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Eur J Cardiothorac Surg 2007;31:501-505. doi:10.1016/j.ejcts.2006.12.016
Copyright © 2007, European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved

A comparison of outcomes after robotic open extended thymectomy for myasthenia gravis

Ferguel Cakara,1, Philipp Wernerb,1, Florian Augustina, Thomas Schmida, Astrid Wolf-Magelea, Michael Sieba, Johannes Bodnera,*

a Department of General and Transplant Surgery, Innsbruck Medical University, Austria
b Department of Neurology, Innsbruck University Hospital, Innsbruck Medical University, Austria

Received 14 September 2006; received in revised form 7 December 2006; accepted 12 December 2006.

* Corresponding author. Address: Department of General and Transplant Surgery, Innsbruck University Hospital, Anichstrasse 35, A-6020 Innsbruck, Austria. Tel.: +43 512 504 80763; fax: +43 512 504 22577. (Email: johannes.bodner{at}i-med.ac.at).


   Abstract
Top
 Abstract
1. Introduction
 2. Material and methods
 3. Results
 4. Discussion
 Appendix A
 Appendix B
 References
 
Objective: The aim of this study was to analyze the effect of the surgical approach on surgical and neurologic outcomes after extended thymectomy for myasthenia gravis. Methods: A retrospective analysis of the institutional extended thymectomies for myasthenia gravis within the last decade was performed. Patients of group A (open access by total median sternotomy; n = 10; 1996–2002) and of group B (video assisted thoracoscopic surgery approach with the da Vinci robotic system; n = 9; 2003–2006) did not differ with regard to gender distribution, age, body mass index, American Association of Anaesthetists score and Osserman classification of myasthenia gravis. Primary endpoints were surgical complications and the symptomatic/neurologic outcome of the extended thymectomy. Secondary endpoints were operating times and hospital stay. Results: Median follow-up was 74 ± 23 months in group A and 13 ± 10 months in group B. Surgical complications occurred in 4 patients in group A (requiring 2 re-interventions) and in 1 patient in group B (p < 0.05). The median dose of Pyridostigminbromid was reduced 3 and 6 months postoperatively in group A to 80% and 60% of the preoperative level and in group B to 66% and 60% of the preoperative level, respectively. Within the first postoperative year all patients of group B had an improvement of their disease whereas 2 patients of group A did not benefit from thymectomy or had a worsening of symptoms. Operating times were significantly shorter in group A (110 (42–152) min vs 154 (94–312) min, p < 0.05), hospital stay was significantly shorter in group B (5 (4–15) vs 10 (10–23) days, p < 0.05). Conclusions: The results of this small series favour the robotic approach for extended thymectomy for myasthenia gravis in respect of both surgical and early neurologic outcome. However, prospective randomized trials are required to prove a general validity.

Key Words: Myasthenia gravis • Thymectomy • Sternotomy • Robotic surgery • Thoracoscopy


   1. Introduction
Top
 Abstract
 1. Introduction
2. Material and methods
 3. Results
 4. Discussion
 Appendix A
 Appendix B
 References
 
Extended thymectomy is a generally accepted option in the treatment algorithm of myasthenia gravis [1]. It cannot only benefit thymoma patients but is used independent of the morphologic state of the thymus.

In myasthenia gravis a meticulous resection of the bilaterally extended thymic gland and all retrosternal tissue between both phrenic nerves and down to the diaphragm is mandatory for immunologic and oncologic reasons. This is most easily achieved with a median sternotomy but is accompanied by the morbidity of a major thoracic procedure. The minimally invasive approach by means of conventional video assisted thoracoscopic surgery () is feasible but technically more demanding due to limitated vision and instrument maneuverability.

The three-dimensional vision system and the multiarticulated instruments of the da Vinci surgical robotic system (Surgical Intuitive, Inc., Mountain View, CA, USA) allow an intuitive, ‘open-like’ intervention but with minimally invasive access. Recently, the mediastinum has been found to be a predestined anatomic region for robotic procedures, and robotic extended thymectomy has been shown to be feasible and safe [2,3].

This study aimed to determine whether the surgical and neurologic results following extended thymectomy for myasthenia gravis differ for the open and the minimally invasive robotic approaches.


