Early outcomes in 147 consecutive cases of subxiphoid single-port thymectomy and evaluation of learning curves

Abstract

<jats:title>Abstract</jats:title> <jats:p /> <jats:sec> <jats:title>OBJECTIVES</jats:title> <jats:p>The aim of the present study was to examine some initial results and learning curves concerning subxiphoid single-port thymectomy (SSPT), thereby clarifying the safety of this surgical approach and describing the precautions for adopting it.</jats:p> </jats:sec> <jats:sec> <jats:title>METHODS</jats:title> <jats:p>From March 2011 to August 2019, a total of 203 patients underwent thymectomy for either anterior mediastinal tumours or myasthenia gravis at Fujita Health University Hospital. Of these 203 patients, 147 patients who had undergone SSPT were selected as participants for the present study.</jats:p> </jats:sec> <jats:sec> <jats:title>RESULTS</jats:title> <jats:p>Of the 147 cases, transition to a different approach was required in three (2.0%) cases: two (1.3%) cases transitioned to median sternotomy, whereas one (0.7%) case transitioned to the side chest trans-intercostal approach. The two cases that transitioned to median sternotomy were the second cases for different operators after they began performing this technique. There were six (4.0%) cases with complications and no deaths. The operation time cumulative summation learning curve analysis revealed that the curves descended from the 38th case. In the 83 cases handled by one surgeon, the learning curves descended from the 31st case.</jats:p> </jats:sec> <jats:sec> <jats:title>CONCLUSIONS</jats:title> <jats:p>SSPT is a safe modality with few complications and no associated cases of mortality reported. Operators are required to experience 31–38 cases until the operation time for SSPT was stabilized. Special care should be exercised to prevent vascular damage in the vicinity of the innominate veins during the early stages after SSPT introduction.</jats:p> </jats:sec>

A Comparison of Subxiphoid and Intercostal Wound Pain in the Same Patients Following Thoracic Surgery

“…In contrast to the literature's overwhelming opinion that subxiphoid VATS results in much less early postoperative pain than intercostal VATS following thoracic surgery [12][13][14][15][16]18], our study found the subxiphoid incision produced more pain than the intercostal incision during the early postoperative period (POD-1, POD-2, and POD-Discharge), but only in the bilateral VATS group, not in the unilateral VATS group. The authors suggest one reason for the difference may be because the subxiphoid incision was always made below the xiphoid process and slightly tilted in the direction of the operative costal arch.…”

“…As can be seen in Table 1, males made up sixty-one percent and mean BMI was 23 kg/m 2 . Operative time, blood loss, complications, and postoperative hospital length-of-stay were comparable and similar to those reported in the subxiphoid VATS literature [12][13][14][15][16]. As can be seen in Supplemental table 1, out of the eleven patients receiving bilateral VATS, ve had primary spontaneous pneumothorax with contralateral blebs for which they received surgical treatments following previous reported procedures [24] and six had indeterminate lung nodules or suspected lung cancer and received simultaneous bilateral operations for accurate diagnosis and staging after weighing relative risks and bene ts.…”

“…The debate regarding the relative pain associated with multiportal VATS versus uniportal VATS is also ongoing [5][6][7][8]. Until now, only a few studies have reported a reduction in acute postoperative pain and chronic pain associated with subxiphoid VATS [12][13][14][15][16]18].…”

“…Moreover, proponents of its use have admitted that there may be some cardiac compression when using subxiphoid VATS to perform left thoracic procedures as well as limited visualization of the posterior mediastinum and potential technical di culties [11][12][13][14][15][16].…”

“…In 2012, Suda et al reported their rst concomitant use of subxiphoid single-port thymectomy and CO 2 insu ation [10]. Not long after in 2014, Liu et al reported their rst use of subxiphoid uniportal VATS lobectomy [11], followed by subsequent use of this alternative approach to treat a wide array of thoracic procedures worldwide [12][13][14][15][16]. This relatively new technique often requires division of the rectus abdominis muscle, resection of the xiphoid process and use of a sternal elevator.…”