Robotic Thymectomy for Myasthenia Gravis
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Table of Contents
Myasthenia gravis is an autoimmune disease affecting acetylcholine transmission involved in skeletal muscle contraction. The approach to myasthenic patients is complex as optimal treatment involves a multidisciplinary technique of combined medical and surgical therapies. Medical therapy with acetylcholinesterases and immunomodulators can provide symptom relief and eliminate feelings of fatigue and weakness. Surgical thymectomy can help by reducing symptoms, preventing recurrence, and reducing daily medication requirements. Thymectomy was traditionally performed via a transsternal approach, but minimally invasive and robotic techniques have become increasingly common. Here, we present our approach for robotic total thymectomy through a left-sided approach.
Myasthenia gravis is an autoimmune disease affecting the postsynaptic nicotinic acetylcholine receptors that control voluntary skeletal muscle function. This is commonly mediated by anti-acetylcholine receptor (anti-AChR) antibodies. The onset and magnitude of disease can vary significantly but usually involves some degree of progressive weakness of the eyes, extremities, or oropharyngeal/respiratory muscles.1 In conjunction with medical therapy, surgery has become standard of care as post-thymectomy patients are more likely to have an improvement and/or resolution of symptoms with less reliance on medical therapy.2, 3
The patient is a 23-year-old female who was diagnosed with anti-AChR positive generalized myasthenia gravis several years ago. Her primary complaint was fatigue, facial weakness, and double vision. She was maintained on daily prednisone and pyridostigmine but has had progressively worsening symptoms. She has now required escalating doses of corticosteroids and intravenous immunoglobulin infusions for symptom control. She is otherwise healthy with no pertinent past medical or surgical history. She has no family history of myasthenia gravis or other autoimmune disease.
Physical exam revealed a healthy-appearing young woman with normal vital signs. She has no sensory deficits, tendon reflexes are all normal, and there is no exertional upper or lower extremity weakness. She has mild ptosis that is elicited when holding upward gaze for approximately one minute.
The patient underwent cross-sectional computed tomography of the chest that showed thymic hyperplasia without a dominant thymoma. There was no associated lymphadenopathy or invasion to surrounding structures. A representative image is shown in Figure 1.
Figure 1. Representative cross-section of axial computer-tomography showing thymic hyperplasia with no dominant thymoma.
The treatment of myasthenia gravis is typically multidisciplinary and requires cooperation between both neurologists and thoracic surgeons. After diagnosis, patients usually undergo some combination of medical therapy including acetylcholinesterases like pyridostigmine, muscarinics like propantheline, and immunomodulators like corticosteroids, methotrexate, or cyclophosphamide. Infusion of intravenous immunoglobulin (IVIG) may be necessary for refractory disease.1
Once controlled on a stable regimen, most patients are referred for surgical thymectomy, which has been shown to reduce reliance on medical therapies and lessen reported symptoms.
Our video demonstrates a robotic total thymectomy via a left chest approach. Using either thoracoscopic or robotic techniques, minimally invasive thymectomies are increasingly performed using subxiphoid, left, right, or bilateral approaches. Rarely, a transsternal approach may be necessary for large tumors or those with an invasive component.4-6
Our patient had previously controlled myasthenia that has now required escalating medical therapies. It was thought that thymectomy may allow her to wean from her current medication without recurrence of symptoms.
Myasthenia gravis patients must be optimized prior to undergoing surgical thymectomy. Following surgery, unoptimized patients may experience “myasthenic crisis”, which presents with profound weakness, respiratory failure, and inability to wean from the ventilator. To avoid this, we planned our intervention one week after her last IVIG infusion and also administered intraoperative stress dose steroids. Additionally, specialized anesthesia techniques including avoidance of paralytics and total intravenous anesthesia were utilized to avoid potential postoperative myasthenic complications.
Here we present a robotic total thymectomy via left-sided chest approach. This procedure involves removal of the entirety of the thymus and associated pericardial fat. The borders for this resection include the left and right phrenic nerves laterally, the sternum anteriorly, the pericardium posteriorly, the diaphragm inferiorly, and the superior horns of the thymus superiorly. All fatty tissue within these boundaries is resected while taking care not to injure the important nearby structures including the innominate vein, heart, aorta, and bilateral phrenic nerves.
The patient is positioned supine with a bump under the operative side. This allows full exposure of the left chest while dropping the shoulder out of the field to prevent robotic collisions. Entry is made into the chest at the anterior axillary line in the 4th intercostal space with an 8-mm robotic trocar. Two 8-mm robotic trocars are then placed under direct visualization—one in the midclavicular line in the inframammary fold and another in the posterior axillary line in 3rd intercostal space. Lastly, a 12-mm assistant port is triangulated between the two lower ports in the 5th or 6th intercostal space. Once all the working ports have been placed, the robot is docked. The camera is positioned in the middle robotic port between the two working ports. While there are many options available, our instruments of choice include a Cadiere grasper in the left hand and a long bipolar grasper in the right hand.
Dissection is begun as inferiorly as possible just medial to the phrenic nerve. The fatty tissue of the mediastinum is mobilized off the underlying diaphragm and pericardium in a caudal-to-cephalad fashion. Using a combination of blunt and electrocautery dissection, mobilization continues medially and superiorly until the innominate vein is encountered. This area is approached with meticulous caution and any draining veins to the innominate is controlled with cautery or surgical clips. The right and left superior horns of the thymus are retracted down and dissected free. Lastly, the dissection is carried into the right chest. The right mediastinal pleura can be opened to allow for identification of the right phrenic nerve.
Once the thymus and mediastinal fat is completely mobilized, the specimen is extracted using a retrieval bag from the assistant port. A single Blake drain is used for chest drainage and placed through one of the robotic port incisions. The robot is undocked, and the remainder of the ports are removed and closed with subcuticular sutures.