   2. Material and methods
Top
 Abstract
 1. Introduction
 2. Material and methods
3. Results
 4. Discussion
 Appendix A
 Appendix B
 References
 
This study included 19 patients who underwent thymectomy for myasthenia gravis between 1996 and 2006. Patients in group A (open access with total median sternotomy; n = 10; 1996–2002) and group B (VATS approach with the da Vinci robotic system; n = 9; 2003–2006) were analyzed in terms of preoperative data (age, gender, American Society of Anesthesiologists Score (ASA), body mass index (BMI)), operation data (operating time, intraoperative complications) and postoperative data (postoperative complications, duration of hospital stay, amount and duration of chest tube drainage and symptomatic/neurologic outcome assessed by means of drug reduction and DeFilippi classification of remission (Table 1 ), [4]). The diagnosis of myasthenia gravis was based on the patient's history, physical examination, positive response to anticholinesterase agents, and, when available, positive acetylcholine receptor antibodies and electrophysiology studies. Disease severity was classified according to the Osserman criteria (Table 2 ), [5]).


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  		Table 1 DeFilippi classification of remission
 

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  		Table 2 Disease classification of myasthenia gravis, Osserman criteria
 
2.1 Operative technique
Preoperative management included a CT scan of the chest and pulmonary function tests.

An extended thymectomy with en bloc resection of the anterior mediastinal fat tissue following the rules of Masaoka et al. [6] was performed in all patients regardless of the kind of surgical access. The adipose tissue around the upper poles of the thymus, both brachiocephalic veins and on the pericardium was resected meticulously. The resection borders were the diaphragm caudally, the thyroid gland cranially, and the phrenic nerves laterally.

The transsternal thymectomy was performed through a complete longitudinal sternotomy. The sternal edges were retracted with a sternal retractor. The specimen was dissected free using blunt and sharp dissection and removed. A chest tube was inserted into the anterior mediastinum through a separate substernal incision, and an additional chest tube was placed if the pleural cavity was opened. For closure the sternal edges were approximated with six or seven steel wire sutures.

In the robotic procedure, the port for the robotic endoscope was positioned in the 6th intercostal space in the middle axillary line. The two robotic instrument ports were placed in the 3rd and the 6th intercostal space, one handbreadth left and right of the camera trocar, respectively. An auxiliary port was positioned dorsal between the camera and the left instrument trocar [7]. For dissection, the Cadiere forceps (Surgical Intuitive, Inc., Mountain View, CA, USA) were attached to the robot's left arm, which was mainly used to grasp the tissue. Dissection was performed with a robotic cautery hook on the right arm, starting medially to the right phrenic nerve and working from caudal to cranial. Dissection then continued to the substernal region, already opening the controlateral pleural cavity. In some cases when the en bloc extirpation of fat tissue in the lower anterior mediastinum was hindered by collision of the left robotic arm with the patient's shoulder, a curved thoracoscopic grasper was inserted via the auxiliary port to achieve better exposure. The thymus was freed from the pericardium and dissection proceeded as far as the thymic veins. This was followed by dissection of the right and left upper horn and transsection of the thymic vein(s) (). Larger vessels were clipped, smaller ones were sealed by electrocautery. Also, the left thymic lobe was dissected accurately from a right-sided access. The specimen was removed in an endobag (US Surgical, Norwalk, CT). A single chest tube was inserted into the right pleural cavity.

Data are provided as median (range). With regard to the small number of patients and abnormal distribution of data, the Mann-Whitney U test was used for statistical calculation using SPSS 11.0 for Windows. A p value of <0.05 was considered significant.

Regarding the symptomatic/neurologic outcome all patients were routinely followed-up 3, 6 and every further 6 months postoperatively. (However, not all patients followed every particular appointment and missing data are noted in Table 4).


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  		Table 4 DeFilippi classification of remission 3 and 6 months postoperative
 

   3. Results
Top
 Abstract
 1. Introduction
 2. Material and methods
 3. Results
4. Discussion
 Appendix A
 Appendix B
 References
 
Treatment groups were identical with regard to preoperative management and aftercare operations. Patients in the two groups did not differ with regard to gender distribution, age, BMI, ASA score or Osserman classification of myasthenia gravis (Table 3 ). However, follow-up was 74 ± 23 months in group A versus 13 ± 10 months in group B (for the robotic approach, which was introduced only in 2003).


