Uniportal subxiphoid video-assisted thoracoscopic approach for thymectomy: a case series

Abstract

Background: Minimally invasive techniques are becoming increasingly popular in thoracic surgery.Although median sternotomy is the traditional approach for thymectomy, video-assisted thoracoscopic surgery (VATS) approaches now predominate. This study reports a case series of the novel uniportal subxiphoid-VATS approach to extended thymectomy.Methods: Over the period of study (October 2014-January 2017) 17 patients underwent uniportal subxiphoid-VATS extended thymectomy for a thymic nodule at the Shanghai Pulmonary Centre. Ten patients were female, and the mean age of the cohort was 55 years. The mean size of nodule was 23.6 mm.Results: The mean operative duration was 2.5 hours, with one conversion to thoracotomy for bleeding.The mean operative blood loss was 115 mL. The median length of hospital stay was 4 days. There were no episodes of phrenic nerve palsies. The 30-day survival was 100%.Conclusions: Uniportal subxiphoid-VATS is a feasible and safe surgical approach to extended thymectomy in selected patients, with good post-operative outcomes. Here we present a case series of subxiphoid-VATS thymectomies describing intra and post-operative characteristics that demonstrate the safety and feasibility of this novel surgical approach. MethodsAll procedures were performed in Shanghai Pulmonary Hospital, Shanghai, China, between October 2014 and January 2017.Exclusion criteria for subxiphoid-VATS thymectomy included:(I) thymic tumour, stage II-IV (macroscopic spread to surrounding fatty tissue or beyond, including distal metastases); (II) body mass index >30; (III) cardiomegaly, poor cardiac function or severe arrhythmia (because of reduced operative access to left-side of thymus and risk of cardiovascular compromise). Surgical techniqueUnder general anaesthesia, patients were placed in a supine position with a roll beneath the scapulae (for maximal chest extension). Selective one lung ventilation was used during the procedure. A 4-cm-long horizontal subxiphoid incision was made if the infrasternal angle was within normal limits (≥70°). Alternatively, if the infrasternal angle was less than 70°, a longitudinal incision was made. The xiphoid process was then resected to provide a widened operative view. In these cases, the sternum was not elevated. Blunt finger dissection created a retrosternal tunnel between the incision and the thoracic cavity and a wound protector was placed to further optimize the view. Any obstructing anterior mediastinal adipose tissue was removed. A 10 mm 30 o angle thoracoscope (Karl Storz, Tuttlingen, Germany) was used in each case (Figure 1). The right pleural cavity was opened initially, with the left lung being selectively ventilated. Electrocautery dissection of pericardial and epiphrenic fat pads was performed and then the right lobe of the thymus was identified and dissected from the pericardium and ascending aorta. Care was taken to visualize fully the innominate vein and superior vena cava junction prior to dissection of the thymic horn from the underlying innominate vein. The thymic ...

Subxiphoid uniportal video‐assisted thoracoscopic surgery: A cosmetically superior approach to submammary rib tumor resection

“…Subxiphoid uniportal VATS has been recently described and is being increasingly used in a variety of thoracic procedures, including thymectomy, lobectomy, and resection of giant pleural fibroids . Because this method does not require sternotomy, it is associated with lesser pain because there is no intercostal nerve damage and provides excellent cosmesis as only a single 3 cm abdominal skin incision is made, which is of great advantage to patients.…”

Subxiphoid pneumonectomy: the new frontier?

“…In the case of standard VATS, there are reports of requiring rib spreading and the lung being retrieved in pieces. Furthermore, retrieval may result in compression of the intercostal nerves which can result in chest wall pain which may be chronic in some patients More recently, the subxiphoid uniportal VATS technique has been described, avoiding any intercostal incision or instrumentation (14)(15)(16)(17)(18)(19)(20)(21)28,29). Additionally, since the chest drains are not entering the thoracic cavity through intercostal spaces postoperatively, they do not impinge on the intercostal neurovascular bundle during mobilization of the patient.…”

“…More recently, the subxiphoid-VATS approach has been described and is increasingly utilised for a range of thoracic operations including thymectomy, lobectomy, segmentectomies and resection of giant solitary fibrous tumours of the pleura (14)(15)(16)(17)(18)(19)(20)(21). In this technique, a single vertical muscle-sparing incision is made in the subxiphoid space permitting thoracic surgery to be performed without requiring intercostal incisions.…”

Anesthesia and enhanced recovery in subxiphoid video-assisted thoracoscopic surgery

“…They observed a significant reduction on postoperative pain in the SVATs group which was associated with earlier mobilisation and reduced risk of complication (5). The SVATS approach has become increasingly popular, and there are reports of a wide range of operations being performed from anatomical segmentectomies to pneumonectomies (6)(7)(8)(9)(10)(11)(12)(13)(14)(15).…”