Postoperatively, the pleural drain was monitored and within normal limits. The Blake drain was removed the following morning and the patient was discharged on postoperative day one. Final pathology was consistent with thymic hyperplasia. On 9 month follow-up, the patient is mostly symptom free except for mild diplopia only present with extreme fatigue. She was weaned to low dose prednisone and no longer requires IVIG infusions.
- Constantine Poulos, MD: writing, review, and editing
- Tong-Yan Chen, MD: video production, writing, review, and editing
- Lana Schumacher, MD: video production, writing, review, and editing
All authors declared that there are no conflicts of interest.
The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.
Citations
- Vincent A, Palace J, Hilton-Jones D. Myasthenia gravis. Lancet. 2001;357(9274):2122-2128. doi:10.1016/S0140-6736(00)05186-2.
- Gronseth GS, Barohn R, Narayanaswami P. Practice advisory: thymectomy for myasthenia gravis (Practice parameter update): report of the guideline development, dissemination, and implementation subcommittee of the American Academy of Neurology. Neurology. 2020;94(16):705-709. doi:10.1212/WNL.0000000000009294.
- Wolfe GI, Kaminski HJ, Aban IB, et al. Randomized trial of thymectomy in myasthenia gravis. N Engl J Med. 2016;375(6):511-522. doi:10.1056/NEJMoa1602489.
- Marulli G, Comacchio GM, Rea F. Robotic thymectomy. J Vis Surg. 2017;3:68. doi:10.21037/jovs.2017.05.01.
- Wei B, Cerfolio R. Robotic thymectomy. J Vis Surg. 2016;2:136. doi:10.21037/jovs.2016.07.17.
- Holleran TJ, Napolitano MA, Crowder HR, Sparks AD, Antevil JL, Trachiotis GD. Clinical outcomes and technical approach of thymectomy in the veterans health administration. Ann Thorac Surg. 2022;113(5):1648-1655. doi:10.1016/j.athoracsur.2021.05.020.
Cite this article
Poulos CM, Chen TY, Schumacher L. Robotic thymectomy for myasthenia gravis. J Med Insight. 2024;2024(426). doi:10.24296/jomi/426.
Procedure Outline
Table of Contents
- 1. Introduction
- 2. Placement of Ports
- 3. Robot Docking
- 4. Pericardial Fat Clearing and Exposure of the Thymus and Left Phrenic Nerve
- 5. Left Phrenic Nerve Mobilization
- 6. Clear Tissue from Pericardium and Visualize Innominate Vein
- 7. Mobilization of the Innominate Vein and Division of Branches to the Thymus
- 8. Dissection of Thymic Poles
- 9. Dissection Along the Right Phrenic Nerve to the SVC
- 10. Removal of Specimen, Hemostasis, and Robot Undocking
- Further Mobilization of the Innominate Vein and Division of Branches to the Thymus
- Visualization of Right Phrenic Nerve and Freeing the Pleura off of it
- Continue Mobilization of the Innominate Vein and Division of Branches to the Thymus
Transcription
CHAPTER 1
Hi, I am Dr. Lana Schumacher. I'm the Director of Robotic Surgery at MGH, and today, we are doing a robotic thymectomy. This patient is a 23-year-old woman who was diagnosed with myasthenia gravis several years ago. She was treated with traditional medical therapy for myasthenia gravis; however, her symptoms progressed and were more difficult to control, and she's now on IVIG, as well as Mestinon and steroids. We felt that she would benefit from having a robotic thymectomy to further decrease her risk of myasthenic complications, as well as prevent any further medication escalation as she's now being a little bit more challenging to treat. So she is here, she's optimized with her medications, her myasthenic symptoms are controlled, so we have her here for a robotic thymectomy. So key points to this case - one, our approach is to enter onto the left side, so enter to the left chest cavity. The important points of doing the surgery is that we really wanna clear out all the thymic tissue, we wanna visualize the tissue from each phrenic nerve on the left to the phrenic nerve on the right, so you'll see that in this video that we have cleared off the tissue from medial to each one of these nerves. It's also important to clear off the nest of thymic tissue that tends to rest along the pulmonary artery on the left, so this is a better exposure from the left side. So for these reasons, we choose to enter into the left chest cavity. Our entry is along the inframammary fold, and our highest port is at the inferior axillary line, and we use three robotic ports: one camera, two robotic instruments will be the Cadiere and the Maryland bipolar, and we do have an assistant port to help with retraction, as well as specimen extraction. We'll begin the case by starting low off the diaphragm and clearing off all the pericardial fat and thymic tissue, and run up along the left phrenic nerve all the way up to where it enters into the chest cavity. Then we'll clear off all the tissue from lateral to medial along the innominate vein, dividing the innominate vein branches that come into the thymus, so the thymic veins, you'll see us dissect each thymic pole that extends up into the neck of both the left and the right thymic pole, and we'll visualize the phrenic nerve on the right, starting at our origin from the neck along the subclavian and superior vena cava, down along its course, along the pericardium, and down to the diaphragm on the right. So you'll see all the tissue cleared off, and the thymus removed in its entirety. Once we've done that, we will place it in an Endo Catch bag, remove it from the chest cavity, close our port sites. We use a small Blake drain for drainage and evacuation of air, and postoperatively, the patient will just go to regular recovery, and then have an overnight stay, and be discharged the next day. So the things that we want to watch for anytime you take a myasthenic patient to the operating room is that you can exacerbate their symptoms, they can be put into a myasthenic crisis, which can be quite devastating with profound respiratory failure and hypotension, so these patients need to be optimized medically before they come to the operating room for any surgical procedure, and especially a thymectomy, so we know that that has been done in this patient's case, we've worked closely with her neurologist in the timing of her surgery. She had IVIG treatment a week prior to her surgery, so that she was optimized for this, the patients also receive a stress dose of steroids in the operating room. After they are followed closely, the neurology team follows these patients, as well, we resume all their medications immediately, and if needed, sometimes their steroids need to be advanced to a higher dose in the postoperative setting. It's very rare nowadays in doing this surgery minimally invasive with the robotic approach that the patients have those symptoms. Traditionally, this was performed via sternotomy, so the stress on the patients was higher during the recovery time than it is after a minimally-invasive approach. So we actually rarely see these complications anymore, but we do always follow them closely for that. Usually the patient is just in the hospital one night and discharged the next day. And then it will be up to the neurology team as for when they can attempt to wean the medications down that they're treating these patients for myasthenia gravis, but we don't do that until about a month after surgery to allow them to recover from surgery.
