Thoracoscopic Thymectomy with the da Vinci Robotic System for Myasthenia Gravis
Jens C. Rückert
Klinik für Allgemein-, Viszeral-, Gefäß- und Thoraxchirurgie, Charité-Universitätsmedizin Berlin, Berlin, Germany
Search for more papers by this authorMahmoud Ismail
Klinik für Allgemein-, Viszeral-, Gefäß- und Thoraxchirurgie, Charité-Universitätsmedizin Berlin, Berlin, Germany
Search for more papers by this authorMarc Swierzy
Klinik für Allgemein-, Viszeral-, Gefäß- und Thoraxchirurgie, Charité-Universitätsmedizin Berlin, Berlin, Germany
Search for more papers by this authorHolger Sobel
Klinik für Allgemein-, Viszeral-, Gefäß- und Thoraxchirurgie, Charité-Universitätsmedizin Berlin, Berlin, Germany
Search for more papers by this authorPatrik Rogalla
Department of Radiology, Charité Berlin, Berlin, Germany
Search for more papers by this authorAndreas Meisel
Department of Neurology, Charité Berlin, Berlin, Germany
Search for more papers by this authorKlaus D. Wernecke
SO:ST:ANA (Sophisticated Statistical Analyses) GmbH, Berlin, Germany
Search for more papers by this authorRalph I. Rückert
Department of Surgery, Franziskus-Krankenhaus, Berlin, Germany
Search for more papers by this authorJoachim M. Müller
Klinik für Allgemein-, Viszeral-, Gefäß- und Thoraxchirurgie, Charité-Universitätsmedizin Berlin, Berlin, Germany
Search for more papers by this authorJens C. Rückert
Klinik für Allgemein-, Viszeral-, Gefäß- und Thoraxchirurgie, Charité-Universitätsmedizin Berlin, Berlin, Germany
Search for more papers by this authorMahmoud Ismail
Klinik für Allgemein-, Viszeral-, Gefäß- und Thoraxchirurgie, Charité-Universitätsmedizin Berlin, Berlin, Germany
Search for more papers by this authorMarc Swierzy
Klinik für Allgemein-, Viszeral-, Gefäß- und Thoraxchirurgie, Charité-Universitätsmedizin Berlin, Berlin, Germany
Search for more papers by this authorHolger Sobel
Klinik für Allgemein-, Viszeral-, Gefäß- und Thoraxchirurgie, Charité-Universitätsmedizin Berlin, Berlin, Germany
Search for more papers by this authorPatrik Rogalla
Department of Radiology, Charité Berlin, Berlin, Germany
Search for more papers by this authorAndreas Meisel
Department of Neurology, Charité Berlin, Berlin, Germany
Search for more papers by this authorKlaus D. Wernecke
SO:ST:ANA (Sophisticated Statistical Analyses) GmbH, Berlin, Germany
Search for more papers by this authorRalph I. Rückert
Department of Surgery, Franziskus-Krankenhaus, Berlin, Germany
Search for more papers by this authorJoachim M. Müller
Klinik für Allgemein-, Viszeral-, Gefäß- und Thoraxchirurgie, Charité-Universitätsmedizin Berlin, Berlin, Germany
Search for more papers by this authorAbstract
Complete thymectomy (Thx) is a crucial part of treatment for myasthenia gravis (MG) and thymoma. The discussion about the necessity of radical, complete Thx and reduced invasiveness has led to no less than 14 different surgical approaches for Thx. The latest development is robotic-assisted surgery. Though its impact on minimally invasive surgery is not yet clear, it seems to be most promising for surgery in remote, narrow anatomical regions like the mediastinum. One hundred six consecutive robotic-assisted thymectomies (rThx) with the da Vinci robotic surgical system were performed between January 2003 and April 2007 in a prospective single-center study. Postoperative morbidity was recorded according to the Myasthenia Gravis Foundation of America (MGFA) classification. With zero mortality, the overall postoperative morbidity rate was 2%. The cumulative complete stable remission rate of MG was > 40% for all patients, and there was no statistical difference as compared to non-thymomatous MG patients. The cumulative rate of minimal manifestations (MM0–MM3) according to the MGFA classification showed a postoperative improvement in quality of life for most of the patients. The da Vinci robotic system allowed for technical refinements of the well-defined operation technique of thoracoscopic Thx (tThx). From the technical point of view, rThx has advantages for mediastinal dissection. rThx had a shorter learning curve. There might be better outcome results for rThx in MG patients, as compared with nonrobotic tThx. Therefore, rThx is a promising technique for minimally invasive Thx.
