Subxiphoid VATS thymectomy for myasthenia gravis

Takashi Suda


In recent years, surgeons have come to use less invasive endoscopic surgical techniques than conventional median sternotomy to perform thymectomy. Endoscopic thymectomy includes the transcervical approach via the neck region, video-assisted thoracoscopic surgery via the lateral intercostal space (lateral thoracic intercostal approach), and the subxiphoid approach. The lateral thoracic intercostal approach is currently the most commonly employed technique at facilities that offer endoscopic thymectomy, including robot-assisted surgery. A major drawback of this approach is that the intercostal space is traversed, which guarantees intercostal nerve damage from the concurrently inserted port. An advantage of subxiphoid single-port thymectomy is that it does not cause intercostal nerve damage because it does not traverse the intercostal space. In addition, with this approach, it is easy to verify the location of the bilateral phrenic nerves and to secure the operative field in the neck region within the field of view of the camera that is inserted in the midline of the body. Subxiphoid dual-port thymectomy and subxiphoid robotic thymectomy are surgical approaches with improved operability through additional intercostal ports on the anterior chest and were originally designed for cases when single-port thymectomy is difficult. Thymectomy via the subxiphoid approach for myasthenia gravis is an excellent technique for both surgeons and patients because the operative field in the neck region is secured, bilateral phrenic nerve identification is possible, cosmetic outcomes are superior, and pain is minimal. Further studies on the long-term therapeutic outcomes of subxiphoid thymectomy for myasthenia gravis are required.