CHAPTER 2
So our first port will be our camera port, and that'll be kind of at the anterior axillary line about the fourth intercostal space - fifth intercostal space. And all these ports are placed about a handbreadth apart, usually around the inframammary fold. And she's isolated, correct? Yes. Okay, great. Thank you. And they're all 8-mm ports, and we use CO2 here with a pressure set at 8 mmHg. Can we get the gas on please? So we'll turn that on now. You can see that she does not have any adhesions here. We'll take our next port right at the inferior part of the axillary line at about at the third intercostal space. Doesn't have a lot of thymic tissue. Is that set to eight? Yes. She's just tachycardic, so... Perfect. Perfect. And then one more, it's actually at the midclavicular line. Right there is great. Yeah. So this is right at the inframammary fold at the midclavicular line. And then we'll do one more for our assistant port, because we'll really use our assistant for retraction. The key is to not put the assistant underneath one of the robotic ports, so we're just gonna triangulate the assistant right about here. I think this one will give you more room. And that's a 12. Great. I'm not sure I'll be able to see you. You can always just check it. You feel good? Yeah, I just saw you. Feel good? You can always just stick an instrument there, and see how it feels. There you are, right there. Okay? All right, we can bring the robot in.
CHAPTER 3
We see a lot of room. Take a right turn. More, more, more, more, more, more, more, more, more, more, more. All right, that's good. Yeah. So we'll have to swing it way over. Which arm do you wanna leave out? Okay, we'll leave four out. So when we set up these arms, we'll make sure that there's clearance between all the joints, especially at a small patient, we wanna be able to put a handbreadth in between these joints of these arms, so we can rotate that one down. We will use a Maryland bipolar and a Cadiere forceps as our two arms. And we'll watch these instruments come in. Camera's way in. Okay, great. Can see on the anatomy, the lung is nicely isolated to give us plenty of working room.
CHAPTER 4
So I just start as low as you can go, and dissecting that thymic tissue off, so basically when we're born, we have a large thymus, right? It's producing all of the immune cells. And then it shrivels up as we get older, and we reach adulthood, and then it's basically fatty tissue. So it's hard to, and you have normal fatty tissue in the chest anyways, so it's hard to differentiate what is actually thymus, and what is actually what we call pericardial fat, but if you can clear off everything off the pericardium, I usually start low and bring it all up. Yeah, and we may need to burp. Can you burp number one back a little bit more? And she might be a little challenging because she is so small. Great. Okay. So because we don't know what is what with the thymic tissue - what is fat, what is thymic tissue, we try to just clear off anything. There's also reports that there can be like thymic cells in this fatty tissue, as well. You know, even in the kind of pericardial fat, where the thymus was not. So we do just try to clear off everything we can see. And you're working a little backwards on yourself, so are you okay with that? Once you get that up, just kind of sweep it all, and then we'll go from clearing off all of the pericardium, you wanna think of going, when we do this, we're actually gonna go onto the other side of the chest too, to be able to see, you wanna clear off, you wanna see the other phrenic nerve, and you wanna clear off kind of all the tissue in between to make sure you've gotten all that thymic tissue. Good. And Jess can pull that over for you, as well. And if you can kind of free it up off the bottom, and then just work up. This looks more like pericardial fat than anything. I'm just gonna use this to write. Yep, so you can just take all this and bring it, yeah. Perfect. I pull it towards my camera. Yeah, and if you want, you can also switch your hands at this part. Perfect. If you guys wanna just really quickly take turns looking in here. So the reason why we all believe that robotics is advantageous, all of the robotic surgeons, is that you can see not only do you have these small-wristed instruments, but the camera view is 3D, and high definition, and 10 times magnification. Wow. So the only way you can see 3D - I mean these are nice pictures on the monitor, because you have that high definition and the magnification, but you don't get the 3D visualization until you actually look in the console. So really quickly, if you wanna pop your head in right there and take a look. So his whole job is to preserve that phrenic nerve. That's the most important thing. You know, these patients have overall as generalized weakness as myasthenic patients, they can develop, you know, shortness of breath, and difficulties breathing, so you wanna preserve that nerve, so you can see her nerves so well. Did you guys wanna look in there? Could you see the difference looking in there? Yeah. That's crazy. Are you able to adjust the magnification as well? No, you can't. Or you can say like half a centimeter off that nerve. Make sure you don't get any branches of it. Good. Then you can always zoom out if you need to see the course of that phrenic. Good.
