Subxiphoid robotic thymectomy procedure: tips and pitfalls

Recently, robot-assisted surgery has gained popularity for thymectomy. The advantages of robot-assisted surgery include true three-dimensional (3D) imaging with binocular glasses and the use of multiarticular forceps that allow the performance of high-precision operations. Furthermore, the presence of devices with multiple articulations within the thoracic cavity enables detachment procedures to be achieved in a natural manner. In the subxiphoid robotic thymectomy, the camera scope was inserted through a midline subxiphoid incision, which provides an operative visual field like that obtained during median sternotomy, making it easy to identify the neck structures and the location of the bilateral phrenic nerves and to observe the entire left brachiocephalic vein. This report described the surgical indications and techniques of subxiphoid robot-assisted thymectomy (SRT). The patient is in the supine position with the arms and legs apart. A 3 cm vertical incision is made approximately 1 cm caudal to the xiphoid process. CO₂ insufflation is performed at 8 mmHg. The mediastinal pleura is sectioned bilaterally to expose the thoracic cavity. A 1 cm skin incision is made along each of the bilateral anterior-axillary lines at the sixth intercostal space of the precordium to insert the port for the da Vinci system arm. When using the retraction arm, a port is inserted at least 6 cm from the port on the anterior-axillary line to the mid-axillary line in the right sixth intercostal space. Robot-assisted surgery is performed with multi-articulated forceps that move like human joints. This allows safe clamping of the left brachiocephalic vein even if it is in contact with the tumor. Subxiphoid robotic thymectomy allows for minimally invasive surgery in some patients previously considered unsuitable for thoracoscopic surgery such as in those with brachiocephalic vein involvement or with pericardial invasion requiring a more complicated surgery.