Minimally invasive techniques in thymic surgery (review of literature)

We carried out the systematic review of the domestic and foreign literature focusing on surgical treatment of patients with thymic pathology. Special attention was paid to the discussion of the advantages of minimally invasive surgery, particularly, video endoscopic thymectomy from subxiphoid access. Pubmed, Medline and E-library databases were searched for retrospective and prospective randomized trials. Based on the analysis of literature sources, we presented the data on tumor and non-tumor pathology of the thymus gland, clarified indications for surgical treatment in different types of thymic pathology. Variants of thymectomy were described, a brief historical review of the use of the surgical method in patients with thymus gland pathology was conducted. The technique of surgeries, advantages and weak points of various surgical approaches were described. We focused our attention on minimally invasive interventions, listed its advantages in comparison with the standard “open” surgical approach. The contemporary trends in surgical approaches in thymus pathology were discussed. Minimally invasive thymectomy is modern, safe and feasible variant of surgical treatment of patients with tumor and non-tumor pathology of the thymus gland. The subxiphoid approach allows to reduce postoperative pain, provides an excellent view of mediastinal structures and both pleural cavities, which improves the safety of operation with satisfactory cosmetic results.

1. Pikin O. V., Ryabov A. B., Kolbanov K. I., Stepanov S. О. Mediastinal Tumors / eds by Academician of RAS A. D. Kaprin. Moscow, Young Guard, 2019:232. (In Russ.).

2. Detterbeck F. C., Nicholson A. G., Kondo K. et al. The Masaoka-Koga stage classification for thymic malignancies: clarification and definition of terms // J Thorac Oncol. 2011;(6):S1710–S1716. Doi: 10.1097/ JTO.0b013e31821e8cff.

3. Sanadze A. G. Myasthenia and Myasthenic syndromes. Moscow, Litterra, 2012:255. (In Russ.).

4. Dedaev S. I. Antibodies to autoantigen targets in myasthenia and their value in clinical practice // Neuromuscular Diseases. 2014;(2):6–15. (In Russ.). Doi: 10.17650/2222-8721-2014-0-2-6-15.

5. Wolfe G. I., Kaminski H. J., Aban I. B. et al. Long-term effect of thymectomy in patients with nonthymomatous myasthenia gravis treated with prednisone: 2-year extension of the MGTX randomised trial // Lancet Neurol. 2019;18(3):259–268. Doi: 10.1016/S1474-4422(18)30392-2.

6. Liu Z., Yang J., Lin L., Huang J. and Jiang G. Unilateral video-assisted thoracoscopic extended thymectomy offers long-term outcomes equivalent to that of the bilateral approach in the treatment of non-thymomatous myasthenia gravis // Interactive Cardio Vascular and Thoracic Surgery. 2015;(21):610–615. Doi: 10.1093/icvts/ivv176.

7. Gilhus N. E., Verschuuren J. J. Myasthenia gravis: subgroup classification and therapeutic strategies // Lancet Neurol. 2015;(14):1023–1036. Doi: 10.1016/S1474-4422(15)00145-3.

8. Ellis H. The Mysterious Thymus Gland and Its Surgery // J Perioper Pract. 2018;28(1–2):33–34. Doi: 10.1177/1750458917742058.

9. Overhaus M., Kaminski M., Hirner A., Schäfer N. Die Geschichte der Thymuschirurgie // Khirurg. 2007;(78):950–953. Doi: 10.1007/s00104007-1351-3.

10. Dikhno А. М., Zlotnikova E. Ya. To the role of thymic gland in the pathogenesis of Myasthenia // Neuropathology and psychiatry. 1941;(6):7–8. (In Russ.).

11. Landreneau R. J., Mack M. J., Hazelrigg S. R. et al. Video-assisted thoracic surgery: Basic technical concepts and intercostal approach strategies // Ann Thorac Surg. 1992;(54):800–807. Doi: 10.1016/00034975(92)91040-G.

12. Yim A. P., Kay R. L., Ho J. K. Video-Assisted Thoracoscopic Thymectomy for Myasthenia Gravis // Chest Journal. 1995;108(Is. 5):1440–1443. Doi: 10.1378/che st.108.5.1440.

13. Fyodorov I. V., Sigal E. I., Odintsov V. V. Endoscopic Surgery. Moscow, Geotar Medicine, 1998:212–246. (In Russ.)

14. Sigal E. I., Zhestkov K. G., Burmistrov M. V., Pikin O. V. Thoracoscopic Surgery / eds. by I. V. Fyodorov. Moscow, Book House, 2012:352. (In Russ.).

15. Zieliński M. Definitions and Standard Indications of Minimally-Invasive Techniques in Thymic Surgery // J. Vis. Surg. 2017;(3):99. Doi: 10.21037/ jovs.2017.06.04.

16. Jaretzki III A., Wolff M. «Maximal» thymectomy for myasthenia gravis. Surgical anatomy and operative technique // J. Thoracic Cardiovasc. Surg. 1988;(96):711–716. Doi: 10.1016/S0022-5223(19)35177-3.

