Management of SVC Injury During Right VATS Thymectomy for Myasthenia Gravis

The video begins with an interview featuring thoracic surgeon and CTSNet Editor-in-Chief Joel Dunning and Dr. Leanne Ashrafian, a cardiothoracic surgeon at Guy’s Hospital in London, United Kingdom, interviewing the author of this complex case Dr. Jakraphan Yu, a cardiothoracic surgeon at Vajira Hospital, Bangkok, Thailand. They discuss the intricacies of this case and the surgical approaches that were used. After the interview, the surgical case is presented, with further details provided here.

Case Introduction

Superior vena cava (SVC) injury during video-assisted thoracoscopic surgery (VATS) thymectomy is a rare but potentially catastrophic complication. While such injuries traditionally necessitate immediate conversion to median sternotomy, this video demonstrates that controlled thoracoscopic repair is feasible in experienced hands.

Clinical Presentation

A 42-year-old male with a history of tracheostomy and two episodes of myasthenia gravis (MG) crisis within the preceding six months was referred for surgical intervention. Preoperative computed tomography (CT) showed no evidence of thymoma but highlighted a cachectic sign with significantly reduced muscle mass. Following a multidisciplinary consultation with neurology, a right VATS thymectomy was planned.

Intraoperative Challenge

The procedure commenced with the mobilization of the thymus from the diaphragm. The innominate vein was successfully identified and dissected using hook electrocautery. However, during the dissection of the thymus away from the right phrenic nerve at the SVC-innominate junction, a focal injury to the SVC occurred via the tip of the energy device, resulting in brisk hemorrhage.

Management and Repair

Hemostatic control was immediately established by applying direct pressure with a sponge stick. This maneuver stabilized the field and allowed for the completion of the thymic dissection. Once the thymus was fully removed, the SVC defect was visualized under controlled conditions using a sponge stick at the left hand and repaired primarily using a 4-0 polypropylene suture from the right hand. Complete hemostasis was confirmed without compromising the vessel lumen, and the procedure was finished thoracoscopically without conversion.

Outcomes

The patient’s postoperative course was unremarkable, and he was discharged on postoperative day three. At follow-up, the patient reported significant clinical improvement and a reduced requirement for immunosuppressive therapy. This case underscores the importance of maintaining composure and utilizing pressure-control maneuvers to manage vascular injuries during minimally invasive mediastinal surgery.

Disclaimer

The information and views presented on CTSNet.org represent the views of the authors and contributors of the material and not of CTSNet. Please review our full disclaimer page here.