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  		Table 3 Preoperative Osserman classification of patients of group A and B
 
No major intraoperative surgical complications were observed in either group. Estimated blood loss was <50 cc in all cases. There were no open conversions in group B, and the da Vinci system itself did not show any technical failure.

All patients were extubated within 2 h after operation. None of the patients in either group experienced a myasthenic crisis, required re-intubation or mechanical ventilation.

There were three postoperative complications in group A (30%), prompting two redo-operations: a hematoma caused a revision in patient #1 on postoperative day 6 and a tension pneumothorax was drained with a chest tube in patient #10. One minor complication was a wound infection in patient #4. In contrast, a wound infection on a port site in patient #14 was the only postoperative complication in group B (11%). Embolization of left pulmonary artery occurred in the same patient and was sucessfully treated by intravenous anticoagulation therapy.

Overall operating time was 110 (42–152) min in group A versus 154 (94–312) min in group B (p < 0.05). Drains were removed on postoperative day 3 in group A and on postoperative day 2 in group B. Postoperative hospital stay was 10 (10–23) days in group A and 5 (4–15) days in group B (p < 0.05). Of note is the fact that hospital stay is generally prolonged in Austria due to less pressure from insurance companies.

Median oral pyridostigmin bromide therapy was reduced 3 and 6 months postoperatively to 80% and 60% of the preoperative dose in group A and to 66% and 60%in group B, respectively. Three-, six- and twelve-month postoperative neurologic outcome according to the DeFilippi classification of remission is shown in Table 4 . Whereas all patients of group B had an improvement of their disease (DeFilippi 1-3) at any time, 2 patients of group A did not benefit from thymectomy but experienced no change (DeFilippi 4, n = 1) or a worsening of symptoms (DeFilippi 5, n = 1).

The percentage of patients with a thymoma diagnosed in the resected specimen was higher in group B (4 out of 9, 44%) than in group A (3 out of 10, 30%). However, stage distribution in terms of Muller-Hermelink and WHO classification was similar in both groups (Table 5 ). Pathology revealed totally intact capsules in all thymoma specimens.


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  		Table 5 Stage distribution of patients with thymoma (Muller-Hermelink and WHO)
 

   4. Discussion
Top
 Abstract
 1. Introduction
 2. Material and methods
 3. Results
 4. Discussion
Appendix A
 Appendix B
 References
 
Myasthenia gravis is a chronic, autoimmune disorder of the postsynaptic neuromuscular junction characterized by fatigability of voluntary muscles. The prevalence of mysthenia gravis is approximately five in 100,000 [8]. Treatment includes medical therapy with cholinesterase inhibitors, immunosuppressive medication, or surgery. Thymectomy for myasthenia gravis was first performed by Sauerbruch in 1911 [9]. The efficacy of surgery was first proven by Buckingham, who compared the clinical course of patients after thymectomy with a matched cohort receiving medical therapy [10]. Since then, thymectomy has become an accepted treatment option for myasthenia gravis.

In myasthenia gravis acetylcholine receptor antibodies block the binding of acetylcholine to its receptor at the neuromuscular junction. The rationale for thymectomy is that initial antiacetylcholine receptor sensitization probably occurs in the thymus, and the thymus is a proposed site of acetylcholine receptor antibody production. However, the mechanism by which thymectomy improves the symptoms of myasthenia gravis is not completely known. Removal of the thymus may eliminate a source of continued antigenic stimulation. Also, thymectomy may remove a reservoir of B cells secreting antiacetylcholine receptor antibody [11].

The initial approach to thymectomy through a median sternotomy [6,9,12,13] has been gradually displaced by more minimally invasive techniques [14–16]. The recent introduction of robotic surgical systems marks the momentary end of this process. Although shown to be feasible [2,3], the efficacy of the robotic approach for myasthenia gravis remains to be proven. Thus, the purpose of this study was to compare our first series of patients in which a robotic thymectomy was performed with a former group of patients operated on with the transsternal, open approach.

