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Eur J Cardiothorac Surg 1999;15:861-863
© 1999 Elsevier Science NL

How to do it

Thymectomy in myasthenia gravis via video-assisted infra-mammary cosmetic incision

Istituto di Patologia Chirurgica,(Dir Prof. Aurelio Picciocchi), Divisionne Di Chirurgia Toracica, Università Cattolica del Sacro Cuore, Largo A. Gemelli 8, 00168 Rome, Italy

Received 22 September 1998; received in revised form 3 March 1999; accepted 17 March 1999.

Corresponding author. Tel.: +39-6-30154511; fax: +39-6-3051162
e-mail: alfcesario{at}yahoo.com

	Abstract

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion 5. Conclusion References

 
We describe the technique, the benefits and the drawbacks of an original video-assisted thymectomy (VAT), performed through an infra-mammary cosmetic incision and median sternotomy in myasthenia gravis (MG) patients. This procedure is clinically valuable and cosmetically satisfactory so as to be very well accepted by patients, especially by young women. We report a review of 71 MG patients treated between 1993 and 1997. A clinical remission was obtained in 48 (80%) out of 60 patients who had been followed for at least 12 months from surgery. Fifty-three of these patients (93%) judged their cosmetic results to be excellent or good.

Key Words: Video-assisted thymectomy • Myasthenia Gravis • Infra-mammary cosmetic incision

	1. Introduction

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion 5. Conclusion References

 
Thymectomy is considered the most effective treatment for a good and stable improvement in patients with myasthenia gravis (MG). Complete removal of all the mediastinal thymic tissue is necessary to obtain the best results. Thymectomy has been performed through different surgical approaches, including the trans-cervical, the trans-sternal, the combined trans-sternal and trans-cervical and the video assisted approaches. Efficacy has been demonstrated in all of these procedures. We report a 5-year experience with thymectomy in MG patients performed with the aid of video-assisted thymectomy (VAT) through an infra-mammary cosmetic incision and median sternotomy.

	2. Materials and methods

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion 5. Conclusion References

 
2.1. Patient population
In the period from 1993 to 1997, 71 patients with MG underwent thymectomy at the General Thoracic Surgery Division of the Catholic University of Rome. Patients with clinical evidence or suspicion of thymoma were excluded. Follow-up, including a cosmetic evaluation, has been obtained through outpatient clinic visits and phone conversations.

2.2. Surgical technique
The patient was supine with the arms resting along the body and the head hyperextended. The cutaneous incision was horizontal, with a length of 5–6 cm, lightly upward curvilinear, 4–5 cm above the xyphoid.

A wide cutaneous-subcutaneous flap was created superiorly to the notch, inferiorly to the linear alba and laterally to the hemiclavear lines. The periosteum of the sternum was cut with the electrocautery along the middle line and the posterior face of the bone was prepared by means of digital manoeuvre. A total median sternotomy was accomplished, the sternum was cut from the xyphoid upward using an orthopaedic chisel, a small retractor was placed and the two halves were separated. The incision of the thyroid's muscle sternal insertion and the cervical fascia completed the exposure of the anterior mediastinum. Once the pericardial fat was dissected, the area of the left pleuro-pericardial angle was explored and all the fatty tissue, to the exposition of the left phrenic nerve, was dissected. The thymus was then separated from the left brachio-cephalic vein, with the surrounding fatty tissue; the left upper pole of the thymus was set free by traction of serially applied clamps and gauze-pledget dissection, after the section of the Keynes’ veins. The same procedure was performed on the right side. The thymus was removed en bloc with all the mediastinal fatty tissue. Pleural membranes were not opened. The cutaneous-subcutaneous flap, which interferes with direct vision, affected the preparation of the phrenic nerves, the thymic veins and the gland's upper poles. For these steps and for the fatty tissue radical dissection the use of the thoracoscope was really helpful. In fact, through the use of the thoracoscope the anatomic structures were enhanced and dissection manoeuvres could be performed with usual surgical instruments while looking at the monitor. Pleural drainage was not used unless the pleura was inadvertently entered; single mediastinal drainage was employed. The sternum was closed using re-absorbable sutures. The subcutaneous flap was obliterated and a tight dressing was put after the suture of the cutaneous incision to prevent the formation of seromas.

