Uniportal, robot-assisted and uniportal robot-assisted subxiphoid thymectomy with CO2 insufflation

This study reports the procedures we currently use, including subxiphoid uniportal thymectomy (SUT) and subxiphoid robotic thymectomy (SRT) using CO2 insufflation, as well as subxiphoid uniportal robot-assisted thymectomy (SURT) using the da Vinci Xi surgical system. SUT is the most minimally invasive procedure for thymectomy because it does not pass through the intercostal space; therefore, there is no intercostal nerve damage and post-thoracotomy pain. The disadvantage of single-port surgery is the operability. In this approach, all instruments are inserted via a single port, which results in interference among instruments and poor operability. SRT has the best operability with a wide range of surgical indications, enabling suture insertion and end-to-end anastomosis of blood vessels. SURT using the da Vinci Xi surgical system is an approach that combines the minimal invasiveness of the single-port surgery and good operability of robotic surgery to resolve the need for increased number of ports, which is one shortcoming of the robotic surgery. Selection of the best subxiphoid approach for thymectomy must be guided by the progression of the thymoma. The advantages of CO2 insufflation for endoscopic thymectomy are that tissues and organs are not injured by instruments, surgical manipulations can be performed with bilateral ventilation, and a wide surgical space can be created upon displacing the pericardium and lungs.