Ooi Adrian, Qiang Fu
Department of Cardiothoracic Surgery, Gleneagles Hospital Kuala Lumpur, Kuala Lumpur, Malaysia.
Department of Cardiothoracic Surgery, National Heart Centre, Singapore.
J Vis Surg. 2016 Jan 16;2:12. doi: 10.3978/j.issn.2221-2965.2015.12.18. eCollection 2016.
Video assisted thoracoscopic surgery (VATS) thymectomy for the management of myasthenia gravis and thymoma has been described and routinely performed. With the advent of single port surgery, uniportal thymectomy has gained popularity and left side approach is preferred only if the suspecting tumour is situated on the left mediastinum. However, many doubt or dislike the left side VATS approach to anterior mediastinum as the ventricular apex renders maneuverer of instruments difficult. This is certainly not the case as shown in this video and to date, there is no published manuscript on left uniportal thymectomy.
Patient positioned semi-supine with left sided propped up and the ipsilateral arm placed naturally and secured by the side and below the chest wall. Cleaned and draped as for sterile procedure. General anaesthesia and lung isolation achieved with a double lumen endotracheal intubation. A 2.5 cm incision was made at 4 intercostal space, anterior axillary line (lateral to nipple line). Extra small size wound protector was used and CO insufflation was not needed. Instruments utilised in this case were "not new" and used for laparoscopic surgery 2 decades ago. This video demonstrates the simple technique of left uniportal approach to total thymectomy. Safe en bloc resection of thymus and thymic tumour with surrounding fatty tissue were performed, by combination of careful pleura dissection using diathermy, traction and blunt dissection of thymus. Extra caution when dividing thymic vein branches from innominate vein is prudent in order to prevent intra-operative haemorrhage and subsequent conversion to sternotomy or thoracotomy.
In this video, total thymectomy was performed without complication. The specimen was removed through the port and a single chest tube was placed at end of procedure for 1 day. Patient went home uneventfully on day 2.
Left uniportal VATS thymectomy is feasible, and preferred for left sided thymoma. This simple approach should be encouraged and performed by all enthusiastic VATS thoracic surgeons.
电视辅助胸腔镜手术（VATS）胸腺切除术用于治疗重症肌无力和胸腺瘤已被描述并常规开展。随着单孔手术的出现，单孔胸腺切除术越来越受欢迎，仅当怀疑肿瘤位于左纵隔时才首选左侧入路。然而，许多人怀疑或不喜欢左侧VATS入路至前纵隔，因为心室尖使器械操作困难。但本视频所示情况并非如此，迄今为止，尚无关于左侧单孔胸腺切除术的已发表手稿。
患者半仰卧位，左侧垫高，同侧手臂自然放置并固定于胸壁侧面及下方。按无菌操作进行清洁和铺巾。采用双腔气管插管进行全身麻醉和肺隔离。在腋前线第4肋间（乳头线外侧）做一个2.5cm的切口。使用超小型伤口保护器，无需二氧化碳气腹。本病例中使用的器械“并非新器械”，是20年前用于腹腔镜手术的。本视频展示了左侧单孔入路全胸腺切除术的简单技术。通过使用电刀仔细剥离胸膜、牵引和钝性分离胸腺，安全地整块切除胸腺及胸腺肿瘤和周围脂肪组织。在离无名静脉分支切断胸腺静脉时格外小心，以防止术中出血及随后转为胸骨正中切开术或开胸术。
在本视频中，全胸腺切除术无并发症发生。标本通过切口取出，手术结束时放置一根胸管，留置1天。患者于第2天顺利出院。
左侧单孔VATS胸腺切除术是可行的，对于左侧胸腺瘤更可取。这种简单的方法应得到所有热心的VATS胸外科医生的鼓励并开展。
