The point of debate in the surgical treatment of MG has been the preferred surgical approach. Some centers recommend maximal thymectomy (the Jaretzki approach; transsternal + transcervical) to eliminate the gland and possible extra-anatomical thymic tissue as well,8 whereas other centers favor a standard transsternal approach, while others have adopted a minimally invasive transcervical thymectomy.9,10 A more recent surgical innovation is the modification of this procedure with the introduction of video-assisted transcervical thymectomy.11 During this era of minimally invasive video-assisted surgery, transthoracic thoracoscopic thymectomy has gained popularity, as well. Several variations of this approach exist including unilateral, bilateral, bilateral combined with cervical approach, and robotic. The last surgical innovation for surgical treatment of MG is the infrasternal, either thoracoscopic or mediastinoscopic approach for thymectomy.12 All procedures allow extracapsular resection of thymus and vary somewhat in the extent of mediastinal fat removal, which may contain foci of thymic tissue. The types of thymectomy have not been compared directly in any randomized study. There is a school of thought which advocated that maximal thymectomy is preferred over more conservative approaches to theoretically achieve a more complete resection of thymic tissue.13 A combination of transcervical and transsternal approach was recommended to maximize the resection. The outcome data, however, do not support improved results with “maximal thymectomy” over more minimally invasive approaches. Furthermore, approaches that are more patient-friendly are more easily accepted by the patients and their neurologists. To understand the different surgical approaches and categorize the extent of resection of thymus and surrounding tissue, the Myasthenia Gravis Foundation of America (MGFA) has broadly classified varying surgical techniques based on the approach and the extent of surgical resection. The meta-analysis of 21 retrospective studies showing a positive benefit of thymectomy in patients with MG included all types of thymectomy approaches.5 Furthermore, relatively large case series have shown comparable remission and improvement rates in MG patients with different types of thymectomy.10,11 Thus, it is not clear at all that more extensive thymectomy procedures are more effective. Statistical reshuffling of crude data from different study reports may show different outcomes for different surgical interventions, but this type of reanalysis in itself may produce flawed results and does not provide definitive evidence of the benefits of one surgical approach over another. Ideally, a randomized trial of the different approaches would need to be done. Currently, no such study is planned and there is no consensus on the optimal surgical approach. Without randomized comparative studies, the decision as to surgical approach must rest on the surgeon's individual experience and facility with each given procedure. The underlying principle for thymectomy for MG remains the same regardless of surgical approach: a safe and complete thymectomy.
All patients should have a CT scan of the thorax before surgery to exclude a thymoma. Although VATS seems to be a safe and feasible approach for early stage thymoma, this approach is controversial and the follow-up times are still short considering that pleural metastases can appear more than 10 years after surgery.14 Therefore, if a thymoma is present, the preferred surgical approach remains a sternotomy or partial upper sternotomy.