Chapter 1 of 5 · Surgical Management
Setup & exposure
Patient positioning, port placement, and initial thymic exposure
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What the experts said
The procedure is performed in a seven-year-old patient with myasthenia gravis.
Patient positioning is modified supine with the left side elevated 30 degrees.
3-5 millimeter ports are used for the procedure.
Upon entering the chest, the thymic gland is easily visualized with its surrounding fat pad.
Blunt dissection is used to dissect the thymus off the pericardium.
The phrenic nerve and its surrounding vessels are visible at the lower end of the field.
Great care must be taken to ensure that the phrenic nerve is not damaged during the dissection.
Any dissection using cautery or sharp dissection should be well medial to the phrenic nerve.
The pleura overlying the anterior of the thymus and extending up into the neck is divided, giving access to the left upper pole of the thymus.
The majority of the mobilization is done bluntly to avoid injury to surrounding structures.
Blunt dissection allows easy access up into the thoracic inlet and well above the sternal notch.
Mild gentle traction downward on the left lower pole of the thymus allows exposure of the upper pole.
A lateral division is safely performed, ensuring complete resection of the upper pole of the thymus while preserving the phrenic nerve.
The innominate vein and the thymic vein, which drains directly into the innominate, are identified during dissection.
The thymic vein comes off the back wall of the thymus near the isthmus of the thymus.
The thymic vein is sealed and divided using a ligature device.
There are a number of other small perforating arteries and veins, but none are of significant size and usually can be taken easily using the ligature device.
The thymus gland is pulled into the left chest, thereby pulling over the majority of the right lobe of the thymus.
After the thymic gland is divided, a careful inspection of the mediastinum is made to ensure that no thymic tissue is left.
The right lung is herniating over with its pleura intact.
Tissue that could be residual thymic gland is identified, and although it is not clear that this is exactly thymic tissue, it must be excised to ensure a complete thymectomy.
Continual gradual traction into the left chest allows for safe dissection without injury to the phrenic nerve.
Any residual fat extending up into the thoracic inlet should be removed.
The lower port is changed for a 10 millimeter trocar, and the thymus is placed in an endobag and brought out through the wound.
Final inspection of the thoracic inlet and suprasternal area shows no residual gland.
The patient had an uncomplicated course and was discharged on the 2nd postoperative day.