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One of the originally intended indications for telerobotic surgery was coronary artery bypass grafting because of its perceived advantages in a confined space such as the anterior mediastinum.1 However, despite multiple published feasibility studies and a series of successful mitral valve repairs,2 robotic approaches failed to gain widespread adoption for cardiac surgery. Between 2000 and 2006 the majority of published experience with telerobotic surgery was in the arena of pelvic surgery (urologic and gynecologic). Despite the lack of traction of robotics in cardiothoracic surgery during this early period, there were isolated reports of utilization for mediastinal surgery.35 The first series of robotic-assisted procedures for mediastinal masses was reported by Bodner et al. from Innsbruck and included nine thymectomies, three posterior mediastinal masses, and two non-thymomatous anterior mediastinal lesions.6 While robotic pulmonary resection was slower to evolve, experience with robotic mediastinal procedures, particularly thymectomy, continued to grow.

The standard treatment of isolated disorders of or related to the thymus is typically thymectomy. Indications include known or suspected thymoma, thymic carcinoid tumor, myasthenia gravis (MG) with or without concomitant thymoma, and benign thymic lesions such as cysts or discrete hyperplasia. Regardless of the indication, complete thymectomy is the ultimate goal in order to avoid retention of ectopic thymic tissue. This is thought to be particularly important in the surgical management of MG.7 The most common surgical approach to thymectomy is the classic transsternal approach, which has proved effective and safe in the settings of both thymic neoplasms and MG.8

In the case of MG, however, many patients and neurologists are hesitant to undergo transsternal thymectomy despite evidence demonstrating clinical improvement because of concerns about perioperative morbidity, pain, and cosmesis. As a result, alternative surgical approaches were developed, including the transcervical method, the video-assisted thoracic surgery (VATS) thymectomy, and most recently, robotic thymectomy. VATS thymectomy attempted to replicate complete thymectomy performed under direct intrathoracic vision while eliminating the morbidity associated with dividing and spreading the sternum.9 Meyer et al.10 in a single-institution cohort study of VATS versus transsternal thymectomy for MG demonstrated equivalent clinical outcomes and improved perioperative results (need for postoperative ventilation and length of stay). Despite this demonstration, minimally invasive VATS thymectomy never became a widely accepted technique, and some controversy still exists regarding the optimal surgical approach to thymectomy.

The reason for this controversy is unclear, but similar to VATS lobectomy, it is likely due to a combination of factors, including the technical limitations of an unstable two-dimensional camera platform and limited maneuverability of instrumentation. These issues are especially enhanced in the limited confines of the anterior mediastinum. It was precisely for this application that the master–slave robotic surgical system was developed (da Vinci Surgical System; Intuitive Surgical, Sunnyvale, CA). While the earliest reports of robotic thymectomy were limited to patients with non-thymomatous MG,11,12 subsequent series have included those ...

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