CHAPTER 5
Yeah, and now you can go all along the phrenic nerve, and mobilize that. Yeah, I would just free it up here. I would stay right - I see that phrenic vein right there? Stay right above that. So it's kind of getting pulled up a little bit. Yeah. Yeah. So preserve that. Perfect, right there. Great. And then once you get off this diaphragm, it'll get a lot easier. And now you can come down a little bit more along here now that it's off. You can take that vein now. Yeah. And get all that tissue, you can even get a little bit closer to the phrenic nerve. Here. Yep. Right along here. And Jess, you can push that over for him a little if you can. Good. Yep, a little closer down here. I find it best to just run the tissue off of the phrenic nerve first all the way up. And then you've got that part done, and then you can free up all the rest. But at least it outlines where you need to go. There you go. Good. Because that's like the most important part of this case, right? Good. Move your camera with you. Beautiful. She has very nice anatomy here. Jess, can you suction a little? Move your camera with you. Yep. Good. There isn't a lot more here. Nope. Yeah, I would still free up that plural plane, all the way up to where you see it cross over. Because even though you don't see a lot of fatty tissues, there can be cells in there, right? So this is the area we really wanna clear off. There you go. You're starting to see more thymic gland right underneath where your Cadiere is. Do you see that? Yeah, yeah. Okay. Bring your camera with you. Yep, use the advantage of the magnification, so you can really see that nerve. Push that nerve away as your first move, right? It's the most important part of this case. Now you can see more thymic tissue now, but we have to clear off all the fatty tissue, as well, because that's involuted thymic tissue, so there could be cells in there, but see how this is thicker here? Yes. Do you see the difference there? That is the thymic tissue. Wow. So all right here. So we see more thymic tissue. Yeah, and separate, really push that nerve down. I want it away, all the way up to the top, so we have no risk of getting it. And see how he is getting all this extra fatty tissue, you want that to come out, as well, because there are the nest of cells in there. So even though you can kind of see what's left of that gland, you wanna get this tissue with it. So he is doing an excellent job of clearing this space out. This is a reason why I like the left-sided approach is that move right there that you're doing to clear out that tissue. I can see better in here than out here, so when I'm watching him around this nerve... Yeah, really open up that pleura over it, all the way up. Bring your camera with you. Move your camera so you can really see it. There you go. I'd say just a little bit off of it. The bipolar has very little thermal spread, which is why I like it, but still, the phrenic nerve is very sensitive. Beautiful. Good. So he's protected that nerve all the way up. All right, good.
CHAPTER 6
And clear off that fatty tissue. Get it a little bit more off that nerve. Yep. And we always use - Jess is helping you out. You wanna utilize your assistant, they're there, they have a port, you might as well have them help you. Good. Clean that nerve. Good. Think of half spreads when you do that. A little bit less. Little less than a big spread. When you're in tight spaces, those instruments will fly open because you don't feel the feedback. So you just wanna think when you're spreading with that half - that's it. Especially when you're in tight spaces. Good. Yep, hand that to yourself. Small bites here around important structures. You can almost pull down just gently to the feet, you're hitting the chest wall and the mammary, did you see that? Now roll your - once you control that, roll your wrist a little bit, so you open up that lateral aspect. Uh-huh, I wanna see a little bit better. A little, yeah. Be gentle on your pull on the phrenic, please. Yeah. Okay, now start to go over, you wanna find your innominate vein. Got anything clear off the top? Good, and you can come across that pleura to open up that space to really free that up there. Yeah, the more you open up this, you'll be able to see better. Yeah, just watch... Yeah, you don't need to take the chest wall tissue down. Will that be here? Yep. See that opening right there? Yeah. There you go. Like this fatty tissue, would you leave it or...? You can stay - you'll be able to see where you're opening into the pleura, just pull on that, right there. See it? So it kind of merges a little bit there, but you can put retraction on, you can see where the the pleura is to the other side. Good. You can divide that vessel. Good. You need a little bit more retraction. So when you're using the bipolar, you wanna see a little tension on those fibers. Good. Yeah, now hug the pericardium a little bit, stay in the right plane. Right in here. Are you gonna connect your dots now, or go up to this...? Yeah, free this all up. Good. Because she's so small, she doesn't have a lot of space right here, normally there's a little bit more room to work. Good. If you can connect those dots. Yep. Use your wrist a little bit more. And go to your free edge over here. Yeah, peeling that off to diaphragm. Back up, look where your phrenic is real quick. Okay. Yeah, try to not take the peritoneum of the diaphragm, leave that behind, or the parietal pleura of the diaphragm. Yeah. Oh, that's a little bit into the pericardium. So leave that, stop. Just leave that. Okay, let me see this. This can move back just a tiny bit, Jess. The Cadiere. Great, that's fine. Probably back out your camera too, if you want. Sure. Let me know when's a good time. Go ahead. That's great. I think that's better. I think you can work from here. I just reset things a little bit, so you had more working room. Okay, so now you can take all this tissue up off the pericardium, up, and then go find your innominate. Go ahead. Should be a little bit easier now, right? Yep, handing it to yourself. Yep. Stay out of the pericardium, go from your opening, go from your opening. Get that corner, so you can get the point of maximal tension, right there. Uh-huh. A little closer to the fatty tissue. Yeah, there you go. I don't think you're gonna make it. Yep. Uh-huh. Good. Move your camera in if you need to see. So this is the pericardium, you have a little bit of opening there, which is not a big deal. It was pretty adhesed down there. Uh-huh, and then you were saying that because this patient is smaller, like this space... Yeah, so a lot of times, it's hard, there's not a lot of room right now between her chest cavity, like the sternum and the pericardium. Sometimes on patients that have a larger chest cavity, you have more room, so it's just a little bit challenging here. Do you ever, and I know that the chest cavity won't expand that that much, but I've seen like one like gastrointestinal laparoscopic surgery where they expanded the abdomen a little bit. Would you ever do that here? Well, so we use CO2, which allows, when we use a gentle pressure of 8 mmHg - in the abdomen, you use 15. Okay. So we use 8 here. Yeah, can you ... Yeah, we can burp that back in, and clean the camera if you don't mind. Oh, we're okay. Is your camera, do you wanna - let's clean it, yeah. Thank you. So we use 15 in the abdomen, what happens if you put too much pressure in the chest cavity? Your heart can't be as fast. Yeah, so you're gonna cause what we call is a tension pneumothorax, right? Okay, yep. So you're gonna cause cardiovascular collapse, so we only use a pressure of 8. Granted the more we used, we'd have more room. Sometimes if - some of the patients, if they're obese, they - sometimes you have to go up a little bit higher, because you can't push their diaphragm down. She's not, so... But still we're able to work in this very tight space. What is the recovery time for this procedure? Not much recovery, I don't have any restrictions on my patients, they can do - find your other arm. There it is. So do you see the sidebars that lit up? Did you see the yellow, where the yellow bars light up on the side is it's telling you where your instrument is, the most challenging thing about robotics is that you don't feel. So this instrument could be in the heart, and you wouldn't feel that you hit anything. So you always, everything is by visualization, even when you're kind of retracting tissue, you don't feel it, your eye learns to see the tension. So that's a very important skill that you develop in robotics that is not used in any other types to the level that you have to. You usually, in other fields, you are using these instruments, and you can feel that you're, you know, or you grab something, you can feel that there's tension on this. In robotics, you can't feel that, but your eye learns to see that, so you feel, if you've done thousands of cases like me, you feel like you can see with your, like you can feel with your eye. Which is something that in the beginning, when our surgeons are training, they have to tell themselves like look at the tissue, see how much tension you're putting on it, instead of just pulling. Because the initial time, if no one's been on the system, you'll see someone grab something, they'll keep pulling, pulling, pulling, pulling, because they don't feel it, and tissue can rip, because they're not used to their eye seeing that. Does that make sense? Yeah. So it's different, but you can overcome it very quickly. So eventually, he'll get up to the thymic vein - the innominate vein, and you should see a couple little branches that are coming down off of that vein into the thymus, so he'll get up to that point, but right now he's just really kind of getting it off the pericardium. And I think because she's so small, it's pretty sticky. And he is doing a really good job of clearing off everything he possibly can. Stick with small bites. So don't pass point. Get this off the pericardium. Move your camera with you, always keep the camera view centered, you don't wanna be working in a corner of your camera view. Good. And you can think of pushing that pericardium away a little bit. Yeah, with closed tips, push it down, push it down. Yep. Good. The other thing that takes a little mastery is when you start, you're not used to having wrists, but you can optimize what you can see by using your wrist and how you dissect, but at first, surgeons just come in, and they can open and close this way and that way, but they're not used to using this motion. So that's really important, and that develops over time, where you have mastery of that, as well. So lots of things that are different in robotics that you don't appreciate, like you have to, you're on a learning curve for that. You got a little - at the chest wall. Pardon me? Are you able to switch out instruments? Like at the end of each hand? So the entire instrument changes. Okay, good. I don't know if we have any extra. So this is one that we use sometimes. So you'll take the whole instrument out to bring in it. So there's all different types of robotic instruments that we can use, if we need to suture something, we have a needle driver, if we need to put clips on something, we have a clip applier, so there's everything pretty much that you have in any kind of normal laparoscopic cases are made robotic. Yep, and you again push that pericardium away. Yep. He is very meticulous here of getting every piece of fatty tissue off, because there may be cells in there. Again, push that pericardium away. Make it easier for yourself. Push it down. Yep. And he is doing a very good job of handing himself the tissue. A lot of people just drop it and then they pick it up, but he is handing himself, so he doesn't lose the exposure or the retraction. These are harder cases for me, because sometimes we work with three robotic arms. We left one out here, because in this chest area, as you can see, it's a very tight space, we don't have enough room on this small patient to put in three arms. So we have only two working arms. So I have no instruments right now, it's all him. A lot of times, I'll have one instrument, and he'll have two, and we can actually switch them back and forth. If you saw that I took control. Yeah. Right? So there's a button on here, where I can take the instrument. So I can press one of these, and take one, or I can take all of them. Isn't that cool? Wow. And then you can have three arms that you're using at one time, even though you only have two hands, right? And there's a pedal here that will actually switch. Like if I'm working, I'm using one and three right here, I can hit this side button, I'll use one and four, so I can have three different instruments, I'm using myself by using this, what we call a toggle button to switch my hand of the instrument. Yeah. It's amazing, and we can even change the camera just by pressing a button here. We use 30-degree cameras, so it's a little angle down that you can see, and sometimes if I wanted to see something up, I would just press this button, and the camera would flip up automatically without having to take it out or anything. So there's lots of amazing things that we can do with this. And there you see the thymic tissue again. It's okay if I get them? Yeah, yeah. Taught them... So we'll get up to this with, where he's gonna visualize innominate vein, he'll divide the branches, and then there's a couple little, what we call thymic poles that go a little bit into the neck area that he'll take out, as well. We'll open up, and look on the right side, and see the right phrenic nerve. So that'll kind of be the completion of the case. Sure. So it was really cool to see the phrenic, because I've only seen it in a donor of anatomy. Yeah. Yeah, yeah, yeah. This was great anatomy. Yes. Thank you so much. All right. Come by anytime. Nice seeing you guys. Yeah, just right along here is a perfect path. Thank you so much. You're welcome. Yeah, it's a little sticky there. So just push that pericardium down. So be careful of how much your left hand is hitting the chest wall, right? Drop your wrist. Yep, there you go. You don't realize it, but you're actually pushing up her sternum, so you want less pressure on her. You don't want her to feel that. Drop your wrist even more. There you go. I mean it's nice to move your wrist to be able to see, but in her, there's just not much room. Don't rub the chest wall. Do you see that? Push the pericardium down. Yeah, there we go. You'll get used to dissecting, as well. Yep, and try to not pass point. Yeah, you can do gentle spreads. And it's up to you. Sometimes