Robotic subxiphoid thymectomy: techniques, tips, and tricks
We describe the surgical techniques for robotic subxiphoid thymectomy when using the da Vinci surgical system. A 3-cm vertical incision is made approximately 1 cm below the xiphoid process on the caudal side. A space is then created to allow for port insertion blindly by the finger around the layer at the back of the rectus abdominis muscle. The wound retractor that comes with the GelPOINT Mini®, which is a port designed for single-port surgery, is inserted through the subxiphoid incision. Insufflation and exhaustion tubes are connected to the three-way stopcock of the platform, and CO2 gas is injected at 8 mmHg. The bilateral mediastinal pleura is dissected to bilaterally open the chest cavity. A 1-cm skin incision is made on either side of the 6th intercostal space precordial axillary line, followed by insertion of a robotic surgery port. If a retraction arm is used, the port should be inserted 4–6 cm away from the main port along the anterior to the midaxillary line at the right 6th intercostal space. Bilateral phrenic nerves can be located easily by robotic subxiphoid thymectomy while easily securing a clear view of the operative field. We expect this approach to be applied to more complicated surgeries, such as combined resection of adjacent organs in thymectomy.