1. Robotic-Assisted Thymectomy in Myasthenia Gravis Iskander Al-Githmi, MD, FRCSC, FRCSC (Ts&CDs), FACS, FCCP Department of Surgery. Division of Cardiothoracic Surgery King Abdulaziz University Hospital

2. Objectives  General Robotic Considerations  Anatomy of Thymus  Robotic Technique  Outcomes  Myasthenia Gravis over view  Our early experience of RATS

3. Da Vinci Robotic Surgical System B A C

4. General Robotic Consideration  Provide a stable camera platform  Three- dimensional imaging  Simulate motions of surgeon’s wrist to overcome motion limitation of straight thoracoscopic instruments  Offer the surgeon a comfortable, ergonomically operating position  Magnified and computer enhanced video imaging provide superior exposure and visualization

5. General Robotic Consideration  Telecast the surgeon hand motions to the remote operating room ( telepresence)  -- Transatlantic cholecystectomy (Marescaux)  Telementoring of surgeons  Why have surgeons failed to embrace minimal invasive cardiothoracic surgery?

6. Factors Influencing Decision Anatomy Pathology patient Technology

7. Balance of Outcomes  Dissection required  Propensity of complications  Reduction in organ reserve  Approach  Selection/ preparation  Complication avoidance  Anesthesia

8. Anatomy

10. Thymic Tissue Distribution Jaretzki 3d, et al. Journal of Thoracic and Cardiovascular Surgery, Vol 95, 747- 757, Copyright © 1988

11. Potential sites for ectopic thymic tissue Ann Thorac Surg 2000;69:1537-41

12. Imaging

13. Surgical Approach

14. Robotic Thymectomy Technique

15. Robotic Thymectomy

16. Mack M.J. etal; J Thorac Cardivasc Surg 1996;112:1352-1360

18. Robotic Thymectomy  Surgical therapy of MG necessitate a complete removal of all thymic and fatty tissues in the anterior mediastinum  Is this achievable ? Which surgical approach?, So what!  Balance between extent of resection, morbidity, patients acceptance and results Goals

19. VATS Vs Open M.-W. Lin et al Eur J CT Surgery 37 (2010) 7-12

20. VATS Vs Open M.-W. Lin et al Eur J CT Surgery 37 (2010) 7-12

21. OR Time Ann Thorac Surg 2008;85:7688-771

22. Blood Loss Ann Thorac Surg 2008;85:7688-771

23. Hospital Stay (days) Ann Thorac Surg 2008;85:7688-771

24. Myasthenia Improvement Ann Thorac Surg 2008;85:7688-771

25. Myasthenia improvement CHEST 2005;128:3454-3460

26. VATS Vs Open Ann Thorac Surg 2009;87:385-391

27. Robotic Thymectomy Costs

29. Osserman Classifications J Thorac Cardiovasc Surg 1996;112:1352-13560

30. De Filippi post operative classifications J Thorac Cardiovasc Surg 1996;112:1352-13560

31. Our early experience Design: It is a prospective study of RATS for NTMG in KAUH. Data were collected from medical records & supplemented with telephone survey Methods: Jan 2008- Oct 2010  Patients (n) = 8  Gender : Female = 8 Male= 0  Mean age = 28 yr (16-46)  All with non thymomatous Masthenia Gravis  Left side (3 ports) robotic thymectomies (Da Vinci system)

32. Our early experience Results:  Complete stable remission = 25%  Clinical improvement = 87.5%  Mortality = 0  Left phrenic nerve injury ( n=1)  No significant correlation between age and symptom duration (p=0.51)  No significant correlation between pre-op CT scan and histopathology finding (p= 0.85)

33. Patient Characteristics Mean age (Yr) 28 (16-46) Mean symptom duration (month) 7.75 (3-12) CT scan chest Hyperplasia Normal 3 (37.5%) 5 (62.5%) Acetylcholine receptors Ab Positive Negative 5 (62.5%) 3 (37.5%) Osserman stage Stage I Stage IIa Stage IIb Stabe III Stage IV 0 ( 0%) 2 (25%) 5 (37.5%) 0 (0%) 1 (12.5%) Al-Githmi, Surgical Science J 2011;2:393-396

34. Pt. No Age (y) Osserman classification Symptoms duration (month) Preop CT chest Histopathology Follow-up /De Filippi Classification 6 months 12 months 18 months 116IIb12Hyperplasia Thymic involution Class 4Class 3Class 2 219IIb3Normal Class 4Class 2Class 3 323IIa12Normal Class 4Class 3 426IIb12HyperplasiaNormalClass 4 Class 3 528IIb5Hyperplasia Class 3 Class 2 630IV3NormalHyperplasiaClass 3Class 2Class 1 736IIb7NormalHyperplasiaClass 3 Class 2 846IIb8NormalThymic involution Class 3Class 2Class 1 Selected preoperative variables and patient outcome

35. Post operative status after 12 months follow up Class IN = 112.5% Class IIN = 337.5% Class IIIN = 450% Class IVN = 00% Class VN = 00%

36. Post operative status after 18 months follow up Class IN= 225% Class IIN = 337.5% Class IIIN = 337.5% Class IVN = 00% Class VN = 00% Class VN = 00%

37. Preoperative CT chest & Histopathology Preoperative CT ChestHistopathologyPositive diagnostic yield (%) Normal ( n= 5) Normal (n= 2) Hyperplasia (n= 2) Thymic involution (n = 1) 40 Hyperplasia (n= 3) Normal (n=1) Hyperplasia (n = 1) Thymic involution (n = 1) 33.3

38. Our early experience Conclusions:  Robotic thymectomy is promising procedure, safe and effective  Long-term results are comparable to conventional methods  Global clinical improvement demonstrated in 87.5% after 12 months follow- up

39. THANK YOU