Minimally Invasive Versus Open Thymectomy for Non-Thymomatous Myasthenia Gravis

Background. The Thymectomy Trial in Non-Thymomatous Myasthenia Gravis Receiving Prednisone (MGTX) established that extended transsternal thymectomy combined with prednisone yields superior clinical outcomes compared with prednisone alone in adults with non-thymomatous acetylcholine-receptor-antibody (AChR-Ab)-positive generalised myasthenia gravis (MG). MGTX employed extended transsternal thymectomy exclusively and did not compare surgical approaches, leaving unresolved whether minimally invasive techniques—transcervical, video-assisted thoracoscopic surgery (VATS), and robotic-assisted thymectomy—achieve comparable disease-related and perioperative outcomes. Objective. To synthesise, in a transparent and reproducible manner, the database-indexed literature addressing whether minimally invasive thymectomy approaches achieve comparable clinical remission, symptom control, and perioperative safety relative to open transsternal thymectomy in adults with non-thymomatous AChR-Ab-positive MG. Methods. This is a structured evidence synthesis, not a systematic review or meta-analysis. Three bibliographic databases—PubMed, OpenAlex, and CrossRef—were searched on a single date using eight predefined verbatim query strings, with a retrieval cap of the top 15 records per query per database under each database's native relevance ranking. Records were de-duplicated by digital object identifier (DOI), yielding 206 unique records; the top 40 were carried forward by each database's native relevance ranking. The bibliographic record (DOI, authors, title, venue) of every cited source was verified against CrossRef, OpenAlex, or PubMed to confirm that the source exists and is correctly identified; this verification is bibliographic and does not constitute content-level validation, independent re-analysis of primary data, full-text eligibility adjudication, or risk-of-bias appraisal. Findings are presented narratively and organised by strength of supporting evidence. Results. The available, predominantly retrospective literature suggests that extended thymectomy is beneficial in non-thymomatous AChR-Ab-positive MG and that, when an extended resection is performed, minimally invasive approaches—most frequently reported for VATS and robotic-assisted thymectomy—may achieve clinical remission and symptom-control rates similar to open transsternal thymectomy [27, 35]. Reported completeness of resection may relate to surgeon experience and operative intent rather than to the surgical approach alone, although some sources note anatomic limitations of certain minimally invasive routes [13, 17, 27, 35]. Minimally invasive approaches are associated in the reviewed non-randomised series with perioperative advantages, including shorter hospital length of stay, reduced blood loss, and lower intensive-care utilisation [7, 14, 35]. Areas of ongoing debate include the short-term time-course of remission and the relative strength of evidence among minimally invasive approaches. No randomised controlled trial has directly compared minimally invasive with open thymectomy for MG-related outcomes; the comparative evidence base is non-randomised and predominantly retrospective. Conclusions. The reviewed evidence is consistent with, but does not directly establish, the extrapolation of the MGTX benefit to minimally invasive thymectomy when extended resection is performed by experienced surgeons. Approach selection may reasonably be guided by surgeon expertise, institutional resources, and patient factors rather than by a presumed superiority of any single technique, given the absence of a cited head-to-head randomised comparison. These conclusions are constrained by the non-randomised character of the comparative literature and by the abstract-level scope of this synthesis. ---