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Iskender Algithmi, MDRagab Shehata, MCs
Cardiothoracic SurgeryUnit - KAUH
2010
1st experience with roboticThymectomy in KAUH
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Introduction
7 case underwent robotic Thymectomy in
KAUH between January 2009 to march2010.
Patients characteristics, preoperativepreparation, operative data, postoperativeresults will reviewed.
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Preoperative Characteristics of Patients
Gender Female 7 (100%)
Mean age (range) 25 years (1745 years)Mean duration of symptoms 18 (6 64) (months)Osserman stage
I ocular myasthenia 6 (85%) IIa mild weakness 2 (28%) IIb moderate weakness 3 (44%) III acute sever weakness 1 (14%) IV late sever weakness 1( 14%)
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Preoperative medication therapy:
Anticholinesterase 7 (100%) Steroid 7(100%) Azatioprine 2(28%) Cyclosporine 1(14%)
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Complete labs:
CBC, U&E, LFT, INR,PTT, TFT
Pulmonary function test to asses
respiratory function
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Radiology
Chest x ray PA & Lat. And CT chest.To evaluate any Mediastinal massesReveal enlarged thymus in 3 patient
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Plasmapheresis
For all patient 3 sessions to:
- decrease Ab level- improve symptoms- decrease incidence of Myasthenic crises
Anesthesia assessmentICU referral
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Surgical technique
Under general anesthesia
double lumen endotracheal tube for selectivesingle lung ventilation during the time of operation
One patient required bronchial blocker.
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patient is positioned left side up at a 30-degree angle
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Surgical technique
A camera port for the three-dimensional 0-degree
stereo endoscope is introduced through a 15 mmincision in the fifth intercostal space on themidaxillary lineTwo additional thoracic ports are inserted; one inthe third intercostal space on the midaxillaryregion and another in the fifth intercostal spaceon the midclavicular space
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Surgical technique
Two arms of the da V inci system are then
attached to the two access points and another arm is attached to the port-inserted endoscope.During surgery the hemithorax was inflatedthrough the camera port with CO2 ranging inpressure from 6 to 10 mm Hg
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Surgical technique
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All anterior mediastinal tissue, including fat
between the phrenic nerves, and from innominatetvein to diaphragm dissected and removed
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Surgical technique
After the hemostasis, a 28F drainage tube is
inserted through the port of the fifth intercostalspace, the lung is reinflated, and the other wounds are closed.
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Thymus specimen
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At the end of procedure
5 patient is extubated in the operating
room and, after an adequate period of observation, returns to the floor of thesurgical thoracic ward.2 patient need ICU admission
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Operative Data
Robotic time:118 minutes
(range 95 to 240 minutes)Total operative time: 258 minutes
range (148 - 303 min)
No major Intraopertaive complications
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Post operative
2 patients requires post op. ventilation for
6, 48 hours and ICU stays 1, 4 days.
Chest tube drainage: mean 240 mlPots op analgesia: tramadol 50mg po q6hHospital stay: 4 days (3-10)
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Complications
One patient developed post operative
dyspnoa, wheeze and haemoptysis,Reintubated, ventilated , bronchoscopydone showing bronchial injury,
? Bronchial blocker frequent suction patient stabilized andextubated after 2 days
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Histopathology
Thymic hyperplasia: 3 patient
Atrophic thymus: 2 patient
Normal thymic tissue 2 patient
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Follow up
Follow up for 3 to 18 (mean 6)months shows:
Significant improvement and decreasemedication in 3 patient .Mid to moderate improvement in 2 caseNo improvement in 2 cases
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Brief review of Thymectomy in
myasthenia gravis
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MYASTHEN IA
Autoimmune disease
Affects neuromuscular junction receptorsCharacterized by:
Localized or generalized weakness that improveswith rest
Inability to sustain or repeat muscle contractions
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CLASS IF ICAT IONS
Osserman Group I ocular disease Group IIA mild, general symptoms Group IIB mod, general symptoms Group III acute, severe; lasts weeks-
months; severe bulbar S. Group IV late; severe, marked bulbar S.
and general severe weakness
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MYASTHEN IA
BULBAR WEAKNESS Oropharyngeal weakness, dysphagia Difficulty breathing Difficulty clearing secretions
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MYASTHEN IA
85% have antibodies to ACh receptors in skeletalmuscleAntibody binds close to receptor sitesdestruction of sitesThymus thought to be involved:
30-50% pts with thymoma have MG After Thymectomy
25% remission70-80% improve over weeks to months
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DIAGNOS IS
Clinical symptoms
EMGImprovement after EdrophoniumBulbar symptoms = poor prognostic sign
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TREATMENT
GOAL:
Improving neuromuscular function
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TREATMENT (medical)
Cholinesterase inhibitors Inhibit hydrolysis ACh increase its concentration Successful in mild disease Pyridostigmine (longer duration, less side effects)
60 mg po Q6h
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TREATMENT (medical)
Corticosteroids Dec AChR antibodies
80% remissionLimited by long term Side Effect
G I bleed HTN, hyperglycemia Osteoporosis susceptibility to infection
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TREATMENT (medical)
Immunosuppressive Interferes with formation AChR antibodies Side effects
Bone marrow suppressionSusceptibility to infectionsmalignancy
Cyclophosphamide, azathioprine,cyclosporine
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TREATMENT
Plasmapheresis
Short term improvement significant decease postop. complications
IV Immunoglobulin Short term May be given pre op
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TREATMENT (surgical)
Thymectomy:Major source antibody productionArrests/reverses diseaseIndicated in:
Adults with generalized disease Thymoma Thymic hyperplasia Drug resistant MG
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Thymectomy (approach)
The transsternal approach:w idespread surgical technique for Thymectomy.The main advantages are: an optimal exposition anddissection of the thymus and perithymic fat tissueLow er risks of vascular and nervous injuries.
Disadvantages include invasiveness of the approachand a longer hospitalization.
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Thymectomy
The transcervical thymectomy:
minimally invasive technique that is easily acceptedby young patients and neurologists.The advantages are a short hospitalization, fe w er complications and lo w er costs.
Disadvantage: small space of access makingsurgical manoeuvres difficultImpossible to perform a thymectomy that extends tothe perithymic fat tissue.
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Thymectomy
V ATS thymectomy:
minimally invasive techniquethrough the left- or right-sided approachgood visualization of the anterior mediastinum,achieving an extended thymectomy.
The disadvantages are the 2-dimensional vie w of theoperative field and the limited manipulation of theendoscopic instruments.
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Thymectomy
The robotic Thymectomy:
Combines the advantages of minimally invasivetechniques (fewer complications, minimalthoracic trauma, decreased postoperative pain,early improved pulmonary function, shorter recovery period and optimal cosmetic resultsthe specific advantages is 3-dimensional vision, ascale motion w ith tremor filtering and articulatedmovements.
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Results
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Conclusion
In patients with MG, robot-assisted thymectomy canbe performed safely and efficiently.The improved visualization and instrument and itsadvanced technology may facilitate the minimallyinvasive approach to the thymus.We prefer to use the left-sided approach because it
provides an enhanced visualization of the aorticwindow and it reduces the probability of phrenicnerves injury.A longer follow-up is necessary to verify long-term
clinical results.
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Thank you