Facilitating robotic thymectomy in patients with pectus excavatum deformity
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HOW TO DO IT
Facilitating robotic thymectomy in patients with pectus excavatum deformity Konstantinos Kapriniotis1 · Georgios Geropoulos1 · Thabbta Vianna1 · Sofoklis Mitsos1 · Nikolaos Panagiotopoulos1 Received: 2 August 2020 / Accepted: 5 October 2020 © The Japanese Association for Thoracic Surgery 2020
Abstract Robotic procedures in the anterior mediastinum can be challenging in the existence of pectus excavatum deformity due to the limited intrathoracic working space caused by sternal depression. We propose that the temporary application of a vacuum bell device during the procedure can correct the deformity and thus, facilitate robotic approach similarly to the standard procedure. Keywords Pectus excavatum · Robotic thymectomy · Vacuum bell
Introduction
Surgical technique
Thymectomy, the surgical resection of the thymus gland, is part of the multidisciplinary treatment of myasthenia gravis (MG). Although the procedure is well known from the Blalock era, only a recent prospective randomized clinical trial demonstrated the benefits in myasthenic patients [1]. In the modern era, thymectomy has role and indication in all myasthenic patients with thymoma and in a proportion of patients affected by non-thymomatous generalized MG [1, 2]. A robotic-assisted thymectomy can be a challenging procedure in the existence of a pectus excavatum chest wall deformity. The limited anterior mediastinal space renders the positioning of the robotic arms and movement of the instruments into the thoracic cavity more difficult. Therefore, it might compromise the results of the procedure and increase the risk of intraoperative complications. In this report, we suggest that the correction of pectus excavatum deformity with a vacuum bell device during the procedure can facilitate robotic approach in the anterior mediastinum and contribute to a safe procedure in an optimised surgical field.
In this report, we review the case of a 32-year-old patient, who presented with seropositive myasthenia gravis, computed tomography (CT) of the chest suspicious of thymoma and concurrent pectus excavatum deformity with a maximum depth of 3 cm in the CT scan (Fig. 1). We offer right-sided robotic thymectomy to all patients with myasthenia gravis with or without thymoma. Under general anaesthesia, the patient is intubated with a double lumen endotracheal tube in supine position. The right arm to be suspended below the plane of the body against the edge of the table. A gel roll and a bean bag are placed from the patient’s hip to the shoulder, elevating the right hemithorax and posterior axillary line. The robot is brought over the left shoulder and the anaesthetist is positioned on patient’s right shoulder. A slight, 5°–10°, reverse Trendelenburg position is preferred to allow the diaphragm and mediastinum to fall away from the neck. We applied a 19 cm femaletype vacuum bell on the chest of the patient covering fully the deformity and negative pressure was applied until the skin covered the surface of the transparent plastic part of the vacuum bel
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