17. Yano M., Fujii Y., Yoshida J., Utsumi T., Shiono H., Takao M. et al. A Phase II Study of Partial and Subtotal Thymectomy for Thymoma (JART02) // World J Surg. 2017. № 41. Р. 2033–2038. Doi: 10.1007/ s00268-017-3990-y.

18. Toker A., Sonett J., Zielinski M., Rea F., Tomulescu V., Detterbeck F. C. Standard Terms, Definitions, and Policies for Minimally Invasive Resection of Thymoma // Journal of Thoracic Oncology. 2011;6(7):3. Doi: 10.1097/JTO.0b013e31821ea553.

19. Agasthian T. Beyond the limits, extreme minimally invasive surgery in invasive thymic tumours // J Vis Surg. 2017;(3):58. Doi: 10.21037/ jovs.2017.03.27.

20. Dmitrochenko I. V., Dzidzava I. I., Kotiv B. N., Fufaev E. E.., Yasyuchenya D. A. et al. Comparative analysis of variants of surgical approach in treatment of thymic tumors (meta-analysis) // Grekov’s Bulletin of Surgery. 2017;176(5):106–110. (In Russ.). Doi: 10.24884/0042-46252017-176-5-106-110.

21. Odaka M., Tsukamoto Y., Shibasaki T., Mori S., Asano H. et al. Surgical and Oncological Outcomes of Thoracoscopic Thymectomy for Thymoma // J Vis Surg. 2017;10(3):54. Doi: 10.21037/jovs.2017.03.18.

22. Manoly M., Whistance R. N., Sreekumar R., Khawaja S. et. al. Early and mid-term outcomes of trans-sternal and video-assisted thoracoscopic surgery for thymoma // European Journal of Cardio-Thoracic Surgery. 2014;(45):e187–e193. Doi: 10.1093/ejcts/ezu077.

23. Sigal E. I., Sigal R. E., Sigal A. M., Burmistrov M. V., Potanin V. P. Results of videothoracoscopic thymectomy used for patients with thymoma-associated myasthenia // Oncology bulletin of the Volga region. 2015;(2):11–17. (In Russ.).

24. Shevchenko Yu. L., Ablicov A. Yu., Vetshev P. S., Ablicov Yu. A., Vasilashko V. I. et al. Modern technologies in surgery of the mediastinum // Bulletin of Pirogov National Medical & Surgical Center. 2020;15(1). (In Russ.). Doi: 10.25881/BPNMSC.2020.82.77.001.

25. Yablonsky P. K., Pishchik V. G., Nuraliev S. M. A comparative analysis of the effectiveness of traditional and videothoracoscopic thymectomy in complex treatment of myasthenic thymomas // Grekov’s Bulletin of Surgery. 2005;(3):38–42. (In Russ.).

26. Odaka M., Tsukamoto Y., Shibasaki T., Katou D., Mori S., Asano H., Yamashita M. and Morikawa T. Thoracoscopic thymectomy is a feasible and less invasive alternative for the surgical treatment of large thymomas // Interactive CardioVascular and Thoracic Surgery. 2017;(25):103–108. Doi: 10.1093/icvts/ivx048.

27. Matilla J. R., Klepetko W., Moser B. Thymic minimally invasive surgery: state of the art across the world – Europe // J Vis Surg 2017;(3):70. Doi: 10.21037/jovs.2017.04.01.

28. Cooper J. D., Al-Jilaihawa A. N., Pearson F. G., Humphrey J. G., Humphrey H. E. An Improved Technique to Facilitate Transcervical Thymectomy for Myasthenia Gravis // The Annals of Thoracic Surgery. 1988; 45(3):242–247. Doi: 10.1016/S0003-4975(10)62457-5.

29. Zieliński M., Hauer L., Kuzdzał J., Sośnicki W., Harazda M. et al. Technique of the Transcervical-Subxiphoid-Videothoracoscopic Maximal Thymectomy // J Minim Access Surg. 2007;3(4):168–172. Doi: 10. 4103/0972-9941.38911.

30. Elsayed H. H., Gamal M., Raslan S. and Abdel Hamid H. Video-assisted thoracoscopic thymectomy for non-thymomatous myasthenia gravis: a right-sided or left-sided approach? // Interactive CardioVascular and Thoracic Surgery. 2017;(25):651–653. Doi: 10.1093/icvts/ivx136.

31. Zhikharev V. А., Porkhanov V. А., Koryachkin V. А., Malyshev Yu. P., Danilov V. V. Video-assisted thoracoscopic thymectomy in myasthenia. A new approach // Messenger of Anesthesiology and Resuscitation. 2018;15(3):14–19. (In Russ.). Doi: 10.21292/2078-5658-2018-15-3-14-19.

32. Bayman E. O., Parekh K. R., Keech J., Selte A., Brennan T. J. A prospective study of chronic pain after thoracic surgery // Anesthesiology. 2017;126(5):938–951. (In Russ.). Doi: 10.1097/ALN.0000000000001576.

