Figure 25-7 A, Empty anterior mediastinum. B, Chest tube drainage of the mediastinum.

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