Our results suggest that robotic thymectomy in patients with myasthenia gravis provides at least the same positive effect as open transsternal thymectomy with regard to improvement of neuro-muscular symptoms and drug dose reduction, but with a lower rate of complication and re-intervention. The clinical outcome as assessed by the DeFilippi classification of remission favours the robotic approach. These findings support our opinion that it is possible to dissect and extract at least the same amount of mediastinal fat tissue in addition to thymic tissue with a unilateral robotic technique as with the sternotomy technique. Especially the pericardiophrenic fat tissue was more easily resected with the robotic approach. Although economic aspects were not calculated in this study, it is evident, that the extra costs of the significantly longer operating time in the robotic group are certainly compensated by the 5 days shorter hospital stay.

Of note is the high percentage of thymomas in the resected specimens, especially in group B patients. This aspect of our treatment policy might deserve criticism as the generally accepted gold standard approach in patients with thymomas – with or without myasthenia gravis – is still the transsternal open approach [17]. The concerns involved with minimally invasive techniques do exist in oncologic respects [18]. Indeed conventional thoracoscopy showed determination of the tumor borders and of potential infiltration into adjoining tissues to be crucial due to the flat two-dimensional camera image. Furthermore, precise dissection in conventional thoracoscopy demands great experience and technical skills. However, robotic surgery with the da Vinci system enables a totally different kind of minimally invasive surgery. The three-dimensional image on the console and the seven degrees of freedom of the multiarticular instruments allow very precise dissection, especially in tiny and difficult to reach anatomic areas, as is the mediastinum. Encouraged by laboratory and early clinical experience, we felt that we can account for the application of the robotic technique even in thymoma patients. We have been proven right in this decision by the histologic results of the specimens and the postoperative oncologic course of the patients, who have shown no signs of recurrence to date. Nevertheless, we have restricted the robotic approach to lesions smaller than 3 cm.

Today, various approaches are available for thymectomy in addition to the open transsternal and the robotic approach [19–25]. Comparison of two minimally invasive approaches like the conventional thoracoscopic and the robotic thoracoscopic approach might have provided even more meaningful results with regard to the effect of the robotic technology itself. However, the aim of this study was to compare the very new robotic approach with the momentary gold standard surgical approach for thymectomy, which is still the median sternotomy.

This study showed the robotic approach proven to provide benefits over the momentary gold standard transsternal approach for thymectomy in patients with myasthenia gravis. The small number of patients and the non-randomized retrospective design may make it very difficult to generalize these results. The follow-up periods in both groups differed significantly, which is a common problem when comparing consecutive surgical techniques. Thus, this outcome analysis can not compete with the results of prospective randomized trials. However, as such trials do not yet exist, it is important to present the momentary standard of knowledge and experience, thereby underscoring the need for prospective trials.


   Appendix A
Top
 Abstract
 1. Introduction
 2. Material and methods
 3. Results
 4. Discussion
 Appendix A
Appendix B
 References
 
Conference discussion

Dr M. Dusmet (London, United Kingdom): I would like to challenge you just a little bit on a couple of points. First of all, if you read slightly older literature, you’ll find three series, Papatestas, Maggi, and the Levasseur group in Paris, 1,700 patients – I think that's a big enough number – of transcervical thymectomy, and I think that you’ll find that extended thymectomy, the gold standard, is a somewhat difficult concept to really sustain. If you want big numbers, 1,700 patients, that's pretty big numbers. Transcervical thymectomy gives excellent results. So I challenge you that the extended transsternal thymectomy is perhaps not the only gold standard, especially if you want minimally invasive techniques.

The second thing that I’m slightly surprised by is the 10-day average stay for a transsternal thymectomy. I find that when I split the sternum and do a simple thymectomy, most of my patients are going home on day 3, day 4. So why are your patients spending 10 days in the hospital just because they have had their sternum split?

Dr Bodner: I think you are definitely right. As mentioned, there is a variety of different approaches, and maybe it's not only the transsternal approach to be called the gold standard; however, it's an approach which gives an excellent exposure to all of the mediastinum, and therefore I think for a variety of surgeons for a very long period of time it has been accepted as the gold standard, and different minimally invasive or semi-minimally invasive or combined approaches have been established.

To your other question, I think that's also a question of policy within different nations and states. We feel less pressure by the insurance companies regarding the period of hospital stay. And we do not send them back to any referring hospital, but we discharge them and they go home. So with our stay, they usually go home in the times as shown on these slides.

Dr Dusmet: When I said discharged home, I meant discharged home, not discharged to another hospital. I meant home, taking care of themselves, on day 3 and day 4.

