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J Thorac Cardiovasc Surg 1997;114:516-517
© 1997 Mosby, Inc.

LETTERS TO THE EDITOR

Video-assisted thoracoscopic thymectomy: From the right or from the left?

Department of Thoracic Surgery
Myasthenia Gravis Unit
Tor Vergata University School Of Medicine
Ospedale S. Eugenio
P.le Umanesimo 10—00144 Rome, Italy

To the Editor:

Mack and colleagues ¹ are to be congratulated on their excellent multiinstitutional study on video-assisted thoracoscopic (VAT) thymectomy, which we prefer to perform by the left-sided approach as we have previously described. ² Although we believe that the thymus can be safely approached from either side for VAT techniques, we have chosen the left access for a number of reasons, including our experience with standard surgical transcervical and transsternal approaches. ^{3, 4} First, the left side of the thymus gland is usually larger, extending down to the pericardiophrenic area, and is more frequently affected by neoplastic degeneration. Second, the innominate vein runs mainly in the left region of the anterosuperior mediastinum. Finally, the aortopulmonary window is a frequent site of ectopic thymic tissue, as pointed out by Jaretzki and Wolf. ⁵

It is our impression that all mediastinal perithymic tissue, including fat in the aortopulmonary window, can be totally removed by the left-sided approach. We routinely perform this step in our procedures, considering it essential to achieving intentional extended thymectomy. Adjuvant pneumomediastinum can be considered a useful tool to facilitate all these surgical maneuvers, whatever the VAT approach. We agree that VAT thymectomy is a technically advanced procedure that is gaining acceptance by both patients and neurologists because of the less invasive access and excellent cosmetic results. ¹ In accordance with the intermediate-term results of Mack and colleagues, ¹ our preliminary experience based on 12 VAT thymectomies seems to suggest equivalent results to those provided by conventional surgical techniques.

However, the effectiveness of VAT thymectomy in myasthenia gravis still must be proved by means of a larger series of patients and a longer follow-up. For this purpose we are now completing a prospective multiinstitutional trial on VAT thymectomy performed by a sole left-sided approach.

May one really say that VAT thymectomy is preferable from the right side? Why not from the left? A multiinstitutional comparative study based on a homogeneous series of patients might answer the question before one should decide to insert the thoracoscope through the cervical incision, as properly suggested by Cooper. ⁶

12/8/83413

References

1. Mack JM, Landreneau R, Yim AP, Hazelrigg SR, Scruggs GR. Results of video-assisted thymectomy in patients with myasthenia gravis. J Thorac Cardiovasc Surg 1996;112:1352-60. [Abstract/Free Full Text]
   
2. Mineo TC, Pompeo E, Ambrogi V, Sabato AF, Bernardi G, Casciani CU. Adjuvant pneumomediastinum in thoracoscopic thymectomy for myasthenia gravis. Ann Thorac Surg 1996;62:1210-2. [Abstract/Free Full Text]
   
3. Mineo TC, Cirulli G, Rea S, De Leo G, Ricci C. La via transcervicale della chirurgia del timo. Sett Osped 1978;20:59-63.
   
4. Mineo TC, Terapia chirurgica della miastenia grave. Atti Acad Lancisiana Roma 1978;23:1-12.
   
5. Jaretzki A, Wolf M. "Maximal" thymectomy for myasthenia gravis: surgical anatomy and operative technique. J Thorac Cardiovasc Surg 1988;96:711-6. [Abstract]
   
6. Cooper JD. Discussion of Mack et al. ¹
   

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