Key Frames

  • Patient’s position.
  • Dissection of mediastinum along phrenic nerve.
  • Dissection of left thymic horn.
  • Dissection of the thymus gland from mediastinal right pleura .
  • Dissection of the innominate vein dissection and clipping of thymic vein.
  • Dissection of right thymic horn.

Dott. Alberto Terminella: Robotic Thymectomy for MG

Intervention Description

Patient is undergone general anesthesia and left pulmonary exclusion is obtained by double-lumen endotracheal tube to guarantee selective single lung ventilation during all the time of operation.

The patient is positioned left side up at about 30° angle with long gel roll.

Operative field must be prepared for an eventual conversion to median sternotomy.

A camera port for the three-dimensional 30° stereo endoscope is introduced through 8 mm incision on the fifth intercostal space on the midaxillary line. The camera port is placed first and is inserted carefully to avoid injury to the lung or to the heart. Once the camera port is inserted, carbon dioxide is insufflated in a special access port at a pressure of 5-8 mmHg

Two additional thoracic ports are inserted: one on the third intercostal space on the midaxillary region and another on the fifth intercostal space on the midclavicular space. Generally, two arms of the da Vinci system are enough to perform intervention and the third robotic arm does not usually use.  A forth access can be placed on the fifth intercostal space on posterior axillary line as utility access to introduce aspiration, gauze etc.

Once the ports are placed, the Xi robot is docked and robotic instruments are placed. The left arm has an EndoWrist to grasps tissues and the right arm has a cautery hook device used to perform the dissection.

The dissection starts along the anterior border of the phrenic nerve and anterior mediastinal tissue, including fat, is dissected from the pericardium. The thymic gland is separated from the retrosternal area until the right mediastinal pleura. The left and right inferior horns are then found and dissected. After mobilization of the lower part of the thymus gland the dissection continues upward to the neck until the superior left horn that is identified and divided from the inferior portion of the thyroid gland. The left innominate vein is identified, dissected up to the point where the thymic veins are identified, clipped, and divided. The right horn is identified and divided from the inferior portion of the thyroid gland. The thymus together with fatty tissue are radically resected and the specimen removed through trocar incision by an Endobag.

After hemostasis control, a mediastinal 24F drainage tube is inserted through the port of the fifth midaxillary intercostal space, the lung is inflated, and the other wounds are closed. The patient is extubated in the operating room returns to the floor of the surgical thoracic ward after an adequate period of observation.

Primo Operatore

Dott. Alberto Terminella

Director of Thoracic Surgery

Policlinico San Marco Hospital Catania


Secondo Operatore

Dott. Giacomo Cusumano

Medico Chirurgo

Policlinico San Marco Hospital Catania


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