Objective To explore the technical points on robotic or video assisted thoracoscopic thymectomy. Methods From November 2006 to June 2012, a total of 66 cases with thymomas or myasthenia gravis (MG) were performed minimally invasive thymectomy in our hospital, including 30 video assisted thoracoscopy and 36 robotic surgery with da Vinci. Among them, there'were 18 cases of thymomas (11 out of 18 with MG) , 3 cases of thymus cyst (1 out of 3 with MG) and 45 non-thymomatous MG. 31 MG patients with bulbar dysfunction appeared severe breath problem such as dyspnea and dysphagia. All the patients were prepared preop-eratively, then received double lumen endobronchial intubation with one lung ventilation, combining anesthesia with inhale and intravenous drug infusion. 20° tilt partial supine position with head high and foot low in the robotic procedures, and with 30°operating side tilt simultaneously. The first skin cut line was about 1.5 cm, and then a trocar was placed in the 5th intercostals space between the anterior and middle axillary line, the camera was introduced, under the inspection of the screen, then, two mechanical arms, left and right, were inserted at the site from both side of the first trocar about 8 to 10 cm, a fist distance. The third or accessory port was used if necessary. Complete lateral decubitus position or robotic position above described was used during the video-assisted thoracoscopic surgery. Results There were 6 patients showed hypoventilation inadequate and low oxygen saturation during the operation period, and improved immediately after high frequency ventilation was given on the operating side lung accessorily. 2 patients (3. 03% ) underwent thorascopic surgery were converted to thoracotomy because of tumor penetrating the blood vessel, the other 64 patients were completed the robotic or video assisted thorascopic surgery successfully. No death occurred in peroperative period. Postoperative bleeding was found in 4 patients (6. 06% ) , including one of robotic and 3 of thorascopic surgery. Lung atelectasis or pulmonary infection occurred in 5 patients (7. 58% ) . There was no permanent phrenic nerve damage occurred. Two patients had myasthenia crisis, and recovered after treatment. Except 4 cases lost, the other 62 cases were followed up for 1 to 65 months with an average of 22. 6 months. One thymic carcinoma patient underwent thorascopy died of recurrence and metastasis, 2 patients with residual tumor survived for two years. 49 MG patients obtained symptoms improved or disappeared after surgery and the effective rate was 89. 09% . Conclusions Thymectomy can be successfully performed via video assisted thoracoscopy or robotic surgery. Open surgery is needed sometimes. 4 points must be attention during peroperative period: ①Position: tilt head high and foot low, with partial lateral decubitus position. ②Double lumen intubation with one lung ventilation, high frequence jet ventilation for the operating side lung was a good method for patients who had inadequate gas exchanges. ③Which side (left or right approach ) is better for surgery should be individualized after consideration of pros and cons. ④Phrenic nerve should be protected well and avoided to injury.%目的 探讨胸腺微创手术有关技术问题. 方法 2006年11月～2012年6月我院开展微创机器人和胸腔镜胸腺扩大切除术66例,其中电视胸腔镜手术30例,达芬奇机器人手术36例.66例患者中胸腺瘤18例,其中合并重症肌无力11例;胸腺囊肿3例,其中合并重症肌无力1例;单纯重症肌无力45例.重症肌无力者中31例为延髓型,有呼吸困难或吞咽问题.所有患者均经术前准备后,采用双腔气管插管,单肺通气,吸入与静脉复合全麻实施麻醉. 结果 66例患者中,术中出现通气不足6例,术侧肺加用高频通气后改善;2例(3.03％)胸腔镜手术患者中转开胸手术,其余64例患者均顺利完成腔镜或机器人手术.本组无围手术期死亡.术后出血4例(6.06％),其中机器人手术1例,胸腔镜手术3例.发生肺不张及肺部感染5例(7.58％).所有病例均无永久性膈神经损伤.本组失访4例,余62例患者平均随访22.6月(1～ 65月).1例胸腺癌胸腔镜手术患者死于胸腺癌复发,1例胸腺瘤胸腔镜手术患者和另1例胸腺癌机器人手术患者手术后有肿瘤残留,带瘤生存2年以上,其余目前均存活良好.重症肌无力患者中症状消失或改善49例,占89.09％. 结论 不论采用胸腔镜还是机器人手术,均能完成胸腺切除术.术中通气不足,可于术侧肺加用高频通气呼吸机;遇有特殊情况,要及时中转开胸手术;术中应注意避免膈神经损伤.
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