Dr Bodner: I definitely accept your point of view. I just wanted to say that in our country these times are quite usual.

Dr P. Van Schil (Antwerp, Belgium): I agree completely that the robot allows for a very precise anatomical dissection of the thymus. At the breakfast session yesterday, there was an ongoing discussion whether you should do it from the left or the right side or combine it with a cervical or subxiphoid incision. Which technique is your preference?

Secondly, regarding the indications for robotic thymectomy, you said that you also included patients with thymoma. So in your series, did all the patients have thymic hyperplasia and some also had thymoma, or were there cases with thymoma without myasthenia? Could you comment on that also?

Dr Bodner: Regarding your first question, Professor Rueckert has a very large experience on thymectomies. He prefers the left-side approach. We always do it from the right side. We did two cases from the left side after talking with him, but we still feel that we have advantages from the right side.

We have done now about 25, 27 thymectomies with the robot. In this study all patients were myasthenia patients and some of them also had thymoma. Of course, there were other patients with thymoma but not with myasthenia gravis not included in this study. There were other patients without thymoma also in this study.

Dr M. Zielinski (Zakopane, Poland): I would like to support your point of view regarding the gold standard of thymectomy and to defend you against Mr Dusmet. I think that you are right, that transsternal thymectomy should remain the gold standard. Additionally, I would like to add that I also agree with you that there is no need for early discharge of patients after sternotomy. I think that 3 or 4 days is too early, in my opinion. So I totally agree with you. On the other hand, I cannot agree that robotic thymectomy gives you the opportunity to remove as much as during complete sternotomy.

Dr Bodner: The fact that there is such a variety of different approaches for me shows that there is not a perfect approach, and therefore I think these different opinions are justified and we will go on discussing it.

Dr J. Rueckert (Berlin, Germany): I have two comments. The first thing, I would strongly recommend using the MGFA guidelines for functional analysis of the outcome, and you have to use the Kaplan-Meier analysis, including the time of the events, of any event of improvement. The second thing is that the debate between transcervical and transsternal exposure and approaches has never ended. I think there are new data from Kaiser from Philadelphia. We know that the transcervical incision gets good results, but it was never aimed at achieving a radical and complete thymectomy. Proponents have the opinion that it's not necessary to have a complete thymectomy, and the robotic approach combines the striving at radicality and the most minimal invasion, and that's the advantage.

Dr Bodner: Thank you very much. Of course, we will do this. We know your publications and your presentations 3 days ago, and, of course, we will also do this analysis with our patients.


   Appendix B
Top
 Abstract
 1. Introduction
 2. Material and methods
 3. Results
 4. Discussion
 Appendix A
 Appendix B
References
 
Supplementary data

Supplementary data associated with this article can be found, in the online version, at doi:10.1016/j.ejcts.2006.12.016.


   Footnotes
 
\#9734; Presented at the joint 20th Annual Meeting of the European Association for Cardio-thoracic Surgery and the 14th Annual Meeting of the European Society of Thoracic Surgeons, Stockholm, Sweden, September 10–13, 2006.

1 Equally contributed. Back


   References
Top
 Abstract
 1. Introduction
 2. Material and methods
 3. Results
 4. Discussion
 Appendix A
 Appendix B
 References
 

