VATS Thymectomy with 3D Vision: A Chance to Further Improve the Outcomes of Thymus Minimally Invasive Surgery
Authors: Federico Attene, Fabrizio Scognamillo, Panagiotis Paliogiannis
Journal: Journal of Thoracic Oncology (2017)

We read with interest the article published in the last issue of the Journal of Thoracic Oncology by Burt et al. regarding the determinants of complete thymoma resection by minimally invasive and open thymectomy.1Burt B.M. Yao X. Shrager J. et al.Determinants of complete resection of thymoma by minimally invasive and open thymectomy: analysis of an international registry.J Thorac Oncol. 2017; 12: 129-136Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar Through a rigorous statistical analysis of data retrieved from one of the most relevant databases worldwide, the authors provided evidence that minimally invasive surgery performed with either video-assisted thoracoscopic surgery (VATS) or robotic-assisted thoracoscopic surgery (RATS) techniques can achieve rates of thymoma complete resection similar to those achieved with open surgery.1Burt B.M. Yao X. Shrager J. et al.Determinants of complete resection of thymoma by minimally invasive and open thymectomy: analysis of an international registry.J Thorac Oncol. 2017; 12: 129-136Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar These findings, in addition to further recent evidence supporting the safety and efficacy of VATS in thymomas and other thymus diseases,2Friedant A.J. Handorf E.A. Su S. Scott W.J. Minimally invasive versus open thymectomy for thymic malignancies: systematic review and meta-analysis.J Thorac Oncol. 2016; 11: 30-38Abstract Full Text Full Text PDF PubMed Scopus (83) Google Scholar, 3Xie A. Tjahjono R. Phan K. Yan T.D. Video-assisted thoracoscopic surgery versus open thymectomy for thymoma: a systematic review.Ann Cardiothorac Surg. 2015; 4: 495-508PubMed Google Scholar, 4Gung Y. Zhang H. Li S. Wang Y. Sternotomy versus video-assisted thoracoscopic surgery for thymectomy of myasthenia gravis patients: a meta-analysis.Asian J Endosc Surg. 2016; 9: 285-294Crossref PubMed Scopus (13) Google Scholar explain the fact that use of minimally invasive surgery has been increasing substantially over time1Burt B.M. Yao X. Shrager J. et al.Determinants of complete resection of thymoma by minimally invasive and open thymectomy: analysis of an international registry.J Thorac Oncol. 2017; 12: 129-136Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar and will potentially represent the definitive standard in the future. To achieve such legitimacy, further technological improvements to the current techniques are necessary. In this letter, we would like to share our recent innovative experience in this regard. VATS represents today the minimally invasive technique most commonly used for thymoma resection (used in 68% of the 461 procedures reported by Burt et al.1Burt B.M. Yao X. Shrager J. et al.Determinants of complete resection of thymoma by minimally invasive and open thymectomy: analysis of an international registry.J Thorac Oncol. 2017; 12: 129-136Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar). One of the weak points of VATS techniques is the bidimensional operative vision, and it has been postulated that modern three-dimensional (3D) image systems would consistently improve the outcomes of VATS techniques.5Gonzalez-Rivas D. Yang Y. Ng C. Advances in uniportal video-assisted thoracoscopic surgery: pushing the envelope.Thorac Surg Clin. 2016; 26: 187-201Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar On the other hand, 3D operative vision represents one of the main advantages of RATS, which unfortunately has other limitations, such as costs, operative times, and lack of tactile feedback for the surgeons. A 3D image system has been recently introduced for laparoscopy (ENDOEYE FLEX 3D [Olympus Winter and IBE GMBH, Hamburg, Germany]), adding the vision advantages of RATS to conventional video-assisted systems. We used this system for a VATS thymectomy, experiencing a great improvement in execution of the surgical procedure, especially in terms of vision, precision, speed, and safety. The patient was a white 46-year-old man affected by myasthenia. We used a left unilateral approach, with the patient in right oblique decubitus and three trocars (Fig. 1). The videoscope was deflectable, as opposed to those of traditional VATS systems, and had to be used with caution because of the narrowness of the operative field. The steps of the procedure (Supplementary Video 1) were the same as those of the traditional VATS approach, but they were carried out with greater comfort, precision, and rapidity. The operative time was approximately 90 minutes, and no intraoperative or postoperative complications occurred. On the basis of this experience, which to our knowledge is the first to be published, we believe that the 3D system used, and future surgical visualization systems in general, offer a substantial contribution to VATS surgery, empowering it with RATS intraoperative vision. Further cases are necessary to better address the issue; we hope that this letter will be a stimulus for thoracic surgeons to explore new applications in VATS approaches to the thymus. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiI3ZjkzNzFlMmY0OTU5NjFlNjdmNjgwNTQ3YzNhNDY4MiIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjc4ODM4ODg3fQ.fV_-wGQv_8_PTw1ByytjkjBrCPtB5WZZB3MinqRv2Xjph_nIIQKjUB29U2Sq44EQg-nN271IJrIKC_PJMnNdohofTtbeOk-ZABgRkz4r2hS2wZrAGySWC4LtRgz_x9KK1WD5GIoxDOf5SElFxAygymcAa55R6K7tXD7Usla9oGXvbN7aQB-ZBB49AUrRV40l-F29wyzZL3Vwed5MjanSqQLgygdSHBga8oSgjAWKR7MCJAFeaE8rpIhgBX-pXcQsrHPpO3v1rKT6Ko_2SbpHwC1UaABGeFqk4PCpiMPZJoF_d2h9A-Z477lZvLPmow21ImF2D-cwvzHKoexLhrROIw Download .mp4 (30.7 MB) Help with .mp4 files Supplementary Video 1 Response to Lee et al.Journal of Thoracic OncologyVol. 12Issue 9PreviewWe thank Lee et al. for their comments,1 which we address in this response letter. Full-Text PDF Open Archive