Bilateral single-port thoracoscopic extended thymectomy for management of thymoma and myasthenia gravis: case report
Caronia et al. Journal of Cardiothoracic Surgery
Bilateral single-port thoracoscopic extended thymectomy for management of thymoma and myasthenia gravis: case report
Francesco Paolo Caronia 2
Alfonso Fiorelli 0
Ettore Arrigo 2
Sebastiano Trovato 2
Mario Santini 0
Attilio Ignazio Lo Monte 1
0 Thoracic Surgery Unit, Second University of Naples , Piazza Miraglia, 2, I-80138 Naples , Italy
1 Department of Surgery, Università degli Studi di Palermo , Palermo , Italy
2 Thoracic Surgery Unit, Istituto Oncologico del Mediterraneo , Catania , Italy
Background: Video-assisted thoracoscopy is become a widely accepted approach for the resection of anterior mediastinal masses, including thymoma. The current trend is to reduce the number of ports and minimize the length of incisions to further decrease postoperative pain, chest wall paresthesia, and length of hospitalization. Herein, we reported an extended resection of thymoma in a patient with myasthenia gravis through an uniportal bilateral thoracoscopic approach. Case presentation: A 74 years old woman with myasthenia gravis was referred to our attention for management of a 3.5 cm, well capsulate, thymoma. All laboratory and cardio-pulmonary tests were within normal; thus, she was scheduled for thymoma resection through an uniportal bilateral thoracoscopic approach. Under general anaesthesia and selective intubation, the patient was placed in a 60° right lateral decubitus. A 3 cm skin incision was performed in the fourth right intercostal space and, through that a 30° video-camera and working instruments were inserted without rib spreading. After complete dissection of the thymus and mediastinal fat, the contralateral pleura was opened, and, through that the specimen was pushed into the left pleural cavity. Then, the patient was placed in the left lateral decubitus. Similarly to the right side procedure, a 3-cm incision was performed in the fourth left intercostal space to complete thymic dissection and retrieve the specimen. No intraoperative and post-operative complications were found. The patient was discharged four days later. Pathological examination revealed a type A thymoma (Masaoka stage I). No recurrence was found at 18 months of follow-up Conclusions: Bilateral single-port thoracoscopy is an available procedure for management of thymoma associated with myasthenia gravis. The less post-operative pain, the reduction of hospital stay and the better esthetic results are all potential advantages of this approach over traditional technique. Obviously, our impression should be validated by larger studies in terms of long-term oncological outcomes.
Thymoma; Uniportal; Thoracoscopy; Myasthenia gravis; Bilateral; Case report
Surgery using a standard or partial sternotomy is still
the management of choice for management of thymoma.
Over the years, standard multi-port Video Assisted
Thoracoscopic Surgery (VATS) has become with the
recent advances in instrumentation and techniques a
feasible strategy for management of lung and mediastinal
diseases [1–7]. The current trend is to reduce the
number of ports and minimize the length of incisions to
further decrease postoperative pain, chest wall paresthesia,
and length of hospitalization [8–11]. Herein, we reported
the resection of thymoma in a patient with Myasthenia
Gravis (MG) through uniportal bilateral VATS approach.
A 74 years old woman with MG was referred to our
attention for management of thymoma. Chest computed
tomography scan showed a 3.5 cm well capsulated mass
within anterior mediastinum without invasion of
adjacent structure. No other lesions were found. All
laboratory and cardio-pulmonary tests were within normal,
thus, she was scheduled for surgery. Plasmapheresis was
performed preoperatively over a period of three days.
She signed a written informed consent for the operation
and was aware that her data could be used for scientific
Under general anaesthesia and selective intubation, the
patient was placed in a 60° right lateral decubitus with a
roll placed under the shoulder and the ipsilateral arm
wrapped by a sterile stockinet and maintained parallel to
the body. A 3 cm skin incision was performed in the fourth
right intercostal space and through that a 30° camera and
working instruments were inserted without rib spreading.
The dissection started from the peri-cardiophrenic angle
and continued cranially along the anterior border of the
phrenic nerve. The thymus was then mobilized from
the surrounding fat tissue and vena cava. Following, the
contralateral pleura was opened, and, through that the
thymus was pushed into the left pleural cavity. A single
24 fr chest tube was inserted through the same incision
within right costo-phrenic angle. Figure 1 summarized
the right side procedure.
The patient was then placed in the left lateral decubitus.
