Right thoracoscopic thymectomy
During last years, open thymectomies have evolved into minimally invasive ones. Many approaches have been described, but they are esentially complete thoracoscopic approach (either unilateral or bilateral), uniportal VATS and subxiphoid uniportal VATS.
Here I'm going to describe the technique of unilateral right complete thoracoscopic approach, which is the one I'm more experienced.
Complete thoracoscopic means multiportal thoracocopy, without utility incisions and with CO2 insuflation.
Patient position is supine decubitus with 30º oblique angulation by elevating the right side. I usually hang the right arm in a right-angle hanger positioned in the opposite side of the operating bed. This way the instrument for your left hand is not continuously hitting the hanger.
Port location has not to be dogmatic: I always first place the lower 11 mm port for the 10 mm 30º thoracoscope, approximately in the anterior axillary line just above the diaphragm (7th-8th intercostal space). Then I place the other 2 5 mm ports under direct view, approximately in the 3rd and 5th intercostal space, but for obese patients sometimes you need to place them in the 2nd and 4th.
CO2 is insuflated by the camera port at about 10-12 mmHg pressure. There is no need for one-lung ventilation; a simple orotracheal tube can be placed and with CO2 insuflation lung collapses amazingly. When positioning the camera port, ask the anesthesiologist to stop ventilation for a moment (apnea) in order to avoid lung injury.
Under this position and approach, you get a horizontal view of anterior mediastinum. I usually start opening mediastinal pleura and removing thymus/mediastinal fat from the lower mediastinum, just in contact with the pericardium. You can easilly identify the right phrenic nerve, so your dissection starts just preserving the nerve.
As you progress in your mediastinal dissection, CO2 widens the mediastinum so the view becomes really awesome and detailed.
In relation to achieving complete resection until the contralateral phrenic nerve, I find really useful to open the contralateral pleural to identify the excat location of phrenic nerve, specially when approaching the left upper horn where the nerve becomes more anterior. Opening the pleura is not a problem and can be drained postoperatively with the right chest tube with no complications, and prevents a huge complication as a phrenic nerve injury.
I usually take my dissection from inferior to superior, and from right to left; when I approach the confluence of innominate vein and superior vena cava, it's really easy to follow from that point innominate vein in order to identify thymic veins, that can be easilly divided with endoscopic clips.
It's also important to precisely dissect the thymus and the fatty tissue from the anterior wall, this is the sternum and keep in mind bilateral mammary vessels.
Right horn is easilly resected but left horn can be a little bit more difficult to identify: usually you find it after dividing thymic vessels, as a more dense tissue going towards the neck.
Thoracoscopic approach for thymectomy is a smooth procedure, and if you progress gently the dissection there is almost no bleeding.
At the end, I usually enlarge the middle incision to remove the specimen, and use it to introduce the chest tube; then you close all the incisions.
Bipolar energy in devices such as Ligasure Maryland, or Ultrasound energy in devices such as Ultracision Harmonic Scalpel is really useful in terms of safety and blunt dissection.