Robotic-Assisted Thymectomy in Myasthenia Gravis
Iskander Al-Githmi, MD, FRCSC, FRCSC (Ts&CDs), FACS, FCCPDepartment of Surgery. Division of Cardiothoracic SurgeryKing Abdulaziz University Hospital
Objectives
General Robotic Considerations Anatomy of Thymus Robotic Technique Outcomes Myasthenia Gravis over view Our early experience of RATS
Da Vinci Robotic Surgical System
B
A
C
General Robotic Consideration
Provide a stable camera platform Three- dimensional imaging Simulate motions of surgeon’s wrist to overcome motion limitation of straight thoracoscopic instruments Offer the surgeon a comfortable, ergonomically operating position Magnified and computer enhanced video imaging provide superior exposure and visualization
General Robotic Consideration
Telecast the surgeon hand motions to the remote operating room ( telepresence)-- Transatlantic cholecystectomy (Marescaux) Telementoring of surgeons Why have surgeons failed to embrace minimal invasive cardiothoracic surgery?
Factors Influencing Decision
Anatomy
Pathology
patient
Technology
Balance of Outcomes
Dissection required
Propensity of complications
Reduction in organ reserve
Approach
Selection/ preparation
Complication avoidance
Anesthesia
Anatomy
Anatomy
Thymic Tissue Distribution
Jaretzki 3d , et al. Journal of Thoracic and Cardiovascular Surgery, Vol 95, 747-757, Copyright © 1988
Potential sites for ectopic thymic tissue
Ann Thorac Surg 2000;69:1537-41
Imaging
Surgical Approach
Robotic Thymectomy Technique
Robotic Thymectomy
Robotic Thymectomy
Mack M .J. etal; J Thorac Cardivasc Surg 1996;112:1352-1360
Robotic Thymectomy
Surgical therapy of MG necessitate a complete removal of all thymic and fatty tissues in the anterior mediastinum Is this achievable ? Which surgical approach?, So what! Balance between extent of resection, morbidity, patients acceptance and results
Goals
VATS Vs Open
M.-W. Lin et al Eur J CT Surgery 37 (2010) 7-12
VATS Vs Open
M.-W. Lin et al Eur J CT Surgery 37 (2010) 7-12
OR Time
Ann Thorac Surg 2008;85:7688-771
Blood Loss
Ann Thorac Surg 2008;85:7688-771
Hospital Stay (days)
Ann Thorac Surg 2008;85:7688-771
Myasthenia Improvement
Ann Thorac Surg 2008;85:7688-771
Myasthenia improvement
CHEST 2005;128:3454-3460
VATS Vs Open
Ann Thorac Surg 2009;87:385-391
Robotic Thymectomy Costs
Osserman Classifications
J Thorac Cardiovasc Surg 1996;112:1352-13560
De Filippi post operative classifications
J Thorac Cardiovasc Surg 1996;112:1352-13560
Our early experienceDesign:It is a prospective study of RATS for NTMG in KAUH. Data were collected from medical records & supplemented with telephone survey
Methods: Jan 2008- Oct 2010 Patients (n) = 8Gender : Female = 8 Male= 0Mean age = 28 yr (16-46) All with non thymomatous Masthenia Gravis Left side (3 ports) robotic thymectomies (Da Vinci system)
Our early experience
Results: Complete stable remission = 25% Clinical improvement = 87.5% Mortality = 0 Left phrenic nerve injury ( n=1) No significant correlation between age and symptom duration (p=0.51) No significant correlation between pre-op CT scan and histopathology finding (p= 0.85)
Patient Characteristics
Mean age (Yr) 28 (16-46)
Mean symptom duration (month) 7.75 (3-12)
CT scan chest
• Hyperplasia • Normal
3 (37.5%)5 (62.5%)
Acetylcholine receptors Ab
• Positive• Negative
5 (62.5%)3 (37.5%)
Osserman stage
• Stage I• Stage IIa• Stage IIb• Stabe III• Stage IV
0 ( 0%)2 (25%)5 (37.5%)0 (0%)1 (12.5%)
Al-Githmi, Surgical Science J 2011;2:393-396
Pt. No Age
(y)
Osserman
classification
Symptoms
duration
(month)
Preop CT
chest
Histopathology Follow-up /De Filippi
Classification
6
months
12
months
18 months
1 16 IIb 12 Hyperplasia Thymic
involution
Class 4 Class 3 Class 2
2 19 IIb 3 Normal Normal Class 4 Class 2 Class 3
3 23 IIa 12 Normal Normal Class 4 Class 3 Class 3
4 26 IIb 12 Hyperplasia Normal Class 4 Class 4 Class 3
5 28 IIb 5 Hyperplasia Hyperplasia Class 3 Class 3 Class 2
6 30 IV 3 Normal Hyperplasia Class 3 Class 2 Class 1
7 36 IIb 7 Normal Hyperplasia Class 3 Class 3 Class 2
8 46 IIb 8 Normal Thymic
involution
Class 3 Class 2 Class 1
Selected preoperative variables and patient outcome
Post operative status after 12 months follow up
Class I N = 1 12.5%
Class II N = 3 37.5%
Class III N = 4 50%
Class IV N = 0 0%
Class V N = 0 0%
Post operative status after 18 months follow up
Class I N= 2 25%
Class II N = 3 37.5%
Class III N = 3 37.5%
Class IV N = 0 0%
Class V N = 0 0%
Class V N = 0 0%
Preoperative CT chest & Histopathology
Preoperative CT Chest Histopathology Positive diagnostic yield(%)
Normal ( n= 5) • Normal (n= 2)• Hyperplasia (n= 2)• Thymic involution (n = 1)
40
Hyperplasia (n= 3) • Normal (n=1)• Hyperplasia (n = 1)• Thymic involution (n = 1)
33.3
Our early experience
Conclusions: Robotic thymectomy is promising procedure, safe and effective Long-term results are comparable to conventional methods Global clinical improvement demonstrated in 87.5% after 12 months follow- up
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