References
- 1
Evoli, A.,
A.P. Batocchi,
C. Provenzano,
et al.
1988. Thymectomy in the treatment of myasthenia gravis: report of 247 patients.
J. Neurol.
235: 272–276.
- 2
Sanders, D.B. &
Scopetta. 1994. The treatment of patients with myasthenia gravis.
Neurol. Clin. North Am.
12: 343–368.
- 3
Vincent, A. &
N. Willcox. 1999. The role of T-cells in the initiation of autoantibody responses in thymoma patients.
Pathol. Res. Pract.
195: 535–540.
- 4
Evoli, A.,
E. Bartoccioni,
A.P. Batocchi,
et al.
1989. Anti-AChR-negative myasthenia gravis: clinical and immunological features.
Clin. Invest. Med.
12: 104–109.
- 5
Sanders, D.B.,
P.I. Andrews,
J.F. Howard, Jr. &
J.M. Massey. 1997. Seronegative myasthenia gravis.
Neurology
48(Suppl 5): S40–S45.
- 6
Vincent, A. &
M.I. Leite. 2005. Neuromuscular junction autoimmune disease: muscle specific kinase antibodies and treatments for myasthenia gravis.
Curr. Opin. Neurol.
18: 519–525.
- 7
Hohlfeld, R.,
A. Melms,
C. Schneider,
K.V. Toyka &
D.B. Drachman. 2003. Neurological Disorders — Course and Treatment. T. Brandt,
L.R. Kaplan,
J. Dichgans,
H.C. Diener &
C. Kennard, Eds. Elsevier,
Amsterdam
.
- 8
Weigert, C. 1901. Pathologisch-anatomischer Beitrag zur Erbschen Krankheit (Myasthenia gravis).
Neurol. Centralbl.
20: 597–601.
- 9
Wekerle, H.,
B. Paterson,
U.P. Ketelsen &
M. Feldman. 1975. Striated muscle fibres differential in monolayer cultures of adult thymus reticulum.
Nature
256: 493–494.
- 10
Schumacher, E. &
J. Roth. 1912. Thymektomie bei einem Fall von Morbus Basedowi mit Myasthenie.
Grenzgeb. d. Med. u. Chir.
25: 746–765.
- 11
Walker, M.B. 1934. Treatment of myasthenia gravis with physostigmine.
Lancet
1: 1200–1201.
- 12
Mertens, H.G.,
M. Balzereit &
M. Leipert. 1969. The treatment of severe myasthenia gravis with immunosuppressive agents.
Eur. Neurol.
2: 321–339.
- 13
Drachman, D.B. 1994. Myasthenia gravis.
N. Engl. J. Med.
330: 1797–1810.
- 14
Ponseti, J.M.,
E. Espin,
J.M. Fort,
et al.
1997. Epithelial Tumors of the Thymus. A. Marx &
H.K. Müller-Hermelink, Eds.: 305–314. Plenum Press.
New York
.
- 15
Skeie, G.O.
et al.
2006. Guidelines for the treatment of autoimmune neuromuscular transmission disorders.
Eur. J. Neurol.
13: 691–699.
- 16
Bulkley, G.B.
et al.
1997. Extended cervicomediastinal thymectomy in the integrated management of myasthenia gravis.
Ann. Surg.
226: 324–334.
- 17
Cornelio, F.,
D. Peluchetti,
R. Mantegazza,
et al.
1981. The course of mysthenia gravis in patients treated with corticosteroids, azathioprine and plasmapheresis.
Ann. N.Y. Acad. Sci.
377: 517–525.
- 18
Gronseth, G.S. &
R.J. Barohn. 2002. Thymectomy for myasthenia gravis.
Curr. Treat. Options Neurol.
4: 203–209.
- 19
Jaretzki, III A.
et al.
1988. “Maximal” thymectomy for myasthenia gravis. Results.
J. Thorac. Cardiovasc. Surg.
95: 747–757.
- 20
Jaretzki, III A. &
M. Wolf. 1988. “Maximal” thymectomy for MG. Surgical anatomy and operative technique.
J. Thorac. Cardiovasc. Surg.
96: 711–716.
- 21
Masaoka, A.,
Y. Nagaoka &
Y. Kotake. 1975. Distribution of thymic tissue at the anterior mediastinum. Current procedures in thymectomy.
J. Thorac. Cardiovasc. Surg.
70: 747–754.
- 22
Mulder, D.G. 1996. Extended transsternal thymectomy.
