VATS Thymectomy

The video-assisted thoracoscopic thymectomy is presented here using a 3-port technique with CO2 insufflation. During operations on the mediastinum, CO2 insufflation significantly facilitates layer-specific dissection, so trocars with appropriate valves and gas connections, as used in visceral surgery. The first access is created via a mini-incision in the area of approximately the 5th intercostal space, anterior axillary line, in extension of the inframammary fold. The placement of the 2 additional incisions should only be performed after inspection of the site. There are various possibilities here. Usually, a trocar in the 3rd intercostal space in the anterior axillary line and another a few centimeters ventral to the first trocar in the same intercostal space are suitable for the additional accesses. Alternatively, a substernal trocar is also possible, which can be more easily expanded for later retrieval in the case of larger tumors.

Note:

• The thoracoscopic thymectomy can be performed from the left as shown here. Alternatively, access from the right or subxiphoidally is also possible.
• Especially in obese patients, CO2 insufflation can be advantageous.

First, the pleural covering at the mediastinum is gradually opened with the endoscopic dissecting scissors. Subsequently, the phrenic nerve must be clearly identified. The nerve forms the lateral resection margin. Through CO2 insufflation, the tissue planes become clearly visible after incision of the pleura, allowing for bloodless and layer-appropriate dissection.

After clearly visualizing the phrenic nerve, further dissection can be continued with a high-energy device to prevent smaller bleedings, which lead to poorer visibility, or later lymphatic fistulas. The dissection is now continued circumferentially around the thymus.

Now follows the visualization of the left thymic horn. Here are also located the thymic veins, which drain blood from the thymus into the left brachiocephalic vein (=vena anonyma). The thymic veins are occasionally so weakly developed that they can be safely transected using a high energy device. Otherwise, clipping is advisable. During dissection, always pay attention to the brachiocephalic vein.