Robotic assisted thymectomy for the management of autoimmune myasthenia gravis
Epublication WebSurg.com, Jan 2013;13(01). URL: http://websurg.com/doi/vd01en3832
We present the case of a 16-year-old female patient who has had an autoimmune myasthenia gravis for 8 months. Symptoms are generalized to her four arms. Anti-acetylcholine antibodies and the therapeutic test of Mestinon® (Pyridostigmine) are positive. In recent months, her symptoms worsened with the onset of swallowing disorders. Immunoglobulin treatment was poorly effective and was complicated by the appearance of jaundice. CT-scan showed a mediastinal thymic hyperplasia. Thymectomy is indicated. To do so, a left thoracoscopy is performed and assisted by means of the Da Vinci™ robot. Pathological findings demonstrated the presence of a lymphoid thymic hyperplasia. The use of the Da Vinci® robot for this type of intervention has been recognized many years ago now with the works of Federico Rea and Jens Ruckert among others. The advantage of this technique is the possibility to proceed with a radical thymectomy enlarged to the mediastinal fat exactly in the same way as for a median sternotomy, which is the standard technique. When compared to thoracoscopy, the advantage stems from 3D vision, segmentation of the operator’s movements, and exceptional maneuverability of the instruments which have 7 degrees of freedom. These instruments allow for an access to the lower cervical area without the use of a cervicotomy. The choice of the left side is explained by the need to identify the phrenic nerve’s position, which is more difficult to predict than the right nerve’s position, which can be easily identified on the right lateral aspect of the superior vena cava.