10．剣状突起下アプローチによる胸腺摘出術

Thymectomy via Trans-subxiphoid Approach

従来，胸腺摘出術は胸骨正中切開アプローチで行われていたが，手術手技と機器の改良により非浸潤性胸腺腫や重症筋無力症に対しては，より低侵襲な胸腔鏡下胸腺摘出術が適応されるようになってきた．しかし，胸骨と左右肺および心膜に囲まれた前縦隔は解剖学的にきわめて狭小で，鏡視下に左右腕頭静脈・上大静脈などの大血管や横隔神経周囲を安全に剝離するためにはさまざまな工夫が必要である．

Minimally invasive thoracoscopic thymectomy has been indicated in patients with non-invasive thymic epithelial tumors or myasthenia gravis. Sub-xiphoid thymectomy has an advantage of similar surgical view of median sternotomy as compare to lateral approach. Since anterior mediastinum is anatomically limited space, robotic approach with carbon dioxide （CO2） insufflation has led a drastic innovation in thymectomy. We introduced robotic subxiphoid-optical thymectomy （RST） and experienced 38 cases without open conversion, so far. RST contributes a sufficient surgical view for total and extended thymectomy with its fine dissection, especially around innominate vein. RST with combined resection of left brachiocephalic vein or pericardium was feasible. Postoperative pain evaluated using numeric rating scale was minimal and epidural anesthesia is not required. Furthermore, we herein describe thoracoscopic subxiphoid-optical thymectomy based on the RST for institutes where thoracic robotic surgery has not been adopted.