Thoracoscopic thymectomy: Technical pearls to a 21st century approach

Purpose: Thoracoscopic approaches to thymectomy have increased as imaging and instrumentation have advanced. Indications for the thoracoscopic approach are evolving. We reviewed our experience in the transition from sternotomy to thoracoscopy and have gleaned technical points to aid in performing thymectomy. Methods: The experience during the transition of sternotomy to thoracoscopy was reviewed. Results: The following components have been observed to be advantageous: (I) initial patient positioning is crucial; (II) thoracoscopy provides improved visualization (a separate camera setup can facilitate visualization of the left phrenic nerve); (III) CO2 aids in dissection; (IV) electrocautery and harmonic scalpel aid in dissection and hemostasis; (V) circumferential dissection identifies anatomic boundaries; (VI) endoscopic ligation of innominate vein branches is adequate; and (VII) minimal access techniques impart a shorter convalescence. In our transition, the length of stay has decreased from 4.3 ± 2.9 to 2.3±1.2 days (P=0.0217).Conclusions: We are routinely able to employ this thoracoscopic approach for complete removal of thymic tissue in patients with myasthenia gravis and those with small (<3 cm) thymic masses. A standard approach to dissection in thoracoscopic thymectomy streamlines the procedure and enables safe resection.