Subxiphoid Incision Research Articles

Minimally invasive approach for coronary artery fistula correction.

Minimally invasive cardiac surgery has recently become widespread. The aim of this study is to analyse the feasibility of a minimally invasive approach for coronary artery fistula (CAF) correction. From February 2001 to June 2014, 49 patients in our centre underwent minimally invasive CAF correction without cardiopulmonary bypass (CPB). The mean age was 21.18 ± 11.24 years (range, 5 months to 64 years). Patients with cardiac anomalies who underwent CAF correction and those who underwent CAF via the minimally invasive approach with CPB were excluded. There were no in-hospital mortalities or conversions to median sternotomy. Subxiphoid incisions (22 cases) and parasternal incisions (20 cases) were the most commonly used approaches for the procedure. The operative time was 67.45 ± 22.69 min (30-125 min). The intubation time was 3.72 ± 1.82 h (2-12 h), and the ICU stay was 9.67 ± 5.43 h (4-24 h). A trivial residual shunt was identified in only 1 patient during the procedure; however, this shunt had disappeared by discharge. The minimally invasive approach can provide excellent surgical exposure for CAF ligation in select patients. This approach is a safe and cosmetic alternative to conventional treatment and may minimize the length of stay.

The Minimally Invasive Repair of Pectus Excavatum Using a Subxiphoid Incision.

Purpose Several surgeons have documented outcomes following the Nuss operation. Most reports have described the use of thoracoscopy to avoid cardiac injury. Since 1999, our group has utilized a subxiphoid incision, allowing insertion of the surgeon's finger into the substernal space to help guide the bar across the mediastinum. Our initial experience has been reported and we are now reporting our entire experience to date. Methods A retrospective review was conducted on all patients who underwent pectus excavatum repair using a subxiphoid incision from December, 1999 to September, 2015. Results During the study period, 554 repairs were performed. A total of 80% of the patients were male. The mean age was 14.3 years ± 3.1, the mean operating time was 52 minutes ± 17.4, the mean length of stay was 4.2 days ± 1.1, and the mean time to bar removal was 2.7 years ± 0.7. A total of 20 patients (3.6%) received two bars. No patients sustained cardiac injury or evidence of pericarditis. Postoperatively, 22 patients (4%) developed an infection, either cellulitis or a local abscess requiring incision and drainage and/or antibiotics. In four of these 22 patients, the wound infection developed after the bar had been removed. Only one patient required bar removal before 2 years due to an infection. A total of 12 patients required either repositioning of the bar due to rotation (4) or removal of a stabilizer due to chronic discomfort (8), 2 required early bar removal for chronic pain, and 1 patient developed a tension pneumothorax in the operating room. A recurrence has developed in two patients but neither patient has desired correction. Conclusion In this relatively large series of patients, the addition of a subxiphoid incision to the technique has allowed for safe passage of the bar across the mediastinum to avoid cardiac injury during the Nuss operation.

Modified Transsubxiphoid Thoracoscopic Extended Thymectomy in Patients with Myasthenia Gravis.

We developed a new minimally invasive thoracoscopic technique of extended thymectomy for myasthenia gravis by combining a subxiphoid incision with dual costal margin incisions. In our experience of 31 consecutive cases, this procedure provides a good operative view in the neck region and makes verification of the bilateral phrenic nerves easy. All the patients recovered smoothly with less trauma, less bleeding, less complication, and good cosmetic results. This modified transsubxiphoid approach is a satisfactory procedure for performing extended thymectomy in patients with myasthenia gravis.

Robotic subxiphoid thymectomy.