  1. Schwendimann RN, Burton E, Minagar A. Management of myasthenia gravis. Am J Ther 2005;12:262-268.[Medline]
  2. Bodner J, Wykypiel H, Schmid T. Early experience with robot-assisted surgery for mediastinal masses. Ann Thorac Surg 2004;78:259-265.[Abstract/Free Full Text]
  3. Rea F, Marulli G, Bortolotti L. Experience with the ‘da Vinci’ robotic system for thymectomy in patients with myasthenia gravis: report of 33 cases. Ann Thorac Surg 2006;81:455-459.[Abstract/Free Full Text]
  4. DeFilippi VJ, Richman DP, Ferguson MK. Transcervical thymectomy for myasthenia gravis. Ann Thorac Surg 1994;57:194-197.[Abstract]
  5. Osserman KE, Genkins G. Studies in myasthenia gravis: review of a twenty-year experience in over 1200 patients. Mt Sinai J Med 1972;38:497-534.
  6. Masaoka A, Yamakawa Y, Niwa H. Extended thymectomy for myasthenia gravis a 20-year review. Ann Thorac Surg 1996;62:853-859.[Abstract/Free Full Text]
  7. Bodner J, Wykypiel H, Wetscher G, Schmid T. First experiences with the da Vinci operating robot in thoracic surgery. Eur J Cardiothorac Surg 2004;25:844-851.[Abstract/Free Full Text]
  8. Millichap JG, Dodge PR. Diagnosis and treatment of myasthenia gravis in infancy, childhood and adolescence. Neurology 1960;10:1007-1014.[Free Full Text]
  9. Schumacher D, Roth J. Thymectomie bei einem Fall von Morbus basedowii mit Myasthenia. Mitt Gregzeb D Med Chir 1912;25:746.
  10. Buckingham JM, Howard FM, Benrnatz PE. The value of thymectomy in myasthenia gravis: a computer-assisted matched study. Ann Surg 1976;184:453-458.[Medline]
  11. Melms A, Schalke BC, Kirchner HK, Muller-Hermelink HK, Albert E, Wekerle H. Thymus in myasthenia gravis: isolation of T-lymphocyte lines specific for the nicotinic acetylcholine receptor from thymuses of myasthenic patients. J Clin Invest 1988;81:902-908.[Medline]
  12. Jaretzki A, Bethea M, Wolff M, Olarte MR, Lovelace RE, Penn AS, Rowland L. A rational approach to total thymectomy in the treatment of myasthenia gravis. Ann Thorac Surg 1977;24:120-130.[Abstract]
  13. Maggi G, Casadio C, Cavallo A. Thymectomy in myasthenia gravis. Results of 662 cases operated upon in 15 years. Eur J Cardiothorac Surg 1989;3:504-511.[Abstract]
  14. Yim AP, Kay RL, Ho JK. Video-assisted thoracoscopic thymectomy for myasthenia gravis. Chest 1995;108:1440-1443.[Abstract/Free Full Text]
  15. Mack MJ, Landreneau RJ, Yim AP, Hazelrigg SR, Scruggs GR. Results of video-assisted thymectomy in patients with myasthenia gravis. J Thorac Cardiovasc Surg 1996;112:1352-1360.[Abstract/Free Full Text]
  16. Yim AP. Paradigm shift in surgical approaches to thymectomy. ANZ J Surg 2002;72:40-45.[CrossRef][Medline]
  17. Conkle DM, Adkins DM. Primary malignant tumors of the mediastinum. Ann Thorac Surg 1972;14:533-567.[Medline]
  18. Kern JA, Daniel TM, Tribble CG. Thoracoscopic diagnosis and treatment of mediastinal masses. Ann Thorac Surg 1993;56:92-96.[Abstract]
  19. Cooper JD, Al-Jilaihawa AN, Pearson FG. An improved technique to facilitate transcervical thymectomy for myasthenia gravis. Ann Thorac Surg 1988;45:242-247.[Abstract]
  20. Mack MJ, Scruggs G. Video-assisted thoracic surgery thymectomy for myasthenia gravis. Chest Surg Clin N Am 1998;8:809-825.[Medline]
  21. Mineo TC, Pompeo E, Lerut T. Thoracoscopic thymectomy in autoimmune myasthenia results of left-sided approach. Ann Thorac Surg 2000;69:1537-1541.[Abstract/Free Full Text]
  22. Milanez de Campos JR, Filomeno LTB, Marchiori. Parital sternotomy approach to the thymus. In: Yim APC, Hazelrigg SR, Izzat MB, editors. Minimal access cardiothoracic surgery. St Louis, MO: WB Saunders; 2000. pp. 205-208.
  23. Granone P, Margaritora S, Cesario A. Thymectomy in myasthenia gravis via video-assisted infra-mammary cosmetic incision. Eur J Cardiothorac Surg 1999;15:861-863.[Abstract/Free Full Text]
  24. 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 techniques in the treatment of myasthenia gravis. Int Surg 1994;79:378-381.[Medline]
  25. Zielinski M, Kuzdzal J, Szlubowski A. Transcervical-subxiphoid-videothoracoscopic ‘maximal’ thymectomy – operative technique and early results. Ann Thorac Surg 2004;78:404-409.[Abstract/Free Full Text]




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