33. Harris C. G., James R. S., Tian D. H., Yan T. D., Doyle M. P., GonzalezRivas D., Cao C. Systematic review and meta-analysis of uniportal versus multiportal video-assisted thoracoscopic lobectomy for lung cancer // Ann Cardiothorac Surg. 2016;5(2):76–84. (In Russ.). Doi: 10. 21037/acs.2016.03.17.

34. Dunning J. Video-assisted Thoracoscopic Microthymectomy // Ann. Cardiothorac Surg. 2015;4(6):550–555. Doi: 10.3978/j.issn.2225319X.2015.11.04.

35. Kido T., Hazama K., Inoue Y., Tanaka Y., Takao T. Resection of Anterior Mediastinal Masses Through an Infrasternal Approach // Ann Thorac Surg. 1999;67(Is. 1):263–265. Doi: 10.1016/S0003-4975(98)01210-7.

36. Suda T., Sugimura H., Tochii D., Kihara M., Hattori Y. Single-Port Thymectomy Through an Infrasternal Approach // Ann Thorac Surg. 2012; 93(Is. 1):334–336. Doi: 10.1016/j.athoracsur.2011.08.047.

37. Chen H., Xu G., Zheng W., Chen C. Video-assisted thoracoscopic extended thymectomy using the subxiphoid approach // J Vis Surg. 2016; (2):157. Doi: 10.21037/jovs.2016.09.02.

38. Qiu Z., Chen L., Lin Q., Wu H., Sun H., Zhou X., Hu Y. et al. Perioperative outcomes and mid-term effects in performing videoassisted thoracoscopic extended thymectomy for myasthenia gravis: subxiphoid versus right thoracic approaches // Ann Cardiothorac Surg. 2016;5(1):56–58. Doi: 10.21037/jtd.2020.03.43.

39. Liu Z., Yang R. Comparison of Subxiphoid and Intercostal Uniportal Thoracoscopic Thymectomy for Nonmyasthenic Early-Stage Thymoma: A Retrospective Single-Center Propensity-Score Matching Analysis // Thorac Cardiovasc Surg. 2020. Doi: https://doi.org/ 10.1055/s-00401713878.

40. Negi T., Suda T. Subxiphoid single-port pulmonary bilateral metastasectomy // Journal of Visualized Surgery. 2019;(5):50. Doi: 10.21037/ jovs.2019.05.02.

41. Mineo T. C., Pompeo E., Ambrogi V., Pistolese C. Video-Assisted Approach for Transxiphoid Bilateral Lung Metastasectomy // Ann Thorac Surg. 1999;(67):1808–1810. Doi: 10.1016/S0003-4975(99)00350-1.

42. Chiu C.-H., Chao Y.-K., Liu Y-H. Subxiphoid approach for video-assisted thoracoscopic surgery: an update // Journal of Thoracic Disease. 2018;10(Suppl. 14):S1662–S1665. Doi: 10.21037/jtd.2018.04.01.

43. Suda T. Subxiphoid thymectomy: single-port, dual-port, and robot-assisted // Journal of Visualized Surgery. 2017;(3):75. Doi: 10.21037/jovs. 2017.05.07.

44. Zhao J., Wang J., Zhao Z., Han Y. et al. Subxiphoid and subcostal arch thoracoscopic extended thymectomy: a safe and feasible minimally invasive procedure for selective stage III thymomas // Journal of Thoracic Disease. 2016;8(Suppl. 3). Doi: 10.3978/j.issn.2072-1439. 2016.02.42.

45. Lu Q., Zhao J., Wang J., Chen Z. et al. Subxiphoid and subcostal arch «Three ports» thoracoscopic extended thymectomy for myasthenia gravis // J Thorac Dis. 2018;10(3):1711–1720. Doi: 10.21037/jtd.2018.02.11.

46. Li J., Qi G., Liu Y., Zheng X., Zhang X. Meta-analysis of subxiphoid approach versus lateral approach for thoracoscopic Thymectomy // J Cardiothorac Surg. 2020;15(1):89. Doi: 10.1186/s13019-020-01135-w.

47. Ashton R. C., McGinnis K. M., Connery C. P., Swistel D. G. et al. Totally Endoscopic Robotic Thymectomy for Myasthenia Gravis // Ann Thorac Surg 2003;(75):569–571. Doi: 10.1016/S0003-4975(02)04296-0.

48. Shevchenko Yu. L., Ablicov A. Yu., Vetshev P. S., Sanadze A. G., Sidnev D. V., Ablicov Yu. A. et al. Robot-assisted thymectomy in the treatment of Myasthenia Gravis // Bulletin of Pirogov National Medical & Surgical Center. 2017;12(1):15–20. (In Russ.).

49. O’Sullivan K., Kreaden U., Hebert A., Eaton D., Redmond K. A systematic review of robotic versus open and video assisted thoracoscopic surgery (VATS) approaches for thymectomy // Ann Cardiothorac Surg. 2019;8(2):174–193. Doi: 10.21037/acs.2019.02.04.

50. Suda T. Robotic subxiphoid thymectomy // Journal of Visualized Surgery. 2016;(2):118. Doi: 10.21037/jovs.2016.07.02.