When endoscopic surgery is indicated for myasthenia gravis and thymomas, most institutions use a lateral thoracic approach that includes robot-assisted surgery. However, with the unilateral thoracic approach, it can be difficult to ensure the operative field in the neck and difficult to identify the location of the contralateral phrenic nerve. In 2015, we reported on a robotic subxiphoid thymectomy (RST) in which the camera is inserted from the subxiphoid incision and robotic forceps are inserted from the bilateral intercostal spaces. With this approach, a camera is inserted into a subxiphoid incision which is the midline of the body and a surgical field comparable to that in a median sternotomy can be achieved. This makes it easier to identify the location of the bilateral phrenic nerves and offer the good visualization in the neck area. Here we report on our RST techniques. For a thymectomy without suturing, a subxiphoid, single-port thymectomy is performed because it is minimally invasive. In patients who require suturing, such as with a pericardial patch closure, RST is selected. The RST has excellent operability when performed with a robot, making it suitable for more difficult procedures. In the future, we believe that a robot-assisted thymectomy might become the standard method.

Uniportal subxiphoid video-assisted thoracoscopic thymectomy.

With a uniportal subxiphoid video-assisted thoracoscopic surgery (VATS) thymectomy, the thymus is not accessed through the ribs, which avoids intercostal nerve damage. Furthermore, compared to a VATS thymectomy via the lateral chest, decreased use of postoperative analgesics (lower doses and shorter duration), decreased blood loss, and shorter surgical duration and hospital stay have been reported. Here we report our surgical method and solutions for a uniportal subxiphoid VATS thymectomy. A uniportal subxiphoid VATS thymectomy is indicated for patients with myasthenia gravis and anterior mediastinal tumors who do not require surgical suturing. The operator stands between the patient's legs and the scopist stands to the right of the patient to operate the camera scope. To begin with, a 3-cm transverse incision was made along Langer's lines 1 cm caudal below the xiphoid process. The CO2 insufflation is performed in the mediastinum at 8 mmHg. The pericardial adipose tissue and thymus are detached from the pericardium in an anterior manner from the bilateral phrenic nerves. The resected thymus is placed in a pouch in the mediastinum and removed from the body through the subxiphoid incision. The subxiphoid approach is highly beneficial for the patient in that it results in superior esthetic outcomes considering that there is no sternotomy and no intercostal nerve damage; thus, it is a surgical procedure that surgeons should learn.

Learning curve and subxiphoid lung resections most common technical issues.

Subxiphoid uniportal video-assisted thoracic surgery (SVATS) for major lung resections is a new approach. Clinical evidence is lacking. The aim of this article is to describe the learning curve of the 200 selected patients who underwent uniportal subxiphoid lobectomy or segmentectomy by subxiphoid midline incision, and with the lessons learned from this early experience in SVATS and from the experience with transthoracic uniportal VATS we sought to compile "tips and tricks" for managing the multiple intraoperative technical difficulties that can arise during the SVATS and help to set the recommendations for a SVATS program. We describe the learning curve of the first 200 selected patients who underwent uniportal subxiphoid lobectomy or segmentectomy by subxiphoid midline incision From September 2014 with early-stage non-small cell lung carcinoma (NSCLC) and benign disease. We examine the rate of conversion and the operating time comparing group one (first 100 cases) with group two (subsequent 100 cases). Of the 200 consecutive selected cases (72 males, 128 females) with a mean age of 57.4±9 years, underwent either uniportal subxiphoid lobectomy or segmentectomy 136 were lobectomies and 64 were segmental resections The mean operating time was 170±45 mins; the average and after the case 86 the rate of the operating time appears to be similar. The conversion rate decrease from 13% in group one to 8% in group two. There is a gradual reduction in the operating time and rate conversion with increasing experience. Lessons from our initial experience in the learning curve period in SVATS helps to create this trouble shooting guide that offers "tips and tricks" to both avoid and manage numerous intra-operative technical difficulties that commonly arise during the SVATS initial experience.

Subxiphoid single-port video-assisted thoracoscopic surgery.

