Case Report
AB046. Robotic resection of thymoma recurrence with intra thoracic phrenic nerve reconstruction using a sural nerve graft: a case report
Jamie L. R. Romeo1, Jos G. Maessen1, Patrique Segers1, Florit D. Marcuse2, Monique M. H. Hochstenbag2, Hester A. Gietema3, Ulrich C. Lalji3, Myrurgia Abdul Hamid4, Shan Shan Qiu5
1Department of Cardiothoracic Surgery, Maastricht UMC+, Maastricht, the Netherlands; 2Department of Pulmonology, Maastricht UMC+, Maastricht, the Netherlands; 3Department of Radiology and Nuclear Medicine, Maastricht UMC+, the Maastricht, Netherlands; 4Department of Pathology, Maastricht UMC+, Maastricht, the Netherlands; 5Department of Plastic and Reconstructive Surgery, Maastricht UMC+, Maastricht, the Netherlands
Correspondence to: Jamie L. R. Romeo, MD, PhD. Department of Cardiothoracic Surgery, Maastricht UMC+, P. Debyelaan 25, Maastricht, 6229 ET, the Netherlands. Email: jamieromeo@live.nl.
Background: Radical resection of extensive or recurrent thymoma may require phrenic nerve resection which can be associated with significant respiratory morbidity. This study aims to demonstrate the feasibility of nerve reconstruction using a sural nerve graft by total robotic approach which has never been reported before.
Case Description: This case involved a 75-year-old male patient who underwent thymomectomy 5 years earlier in a different hospital. After 5 years, a local recurrence was evident exactly on the location of the left phrenic nerve at the level of the right ventricular outflow tract. Radical resection was deemed possible only if the phrenic nerve was excised together with the mass. To this end, we used our standardized three-port robotic-assisted thoracoscopic surgery (RATS) approach using the DaVinci Xi system (Intuitive surgical Inc., Sunnyvale, CA, USA) from the left mid-axillary intercostal plane and added a 12-mm assistant port. After careful introduction of the camera trocard, CO2 insufflation was started and the other trocards and instruments are introduced by sight. After dissection of the initially adhesive plain between the mediastinal pleura and the pericardium, the part of the pericardium overlaying the right ventricular outflow tract up to the level of the aortic arch was clear and the phrenic nerve was visible. The mass was located directly on the phrenic nerve and as expected no surgical plain with safe oncological margins could be achieved. There were no signs of growth into the pericardium or lung parenchyma. The phrenic nerve was transected caudally and cranially 3 cm from the mass and removed en-bloc with the recurrence within an endobag. The distal end of the sural nerve was anastomosed to the proximal end of the phrenic nerve due to the direction of development of the fascicles. A single 7-0 Prolene Suture (Ethicon Inc., New Jersey, US) was attached to this distal end before introduction in the thorax, to facilitate the first anastomosis and avoid the need for an additional instrument to present the graft. Each anastomosis was made by four single 7-0 Prolene epineural sutures using the Black Diamond micro forceps (Intuitive surgical Inc., Sunnyvale, CA, USA) (Figure 1).
Conclusions: The sural nerve is a preferred donor graft for reconstruction due to its well tolerated morbidity, ease of harvesting, multiple fascicles, and available length. Total robotic reconstruction is technically feasible and preferred in a minimal invasive approach. The postoperative course was uneventful and the patient was discharged after 3 days. Histopathological analysis revealed a B2 thymoma (World Health Organization).
Keywords: Case report; phrenic reconstruction; nerve; sural; thymoma
Acknowledgments
None.
Funding: None.
Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://med.amegroups.com/article/view/10.21037/med-25-ab046/coif). The authors have no conflicts of interest to declare.
Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.
Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.
doi: 10.21037/med-25-ab046
Cite this abstract as: Romeo JLR, Maessen JG, Segers P, Marcuse FD, Hochstenbag MMH, Gietema HA, Lalji UC, Abdul Hamid M, Qiu SS. AB046. Robotic resection of thymoma recurrence with intra thoracic phrenic nerve reconstruction using a sural nerve graft: a case report. Mediastinum 2025;9:AB046.
