Video-assisted thoracic surgery for thymectomy

Abstract

It is now common knowledge that MG is an autoimmune disorder of the postsynaptic nicotinic acetylcholine receptor, and is characterized by weakness and fatigability of voluntary muscles. The ocular muscles are frequently involved, rendering ptosis and diplopia the most common mode of presentation. Despite the fact that the condition has been recognized for more than three centuries, considerable controversies still remain over its diagnosis, natural history, and therapy. This chapter is primarily focused on the surgical therapy. Thymectomy is now an established therapy in the management of generalized MG in conjunction with medical treatment. However, a randomized, prospective study investigating the role of thymectomy has never been undertaken, and is unlikely to ever happen. A recent meta-analysis of 28 controlled studies showed that MG patients undergoing thymectomy were twice as likely to attain medication-free remission, 1.6 times as likely to become asymptomatic, and 1.7 times as likely to improve. Different demographics and baseline characteristics however existed between groups (Gronseth and Barohn 2000). Uncertainties remain over the role of thymectomy for patients with purely ocular symptoms and those with late onset of disease. Several surgical approaches to thymectomy exist. The most commonly adopted surgical approach to thymectomy is via a median sternotomy. Other thymectomy techniques include the transcervical, the combine median sternotomy with a transcervical incision (T-incision), video-assisted thoracic surgery (VATS) (unilateral) (Yim 2002; Yim et al. 1995b), partial sternotomy involving either the upper (Milanez de Campos et al. 2000) or lower sternum (Granone et al. 1999), and the bilateral thoracoscopic approach combined with a cervical incision (video-assisted thoracoscopic extended thymectomy; VATET) (Novellino et al. 1994). This chapter reviews our technique regarding VATS for thymectomy, discusses the perioperative management in our institution and our criteria for patient selection, and reports on our intermediate results. © Springer-Verlag Berlin Heidelberg 2008.