We report the feasibility and safety of chest surgery through the subxiphoid single port approach based on our preliminary experience. From December 2013 till January 2016, 39 patients underwent 40 thoracoscopic surgeries via a 3- to 4-cm subxiphoid single incision. A sternal lifter was applied for better entrance and working angle. A zero-degree deflectable scope was preferred. The technique for anatomic resection was similar to that in the traditional single-port approach. Patient characteristics and demographic data were analyzed. There were 29 females and 10 males, with a median age of 56 years. Indication for surgery included 24 patients with primary lung cancer, eight with lung metastases, two with benign lung lesions, one with bilateral pneumothorax, and five with mediastinal tumors. Surgeries included lobectomy in 21, segmentectomy in five, wedge resection in nine, and mediastinal surgery in five patients. There was no surgical mortality. Complications (10%, 4 in 40) included postoperative bleeding in one patient, chylothorax in one patient, and transient arrhythmia in the early learning curve in two patients. Our results indicated that subxiphoid single-incision thoracoscopic pulmonary resection could be performed safely but under careful patient selection with modification of instruments. Moreover, having a previous single-port incision experience was crucial. Major limitations of this approach included more frequently encountered instrument fighting; interference of left-side procedure related to heartbeat and radical mediastinal lymph node (LN) dissection; and the ability to handle complex conditions, such as anthracotic LNs, diffuse adhesion, and major bleeding.

Video-assisted thoracic surgery micro pneumonectomy, a new approach.

Video-assisted thoracic surgery (VATS) pneumonectomy is normally limited due to the difficulty to remove the whole lung via the utility incision. We present our technique of VATS pneumonectomy, this we call micropneumonectomy. A 75-year-old male current smoker with a right hilar mass, invading both upper and lower lobe bronchi to segmental level on CT scan and PET scan, pathology from CT guided biopsy showed squamous cell carcinoma. The patient had a mediastinoscopy just prior to pneumonectomy, primarily to remove station 7 lymph nodes and to mobilize the carina to facilitate the VATS pneumonectomy. Smooth postoperative course, and patient was fit for discharge two and half days post operatively. Our technique showed an effective way of doing pneumonectomy via VATS technique, which expands the use of VATS technique into pneumonectomies, with three intercostals incisions smaller than 5 mm, in addition to a single sub-xiphoid incision which can take 12 mm instruments.

Pericardial hernia: an unusual complication of convergent atrial fibrillation ablation.

A 59-year-old woman with highly symptomatic recurrent paroxysmal atrial fibrillation had failed antiarrhythmic therapy and pulmonary vein isolation. Owing to her large left atrial size and failed pulmonary vein isolation, she underwent the convergent atrial fibrillation ablation. A 3-cm subxiphoid incision was made at the central tendon of diaphragm above the liver, medial to the falciform ligament. Through this port, the VisiTrax ablation device (nContact, Inc., Morrisville, NC, USA) was advanced into the pericardial space and ablation was performed at the posterior left atrium and around the pulmonary veins. Subsequently, through an transseptal approach, endocardial lesions were created at the posterior antrum of the left superior pulmonary vein. Bidirectional block was confirmed across all four veins and a right-sided cavotricuspid isthmus line was created. Amiodarone was continued for 3 months. Four months after the procedure, she complained of constant bloating. Physical examination and routine laboratories were normal. Echocardiography showed an echogenic mass anterior to her heart. Computed tomography of her chest confirmed a diaphragmatic hernia with portions of greater omentum and transverse colon extending into the pericardium (Fig. 1). Laparoscopic hernia repair was performed. Diaphragmatic and pericardial openings were closed with figure of eight sutures and her abdominal symptoms resolved. Figure 1: CT chest showing diaphragmatic hernia with portions of greater omentum and transverse colon extending into the pericardium. Diaphragmatic hernia is rare and usually congenital or traumatic [1]. There are few case reports documenting diaphragmatic hernias following a pericardial window, pacemaker placement [2] and coronary artery bypass graft [3]. Being a minimally invasive procedure, the convergent ablation has minimal complications [4]. We have modified our technique to create a more posterior pericardial access site and we have not had any further cases of intrapericardial hernia. Alternatively, routine closure of the diaphragmatic access with a suture may also reduce the possibility of hernia formation.

