Phrenic nerve interposition in a completely portal robotic thymectomy

摘要

Central MessageRobotic-assisted surgery may be useful in reconstructive procedures. This report demonstrates the technical tips for phrenic nerve interposition in a completely portal robotic thymectomy.See Commentary on page XXX. Robotic-assisted surgery may be useful in reconstructive procedures. This report demonstrates the technical tips for phrenic nerve interposition in a completely portal robotic thymectomy. See Commentary on page XXX. Robotic-assisted surgery allows precise and stable surgical manipulation owing to its dexterity and magnified stereoscopic view during minimally invasive surgery. These characteristics can facilitate the anastomosis of small and delicate structures, such as bile duct anastomosis or coronary artery bypass surgery.1Cao C. Indraratna P. Doyle M. Tian D.H. Liou K. Munkholm-Larsen S. et al.A systematic review on robotic coronary artery bypass graft surgery.Ann Cardiothorac Surg. 2016; 5: 530-543Crossref PubMed Scopus (36) Google Scholar However, reports on robotic-assisted nerve reconstruction are limited despite its theoretical advantages. Here, we report a case of robot-assisted thymectomy with reconstruction of the phrenic nerve using a segmental intercostal nerve graft, taking advantage of the benefits of robot-assisted surgery. Institutional review board approval was waived, and a consent form for publication of study data was obtained. A 60-year-old man presented with an anterior mediastinal mass (38 × 18 × 67 mm), detected on chest computed tomography during a medical checkup, which was suspected to be a thymoma (Figure 1 and Video 1). Symptoms of myasthenia gravis were absent, and antiacetylcholine receptor antibodies were negative. Robot-assisted thymectomy via a subxiphoid approach was planned. The Da Vinci Xi (Intuitive Surgical) robotic system was used. The port placement is shown in Figure E1. The camera was inserted through the subxiphoid incision for thymectomy and then switched to the left medial port for phrenic nerve reconstruction using the port-hop function. First, both chest cavities were opened and insufflated with carbon dioxide at 8 mm Hg. The left upper lobe, which was firmly attached to the tumor, was stapled off. The left phrenic nerve was encased in the tumor, and approximately 4 to 5 cm of the nerve was transected. Thymectomy was completed with the specimen removed in a bag. A silk thread was cut to the length of the left phrenic nerve defect (Figure 2, A), and the required length of the intercostal nerve graft was marked on the chest wall in the right third intercostal space (Figure 2, B). The intercostal nerve was carefully dissected and harvested segmentally according to the marked length. Using a 6-0 woven suture, the phrenic nerve and intercostal nerve graft were anastomosed (superior cut end of the phrenic nerve to the posterior end of the intercostal nerve graft). The epineural approach was used with a figure-of-8 suture at each end (Figure 2, C). Phrenic nerve reconstruction was completed without tension at the anastomotic site (Figure 2, D). No postoperative complications occurred. Histopathological analysis of the mass revealed a thymoma (World Health Organization histology type B1-B2; p-stage I or Masaoka stage I). There was no microscopic invasion of the phrenic nerve or lungs. Chest radiographs at 1 and 3 months after surgery are shown in Figure E2. At 3 months, the left diaphragmatic elevation seemed to have recovered. On the sniff test at 1 month postoperatively, paradoxical movement of the left diaphragm (ie, the left diaphragm was rising while the right diaphragm was falling) was observed. At 9 months, movements of the right and left diaphragms were almost synchronous. The patient experienced mild dyspnea on exertion postoperatively, which improved during follow-up. No signs of recurrence were observed during the study period. In this report, we describe a case of robot-assisted thymectomy with combined phrenic nerve resection followed by reconstruc