TAKAHIRO NEGI

We report the surgical technique for subxiphoid robotic thymectomy with combined superior vena cava (SVC) resection. A blood-drainage cannula was inserted into the left internal jugular vein as a blood-drainage route. A blood infusion cannula was inserted into the left femoral vein. During SVC clamping, an assistant pumped blood through the circuit to prevent clotting. The tumour, SVC, thymus, part of the pericardium and part of the right lung were excised en bloc through a subxiphoid incision. We limited reconstruction to the right brachiocephalic-SVC anastomosis. Robotic-assisted thymectomy via the subxiphoid approach enables SVC replacement, which was previously feasible only with open surgery.

OBJECTIVE: Thymomas sometimes are located in the cervical region, and strategies are needed to safely remove these tumors. The purpose of this study was to evaluate the feasibility and safety of subxiphoid robotic thymectomy (SRT) for anterior mediastinal tumors located in cervical region. METHODS: This was a retrospective database review of patients who underwent SRT from January 2011 to April 2024. Of the 81 patients who underwent SRT for anterior mediastinal tumors, 79 patients were included, excluding 2 patients who underwent reconstruction using artificial blood vessels. RESULTS: In total, 41 patients in whom part of the tumor was located above or in contact with the innominate vein were classified as group A, and 38 patients in which the tumor was located caudal to the innominate vein were classified as group B. The patients in group A were significantly younger (median, 54 years vs 63 years; P = .035). There were no differences in perioperative data between the 2 groups: operative time (median, 192 vs 188 minutes; P = .961), intraoperative blood loss (median: 5 vs 5 g; P = .235), combined resection rate (17.1% vs 21.1%; P = .776), duration of thoracic drain insertion (median: 1 vs 1 day; P = .221), postoperative hospital stay (median: 4 vs 4 day; P = .694), and postoperative complications (9.8% vs 5.3%; P = .677). Conversion to other approaches and perioperative mortality were not observed in either group. CONCLUSIONS: SRT, which enables full visualization of the innominate vein from the midline view, may offer increased safety for complicated thymectomies, including those requiring combined resection of the innominate vein, and may demonstrate safety comparable with that of procedures performed for cases caudal to the innominate vein.

We report subxiphoid uniportal robotic thymectomy without intercostal access using the da Vinci Xi multi-port robot system. A 4-cm vertical incision was made 1 cm caudal to the xiphoid process. The AIRSEAL ROBOTIC SOLUTION, an air seal system compatible with the da Vinci port was used to insufflate CO2 at 8 mmHg. During port insertion, the left and right hands were crossed into the wound, with the camera, left hand, and right hand inserted in the order from the anterior chest to the dorsal side. To reduce the interference between the ports at the head, a key technique is to pull the camera port forward to prevent it from colliding with the other ports. Subxiphoid uniportal robotic thymectomy using the da Vinci Xi is a technique that combines excellent surgical visibility from the subxiphoid process, minimal invasiveness and enhanced operability provided by the robotic system.

We performed the first case of major lung resection using the hinotori™ surgical robot system, which is a new surgical support robot system developed in Japan. A left lower lobectomy and subcarinal lymph node dissection were performed. The operation time was 3 h and 5 min, the cockpit time (console time) was 2 h and 5 min, and the blood loss was 40 g. Although the hinotori™ surgical robot system requires further improvements to be used for lung cancer surgery, even in its current state, there is no difference in operability compared to the da Vinci robot, and it is possible to perform the same surgery. Further evaluation with additional cases is required in future.

BACKGROUND: We previously reported on subxiphoid uniportal thymectomy (SUT) and subxiphoid robotic thymectomy (SRT). This descriptive study aimed to evaluate the feasibility and safety of both SUT and SRT techniques. METHODS: Between March 2011 and December 2022, 268 patients underwent subxiphoid thymectomy. In cases demonstrating no evidence of invasion into other organs, SUT was selected due to its minimal invasiveness. In cases where the tumor was in contact with the innominate vein or those with suspected invasion into other organs, SRT with additional intercostal ports was selected due to the enhanced operability provided by the robotic system. The patients' backgrounds and the perioperative outcomes of each technique were evaluated. RESULTS: SUT was performed in 207 patients, while SRT was performed in 61 patients. In the SUT group, 15 patients required an additional intercostal port, and 2 patients required a median sternotomy; the SUT completion rate was 91.78%. The median operative time was 117.00 [interquartile range (IQR), 88.00-148.50] min, with a median blood loss of 5.00 (IQR, 1.00-5.00) mL. Combined resection was performed in 11 (5.31%) patients, and postoperative complications were observed in 4 patients (1.93%). None of the patients in the SRT group required median sternotomy. The median operative time was 203.00 (IQR, 158.00-278.00) min, with a median blood loss of 5.00 (IQR, 5.00-22.00) mL. Combined resection was performed in 14 patients (22.95%), and postoperative complications were observed in 5 patients (8.20%). No mortalities occurred in either group. CONCLUSIONS: Subxiphoid thymectomy is a safe and feasible technique for both early and advanced stages of the disease requiring complex surgical procedures.