Single Port Thymectomy: A Step Toward “Scarless” Thymectomy to Replace Robotics?

We read with great interest the case report by Suda and associates [1Suda T. Sugimura H. Tochii D. Kihara M. Hattori Y. Single-port thymectomy through an infrasternal approach.Ann Thorac Surg. 2012; 93: 334-336Abstract Full Text Full Text PDF PubMed Scopus (71) Google Scholar] on their single-port approach to thymectomy. We congratulate the authors for their innovative approach to thymectomy and would like to discuss how this compares with other forms of minimally invasive thymectomy.Thymectomy by video-assisted thoracic surgery (VATS) has been shown to produce long-term clinical outcomes equivalent to that of the extended transsternal approach, with lower complication rates [2Meyer D.M. Herbert M.A. Sobhani M.C. et al.Comparative clinical outcomes of thymectomy for myasthenia gravis performed by extended transsternal and minimally invasive approaches.Ann Thorac Surg. 2009; 87: 385-391Abstract Full Text Full Text PDF PubMed Scopus (99) Google Scholar]. With the advent of robotic surgery, reference centers have transitioned to this modality, and the superiority of robotic thymectomy has been shown [3Ruckert J.C. Swierzy M. Ismail M. Comparison of robotic and nonrobotic thoracoscopic thymectomy: a cohort study.J Thorac Cardiovasc Surg. 2011; 141: 673-677Abstract Full Text Full Text PDF PubMed Scopus (94) Google Scholar].We have strived to develop robotic cardiothoracic surgery as a routine approach applicable even in small or developing programs, and we have shown the feasibility of robotic heart valve repair [4Panos A. Myers P.O. Kalangos A. Thoracoscopic and robotic tricuspid valve annuloplasty with a biodegradable ring: an initial experience.J Heart Valve Dis. 2010; 19: 201-205PubMed Google Scholar, 5Myers P.O. Panos A. Kalangos A. Simplifying robotic mitral valve repair: minimizing sutures with intra-annular ring implantation.J Thorac Cardiovasc Surg. 2010; 140: 1441-1442Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar], septal defect repairs [6Panos A. Myers P.O. Routine robotic and video-assisted mitral valve repair in everyday surgery.Cardiovasc Med. 2011; 14: 92-94Google Scholar], and myxoma resection [7Panos A. Myers P.O. Video-assisted cardiac myxoma resection: basket technique for complete and safe removal from the heart.Ann Thorac Surg. 2012; 93: e109-e110Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar]. For thymectomy, the port positioning is illustrated in Figure 1. We have found that gentle blunt robotic dissection allows for safe and complete resection, inasmuch as the six degrees of liberty of the robotic instruments allow for easier dissection and maneuverability in limited space. This approach allows for adequate and safe exposure of the superior thymic horns from the left side of the chest, which is possibly more difficult from a subxyphoid incision. Furthermore, each incision is 10 mm or less, making the cumulative incision smaller. We also would humbly ask whether xyphoidectomy, the extended horizontal incision, and the upper presternal traction wire wouldn't be a combination at higher risk for generating postoperative pain.Our esteemed colleagues in abdominal surgery have been very creative in developing less invasive surgery, such as transumbilical laparoendoscopic single-site surgery and natural orifice transluminal endoscopic surgery, striving toward “scarless” surgery [8Bucher P. Pugin F. Ostermann S. Ris F. Chilcott M. Morel P. Population perception of surgical safety and body image trauma: a plea for scarless surgery?.Surg Endosc. 2011; 25: 408-415Crossref PubMed Scopus (66) Google Scholar]. Is this the direction we should be looking at for the future of thymectomy, or even cardiac surgery, as it has been reported in animal models [9Kalejs M. Ferrari E. von Segesser L.K. Towards no-scar cardiac surgery: minimally invasive access through umbilicus for aortic valve replacement.Eur J Cardiothorac Surg. 2009; 36: 773-775Crossref PubMed Scopus (8) Google Scholar]? We read with great interest the case report by Suda and associates [1Suda T. Sugimura H. Tochii D. Kihara M. Hattori Y. Single-port thymectomy through an infrasternal approach.Ann Thorac Surg. 2012; 93: 334-336Abstract Full Text Full Text PDF PubMed Scopus (71) Google Scholar] on their single-port approach to