Using robotic technology to improve outcomes in myasthenia gravis and thymoma

December 28, 2011 Brian E. Louie, MD

One of the more challenging aspects of being a surgeon is to understand how new technologies can benefit your patients and how those technologies might become part of your practice. If you’ve watched Grey’s Anatomy, read Time magazine or the Wall Street Journal or surfed the web recently, you’ll be aware of the da Vinci surgical robot. The robot has allowed many different surgical specialties to operate in confined areas of the body with tiny instruments placed through equally small incisions thereby avoiding a larger incision. In thoracic surgery, one of the confined spaces is an area in front of the heart where a gland called the thymus resides.

Most people don’t even realize they have a thymus nor do they know it’s responsible for the development of immunity. However, for a small number of patients the thymus can be source of disease either by generating a tumor called a thymoma or by producing antibodies that block transmission of nerve impulses making the patient fatigue or weaken very quickly which is called myasthenia gravis (MG). Removing the thymus gland (thymectomy) is an important part of the treatment in both diseases.

Traditionally, thymectomy is accomplished by dividing the breast bone (called a sternotomy), which requires a 4-5 day stay in the hospital, pain while the bone healed, a long scar at the front of the chest and 4-6 weeks of recovery. For patients with MG, the recovery can be even more challenging because of the continued weakness created by the disease. In 2008, we began to think about how to lessen the impact of thymectomy on our patients with MG and speed up their recovery. We began to draw on our experience using camera or minimally invasive surgery (called VATS) to remove portions of the lung and apply those same techniques to thymectomy. In the end, VATS thymectomy required 3 or 4 small incisions on each side of the chest and occasionally a small incision at the base of the neck. Fortunately, when we compared these patients with traditional sternotomy their hospital stay was shorter and their recovery much faster.

Even though we were pleased with the improvements from VATS thymectomy, we continued to seek further improvements to benefit the patients. In 2009, we began to explore robotic thymectomy. The robot gave us 3D vision with magnification and instruments with motion similar to the wrist. This allowed us to see and handle the patient’s tissue with substantially more precision than VATS. Because of this, it allowed us to perform robotic thymectomy through 3 small incisions on the right chest. When we reviewed our results with robotic thymectomy, we were surprised to see that robotic thymectomy has allowed us to shorten the length of stay for most patients to about one day in the hospital. But more surprisingly, there seems to be less pain that even VATS thymectomy.

Although more research is still required to determine if robotic thymectomy will produce the same outcomes as thymectomy via sternotomy, the early outcomes have been clearly better than previous techniques (VATS and sternotomy). New technologies have the potential to improve patient outcomes but need to be carefully studied so that patients will maximally benefit.

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