Combined Thymectomy and Right Lower Lobe Pulmonary Wedge Resection by Thoracoscopy

1. Introduction

1. Overview of Case
2. Anesthetic Regimen
   • General anesthesia with IV and inhalational anesthesia, no muscle relaxation.
3. Diagnostic Bronchoscopy
   • Bronchoscopy to assess for airway abnormalities.
   • Reintubation with left-sided double-lumen endotracheal tube.
   • Radial arterial catheter placed for blood pressure monitoring.

2. Right Lower Lobe Wedge Resection

1. Patient Positioning and Access Ports Selection
   • Left lateral decubitus position is achieved with appropriate padding: rolled blankets support the patient in front and back, pillow between the legs to protect the bony prominences of the knees with dependent leg in flexed position, left arm on padded arm board, and right arm on arm rest. Bed is flexed to provide maximum opening of the rib spaces. Neck and head are maintained in neutral position with additional cushions if needed.
   • Right lung is isolated, and the chest is prepped and draped in sterile fashion.
2. Incision and Entry into Thoracic Cavity
   
   • Camera port in midaxillary line facing the slope of the diaphragm (often 9th intercostal space); accessory port in posterior axillary line at the level of the fissure (5th intercostal space).
   • Utility thoracotomy anterior axillary line (5th intercostal space anteriorly); wound protector placed.
3. Exposure of Lung Nodule
   • Visual and palpatory identification of right lower lobe lung nodule.
4. Dissection of Fissure
   • Dissection of fissure and pulmonary artery.
5. Lung Specimen Resection
   • Isolation of nodule with non-crushing clamp to gain margin by traction.
   • Wedge resection using thick-tissue stapler.
   • Inspection to ensure complete excision.
   • Frozen section examination.
6. Lymph Node Dissection from Fissure
   • Lymph node sampling, here stations 7 and 12.
7. Lymph Node Subcarinal Dissection

3. Thymectomy: Right-Sided Dissection

1. Discuss Positioning and Overview
   • Right-tilt table to expose anterior mediastinum.
2. Thymic Tissue Isolation from Pericardial Fat
   • Identify the course of the right phrenic nerve from the top to the bottom of the chest.
   • Begin thymic dissection separating pericardial fat and thymus from diaphragm and pericardial sac.
3. Mediastinum Dissection and Pleura Incision
4. Innominate Vein Dissection
5. Contralateral Pericardial Fat Dissection
6. Review
   • After posterior separation, plane between sternum and anterior mediastinal fat and thymus is entered toward left pleura to the safe limits of this position. Lung is re-expanded, and all incisions are temporarily closed.

4. Thymectomy: Dissection Continued Anteriorly

1. Repositioning Position and Camera
   • Supine position with roll under the right chest.
   • Right arm is positioned behind the chest and the chest is prepped and draped in sterile fashion.
   • The anterior access ports are reopened. Laparoscopic port is used to insufflate the chest to pressures of 8–12 mmHg.
   • Additional 5-mm access port is inserted in the second intercostal space.
2. Anterior Mediastinum Dissection
   • Anterior dissection to separate the thymic tissues from the sternum.
   • Thymus dissection off of contralateral left pleura, avoiding left phrenic nerve.
   • Separation of thymic tissue from pericardium and innominate vein.
   • Dissection of the plane anterior to innominate vein and division of thymic veins.
3. Division of Internal Mammary Vein (Post-op Bleeding)
   • Division of internal mammary vein and exposure of cervical thymus.
4. Cervical Dissection
   • Dissection of thymic tissue from neck and division of vascular attachments to cervical thymus.
5. Review and Extraction and Examination of Specimen
   • Placement of specimen in bag and orientation for permanent section.

5. Closure

1. Chest Tube Insertion
2. Ensure Hemostasis
3. Lung Reexpansion
4. Close Incisions and Access Ports

6. Postoperative Care

• • Close overnight monitoring of respiratory status.
  • Chest tube is usually removed on postoperative day 1. Please listen to our comment regarding postoperative course and pathology in this patient.