I go up to the innominate, then kind of go from lateral to medial over into the right chest, so that's something that you could do if you feel like I'm kind of stuck here. Don't get the pericardium, push it down. Yep. Yep. And we can open up the pleura too. So what I would do is I'd go, once you do this a little bit more, I would go up to the top, identify your innominate vein, and roll all the tissue from lateral to medial, then you open up the pleura, so you enter into the right chest, it'll give you more room. You feel like you're like, "I don't have much room now," it's because you haven't opened up the right pleura. Does that make sense? It's fine, because you're doing a nice job dissecting this off. Yep. And you can see she has a decent amount of true thymic tissue here. Yeah, yeah. So that's a good sign I feel like in these myasthenic patients. Hand that to yourself if you need to. Good. Don't pass point. Good, move your camera. Can you sweep that, are we detached there? Are we attached? Back up just a little bit. Or is that something ... Yeah, Jess can sweep that over out of your way if you want. Yeah. Good. Yep. Yeah, I'd rather you dissect off your plane then pass point, right? Because that's - as you get up to where we're getting a little bit closer to the innominate, you don't wanna pass point. Yep. We're still off the aorta. Or hit the aorta. Good. Right in the areolar tissue, you're fine here. Just a little bit lower. Yeah. A little pericardium. She's really pretty sticky. Which is interesting to see, I mean maybe it's because of her myasthenia process here. Uh-huh. Move your camera, center your view, center your view. Yep, mm-hmm. And then you'll look - Wait, whoa, whoa, whoa, you wanna look where these thymic poles are. So drop your wrist down on your Cadiere. Yep, look above and see if you have the thymic poles that are going up to the neck. Just - you wanna identify them. Okay, good, all right. Get that old vessel there. Good. Little smaller bites here. I wanna clean off your... Yeah, let go for a second. Clean that off. You can give that to Jess. This can just go in the bag. That'll go with specimen. If you're here, you're gonna keep your wrist low on your Cadiere. Uh-huh. There you go. Yep, so they should be coming up in here. Might be a little bit in here. Dr. Schumacher? Yes. What vessel's at the top right of the screen? Right here? The subclavian. Subclavian. Yeah. Thank you. I was just curious What was it? The subclavian. Are you seeing the innominate under here? Where are you? I see the innominate here. Okay. Oh, she's high. Is that a thymic tail up there? Okay. No, I'm okay. I just - because you wanna just make sure that you really thin things out here, right?
CHAPTER 7
Yeah, that's good. I can only draw on that screen, so now I have to go all the way over. I can point but I can't draw. I don't know what structure that was that you just took. Yep. Yep. That's gonna - you're gonna follow that up. Don't divide it. Yeah. You're gonna follow that up. Yep. And push that tissue away. Thin it out. Nice. Yep. There you go. Nice. All that needs to come out, so hand it to yourself. Very good. Yep, just don't pass point. One thing that you can do - I would look underneath right now and see if you see any little thymic veins right there before you pull the thymic poles out. You know what I mean? So see if you see any branches there. Hi, how are you? Yeah. Yeah, that's a good move. Yep, that tissue can go. So if you free up all of this, or you free up off the innominate, it's a little bit easier to pull those thymic poles down a little bit. You know what I mean? Because you're freed up underneath. You can just divide the band that you have. You don't have to chase it up, the carotid, divide that there. Watch where your underneath hand goes. Yep. Drop your left wrist. There you go. Good. Can you, before you go on, stop, there's a little vessel bleeding right on the other side of that carotid there. Right in there. See it? Suction, just one of these little vessels, I think. That one right on this side. Uh-huh, I think you got it. Yep. Yes. Good, free up that innominate a little bit more. Drop your left hand down. Yep. Yep. Good. Get the tissue above the innominate right now. Getting it under. Don't pass point. You can see a little branch coming in. Do you see that? Yeah. You can divide it, clear it off on top, and then I just buzz on each side, and then do it in the middle. Okay?
CHAPTER 8
You are gonna get this guy out first? Get which guy out? The thymic pole. This one here? Yeah. I think so, what do you... That's fine, I'm fine. Drop your hand down, work above. And you can really hug it. Otherwise you get into some of the neck muscles. Yep, spread in there. It's the other side. A little close to the innominate there. If you need to, you can look down to look up, put the camera 30 degree up. You might be able to see better in this area. Can I do that for you? If you're okay with me struggling for a second more. Yeah, I just think that very last corner, you're gonna have to do that. Okay, do you wanna just do it now? No, you can divide that. Right there, see how you cannot see that little corner? I think you're gonna be happier if you do that. And then I would roll your left hand wrist, because it's starting to rip. I would roll it counterclockwise, and see if you can see that corner, do not grab the innominate, free that innominate up. Can we try it real quick? Let's just see how it looks. Don't let ... I was gonna say don't let go. Too late, sorry. That's okay. See if this helps you. It's a little bit disorienting in the very beginning, but I think you'll get that last bit easier, and then you can go back to the normal view. I can see why you didn't want me to let go. Yeah, because you're way up there. It's good. Now you can see that corner that you couldn't see before. Jess, are you able to lean on the innominate? I don't know if you can get way up here. Okay. Hard time getting up there. Okay, I figured. That's okay. We're okay. Yeah, you can see the top of it now. Push that innominate away. Good. Take that tissue right there. Yep. You're at the top now. Can you see that? Now you're starting to see through the tissue, so you can amputate it there. This is nice. You see, I think you can come right here. Good. Right there. Once you release this - a little closer, a little lower. Once you release this, it makes it so much easier. Just this top aspect. Yep. Now you just hug it, hug the thymic pole. Stay out of that tissue. You can see the white of the tissue, you wanna be right there. Yep. I'm just gonna help you out. Get that little - hug the tissue even more. You don't wanna be way up there. Yeah, stay lower, hug the thymic tissue. You don't need to go up into the neck, once you've got that pole released. Yep, so you wanna be down here. Very good. See the difference? You just don't need to chase all that neck tissue. And then when you want, you can flip back over. I just feel like you needed that 30 up to see that corner. Yeah. And now you can go back to normal, because that was really helpful. Did you see the difference on that? Yeah. Nice. Look at all that work. Keep rolling that down. And just hug that thymus, thymic pole. And then you'll have the other one come up at some point. That might be it. That's the other one.
