Robotic Versus VATS Thymectomy for Encapsulated Thymoma


Author

N° patients

SA

Masaoka stage I/II

TS (cm)

5-year survival (%)

FU (months)

RR (%)

OC (%)

OT (min)

POS (days)

Roviaro et al. [3]

22

uVATS

22




4.5

4.5

75a

6a

Cheng et al. [12]

44

uVATS

27/17

7.7a

100

34.6a

0

0

194a

7.6a

Odaka et al. [14]

22

uVATS




21.6a

0

0

194a

4.6a

Agasthian et al. [15]

50

uVATS

25/25

5a

100

58a

2

0

150a

5a

Pennathur et al. [11]

18

bVATS

5/13

3.5a

100

27b

0

0


2.9

Takeo et al. [16]

34

bVATS

15/19

5.2a

100

65a

2.8

0

219a

10.5a

Kimura et al. [17]

45

uVATS

41/4

4.8a



6.7

0

180a

14a

Liu et al. [13]

76

u/bVATS

57/19

4.6a

100

61.9a

2.6

1.3

142a

7.1a

Odaka et al. [18]

57

uVATS

29/28

4.3a

100

43a

1.7

0

225a

4a

Mussi et al. [19]

13

Robotic

7/6

3.3a

100

14.5b

0

7.7

139a

4a

Marulli et al. [20]

79

Robotic

30/49

3.7a

90

51.7a

1.3

1.3

165a

4.4a

Ye et al. [10]

23

Robotic

21/2

2.9a


16.9a

0

0

97a

3.7a

Schneiter et al. [21]

19

Robotic

8/11

4.0b


26b

11.1

0


5b


Legend : SA surgical access. bVATS bilateral video-assisted thoracic surgery, uVATS unilateral video-assisted thoracic surgery, TS tumor size, FU median follow-up, RR recurrence rate, OC open conversion, OT operative time, POS post-operative length of stay

aMean value

bMedian value





Is There a Technological Advantage of Robotic Compared to VATS Thymectomy?


Many surgeons are still reluctant to undertake a VATS or robotic thymectomy in patients with thymoma for several reasons that stem from technical and oncologic concerns. The main technical reasons against VATS are the following: the upper mediastinum is a delicate and, for VATS, difficult-to-reach anatomical area, with vulnerable large vessels and nerves. The two-dimensional view of the operative field, the surgeon’s tremor enhanced by the thoracoscopic instruments and the fact that the instruments do not articulate, make it difficult to operate in a fixed and tiny three-dimensional space such as the mediastinum. Moreover, the VATS thymectomy is considered a technically challenging operation requiring a long learning curve [6]. The oncologic concerns are related to the possible breach of tumor capsule with risk of tumor seeding locally or in the pleural cavity and to the difficult evaluation of resection margins with reduced oncologic accuracy and safety.

The introduction of robotic surgical systems has added a new dimension to conventional VATS providing additional advantages and overcoming some technical and methodological limits: (1) the improved dexterity of instruments that can articulate with 7° of freedom and rotate 360°, allows complex three-dimensional movements superior to that permitted by conventional minimally invasive instruments, enhancing the dissection safe around vessels and nerves and more comfortable in tiny and remote areas such as the superior horns or the contralateral mediastinum; (2) the high-resolution, three-dimensional real-time video image permits the best possible and magnified view of the surgical field, and (3) the filtering of hand tremors allows greater technical precision. To date, however, no studies demonstrated a superiority of robotic approach for thymoma resection compared with standard VATS (level of evidence very low). As reported in Table 54.1, the rate of open conversion, the operative time, the size of the tumor were comparable in VATS and robotic studies. No papers focused on the percentage of capsule breaching, on the rate of open conversion related to technical reasons and on the rate of complete resection (level of evidence very low). In addition there is a significant difference between series regarding the rate of Masaoka stage I and II, the extension of resection, the size of the tumor, the selection criteria for minimally invasive approach and the surgical technique: some authors [20] adopted a “no-touch technique” with an “en bloc” resection of thymus and perithymic fat tissue according to the International Thymic Malignancy Interest Group criteria [22], while other authors [14, 23] preferred a partial thymectomy. In some studies [11, 19] a limit of 3 cm of diameter of the tumor was established, in other series [13, 15, 18, 20] a limit of 5 cm was considered safe, while some authors [12, 16] accepted also greater size. These differences were independent of surgical approach (VATS or robotic).

Only gold members can continue reading. Log In or Register to continue

Dec 30, 2016 | Posted by in CARDIOLOGY | Comments Off on Robotic Versus VATS Thymectomy for Encapsulated Thymoma
Premium Wordpress Themes by UFO Themes