Perioperative management - VATS Thymectomy

Thymoma

Thymomas are epithelial tumors with generally slow growth of the thymic remnant. In principle, thymomas are classified as malignant, but in 75% of cases, they grow slowly and do not metastasize. In contrast, the much more aggressive thymic carcinoma should be distinguished. Surgery with R0 resection is the standard therapy with a good prognosis. For large tumors or preoperative evidence of thymic carcinoma, neoadjuvant therapy or definitive radiochemotherapy should be considered.

Myasthenia Gravis

Due to their ability to mature T-cells, thymomas are associated with a variety of autoimmune diseases and paraneoplastic syndromes. The most common paraneoplasia in this context is myasthenia gravis. A thymectomy often results in a significant improvement in symptoms. Seronegative patients with myasthenia without detectable antibodies do not seem to benefit from surgery.

• Lack of cardiopulmonary reserve
• General anesthesia intolerance
• Coagulation disorder or use of anticoagulants
  • The permanent use of ASA 100mg does not constitute a contraindication.
  • In cases of higher-grade anticoagulation such as platelet aggregation inhibitors (e.g., Clopidogrel), NOACs (e.g., Xarelto), or Vitamin K antagonists (e.g., Falithrom or Marcumar), an interdisciplinary consultation should develop a therapeutic concept regarding the indication for anticoagulation, the possibility of bridging with heparin, and the surgical bleeding risk.

Thymomas are often found incidentally in X-ray examinations. Computed tomography of the thorax is the standard examination for mediastinal tumors. For assessing operability, magnetic resonance imaging, despite motion artifacts caused by cardiac action, is superior to computed tomography in depicting vascular and myocardial invasion and is therefore a valuable addition when such questions arise.

Nuclear Medicine Examination

Conventional diagnostics cannot always differentiate between thymic hyperplasia and thymoma or between scar and tumor tissue. Thymic tumors can be visualized through the expression of somatostatin receptors using somatostatin receptor scintigraphy (DOTATOC-PET/CT). The use of this examination also improves the accuracy of staging by significantly more reliable detection of metastases.

• Shaving of the left thoracic wall and in the area of the sternum, if necessary
• SingleShot antibiotic with Cefuroxime 1.5g intravenously approximately 30 minutes before the skin incision.

In addition to the general surgical risks such as thrombosis, embolism, allergy, infection, bleeding, and wound healing disorders, specific risks must be explained:

• Injury to major vessels, particularly the brachiocephalic vein (= Vena brachiocephalica)
• Injury to nerves, particularly the phrenic nerve and recurrent laryngeal nerve
• Postoperative lymphatic fistula with chylothorax
• Postoperative hemorrhage with potentially necessary reoperation
• Conversion to sternotomy and possibly extension of resection, approach depending on intraoperative findings
• Injury to adjacent structures, particularly the trachea and main bronchi, major vessels, and the esophagus, necessitating corresponding extension of the procedure
• Positioning injuries
• Cardiac arrhythmias
• Local recurrences

Treatment alternative: Depending on the context, fine needle biopsy, radio-/chemotherapy.

Intubation anesthesia with  for one-lung ventilation.

The patient is positioned in a 30° right lateral position using a wedge cushion. The right arm can be extended and the left arm bent at the elbow and suspended over the head. Finally, ensure that pressure-sensitive areas are padded and the head is placed on a gel ring.

For left-sided video-assisted thoracoscopy and thymus resection, the surgeon and assistant stand dorsally (left), with the surgical nurse opposite.

• 3 trocars with valve mechanism for CO2 insufflation, possibly smoke evacuation and gas warming
• Standard MIC instrumentation with grasping forceps, dissector, and ultrasonic scissors
• Endoscopic stapling device, as in rare cases a lung wedge resection is required for invasive tumor
• Titanium clip applicator

• Postoperative Analgesia

Due to the pain from the inserted chest drain, a combination analgesia of a non-opioid analgesic (e.g., Metamizole) in combination with a low-dose opioid (e.g., Tilidine) is advisable. Follow the link here to PROSPECT (Procedures Specific Postoperative Pain Management) and to the current guideline Management of Acute Perioperative and Posttraumatic Pain.

• Medical Follow-up
  • X-ray control on the operating table
  • Chest drain with suction 20mmHg for approximately 2 days postoperatively, removal after X-ray control if secretion volume is under 250ml/24h and no air leak is detected
• Thrombosis Prophylaxis

Standard thrombosis prophylaxis for 14 days with low molecular weight heparin subcutaneously, considering comorbidities, renal function, and laboratory control to exclude HIT. Link to the current guideline: Prophylaxis of Venous Thromboembolism (VTE)

• Mobilization

Full mobilization possible from the 1st postoperative day

• Physical Therapy

Mobilization, breathing exercises, and secretion mobilization

• Diet Progression

Regular diet

• Bowel Regulation

Accompanying opioid analgesia

• Work Incapacity

Approximately 14 days, considering the type of work and patient situation