	3. Results

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion 5. Conclusion References

 
All the patients were transferred to the ICU for the first 24 post-operative hours. No prolonged intubation was needed. No intra or postoperative death or major complications were reported. Mean hospitalization length was 8.3 days (range 7–14 days). We reported four post-operative minor complications, i.e. two wound suppurations and two subcutaneous hematomas. The evaluation of clinical and cosmetic results was obtained through clinical observation immediately after operation, and then every 6 months.

At times of clinical evaluation patients were asked about the cosmetic outcome of their operation. Cosmetic results are reported in Table 1 and Fig. 1.

View larger version (103K): [in this window] [in a new window]   Fig. 1. Six months cosmetic result (I).

	4. Discussion

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion 5. Conclusion References

 
Since the first case was reported by Schumacher and Roth [1], the role of thymectomy in the treatment of MG is now well established. Several approaches have been described including trans-cervical [2]; trans-sternal [3]; ‘combined’ trans-cervical plus trans-sternal (the so-called ‘maximal thymectomy’) [4], and VAT [5–7]. From a comparison of the data reported in the literature, the ‘maximal thymectomy’ is the most radical and effective approach for thymectomy in MG, but an ‘extended’ thymectomy through a sternotomic approach without cervicotomy allows comparable results to be obtained. On the basis of the reported evidences we consider the median sternotomy as the approach of choice in MG patients. In 1992 Orringer [8] described an access to the anterior superior mediastinum performed through a 5–6 cm curvilinear ‘smile’ incision just below the sterno-manubrial junction and a partial upper sternal split with a cosmetic result in our opinion still unsatisfactory. However, we derived the idea of moving few centimetres downward the line of incision and to create a sub-cutaneous flap to perform a complete median sternotomy. The aid of VAT in the dissection of the upper region of the anterior mediastinum is added because the flap affects the direct vision of the area.

	5. Conclusion

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion 5. Conclusion References

 
The approach to total median sternotomy we described to perform an ‘extended’ thymectomy is clinically valuable and did not afflict significantly the intra and post-operative morbidity. The size and location of the incision is very well accepted by patients, especially by young women.

	Footnotes

 
Presented at the 12th Annual Meeting of the European Association for Cardio-thoracic Surgery, Brussels, Belgium, September 20–23, 1998.

	References

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion 5. Conclusion References

 

1. Schumacher E.D., Roth J. Thymektomie bei cenem Fall von Morbus Basedowii mit Myasthenie. Mitt a.d. Grezgeb d. Med Chir 1912;25:746.
2. Crile G., Jr Thymectomy through the neck. Surgery 1964;59:213-215.
3. Kreel I., Ossermann K., Genkins G., Kark A.E. Role of thymectomy in the management of myasthenia gravis. Ann Surg 1967;165(1):111-117.[Medline]
4. Jaretzky A., III, Bethea M., Wolff M., Olarte M., Lovelace R.E., Penn A.S., Rowland L. A rational approach to total thymectomy in the treatment of myasthenia gravis. Ann Thor Surg 1977;24(2):120-130.[Abstract]
5. Landreneau R.J., Dowling R.D., Castillo W.M., Ferson P. Thoracoscopic resection of an anterior mediastinal tumor. Ann Thor Surg 1992;54:142-144.[Abstract]
6. Novellino L., Longoni M., Spinelli L., Andretta M., Cozzi M., Faillace G., Vitellaro M., De Benedetti D., Pezzuoli G. Extended thymectomy, without sternotomy, performed by cervicotomy and thoracoscopic technique in the treatment of myasthenia gravis. Int Surg 1994;79:378-381.[Medline]
7. Mack J.M., Landreneau R.J., Yim A.P., Hazelrigg S.R., Scruggs G.R. Results of video-assisted thymectomy in patients with myasthenia gravis. J Thorac Cardiovasc Surg 1996;112:1352-1360.[Abstract/Free Full Text]
8. Orringer MB. Access to the anterior superior mediastinum. Proceedings from the General Thoracic Surgery Postgraduate Course. 78th Congress of the American College of Surgeons, October 11–16. New Orleans, 1992:19-21.

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