A pitfall of thoracoscopic thymectomy: a case with intraoperative and postoperative complications
© The Author(s). 2017
Received: 20 July 2017
Accepted: 24 August 2017
Published: 2 September 2017
We have reported the usefulness of the subxiphoid approach in thymectomy. However, such a new operation method may have unknown complications that rarely occur. Surgeons cannot completely avoid intraoperative and postoperative complications. We report a case of intraoperative injury of the orifice of the left internal thoracic vein flowing to the left brachiocephalic vein and postoperative pericarditis following video-assisted thoracic surgery (VATS) thymectomy. The innominate vein has been considered to be the vessel that is most frequently injured especially at the orifice of the thymic veins. We also suggest that the orifice of the left internal thoracic vein is the second dangerous location that requires special care. In addition, postoperative pericarditis occurred in this patient. Pericardial drainage was necessary. No additional complications have been found in the 9 months since the operation. Though VATS thymectomy using the subxiphoid approach is a safe and less-invasive operation, intraoperative and postoperative complications were possible to be occurred.
We have reported the usefulness of the subxiphoid approach in thymectomy. However, we cannot completely avoid intraoperative and postoperative complications. We report a case of intraoperative injury of the orifice of the left internal thoracic vein flowing to the left brachiocephalic vein and postoperative pericarditis following VATS thymectomy.
We selected a thoracoscopic operation. Thymectomy was initiated under general anesthesia with the patient in the lithotomy position using a single-lumen tracheal tube. Thoracoscopic thymectomy was performed as previously reported . Dissection of the lateral edge of the thymus was performed using the LigaSure Maryland (Covidien, Mansfield, MA, USA) running along the phrenic nerve. The left side of the thymus was dissected after the right side. However, when the left upper edge of the thymus was dissected, bleeding suddenly occurred. Pressure was immediately applied to the bleeding point with an instrument. We confirmed that hemostasis had almost been obtained and thymectomy was continued. Following thymectomy, the bleeding point became obvious. We recognized a small tear in the orifice of the left internal thoracic vein flowing into the innominate vein. The amount of blood loss was only 10 g, but we were unable to suck the blood flowing into the bottom of the thoracic cavity completely. The total operation time was 165 min (Additional file 1).
We have not experienced intraoperative complications of vascular injury thus far. Özkan and Toker recorded at what number operation catastrophic complications occurred  and found points of occurrence ranging from the 26th to the 290th operation. We therefore endeavor to pay scrupulous attention during all operations, even if the operator is an expert, in order to avoid vessel injury during the operation.
We also experienced a rare complication of postoperative pericarditis. In a large series of VATS thymectomy, no cases of postoperative pericarditis were reported. Rowse et al. only reported two cases of postoperative pericarditis, and it was the second most frequent postoperative complication in his report . Postoperative pericarditis might occur more frequently following sternotomy than VATS thymectomy . The reason why postoperative pericarditis occurred in the present case was unclear. We compressed the bleeding point intraoperatively, and we might compress the underling heart. The cardiac compression might have an effect on the following pericarditis. We must ensure we take great care to avoid critical complications during and following surgery.
The innominate vein is considered to be the vessel that is easily injured especially at the orifice of the thymic veins. Postoperative pericarditis is, also, considered to be postoperative complication.
The authors have nothing to disclose with regard to commercial support.
Mo Y, HN, and Ma Y performed the surgery and perioperative management on the patient. RT and CF collected the data. Mo Y wrote the manuscript, and HM reviewed and edited it. All authors read and approved the final manuscript.
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