Robotic Thymectomy
Removal of the thymus is often needed for a tumour (thymoma) or the neurological condition Myasthenia Gravis. A Thymectomy can usually be performed robotically thereby avoiding splitting the breastbone (sternotomy).
The Thymus
The thymus is a soft organ without a distinct structure, located behind the breastbone (sternum). Its main function is to aid the immune system in maturing the specialised white cells which are termed ‘T’ cells (‘Thymic’ cells). It is large during infancy and slowly becomes smaller with age.
Robotic thoracic surgery is a major advance in treating thymic tumours, myasthenia gravis, and other chest-related conditions. Before the introduction of minimally invasive surgery, such procedures required large and invasive incisions such as a sternotomy or thoracotomy, which could lead to significant pain, substantial blood loss, and extended recovery times—often delaying a return to normal activities by 4-6 weeks. In contrast, robotic resection offers superior precision and visibility while avoiding these major incisions, resulting in reduced pain and a faster recovery. Dr. Bassin, a leading expert in robotic thymectomy, uses the DaVinci surgical robot to perform thymectomies, eliminating the need for sternotomy and facilitating quicker recoveries for patients with thymomas or myasthenia gravis. Beyond his surgical practice, Dr. Bassin also contributes to the field as a formally authorised instructor for the DaVinci Xi system, training qualified cardiothoracic surgeons through a comprehensive program that includes both observational and hands-on learning experiences to enhance their skills with robotic technology.
Robotic Surgery avoids the need for splitting the breastbone.
The thymus is a soft organ without a distinct structure, located behind the breastbone (sternum). It is large during infancy and slowly becomes smaller with age.
Diagnosis
There are two major indications for thymectomy. These include tumours of the thymus (thymoma), and/or the neurological condition Myasthenia Gravis. Thymic tumours are usually diagnosed by a CT scan of the chest for other reasons, such as investigation of chest pain or shortness of breath. A biopsy may be performed using local anaesthetic to determine the nature of the tumour. In many cases however a biopsy is contra-indicated or not feasible, and so surgery is planned without a definitive diagnosis. In these cases, surgical removal provides the diagnosis (a specialist pathologist analyses the tumour in the laboratory) as well as the treatment at the same time.
Myasthenia Gravis is the other common indication for a thymectomy. This is a neuromuscular condition that causes weakness of skeletal muscles due to autoimmune antibodies produced by the thymus which attack the muscle receptors responsible for contraction. The symptoms include tiredness particularly later in the day, muscle weakness, and can include double vision as the weakness can involve the muscles that move the eye.Following referral to Dr Bassin, he will review your imaging in detail which in the first instance is usually a CT scan of the chest. A consultation is then booked and Dr Bassin will meet you in person or via telehealth for rural or interstate patients. A number of tests are then ordered to clarify the nature of the thymic tumour. These can include: blood tests, repeat CT chest with contrast, MRI of the chest, and in some cases a biopsy.
What is involved?
The thymus can be removed robotically depending on the size and location of the tumour. Usually tumours up to 7 cm or larger can be removed robotically depending on the location. In almost all cases of myasthenia gravis a robotic thymectomy is feasible, as the thymus is often small and easily accessible.
Dr Bassin uses the Da Vinci Xi surgical robot for all robotic chest surgery. This involves placing up to four 7 mm ports in between the ribs on one side of the chest. The lung on that side is deflated and the robotic instruments are then used to remove the thymus/thymic tumour. The robotic approach gives the clearest view of the chest and can assist in preventing injury to major structures including the phrenic nerve which innervates the diaphragm and is responsible for breathing. The surgery takes anywhere between 1 and 3 hours and patients can generally be discharged 2 days after surgery.
The alternative approach for thymectomy when a robotic approach is not possible is a median sternotomy – splitting the breastbone. This is the same approach used for open heart surgery and provides excellent exposure of the thymus and the surrounding structures. Although a very safe and well tested technique, the sternotomy is associated with more pain and blood loss, a longer hospital stay, and the risk of sternal infection. Dr Bassin is a very high volume robotic thymectomy surgeon and can remove the thymus robotically in the majority of cases subject to review of the imaging and clinical examination.
Robotic Thymectomy for Myasthenia Gravis
Removal of the thymus has been shown to significantly improve symptoms in many patients with Myasthenia Gravis. This can mean a reduction in the powerful immunosuppresant medications (with their potential significant side effects) that are required to combat this autoimmune disease. Approximately 10% of patients with Myasthenia Gravis have a thymoma (thymic tumour), and surgery to remove the thymoma is clearly indicated. In the other 90% of patients without a thymoma, surgical removal of thymus can have significant benefits. Patients will see the greatest improvement in symptoms if: i) they are under 60, ii) they have been diagnosed with Myasthenia within the last 5 years, and iii) they have antibodies to the acetylcholine receptors in the blood. There can still be a benefit for patients outside of these conditions, and Dr Bassin can explain what is suitable for each individual patient.
For Myasthenia Gravis an extended thymectomy is required. This involved removing the entire thymus and all the surrounding fat from the anterior mediastinum (area behind the breastbone). Anything short of an extended thymectomy can leave residual thymic tissue and reduce the chance of symptom control. The surgical robot is ideally suited to this with superior visualisation and control, and can also minimse the risk to the major nerves that supply the diaphragm and breathing control (phrenic nerves).
Dr Bassin will liase with your Neurologist to optimise your function prior to surgery. Ideally the symptoms will be relatively well controlled and therapies could include corticosteroid (predinose), intravenous immunoglobulin (IVIG), plasapharesis, and plasm-exchange (PEX). Our expert anaesthetists are experiend with patients suffering from Myasthenia Gravis, and will optimise the pre-operative, intra-operative, and post-operative care to cater to each individuals condition to enure very safe surgery. Patients will be transferred to the Intensive Care Unit following surgery where they will be closely monitored and usually transferred to the Cardiothoracic ward on the day following surgery. Most patients can be discharged within a day or two following robotic surgery.
What is the recovery like?
When can I drive?
Patients can generally drive 1 week following a robotic thymectomy and 4 weeks if a sternotomy is required. Dr Bassin will give you individualised advice on return to driving and work.
What are the benefits and risks of this procedure?
The major benefit and reason to perform a thymectomy is to remove a tumour that either is cancerous or can transform from a more benign to a malignant tumour. Thymomas can continue to grow and eventually spread, and non-surgical forms of treatment such as chemotherapy and radiotherapy are not as effective as a complete surgical resection.
The risks of a thymectomy include: infection, bleeding, a very low risk of mortality, ongoing pain, and damage to surrounding structures including the heart, major blood vessels, the lungs, and important nerves (phrenic nerve and recurrent laryngeal nerve). A Robotic approach has a very low risk of requiring a sternotomy because the tumour is more aggressive than anticipated, or if there is injury to a major blood vessel. The benefits of the robotic approach including reduced trauma, reduced bleeding, reduced pain, and a more rapid recovery.