So you wanna go get the other thymic pole now? Do you wanna do that now or what do you wanna do? I think I can still see a little bit of that... Off the innominate? Oh yeah, we didn't divide that. Yeah, divide that vein, so kind of dissect it out to get that thymic vein branch. Now be careful of your wrists here. She just doesn't have a lot of working room, so you wanna not rub the mammary. Yep. Good. And you wanna kind of buzz a little bit distal on that, because if you needed to clip it, then you would have some room. You know what I mean? So you wanna give yourself a little stub off of the vein. Yep. You're fine. You can divide the vein now. So right at its insertion, closer to the thymus. Up, up, up, up. Yep, there. Wanna back up and see how it looks? Yep, and then just come through up there. Really burn it. Close your jaws. There you go. Mm-hmm. A little bit scary. I know. Now go get the other pole if you can. You might wanna free up on top. Find your other hand. Yep, and Jess can get on that. Can you, Jess, can you grab this? Yeah, so you can open - stay a little bit right in that opening, yeah. I almost feel like I am not sure if that's... Yeah. So you can enter into the right pleura if you want right now. That's along right there. So just open that all up, actually wanna open up the pleura, so that everything will drop away, and you'll have more working room. There you go. Not right now, you can just open that all up. Let's finish getting off of the right thymic pole, the right thymic vein, and then you can clear off the right side, and we'll identify the phrenic. Because that's when if you free up that second thymic pole, Jess will be able to retract over, and you'll be able to see, even though she doesn't have much fatty tissue, you'll probably be able to have a nice view of the phrenic nerve. Does that make sense? Yeah.
I mean, if you wanna look for the nerve, you can. You can see her... See if you see it. Right in there. Drive that. Right there. If you want, once I see it, I like to free up that pleura off of it, so it falls away. I think that might be it. Yeah, so yep. So can you score this pleura right there? Or just like by - yeah, open up. Right up to here. Right here. Use your wrist of your bipolar. Drop your fingertips down. Yep. Yep. Yep, that looks nice. You can see the edge of her thymus too. Good. Go for the other part? Yeah.
And push that down. Did you see a second thymic vein branch? Go from - no, no, no, go from the left side. Follow that innominate along. I did not yet, but I just didn't know if you did. We can clear it off a little bit, and then you can get that thymic pole, and then you're gonna just open up along the right phrenic nerve, and clear off that tissue, so you're almost there. Yep, clear off all that tissue. Nice and gentle. Take it off of the aorta. There you go. Yep, thin that out a little bit. Yep, clear off right there. Yep, get this little band here. Yep. Before you go up, can you just free up this last little bit down here? Yep, right in there. Great, connect those two dots. Yeah, open up here. Can you just suck in there? Thank you. Yeah, free that off here. You can drop that all over into the right chest if you want. Yeah, move your camera so you can see. Yep. Make sure you're not pressing on the chest. You're lifting the whole chest up. Did you see that? Yep. Thank you. Mm-hmm. Nice. So I don't see any other branches. You're pretty much off, right? Yep. So do you wanna go get your thymic pole? Because I want a different view when you're clearing this off the SVC, I wanna go on the other side, and really make sure we see that phrenic again, because we just can't see it from this view, right? Have to clean again. So I'd get that thymic pole, let's clean real quick, remember there's a little vein right there. Oh, you have too much tissue. There's a vein right underneath your Cadiere, see that? Leave that vein. There's another vein back there. Just watch it. Clear it off the... Don't - get yourself in a tunnel, go from the either outer edge in... Yeah, and hug this thymic pole. Yep, I would free this up, up here first. And then it starts to retract down, it's a lot easier, and you wanna not go there, because you don't know where your phrenic nerve is, so I would stay away from there till you get this pole out. You're gonna be able to retract better. Yeah, get the thymic pole outta your way. So finish that first before going ahead of yourself, because if you get this down, you're gonna see better. And hug the thymus. I think it's easiest to amputate it at the top and roll it down. Oh, you're getting a bruise there. Stop. Okay. Up top. Or from the top? Yeah. Just amputate that tip right there. You're already past it there. Right where the... You think it ends here? Yeah. Or up here? No, it ends down there. Okay. Right there. See it? So if you start from... Here, let me show you. Because if you start where you can see it... Right here, you can see where it ends. It's harder to see from up here, I think, but if you see here, it's pretty much ended. And so you can come in right here, and leave this, you can divide that little side branch, take this over right here, you're all past it here, and then roll it all down and then we'll go, and we'll look at the nerve from this side, and make sure we see where it is, because you don't wanna injure it going this way, right? So do you see where it ends right here? Yeah, I guess I was, I thought it continued a little bit higher, like it wasn't anywhere. Oh maybe there's a little bit up there. Of thymic tissue, that's why I was going up I see. I see. Yeah. Yeah, there's a little bit. Oh, you're right. There's a little teeny wisp right here. Yeah. A long tail. Yeah. There you go. That's so good. Here you could - sorry. Go ahead. Yeah, and really hug it, yeah? There's another little, is that a wisp, as well? I see it, yep. Yep. It's like branches. Very good. Use the wrist on the bipolar, you're gonna have to drop your wrist down a little bit, so you don't rub the chest wall. There you go. Now we're down. Hug it, hug it. Yep. And we'll look on the other side and really look at that. You can amputate it right there. There, right? Uh-huh. Now let's kind of pull that over, and look for the phrenic again.
