Left-sided video-assisted thoracic surgery thymectomy
Thymectomy is widely used as integrated treatment of patients with non-thymomatous myasthenia gravis (MG) and in the case of early thymomas. However, the best approach to thymus is still under debate. For decades, median sternotomy was the only option offered. This access provides a massive exposure of the anterior mediastinum allowing an extended thymectomy with the exenteration of the whole mediastinal fat, which are the two mainstays for the therapeutic success of the procedure. Unfortunately, median sternotomy produces a quite significant tissue trauma, with a certain morbidity rate and relevant postoperative pain, thus leading to longer hospital stay. Furthermore, it implies the creation of an unpleasant scar thus meeting a very low acceptance rate in patient’s population manly represented by young women. Over the years, video-assisted thoracic surgery (VATS) thymectomy has progressively replaced transsternal accesses. This approach proved safe and as extended as an open one. The procedure is better accepted by both patients and neurologists given the less postoperative pain, the insignificant cosmetic side-effects and the faster return to normal living and occupational activities. VATS thymectomy requires a perfect preparation and stabilization of the patient by a multidisciplinary group, perfect patient lying on operatory table, correct positioning of trocars, excellent knowledge of mediastinal anatomy gained through a certain number of previous sternotomies, rehearsed surgical team including an anesthesiologist experienced in myasthenic disease. Surgical steps follow grossly a precise sequence, which entails dissection of lower horns, dissection of the veins and dissection of the upper horns. Major complications are represented by innominate vein injury, which often requires rapid conversion to median sternotomy. The procedure can be feasible from either side of the thorax. Since the beginning we preferred the left-sided approach for a number of reasons such as best visualization of the left pericardio-phrenic angle, innominate vein and aorto-pulmonary window, which are most frequently sites of ectopic thymic tissue. However, each side presents different advantages and limits. Long-term results appear similarly effective in the majority of the available series. The choice of the side is prevalently based on the surgeon’s preference and experience, but one should also consider the prevalent location of the thymus or thymoma, and other local conditions predicted by imaging. In conclusion, whatever the side VATS can provide safe, effective and extended thymectomy.