Techn. Mediast. Surg.
6: 95–103.
- 23
Masaoka, A. &
Y. Monden. 1981. Comparison of the results of transsternal simple, transcervical simple, and extended thymectomy.
Ann. N.Y. Acad. Sci.
377: 755–765.
- 24
Rückert, J.C.,
D. Czyzewski,
S. Pest &
J.M. Müller. 2000. Radicality of thoracoscopic thymectomy—an anatomical study.
Eur. J. Cardiothorac. Surg.
18: 735–736.
- 25
Jaretzki, III A. 1997. Thymectomy for myasthenia gravis: analysis of the controversies regarding technique and results.
Neurology
48(Suppl 5): S52–S63.
- 26
Cooper, J.D.,
A.N. Al-Jilaihawa,
F.G. Pearson,
et al.
1988. An improved technique to facilitate transcervical thymectomy for myasthenia gravis.
Ann. Thorac. Surg.
45: 242–247.
- 27
Shrager, J.B.
et al.
2002. Transcervical thymectomy for myasthenia gravis achieves results comparable to thymectomy by sternotomy.
Ann. Thorac. Surg.
74: 320–327.
- 28
Blalock, A.,
M.F. Mason,
H.J. Morgan &
S.S. Riven. 1939. Myasthenia gravis and tumors of the thymic region. Report of a case in which the tumor was removed.
Ann. Surg.
110: 554–559.
- 29
Blalock, A. 1944. Thymectomy in the treatment of myasthenia gravis. Report of twenty cases.
J. Thorac. Surg.
13: 316–339.
- 30
Rückert, J.C.,
M. Walter &
J.M. Müller. 2000. Pulmonary function after thoracoscopic thymectomy versus median sternotomy for myasthenia gravis.
Ann. Thorac. Surg.
70: 1656–1661.
- 31
Kark, A.E. &
P.A. Kirschner. 1971. Total thymectomy by the transcervical approach.
Br. J. Surg.
58: 321–326.
- 32
Kaiser, L.R.
1996. Thoracoscopic resection of mediastinal tumors and the thymus.
Chest Surg. Clin. North Am.
6: 41–52.
- 33
Calhoun, R.F.
et al.
1999. Results of transcervical thymectomy for myasthenia gravis in 100 consecutive patients.
Ann. Surg.
230: 555–559.
- 34
De Perrot, M.,
V. Bril,
K. McRae &
S. Keshavjee. 2003. Impact of minimally invasive trans-cervical thymectomy on outcome in patients with myasthenia gravis.
Eur. J. Cardiothorac. Surg.
24: 677–683.
- 35
Ferguson, M.K. 1999. Transcervical thymectomy.
Sem. Thorac. Cardiovasc. Surg.
11: 59–64.
- 36
Maggi, G.,
C.A. Casadio,
R. Cianci,
et al.
1989. Thymectomy in myasthenia gravis. Results of 662 cases operated upon in 15 years.
Eur. J. Cardiothorac. Surg.
3: 504–509.
- 37
Papatestas, A.E. 1987. Prognosis in occult thymomas in MG following transcervical thymectomy.
Arch. Surg.
122: 1352–1356.
- 38
Novellino, L.
et al.
1994. “Extended” thymectomy without sternotomy, performed by cervicotomy and thoracoscopic technique in the treatment of MG.
Int. Surg.
79: 378–381.
- 39
Landreneau, R.J.,
R.D. Dowling,
W. Castillo &
P.F. Ferson. 1992. Thoracoscopic resection of an anterior mediastinal tumor.
Ann. Thorac. Surg.
54: 142–144.
- 40
Mack, M.J.
2001. Video-assisted thoracoscopy thymectomy for myasthenia gravis.
Chest Surg. Clin. North Am.
11: 389–405.
- 41
Mineo, T.C.
et al.
1998. Video-assisted completion thymectomy in refractory myasthenia gravis.
J. Thorac. Cardiovasc. Surg.
115: 252–254.
- 42
Rückert, J.C.,
K. Gellert,
B. Rudolph,
et al.
1996. Thorakoskopische Thymektomie wegen Myasthenie bei Thymom.
Akt. Chir.
31: 55–57.
- 43
Sugarbaker, D.J. 1993. Thoracoscopy in the management of anterior mediastinal masses.
Ann. Thorac. Surg.
56: 653–656.
- 44
Yim, A.P.C.,
R.L.C. Kay,
M.B. Izzat &
S.K. Ng. 1999. Video-assisted thoracoscopic thymectomy for myasthenia gravis.