Contemporary outcomes after pericardial window surgery: impact of operative technique

BackgroundThe optimal window procedure for drainage of a large pericardial effusion has yet to be established. The purpose of this study was to compare the outcomes associated with the subxiphoid and thoracotomy pericardial window techniques, with a focus on perioperative pain and effusion recurrence rates.MethodsA retrospective single-center observational study of all pericardial window operations was performed, with the incision based on surgeon preference. Perioperative data was recorded including time to extubation, narcotic requirements, and the development of a recurrent pericardial effusion.ResultsFrom 2002 to 2015, 179 patients with a large pericardial effusion underwent either a subxiphoid (n = 127) or left anterior mini-thoracotomy (n = 52) pericardial window procedure. Patients (mean age 73.2 years, 56 % female) had a high incidence of previous malignancy (49 %), chronic anticoagulation (34 %), recent infection (26 %), or renal failure (18 %). Cardiac tamponade was present in 50 %, and 12 % had undergone previous pericardiocentesis. Comparing the two techniques, there was no difference in the amount of fluid drained or in the perioperative mortality rate. Postoperatively, patients who had the subxiphoid approach required less time before extubation (P = 0.002) and needed less narcotics within 48 h after surgery (P = 0.0001) compared to thoracotomy patients. However, patients treated with the subxiphoid technique more often developed recurrent moderate or large pericardial effusions (P = 0.02), and there was a trend towards more repeat operations needed (P = 0.15).ConclusionPericardial window surgery via a subxiphoid incision is associated with less postoperative pain and faster time to extubation. However, the thoracotomy approach may be more effective at preventing effusion recurrence and the need for repeat surgery.

Uniportal video-assisted thoracic surgery.

Even though the development of thoracoscopic procedures has a history of over a hundred years, it is only in the last two decades that interest in minimally invasive thoracic surgery has been renewed by two key technological improvements. These are the development of endoscopic cameras offering a panoramic view and the availability of new endoscopic instruments such as mechanical staplers. As a result of these advances, video-assisted thoracic surgery (VATS) was born. In 1992, there was a revolution in thoracic surgery when the first anatomic lung resection was performed by VATS through small incisions and with no rib spreading. In the following years, the progress of VATS was slow and accompanied by constant criticism until studies showing clear benefits of VATS over open surgery started to be published. From that point on, the technique spread throughout the world and variations of the technique regarding the number and placement of incisions, surgical approaches and new surgical instruments started to emerge. The information available on the Internet, live surgical events and experimental courses were important factors facilitating the rapid learning curve for minimally invasive surgery during the last decade. While initially slow to catch on, the traditional multi-port approach has evolved into a single-port (uniportal) approach that mimics open surgical vantage points while utilizing a non-rib-spreading, non-thoracotomy micro-incision. The early development of uniportal VATS was focused on minor procedures until the second phase of uniportal VATS started in 2010 with application of the technique to major pulmonary resections. In a period of only five to six years, experts have been able to apply the uniportal VATS technique to more complex procedures such as bronchial sleeve and carinal resections as well as vascular reconstructions. In contrast, non-intubated thoracic surgical techniques, described since the early history of thoracic surgery, peaked in the decades before the invention of the double-lumen endotracheal tube and have failed to gain widespread acceptance following their re-emergence over a decade ago thanks to improvements in video-assisted thoracoscopic techniques. In addition, experienced uniportal VATS surgeons are able to explore new and even less invasive approaches. Recently, the aim to avoid intercostal nerve damage by the transthoracic incision has led to the use of the technique through a single subxiphoid incision. It’s interesting to note that from the first thoracoscopic procedure performed more than a century ago, the biggest developments have taken place in the last five years. Several factors are responsible for this. The Internet has provided an invaluable platform to share knowledge. The development of specialized websites to which videos can be uploaded and scientific journals that include videos have contributed enormously to the dissemination and learning of minimally invasive techniques, especially uniportal VATS. The development of modern, narrowed and angulated endostaplers and other specialized surgical instruments have also been key factors contributing to the growing interest in uniportal video-assisted surgery in the last few years. At the same time, advances in the technology of ultra-high definition cameras, 3D technology and precise robotic systems have contributed to the progressive adoption of minimally invasive surgery throughout the globe. This special issue provides a summary of different aspects of uniportal VATS including several articles written by some of the best world experts in this technique. Areas covered range from the early experience of several groups to reports from the most experienced surgical teams, as well as emerging techniques such as uniportal non-intubated and subxiphoid approaches. Alongside medical and radiation oncology, which are advancing rapidly due to the development of more effective chemotherapeutic agents with less toxicity and novel radiation techniques such as stereotactic body radiation therapy (SBRT), the role of the surgeon is to offer the patient the best oncologic procedure with the least invasive approach possible. During the last couple of years, rapid progress in instrument design and technology have triggered the development of narrower and more angulated endostaplers, sealing devices for vessels and other refined thoracoscopic instruments. We truly believe in the use of the least invasive techniques such as the uniportal approach combined with modern ‘naked eye’ 3D image systems, wireless cameras and improved robotic technology to perform major pulmonary resections. Further advancements in technology will facilitate the adoption of single-incision minimally invasive techniques worldwide in the upcoming years. Video Uniportal video-assisted thoracic surgery.