Similarly to the right side procedure, a 3-cm incision was
performed in the fourth left intercostal space. The
mediastinal pleura was dissected along the anterior border of the
phrenic nerve. The thymus was mobilized to expose the
thymic veins, the innominate vein and the thyroid-thymic
Fig. 1 The chest computed tomography scan showed a 3,5 cm thymoma (Part a). Patient was placed in left lateral decubitus position, with the
surgeon and the assistant standing on the posterior side (Part b). Dissection was landmarked by the superior border of phrenic nerve (Part c). The
thymus was retracted superiorly and medially; the superior vena cava and the ascending aorta were skeletonised (Part d). Right side thymic and
perithymic fatty tissue dissection was completed and left lung visible (Part e). Closure of right incision with a chest drainage (Part f)
ligaments. Then, the mediastinal fat was fully dissected
from the phrenic nerve, the innominate vein, the
aortopulmonary window, the aorto-caval groove, and the
pericardiophrenic angle. After completing thymic dissection,
the specimen was retrieved through the same incision and a
chest tube was then inserted. Figure 2 summarized the left
side procedure. No intraoperative and post-operative
complications were found. The patient was discharged four days
later. Pathological examination revealed a type A thymoma
(Masaoka stage I). At 18 months of follow-up, the patient
did not present recurrence. The main steps of the
procedure are summarized in Additional file 1: Video 1.
Over the past 10 years, VATS is become a widely
accepted approach for the resection of anterior mediastinal
masses, including thymoma. Numerous studies [5–7]
confirmed that VATS thymectomy, when an en bloc resection
of the tumor is achieved, has the same oncological results
of standard sternotomy but with the advantages of less
post-operative pain, better cosmesis and preservation of
pulmonary function. The most popular approach is
threeport VATS. Since 2004, single-incision thoracoscopic
surgery has been reported but for a time its use was limited
to pleural disease or wedge resection, until Gonzalez-Rivas
et al.  described their first experiences of single-port
thoracoscopic lobectomy. However, there are very few
reports about single-port mediastinal tumour resection. We
firstly reported the resection of thymic hyperplasia for
management of MG using an uniportal bilateral VATS
approach . After that, other authors [1, 10, 11] confirmed
the feasibility of our experience. Scarci et al.  reported a
case series of 11 uniportal VATS thymectomies performed
with an unilateral VATS approach. Wu L et al. 
published thoracoscopic extended thymectomy through a
single subxiphoid incision in 6 consecutive patients. Wu CF et
al.  reported single-port VATS resection of thymoma,
mediastinal cystic lesions and posterior mediastinal
From a technical point of view, the patient position and
the bilateral approach are the main differences of our
compared to other techniques. Instead of 30° semisupine or
semiprone position proposed by Wu CF et al. , we
preferred to place the patient in a 60° right lateral decubitus
Fig. 2 A 4 cm length incision was performed at the level of the fourth intercostal among the anterior and middle axillary line (Part a). A well
capsulated thymoma is visible (Part b). Thymic dissection is conducted parallel to left phrenic nerve (Part c). The left thyroid-thymic ligament is
shown before its section (Part d). The "en bloc specimen consisting of thymus, peri-thymic and peri-cardiophrenic fatty tissue (Part e). Closure of
left incision with a chest drainage (Part f)
position with the ipsilateral arm maintained parallel to the
body to facilitate the dissection of mediastinal fat dissection
in a difficult anatomical region as the cardio-phrenic area.
Conversely to unilateral approach proposed by Scarci et al.
 and Wu L et al , we performed a bilateral approach
that allowed to carry out an en bloc dissection of thymus,
peri-thymic and bilateral peri-cardiophrenic fatty tissue. It
is crucial to prevent tumor and MG recurrences. Compared
to our first case , in the current the presence of
thymoma made the procedure more challenging. Thus, we
started the dissection from the right side where the
thymoma was less protruding to the mediastinum in order to
minimize the risk of capsular breakage and tumour seeding.
Then, the left approach allowed the complete resection of
the tumor and its removal under endoscopic vision.
The patient selection is critical for the successful of the
procedure. Our minimally invasive approach is indicated
for resection of small and early stage thymomas, while, in
line with other experiences [12, 13], conventional open
sternotomy remained the strategy of choice for management of
thymomas > 4 cm and/or advanced stage thymomas to
avoid capsule injury and/or lesion of vital structures during
dissection. Ye et al.  reported a conversion to
sternotomy in 4/125 patients undergoing VATS resection for
thymomas having a mean size of 40 ± 8.2 mm because of
injury to the innominate vein. The presence of MG
associated to thymoma is not a main contraindication for VATS.
However, in these cases a bilateral approach is the preferred
choice in order to carry out the “en bloc” resection of
thymoma and of bilateral mediastinal fat for preventing
thymoma and MG recurrences. The procedure should be
performed under general anesthesia and selective-lung
ventilation. However, the use of CO2 gas insufflation could be
an additional strategy to improve the operative field vision
especially when complete lung exclusion is not available.
Bilateral single-port thoracoscopy is an available procedure
for management of thymoma associated with MG. The less
post-operative pain, the reduction of hospital stay and the
better esthetic results are all potential advantages of this
approach over traditional technique. Obviously, our
impression should be validated by larger studies in terms of
long-term oncological outcomes.
Additional file 1: Video 1. Video edited the main steps of operation on
the right and on the left side. (M4V 481 mb)
Availability of data and materials
The materials described in the manuscript, including all relevant raw data,
will be freely available to any scientist wishing to use them for non-commercial
purposes, without breaching participant confidentiality.
Ethics approval and consent to participate
Patient signed an informed consent for the operation and was aware that
his data could be used for scientific purpose.
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