Endoscopic robot-assisted extended thymectomy by subxiphoid approach with sternal lifting:: Feasibility in the pig

Background: In the search for novel approaches to thoracoscopic thymectomy we assessed the feasibility of a subxiphoid approach using computer-enhanced instruments and sternal lifting. Methods: In 12 pigs, after lifting of the sternum, ports were placed subxiphoid (stereoscope) and in the left and right fourth intercostal space (instruments). Using computer-enhanced instruments, dissection of the thymus and anterior mediastinal fat pads was started at the diaphragm and continued cephalad. Results: After setup of the robot system (23 +/- 6 min, mean +/- SD), the thymus, including both superior horns, and fat pads in the anterior mediastinum and cardiophrenic angles were dissected (109 +/- 23 min), with excellent view of the phrenic nerves. Visual inspection after sternotomy after the procedure showed all thymic and fatty tissue was removed. Conclusions: In the pig, endoscopic extended thymectomy can be safely performed by subxiphoid access using computer-enhanced instruments, sternal lifting, and three ports total.