Sem. Thorac. Cardiovasc. Surg.
11: 65–73.
- 45
Rückert, J.C. 2003. Die Entwicklung der thorakoskopischen Thymektomie - klinische und experimentelle Untersuchung. http://dochost.rz.hu-berlin.de/habilitationen/rueckert-jens-carsten-2003-10-23/html/2003.
- 46
Yoshino, I.
et al.
2001. Thoracoscopic thymectomy with the da Vinci computer-enhanced surgical system.
J. Thorac. Cardiovasc. Surg.
122: 783–785.
- 47
Bodner, J.,
H. Wykyspiel,
G. Wetscher &
T. Schmid. 2004. First experiences with the da Vinci operating robot in thoracic surgery.
Eur. J. Cardiothorac. Surg.
25: 844–851.
- 48
Rea, F.,
L. Bortolotti,
R. Girardi &
F. Sartori. 2003. Thoracoscopic thymectomy with the ‘da Vinci’ surgical system in patient with myasthenia gravis.
Interact. Cardiovasc. Thorac. Surg.
2: 70–72.
- 49
Rückert, J.C.,
K. Gellert &
J.M. Müller. 1999. Operative technique for thoracoscopic thymectomy.
Surg. Endosc.
13: 943–946.
- 50
Jaretzki, III A.
et al.
2000. Myasthenia gravis: recommendations for clinical research standards.
Ann. Thorac. Surg.
70: 327–334.
- 51
Kaplan, E.L. &
P. Meier. 1958. Nonparametric estimation from incomplete observation.
J. Am. Stat. Assoc.
53: 457–481.
- 52
Blalock, A.,
A.H. McGehee &
F.R. Ford. 1941. The treatment of myasthenia gravis by removal of the thymus.
JAMA
18: 1529–1533.
- 53
Drachman, D.B. 1981. Humoral pathogenesis of myasthenia gravis.
Ann. N.Y. Acad. Sci.
377: 90–105.
- 54
Wekerle, H. &
H.K. Müller-Hermelink. 1986. The thymus in myasthenia gravis.
Curr. Top. Pathol.
75: 179–206.
- 55
Melms, A. &
Hohlfeld. 1998. Zur Ätiologie und Pathogenese der Myasthenia gravis.
Akt. Neurologie
25(S39): S41.
- 56
Buckingham, J.M.,
F.M. Howard &
P.E. Bernatz. 1976. The value of thymectomy in MG: a computer-assisted matched pair study.
Ann. Surg.
184: 453–458.
- 57
Keynes, G. 1946. The surgery of the thymus gland.
Br. J. Surg.
33: 201–214.
- 58
Keynes, G. 1954. Surgery of the thymus gland.
Lancet
12: 1197–1202.
- 59
Barohn, R.J.,
D. McIntire &
L. Herbelin. 1998. Reliability testing of the quantitative myasthenia gravis score.
Ann. N.Y. Acad. Sci.
841: 769–772.
- 60
Lanska, D. 1990. Indications for thymectomy in MG.
Neurology
40: 1828–1829.
- 61
Zielinski, M.,
J. Kuzdzal,
A. Szlubowski &
J. Soja. 2004. Transcervical-subxiphoid-videothoracoscopic “maximal” thymectomy–operative technique and early results.
Ann. Thorac. Surg.
78: 404–410.
- 62
Giulianotti, P.C. 2007. Robotic-assisted techniques. Mira Meeting January 2007,
New York
.
- 63
Mantegazza, R.
et al.
1998. Video-assisted thoracoscopic extended thymectomy (VATET) in myasthenia gravis. Two-year follow-up in 101 patients and comparison with the transsternal approach.
Ann. N.Y. Acad. Sci.
841: 749–752.
- 64
Aggarwal, R.,
J. Hance &
A. Darzi. 2004. Surgical education and training in the new millennium.
Surg. Endosc.
18: 1409–1410.
- 65
Moorthy, K.
et al.
2004. Bimodal assessment of laparoscopic suturing skills: construct and concurrent validity.
Surg. Endosc.
18: 1608–1612.
- 66
Moorthy, K.
et al.
2004. An innovative method for the assessment of skills in lower gastrointestinal endoscopy.
Surg. Endosc. 18: 1613–1619.
- 67
Mineo, T.C.
et al.
2000. Thoracoscopic thymectomy in autoimmune myasthenia: results of left-sided approach.
Ann. Thorac. Surg.
69: 1537–1541.
