Robotic-Assisted Thymectomy in Myasthenia Gravis Iskander Al-Githmi, MD, FRCSC, FRCSC (Ts&CDs), FACS, FCCP Department of Surgery. Division of Cardiothoracic Surgery King Abdulaziz University Hospital
Objectives General Robotic Considerations Anatomy of Thymus Robotic Technique Outcomes Myasthenia Gravis over view Our early experience of RATS
Da Vinci Robotic Surgical System B A C
General Robotic Consideration Provide a stable camera platform Three- dimensional imaging Simulate motions of surgeon’s wrist to overcome motion limitation of straight thoracoscopic instruments Offer the surgeon a comfortable, ergonomically operating position Magnified and computer enhanced video imaging provide superior exposure and visualization
General Robotic Consideration Telecast the surgeon hand motions to the remote operating room ( telepresence) -- Transatlantic cholecystectomy (Marescaux) Telementoring of surgeons Why have surgeons failed to embrace minimal invasive cardiothoracic surgery?
Factors Influencing Decision Anatomy Pathology patient Technology
Balance of Outcomes Dissection required Propensity of complications Reduction in organ reserve Approach Selection/ preparation Complication avoidance Anesthesia
Anatomy
Thymic Tissue Distribution Jaretzki 3d, et al. Journal of Thoracic and Cardiovascular Surgery, Vol 95, , Copyright © 1988
Potential sites for ectopic thymic tissue Ann Thorac Surg 2000;69:
Imaging
Surgical Approach
Robotic Thymectomy Technique
Robotic Thymectomy
Mack M.J. etal; J Thorac Cardivasc Surg 1996;112:
Robotic Thymectomy Surgical therapy of MG necessitate a complete removal of all thymic and fatty tissues in the anterior mediastinum Is this achievable ? Which surgical approach?, So what! Balance between extent of resection, morbidity, patients acceptance and results Goals
VATS Vs Open M.-W. Lin et al Eur J CT Surgery 37 (2010) 7-12
VATS Vs Open M.-W. Lin et al Eur J CT Surgery 37 (2010) 7-12
OR Time Ann Thorac Surg 2008;85:
Blood Loss Ann Thorac Surg 2008;85:
Hospital Stay (days) Ann Thorac Surg 2008;85:
Myasthenia Improvement Ann Thorac Surg 2008;85:
Myasthenia improvement CHEST 2005;128:
VATS Vs Open Ann Thorac Surg 2009;87:
Robotic Thymectomy Costs
Osserman Classifications J Thorac Cardiovasc Surg 1996;112:
De Filippi post operative classifications J Thorac Cardiovasc Surg 1996;112:
Our early experience Design: It is a prospective study of RATS for NTMG in KAUH. Data were collected from medical records & supplemented with telephone survey Methods: Jan Oct 2010 Patients (n) = 8 Gender : Female = 8 Male= 0 Mean age = 28 yr (16-46) All with non thymomatous Masthenia Gravis Left side (3 ports) robotic thymectomies (Da Vinci system)
Our early experience Results: Complete stable remission = 25% Clinical improvement = 87.5% Mortality = 0 Left phrenic nerve injury ( n=1) No significant correlation between age and symptom duration (p=0.51) No significant correlation between pre-op CT scan and histopathology finding (p= 0.85)
Patient Characteristics Mean age (Yr) 28 (16-46) Mean symptom duration (month) 7.75 (3-12) CT scan chest Hyperplasia Normal 3 (37.5%) 5 (62.5%) Acetylcholine receptors Ab Positive Negative 5 (62.5%) 3 (37.5%) Osserman stage Stage I Stage IIa Stage IIb Stabe III Stage IV 0 ( 0%) 2 (25%) 5 (37.5%) 0 (0%) 1 (12.5%) Al-Githmi, Surgical Science J 2011;2:
Pt. No Age (y) Osserman classification Symptoms duration (month) Preop CT chest Histopathology Follow-up /De Filippi Classification 6 months 12 months 18 months 116IIb12Hyperplasia Thymic involution Class 4Class 3Class 2 219IIb3Normal Class 4Class 2Class 3 323IIa12Normal Class 4Class 3 426IIb12HyperplasiaNormalClass 4 Class 3 528IIb5Hyperplasia Class 3 Class 2 630IV3NormalHyperplasiaClass 3Class 2Class 1 736IIb7NormalHyperplasiaClass 3 Class 2 846IIb8NormalThymic involution Class 3Class 2Class 1 Selected preoperative variables and patient outcome
Post operative status after 12 months follow up Class IN = 112.5% Class IIN = 337.5% Class IIIN = 450% Class IVN = 00% Class VN = 00%
Post operative status after 18 months follow up Class IN= 225% Class IIN = 337.5% Class IIIN = 337.5% Class IVN = 00% Class VN = 00% Class VN = 00%
Preoperative CT chest & Histopathology Preoperative CT ChestHistopathologyPositive diagnostic yield (%) Normal ( n= 5) Normal (n= 2) Hyperplasia (n= 2) Thymic involution (n = 1) 40 Hyperplasia (n= 3) Normal (n=1) Hyperplasia (n = 1) Thymic involution (n = 1) 33.3
Our early experience Conclusions: Robotic thymectomy is promising procedure, safe and effective Long-term results are comparable to conventional methods Global clinical improvement demonstrated in 87.5% after 12 months follow- up
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