Subxiphoid thymectomy: single-port, dual-port, and robot-assisted

Abstract

Currently, surgical techniques that are less invasive than conventional median sternotomy are used for thymectomy in the treatment of myasthenia gravis and anterior mediastinal tumors as no sternal incision is required. We reported on a subxiphoid single-port thymectomy using CO 2 insufflation, which has the following advantages: (I) the field of view offered by the camera scope inserted from the midline of the body helps confirm the location of the superior pole of the thymus and bilateral phrenic nerves; (II) there is minimal pain and no intercostal neuropathy occurs as intercostal spaces are not traversed; and (III) cosmetic outcomes are excellent. However, a drawback of this approach is that it requires familiarity with the singleport surgical procedure. Various surgical modifications have been suggested for the subxiphoid approach, which we currently use for thymectomy. These include subxiphoid single-port thymectomy; subxiphoid dual-port thymectomy (DPT) wherein an additional lateral thoracic intercostal port is added, which is used for more complicated surgeries; and subxiphoid robotic thymectomy using the da Vinci Surgical System.Here we report on these techniques. A subxiphoid approach in thymectomy is advantageous to patients as it minimizes or avoids the occurrence of intercostal neuropathy. Moreover, a subxiphoid approach provides the surgeon with a good field of view of the cervical region and helps confirm the location of the bilateral phrenic nerves. Therefore, thymectomy using a subxiphoid approach should be considered an option for a minimally invasive surgery.

Technique for Myasthenia Gravis

“…To overcome such difficulties, the subxiphoid approach has been used in recent years. 13,18,20,29,34,35 This technique offers the following advantages: the view is similar to the view from median sternotomy and the view looking-up from the main incision using this approach is familiar to thoracic surgeons. Second, to overcome the challenge of the working space, many surgeons have increased the working spaces by lifting the sternum or using CO 2 insufflation, which beneficially compress all organs and structures, thus securing the space from the sternum to the heart.…”

“…In fact, this technique avoids intercostal nerve damage due to the subxiphoid access, and the eventual small collateral incision. Suda and colleagues 13,34 in 2016 published a description of monoportal VATS suxiphoid thymectomy and "multiple-ports" robotic subxiphoid thymectomy. Further steps need to be set to develop a future single-port robotic thymectomy through the subxiphoid access.…”

“…However, the surgical operability and field of view are very poor; thus, this technique is not widely used. 13 The second approach is lateral thoracotomy, which is currently the most widely used technique, especially for large anterior mediastinal masses or infiltrating tumors. Even if the traditional approach to thymectomy by median sternotomy or lateral thoracotomy is based on the assumption that it is the best means to achieve adequate resection margins, complete removal of the thymus and clearance of the anterior mediastinal fat, Landreneau and colleagues 14 in 1992 removed an anterior mediastinal tumor under thoracoscopy.…”

Non-Intubated Anesthesia Video-Assisted Thoracic Surgery for Subxiphoid Anterior Mediastinal Tumor Resection

“…Compared with the trans thoracic approach, the most prominent advantages of subxiphoid approach for mediastinal tumor are more visual and less postoperative pain. [10] A complete resection of tumor is the primary aim. With the help of a camera scope inserted from the midline of the body, it would be convenient to look over the bilateral mediastinum clearly and con rm the location of important blood vessels and nerves nearby.…”

Subxiphoid robotic extended thymectomy – The first Indian report

“…To circumvent these limitations, we tried the trans-subxiphoid robotic approach popularised by Suda et al . [ 6 7 8 9 ] We herein describe our technique and initial experience of 25 cases with subxiphoid robotic thymectomy (SRT) for myasthenia gravis with or without thymoma and review the available literature. To the best of our knowledge, this is the first such report from India.…”