Minimal Invasive Internal Liver Retractor in Conventional and Trans-umbilical Single-Incision Laparoscopic Sleeve Gastrectomy: Video Report

Sleeve gastrectomy (SG) is a safe and efficient procedure with comparable results between conventional and single-incision approach in selected patients. However, the critical point in both approaches is the retraction of the hypertrophic and fatty left lobe of the liver which increases technical difficulties and limit the exposure of the hiatus. Traditional liver retractors require an additional sub-xiphoid incision for insertion and cause post-operative pain as well as iatrogenic liver injuries. Various techniques have been described to allow adequate liver retraction through smaller incisions or fewer ports without compromising patient safety. However, some disadvantages of these methods are the need for incision of the liver ligament or diaphragmatic crura puncture rendering the device difficult to reposition. Two morbidly obese patients underwent a SG by conventional laparoscopy and by trans-umbilical single-incision using a novel minimal invasive internal liver retractor: the Versa Lifter Band®. This soft and flexible internal retractor was fully repositionable and adjustable intraoperatively. The time required to complete the liver retraction was 4 min 12 s in conventional surgery and 5 min 23 s in single-incision approach. Liver retraction was always satisfying resulting in limited intra-operative difficulties without the need of additional retractors/ports or conversion in both patients. No adverse outcomes occurred during the intra and post-operative periods without rise in aspartate aminotransferase and alanine-aminotransferase serum levels. In our preliminary experience, this internal liver retractor was easy to handle and provided an effective and safe retraction with good exposure of the surgical field and improved ergonomy in single incision as well as reduced port laparoscopic SG.

P25: VATS combined with a subxiphoid incision: a novel approach for large thymoma.

In patients with thymoma larger than 5 cm in diameter, video-assisted thoracoscopic surgery (VATS) remains controversial as an approach for total thymectomy. Aside from the concerns such as possible rupture of tumor capsule, reduced safety margins and increased risk of local recurrence, how to remove specimen of this size from incisions of VATS is another problem that surgeons have to confront. We reported a case of a 47-year-old man who was referred to our department with a huge mass located on the anterior mediastinal and right hemithorax. After careful preoperative evaluation and planning, the tumor was completely removed by VATS and taken out of thoracic cavity through a subxiphoid incision. After resection, histologic analysis confirmed the diagnosis of thymoma B1 type. Postoperative course was uneventful and no adjuvant therapy was offered. The patient has continued to do well with no signs of recurrence at a follow-up of 10 months. We stress that VATS combined with a subxiphoid incision may be a useful surgical option for patients with thymoma larger than 5 cm in size.

