Thoracoscopic Thymectomy

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Presentation transcript:

Thoracoscopic Thymectomy Jonathan D'Cunha, MD, PhD, Rafael S. Andrade, MD, Michael A. Maddaus, MD Operative Techniques in Thoracic and Cardiovascular Surgery Volume 15, Issue 2, Pages 102-113 (June 2010) DOI: 10.1053/j.optechstcvs.2010.06.002 Copyright © 2010 Elsevier Inc. Terms and Conditions

Figure 1 Patient positioning in the partial left lateral decubitus position. (A) View from left side of patient. (B) View from right side of patient. Note the 30° angle with a bump under the right side. Operative Techniques in Thoracic and Cardiovascular Surgery 2010 15, 102-113DOI: (10.1053/j.optechstcvs.2010.06.002) Copyright © 2010 Elsevier Inc. Terms and Conditions

Figure 2 Port placement on the right chest wall. Operative Techniques in Thoracic and Cardiovascular Surgery 2010 15, 102-113DOI: (10.1053/j.optechstcvs.2010.06.002) Copyright © 2010 Elsevier Inc. Terms and Conditions

Figure 3 Mobilization of the thymus is begun by incising the mediastinal pleura anterior to the right phrenic nerve with hook electrocautery. IMA = internal mammary artery; IMV = internal mammary vein; n. = nerve. Operative Techniques in Thoracic and Cardiovascular Surgery 2010 15, 102-113DOI: (10.1053/j.optechstcvs.2010.06.002) Copyright © 2010 Elsevier Inc. Terms and Conditions

Figure 4 Dissection of the thymus gland and the associated soft tissue begins at the right inferior pole at the level of the diaphragm. The thymus can be easily dissected off of the pericardium moving superiorly. SVC = superior vena cava. Operative Techniques in Thoracic and Cardiovascular Surgery 2010 15, 102-113DOI: (10.1053/j.optechstcvs.2010.06.002) Copyright © 2010 Elsevier Inc. Terms and Conditions

Figure 5 Demonstration of the use of endoclips to control the numerous vein branches as they are encountered. RIMA = right internal mammary artery; RIMV = right internal mammary vein. Operative Techniques in Thoracic and Cardiovascular Surgery 2010 15, 102-113DOI: (10.1053/j.optechstcvs.2010.06.002) Copyright © 2010 Elsevier Inc. Terms and Conditions

Figure 6 Both superior poles of the thymus are dissected and liberated under direct vision. Exposure of the superior poles is best achieved with gentle downward traction on the thymus and careful use of countertraction. The CO2 insufflation used throughout the dissection also significantly aids with this portion of the procedure. Operative Techniques in Thoracic and Cardiovascular Surgery 2010 15, 102-113DOI: (10.1053/j.optechstcvs.2010.06.002) Copyright © 2010 Elsevier Inc. Terms and Conditions

Figure 7 The thymus is then retracted to the right side and dissection is completed across the chest to expose the left side of the thymus. Operative Techniques in Thoracic and Cardiovascular Surgery 2010 15, 102-113DOI: (10.1053/j.optechstcvs.2010.06.002) Copyright © 2010 Elsevier Inc. Terms and Conditions

Figure 8 Positioning of the VATS port sites for the left-sided approach to visualize the thymus from the left chest. This setup ensures complete resection of the thymus and all accompanying fat, which, importantly, minimizes the chance of left phrenic nerve injury. Operative Techniques in Thoracic and Cardiovascular Surgery 2010 15, 102-113DOI: (10.1053/j.optechstcvs.2010.06.002) Copyright © 2010 Elsevier Inc. Terms and Conditions

Figure 9 Representative thymic specimen obtained. Operative Techniques in Thoracic and Cardiovascular Surgery 2010 15, 102-113DOI: (10.1053/j.optechstcvs.2010.06.002) Copyright © 2010 Elsevier Inc. Terms and Conditions

Figure 10 Final view of the mediastinum with completely skeletonized SVC and brachiocephalic vein. SVC = superior vena cava; v. = vein. Operative Techniques in Thoracic and Cardiovascular Surgery 2010 15, 102-113DOI: (10.1053/j.optechstcvs.2010.06.002) Copyright © 2010 Elsevier Inc. Terms and Conditions