thymectomy. We congratulate the authors for their innovative approach to thymectomy and would like to discuss how this compares with other forms of minimally invasive thymectomy. Thymectomy by video-assisted thoracic surgery (VATS) has been shown to produce long-term clinical outcomes equivalent to that of the extended transsternal approach, with lower complication rates [2Meyer D.M. Herbert M.A. Sobhani M.C. et al.Comparative clinical outcomes of thymectomy for myasthenia gravis performed by extended transsternal and minimally invasive approaches.Ann Thorac Surg. 2009; 87: 385-391Abstract Full Text Full Text PDF PubMed Scopus (99) Google Scholar]. With the advent of robotic surgery, reference centers have transitioned to this modality, and the superiority of robotic thymectomy has been shown [3Ruckert J.C. Swierzy M. Ismail M. Comparison of robotic and nonrobotic thoracoscopic thymectomy: a cohort study.J Thorac Cardiovasc Surg. 2011; 141: 673-677Abstract Full Text Full Text PDF PubMed Scopus (94) Google Scholar]. We have strived to develop robotic cardiothoracic surgery as a routine approach applicable even in small or developing programs, and we have shown the feasibility of robotic heart valve repair [4Panos A. Myers P.O. Kalangos A. Thoracoscopic and robotic tricuspid valve annuloplasty with a biodegradable ring: an initial experience.J Heart Valve Dis. 2010; 19: 201-205PubMed Google Scholar, 5Myers P.O. Panos A. Kalangos A. Simplifying robotic mitral valve repair: minimizing sutures with intra-annular ring implantation.J Thorac Cardiovasc Surg. 2010; 140: 1441-1442Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar], septal defect repairs [6Panos A. Myers P.O. Routine robotic and video-assisted mitral valve repair in everyday surgery.Cardiovasc Med. 2011; 14: 92-94Google Scholar], and myxoma resection [7Panos A. Myers P.O. Video-assisted cardiac myxoma resection: basket technique for complete and safe removal from the heart.Ann Thorac Surg. 2012; 93: e109-e110Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar]. For thymectomy, the port positioning is illustrated in Figure 1. We have found that gentle blunt robotic dissection allows for safe and complete resection, inasmuch as the six degrees of liberty of the robotic instruments allow for easier dissection and maneuverability in limited space. This approach allows for adequate and safe exposure of the superior thymic horns from the left side of the chest, which is possibly more difficult from a subxyphoid incision. Furthermore, each incision is 10 mm or less, making the cumulative incision smaller. We also would humbly ask whether xyphoidectomy, the extended horizontal incision, and the upper presternal traction wire wouldn't be a combination at higher risk for generating postoperative pain. Our esteemed colleagues in abdominal surgery have been very creative in developing less invasive surgery, such as transumbilical laparoendoscopic single-site surgery and natural orifice transluminal endoscopic surgery, striving toward “scarless” surgery [8Bucher P. Pugin F. Ostermann S. Ris F. Chilcott M. Morel P. Population perception of surgical safety and body image trauma: a plea for scarless surgery?.Surg Endosc. 2011; 25: 408-415Crossref PubMed Scopus (66) Google Scholar]. Is this the direction we should be looking at for the future of thymectomy, or even cardiac surgery, as it has been reported in animal models [9Kalejs M. Ferrari E. von Segesser L.K. Towards no-scar cardiac surgery: minimally invasive access through umbilicus for aortic valve replacement.Eur J Cardiothorac Surg. 2009; 36: 773-775Crossref PubMed Scopus (8) Google Scholar]? ReplyThe Annals of Thoracic SurgeryVol. 94Issue 6PreviewWe thank Myers and Panos for their interest [1] in our manuscript on single-port thymectomy [2]. As they point out, robotic assistance allows precise dissection with excellent maneuverability within a limited chest space. It is not surprising to see reports showing advantages of the use of robotics in thymectomy compared with the conventional video-assisted thoracic surgery (VATS) approach. Meanwhile, currently reported robotic-assisted thymectomy involves port access via either side of the chest, and they are still associated with the risk of postoperative intercostal nerve injury, regardless of the size or numbers of the incisions made. Full-Text PDF