P06: A new surgical method for anterior mediastinum tumors: a 3-hole approach

Thoracic Surgery, Fourth Military Medical University, Xi’an 710032, China Background This study was to introduce a new surgical method for resecting anterior mediastinum tumors through a subxiphoid incision, which accurately combines the advantages of both video-assisted thoracic surgery and standard sternotomy for a minimally-invasive procedure with fewer complications.

P30: A case of anterior mediastinitis and bilateral multiple lung abscesses occurring after TsTET

Trans-subxiphoid thoracoscopic extended thymectomy (TsTET), which can provide a better exposure of bilateral upper thymus lobes and the contralateral phrenic nerve, was reported superior to unilateral thoracoscopic approach in treatment of myasthynia gravis or anterior mediastinal tumour. However, the postoperative complications for TsTET have hardly been discussed. Here we reported a 68-year-old female suffered subxiphoid incision infection, anterior mediastinitis, concomitant bilateral pneumonia and multiple lung abscesses after TsTET. In our experience, because the subxipoid incision, the anterior mediastinum and the bilateral thoracic cavity communicated directly after TsTET, it should be aware of the risk of infection in anterior mediastinitis and bilateral thoracic cavity following subxiphoid incision infection.

Robot-assisted real-time magnetic resonance image–guided transcatheter aortic valve replacement

BackgroundReal-time magnetic resonance imaging (rtMRI)-guided transcatheter aortic valve replacement (TAVR) offers improved visualization, real-time imaging, and pinpoint accuracy with device delivery. Unfortunately, performing a TAVR in a MRI scanner can be a difficult task owing to limited space and an awkward working environment. Our solution was to design a MRI-compatible robot-assisted device to insert and deploy a self-expanding valve from a remote computer console. We present our preliminary results in a swine model. MethodsWe used an MRI-compatible robotic arm and developed a valve delivery module. A 12-mm trocar was inserted in the apex of the heart via a subxiphoid incision. The delivery device and nitinol stented prosthesis were mounted on the robot. Two continuous real-time imaging planes provided a virtual real-time 3-dimensional reconstruction. The valve was deployed remotely by the surgeon via a graphic user interface. ResultsIn this acute nonsurvival study, 8 swine underwent robot-assisted rtMRI TAVR for evaluation of feasibility. Device deployment took a mean of 61 ± 5 seconds. Postdeployment necropsy was performed to confirm correlations between imaging and actual valve positions. ConclusionsThese results demonstrate the feasibility of robotic-assisted TAVR using rtMRI guidance. This approach may eliminate some of the challenges of performing a procedure while working inside of an MRI scanner, and may improve the success of TAVR. It provides superior visualization during the insertion process, pinpoint accuracy of deployment, and, potentially, communication between the imaging device and the robotic module to prevent incorrect or misaligned deployment.

Previously Complicated Nuss Procedure Does Not Preclude Blind Removal of the Bar

Nuss procedure has become the procedure of choice for well-selected patients with pectus excavatum. Perioperative complications may pose difficulty during the subsequent bar removal due to adhesions and tissue plane disruptions during the initial surgery and repair. This report describes bar removal experience in patients whose Nuss procedures were complicated by cardiac injury, pericardial breach, and lung parenchyma/diaphragm injury during the initial procedure. A total of 529 patients who underwent Nuss procedure between 2007 and 2014 were recorded in a prospective database. Twenty patients with complications (cardiac injury [n = 1], pericardial breach [n = 3], and lung parenchyma/diaphragm injury [n = 16]) were identified. All bars were removed via subcutaneous tissue dissection, without intrathoracic visualization. Average duration of bars was 36 months (±16 months). All bar removal procedures were completed without any need for extra interventions with negligible blood loss. Eighteen patients were able to be discharged within 2 postoperative days. Blind bar removal in patients with previously complicated Nuss procedure seems safe and no other interventions (videothoracoscopy, subxiphoid incision, etc.) during bar removal seem to be necessary.

Subxiphoid uniportal thoracoscopic extended thymectomy.

