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J Thorac Cardiovasc Surg 2005;130:912-913
© 2005 The American Association for Thoracic Surgery
Brief Communication |
Department of Surgery, School of Medicine, Keio University, Tokyo, Japan.
Received for publication March 11, 2005; accepted for publication April 11, 2005. * Address for reprints: Masazumi Watanabe, MD, PhD, 35 Shinanomachi, Shinjuku, Tokyo 160-8582, Japan (Email: masazumi{at}sc.itc.keio.ac.jp).
Conventional surgery in the anterior mediastinum, including for myasthenia gravis (MG), is usually performed through a median sternotomy. Less invasive thoracoscopic
1,2
or subxyphoid
3,4
procedures, which usually require a bilateral thoracic or cervical approach, have recently been introduced. We have reviewed and present our early experience with extended thymectomy through a horizontal ministernotomy, a new surgical approach for thymic diseases, including MG.
Surgical Techniques
After achievement of general anesthesia with a standard endotracheal tube, the patient was positioned on the operating table in the supine position. An approximately 6-cm-long, horizontal cutaneous incision was made anteriorly at the level of the second intercostal space, and the sternum was traversed. The internal thoracic artery and vein were ligated and divided on one side when necessary. With the assistance of a special sternum retractor and video imaging, extended thymectomy was performed through the ministernotomy (Figure 1). The resected areas were on the ventral side of both phrenic nerves, extending from the thyrothymic ligaments to the diaphragm. The thymic veins were sectioned with a surgical ultrasonic cutting and coagulating device or clipped and divided. At the time of wound closure, absorbable rib joint pins were implanted into the sternum edges to prevent the development of pseudoarthrosis.
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We operated on 2 men and 6 women between the ages of 20 and 71 years (mean, 43 years) through a ministernotomy for resections of anterior mediastinal tumors or MG, with or without thymoma (Table 1). The resections were completed as planned in all cases without need to perform a full sternotomy. Subtotal thymectomy was performed in 3 patients for thymic cysts located in the midmediastinum. Extended thymectomy was performed in 5 patients; 1 patient had a thymoma without MG, 1 had a thymoma with MG, and 3 had MG without thymomas. Blood loss during surgical intervention in 5 extended thymectomies averaged 166 ± 130 g (mean ± SD), which was not significantly less (199 ± 123 g) than during 7 complete sternotomies for the same operations performed during the same time period. The procedural time was 243 ± 37 minutes, which was significantly longer than for operations performed through complete sternotomies (173 ± 38 minutes, P < .05). The duration of hospitalization ranged between 4 and 35 days in 7 patients, excluding 1 case combined with aortic valve replacement. In 5 patients who underwent extended thymectomy, the duration of hospitalization was 5, 7, 8, 9, and 35 days, respectively. One patient (patient 4) had a postoperative myasthenic crisis. Although she required mechanical ventilation for 7 days, she was discharged from the hospital on postoperative day 35, clinically improved compared with her condition before surgical intervention. No perioperative or postoperative complication was observed in 8 patients. Three patients with MG were clinically improved during 19, 42, and 44 months of follow-up, and 1 had no further myasthenic symptoms in the absence of drug therapy during 18 months of follow-up. No recurrence of tumor was observed in 2 patients 24 and 44 months, respectively, after resections of thymomas.
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Several minimally invasive techniques of extended thymectomy have recently been described that use unilateral or bilateral thoracoscopy,
1,2
a subxyphoid approach,
3,4
or a ministernotomy.
5
However, a ministernotomy with a horizontal incision to perform an extended thymectomy, as described in this series of patients, has not been previously reported. We were able to perform safe, effective, and uncomplicated resections in our 8 patients. Handling of the thymic vein, usually the most delicate manipulation during thymectomy, was facilitated by a special retractor and nearly identical to a conventional complete sternotomy. Because this procedure did not require a cervical incision, the cosmetic results were preferred by our patients with MG, whose ages were between 20 and 31 years. One technical challenge, despite the use of endoscopy, was the resection of fatty tissue near the diaphragm, the farthest from the skin incision.
We limited the application of this operative technique to MG without thymoma and to noninvasive thymomas less than 3 cm in diameter. All 4 patients with MG reported clinical improvements, including one complete remission. Although the mean operative time was slightly longer than that associated with complete sternotomies, greater familiarity with this approach, which is still on a learning curve, should ultimately result in shorter procedures.
In conclusion, extended thymectomies through horizontal ministernotomies were successfully performed with minimal invasion and favorable cosmetic results by eliminating a scar in the cervical region. Further investigations with longer follow-ups are warranted to better define the role of this new surgical technique.
References
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