CHAPTER 9
And this is where if you need Jess to hold it to pull it over, you can. We put it all so I would just take it out of the right chest. Yep. Yeah, so you're fine where you opened up that pleura, so now from this side, I like to work from this side now down to the SVC to free up that tissue. Because I think it's a little safer to keep the phrenic and view the entire time. So like this? Yeah, so go over the top. Yeah, as long as you know where that is instead of you were going underneath, but then from the underneath view, you can't see the phrenic, right? So I'd rather you go over the top and divide that tissue. Yeah. Does that make sense? Yeah. Yeah, perfect. So come right here. You know you already made your pleural dissection, so just free that up. That's perfect. Yeah. And you're gonna kind of carry that on, and follow the phrenic nerve down. Yeah. Maybe not that close, but all this junk, yes, that's amazing, thank you. Yep, good. Good. A little lighter off aorta. Do you wanna clean? Yeah. Yeah, you wanna see down there, and you can open up that pleura a little bit more. Good, yeah you can open up all along there. So you have a little chest wall tissue coming down. Do you see that muscle? Right down there? Do you see that? So leave that up. Leave the muscle up. Do you see what I'm talking about? This one here? Yeah, yeah. You have to get underneath that. Not into the pericardium. And you're pretty much down as far as you need to go there. And then this is where I really have to see the extent of the phrenic, the right phrenic nerve, I have Jess pull over on your specimen to kind of bring that up to you, so you can see it along its course. Does that make sense? So let's have her pull on that. It kind of raises up that right hilum, so that you can see, right there. Yep, you can pull a little bit, Jess. So, and then identify it up higher and follow it down. That'll be easier for you. Right there.
CHAPTER 10
Beautiful. I think it's there, right? Yep, it's right there. So see if you can kind of follow that course down. And you're pretty much past all the thymic tissue just to right there, right? You don't have to get any more. So you can go from there to there, right? Beautiful. Very nice. Yep, you can clear up that. Don't get into the pericardium. Right in there. Yep, I saw it. Yeah? Yep. So actually, it's hanging down on my side, right? Yep, so you can just take that. Yep. You can connect your dots there. You have a bag, Jess? Yes, I'm ready. Okay, yep. Let's free this up. And you're done. Great. Beautiful. Get those little poles. Awesome. When you get a chance, can we clean the camera, Jess? When taking it out. Looks good. Yeah, thank you. This phrenic nerve all the way up on the left, going up to where the mammary crosses, that's beautiful. Well, you can't always see it that well. We'll just look around real quick. Is it out? Yeah. Awesome. Thymus. I think you're done. You happy? Yeah. All right. All right, we're good. We'll just leave one Blake? One Blake through the camera port. Thank you. Good job. So we'll undock and leave a small Blake drain, and we're done. All right. Yeah. Great.
CHAPTER 11
Hello, my name is Tong-Yan Chen, I'm the anesthesiologist working with Dr. Schumacher, take care of this young healthy woman. This is a young lady present with symptomatic myasthenia gravis, and she present with weakness of her major facial muscles, and she has the double vision, and currently she's medically managed by the pyridostigmine steroid, and occasionally she had the IVIG. Today, she present for the surgery, robotic thoracoscopic thymectomy. So for this patient then, as you know, myasthenia gravis, the patient has circulating antibody against the - basically binding to the acetylcholine receptors, and that basically make the muscle weakness. The treatment is one is medical treatment as I mentioned, and the other thing is to try to remove the thymus. So the patient has the enlarged thymus, has a thymoma. So today, she's going to have a surgery resection. For anesthesia part, this patient is vulnerable for muscle relaxation, difficult for the non-depolarized muscle relaxation. So we try to avoid all the muscle relaxation, and the anesthesia basically tailored for this patient, so we use the short-acting opioid, plus the induction agents called propofol to get the patient under anesthesia for intubation, and afterwards we use the total IV anesthesia with the combination of propofol infusion, and the remifentanil infusion to maintain this patient under anesthesia for the surgery, and during the surgery, you don't want the patient to have, you know, movement, or that be interfere with the surgical and affect the surgical field for the patient's movement, and it'd be dangerous. So we usually use muscle relaxation, and for this patient, due to her special clinical presentation, we had to avoid that muscle relaxation. So the other thing is for surgery, and this approach goes through her left chest, so we're going to only ventilate one lung, and for airway management, we do one-lung ventilation, use a double-lumen tube, we only ventilate the patient's right lung, and that's basically about the anesthesia, and the other thing we use regular monitoring during the case, we monitor patient's depths of anesthesia with the EEG, we monitor the patient's hemodynamics, blood pressure, heart rate, and oxygenation, and also monitor patient end tidal CO2, and the ventilation parameters. So the goal is to make the patient hemodynamics stable and provide stable surgical situation for the surgical team, and also make the patient have a smooth recovery. For the postoperatively, we be very careful to monitor patient's respiration function typical for this young, healthy patient, and control pain, and the patient going to for after surgery, going to for monitored anesthesia bed. So after surgery, after manipulation of the thymoma tissue, she may have exacerbation of the symptom. So that's why we're going to carefully monitor her, and so that's basically, for this patient, post-op. Yeah. We also control pain, yeah.