By the time people have reached adulthood, the thymus gland has finished most of its immune-boosting work and slowly shrinks to less than half its original size. Unfortunately, the spongy gland can still pose problems.
Abnormalities and tumors in the thymus, called thymomas, are linked to the neuromuscular disease myasthenia gravis, as well as cancer and other life-threatening conditions. Thymec-tomy, or removal of the thymus, forms the mainstay of treatment, but the traditional form of the surgery can be difficult and require a long hospital stay and significant recuperation. Fortunately, City of Hope surgeons now offer a minimally invasive, robotic-assisted option.
City of Hope thoracic surgeons have begun offering robotic-assisted thymectomies using the da Vinci Surgical System. By using the robot, a surgeon can operate through small incisions while seeing vulnerable structures magnified on a large screen, allowing for more precise surgery. For the patient, such minimally invasive surgery means less pain and pain-controlling drugs, a shorter recovery and less scarring.
Kemp H. Kernstine, M.D., professor of surgery, chief of the Division of Thoracic Surgery and director of the Lung Cancer Program, has performed two dozen robotic-assisted thymectomies, ranking him among the top five surgeons worldwide for such surgeries, according to Intuitive Surgical Inc., the da Vinci system’s maker.
“In traditional surgery, removal of the thymus would require a substantial scar on the chest,” Kernstine said. “Many patients, particularly young women, have been reluctant to undergo surgery because of its invasiveness. But the robot allows us to perform the procedure in a gentler way.
“We hope that this surgical innovation will encourage myasthenia gravis patients to seek treatment earlier in the disease process, which we believe may avert debility.”
When a neurologist refers a myasthenia gravis patient to City of Hope, the patient consults not only with Kernstine, but also with pulmonary and critical care specialist David Horak, M.D., and neurology specialist Harry Openshaw, M.D., to ensure a correct diagnosis and appropriate medical and surgical treatment plan. In addition, patients may need evaluation by the City of Hope plasmaphoresis center to potentially receive a preparation that removes nerve-damaging antibodies from the blood, Kernstine said.
“It’s important that myasthenia gravis patients see a multi-disciplinary team,” Horak said. As Openshaw noted: “The American Academy of Neurology’s practice parameter considers thymectomy as a valid, non-emergency treat-ment option in autoimmune myasthenia gravis. For those with thymoma, surgery is absolutely indicated.”
In a robotic-assisted thymectomy, pencil-thin surgical arms and a camera are attached to the arms of the robot and inserted through small incisions in the patient’s chest (the thymus lies in the upper chest, draped in front of the heart and large vessels, and extends to the neck). A team of surgeons and nurses stands beside the patient, interchanges instruments on the robot and monitors the surgical field.
At the same time, Kernstine sits several feet away at a console, watching on a screen as he manipulates surgical controls at the console.
Traditionally, surgeons have performed thymectomy through an open procedure, which requires sternotomy - an incision in the chest that splits the sternum. That generally requires a five-to-seven-day hospital stay and a six-week recovery. Some surgeons offer a transcervical approach, which consists of surgery done through a incision in the neck - and removal of the thymus by using a retractor to reach under the sternum. But the resulting cramped access to the thymus can make it difficult to thoroughly remove the entire thymus and any thymic islands not associated with the main gland.
The da Vinci system allows the surgeon to perform a similar operation to median sternotomy, the big-incision operation, but through small incisions. Precise control of the instruments using the robot and the magnified view provided may potentially allow for a much more thorough removal of all of the thymic tissue. Patients generally leave the hospital within a day and may return to normal activities within a day or two. Although all patients are different, many patients experience relief from myasthenia gravis symptoms after surgery.
City of Hope surgeons are among the very few who perform these robotic-assisted surgical procedures, which require significant expertise. Worldwide, about 100 surgeons have performed a robotic-assisted thymectomy, but only 10 have performed 10 or more such surgeries.
