Introduction:

Currently several surgical approaches are used for thymectomy in patients for benign disease. This video demonstrates a robotic thymectomy performed for resection of a mediastinal parathyroid gland in a patient with recurrent hyperparathyroidism. The patient is a 30 year old female who was initially diagnosed in 1990 after having kidney stones at age 16. She had exploratory neck surgery which failed to find abnormal glands. One year later an angiogram demonstrated a parathyroid in the mediastinum which was ablated. The patient however suffered a second bout of kidney stones with laboratory work that revealed an elevated calcium and PTH level. The film demonstrates the second ablation attempt at an outside institution and the techniques of a robotic thymectomy.

Method:

The procedure was performed under general anesthesia with a double-lumen endotracheal tube for single-lung ventilation. The patient was positioned right side up at a 30 degree angle with a shoulder roll and bean bag. The port for the Da Vinci camera was placed through a 12 mm incision made lateral to the breast in the fifth intercostal space. Robotic arm ports were positioned through a superior 7 mm incision in the third intercostal space in the midclavicular line and a 7 mm submammary incision in the seventh intercostal space in the anterior axillary line. A separate 12 mm accessory port was placed lateral to the camera port and used to facilitate retraction and suctioning. With the right lung deflated and insufflation set at 10 mm HG the dissection was performed using Caudiere forceps, ultrasonic coagulating shears, cautery blade and a 0 degree scope. The dissection is typically performed from right to left. The right side is approached first because of the increased space in the right pleural cavity and better visualization of the superior vena cava and innominate vein. In other situations than the case presented, if the left phrenic nerve is not safely visualized despite retraction of the thymus to the right, then ports are removed and the robotic apparatus is repositioned to the patient’s left side.

Results:

The patient returned home the third post operative day and continues to do well with calcium levels under control. Pathology revealed a thymus gland with lymphoid hyperplasia and a parathyroid gland without pathologic features. This case is typical of the experience of the surgical team which now includes 12 robotic thymectomies with only one case electively converted to an upper sternal split secondary to invasion into the innominate vein.

Conclusion:

The application of robotics shares potential advantages of other minimally invasive techniques with regard to improved postoperative recovery, preservation of pulmonary function and pain control. The robotic system facilitates exposure and control allowing an extended thymectomy similar to that using a traditional transternal approach.

Presented at Minimally Invasive Robotic Association: Innsbruck, Austria. December 2005.