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Page 2 of 9 Brandolini. Mini-invasive Surg 2020;4:45 I http://dx.doi.org/10.20517/2574-1225.2020.27

INTRODUCTION
Since the origin of this procedure, conventional open thymectomy has been considered the gold standard
[1]
for the treatment of patients with thymomatous masses . A gradual transition to minimally invasive
[2]
techniques though, has become evident within the surgical community. In 1993, Coosemans et al.
reported the first cases of video-assisted thoracoscopic surgery (VATS) thymectomy as a safe and effective
approach, with or without additional trans-cervical incision.

With the improvement of technology, however, in terms of optical and surgical instrumentation, VATS
thymectomy has become increasingly popular. Compared to the standard open technique, minimally-
invasive thymectomy has the advantages of reducing surgical trauma, less intraoperative blood loss and
duration of postoperative pleural drainage, less postoperative pain, reduced hospital length of stay, better
[3]
aesthetic result, rapid recovery of lung function and lower complications .
Many retrospectives studies comparing open trans-sternal thymectomy to VATS thymectomy have
reported no significant difference in terms of adverse events, surgical extent, rate of R0 resection, peri- and
post-operative complications. Otherwise, faster recovery times were demonstrated in patients treated with
[4]
bilateral thoracoscopic thymectomy for patients with MG .

Worldwide, VATS is now used in the surgical treatment of early resectable thymomas and thymic
hyperplasia in many thoracic surgery units. In the literature, numerous technical variations to VATS
thymectomy have been described and the final choice depends on the individual surgeon’s preferences and
expertise. A bilateral approach may achieve a more radical thymectomy, as described by some surgeons,
[4-8]
either alone or together with an additional cervical or sub-xyphoid incision .

The choice of the first side of the thorax to be approached varies according to the surgeon’s experience and
preference. The intraoperative steps may also vary: some surgeons prefer to start dissection from the right
side and divide the thymic veins from the left, while others approach the thymic veins from the left first,
and some authors start dissecting the thymic veins from the right [6,9,10] .

In this study, the surgical technique of a minimally invasive, extended thymectomy through a bilateral
approach is illustrated with key features highlighted.

METHODS
All operations were carried out under general anaesthesia with double-lumen intubation. The patients were
placed in a semi-supine decubitus position with the hemithorax raised to about 30° from the horizontal
plane, and widely prepped to allow simple exposure of both sides. The entire chest is elevated from the
table by a soft gel roll placed under the spine with both arms extended overhead for wide exposure of
the two hemithoraces [Figure 1]. The head is also flexed, in order to move the thymus inferiorly into the
mediastinum, out of the cervical neck. The assistant stands beside the operating surgeon, while the scrub is
placed facing the operating surgeon.

Step 1: right side
The right side is accessed first. With the surgical table tilted slightly towards the left, an initial 10-mm trocar
is inserted through the 5th intercostal space (ICS) along the anterior-axillary line; two additional 5-mm
ports are then placed in the fifth ICS along the mid-clavicular line, and in the third ICS along the mid-
axillary line respectively [Figure 1]. CO2 insufflation is used during the whole procedure (the pressure is
commonly maintained al 6 mmHg, and flow around 6 mL/min), in order to favour right lung collapse and
facilitate dissection. A 30-degree (5 mm or 10 mm) scope is used to allow visualisation of the mediastinal
structures from multiple perspectives.