The aim of this article is to present a thoracoscopic technique of extended thymectomy through a subxiphoid incision. Six consecutive patients were successively treated with this approach, which provided a good view of the bilateral pleural cavities. The procedure is safe and technically feasible and yields excellent cosmetic results. We believe that subxiphoid uniportal thoracoscopic approach is a satisfactory procedure for performing extended thymectomy in well selected patients.

Clinical features and outcome of patients with descending necrotizing mediastinitis: prospective analysis of 34 cases.

We aimed to investigate clinical features of patients with descending necrotizing mediastinitis (DNM) in order to improve management and outcome. We prospectively examined all patients with DNM admitted to the Intensive Care Unit (ICU) during the period from April 2007 to December 2013. Demographics, clinical features, microbiology, medical and surgical treatment data were recorded. Survivor and nonsurvivor groups were analyzed to identify factors associated with mortality. Overall, 34 patients with DNM have been included. The mean age was 46.8 ± 11.2 years (range 24-70). The male/female ratio was 3.25. DNM arose from odontogenic infection in 22 (65%) patients; from peritonsillar abscess in 9 (26%) patients and from paranasal sinus in 3 (9%) patients. Microbiological cultures revealed a high percentage of aerobic/anaerobic coinfection. Nonsurvivors were statistically more likely to have higher SAPS II score (mean difference 19.1, 95% CI 12.3-25.9 P < 0.01) and more severe disease (P < 0.01) than survivors. Positive correlation was found between time to ICU admission after head or neck infection diagnosis and SAPS II score (ρ = 0.5, P = 0.03). The same was true for ICU length of stay and time to ICU admission (ρ = 0.6, P < 0.01) and time to surgery (ρ = 0.5, P = 0.03). Surgical treatments consisted in: transcervical drainage in 14 cases, (42%); irrigation through subxiphoid and cervical incisions of the anterior mediastinum with additional percutaneous thoracic drainage when necessary in ten cases, (29 %); thoracotomy with radical mediastinal surgical debridement, excision of necrotic tissue and decortication in ten cases, (29%). We have found a mortality rate of 12%. Patients with DNM type IIB were admitted to the ICU later than patients with DNM type I and type IIA (mean difference 3.2 days, 95% CI 1.2-5.1, P 0.02). Prompt ICU admission in order to manage severe sepsis and/or septic shock, along with early and aggressive surgery and adequate antimicrobial therapy, could be key factors in reducing DNM mortality.

Single-port VATS resection for some pulmonary diseases:strategies of the incision location in different gender

To discuss the feasibility and advantages of aberrant incision location of single-port video-assisted thoracoscopic surgery(VATS) in different gender when treating some lung diseases. Retrospectively analyze the clinical data of these patients who were received lung partial resection from the same surgeon in the First Affiliated Hospital of Soochow University, the 100 Hospital of PLA, Wu Zhong People's Hospital from January 2012 to December 2014. Among the males, 57 were undertook a single-port VATS surgery through areola incision (Observation Group A), and the rest 114 were received conventional uniportal VATS surgery (Control Group A). Among the females, 15 were operated through the subxiphoid incision (Observation Group B) and 45 were received conventional one (Control Group B). The operation time, blood loss, postoperative drainage amount, chest tube drainage duration, postoperative hospital stay, the Visual Analogue Scale (VAS) pain score of the 1st and 2nd postoperative day, the incision discomfort in the 30th and 90th postoperative day, and the incision satisfaction degree were evaluated. All the patients were underwent total VATS surgery successfully and no severe complications were observed.In males, there were no significant differences in operation time, blood loss, postoperative drainage amount, chest tube drainage duration, postoperative hospital day and the VAS score of the 1st postoperative day (P>0.05). Compared to control group A, the VAS score of the 2nd postoperative day was lower (3.5 ± 1.78 vs 4.14 ± 1.62, P=0.035), the incision discomfort of 30th and 90th postoperative day was reduced (33 (57.9%) vs 86 (75.4%), P=0.019; 29 (50.9%) vs 76 (66.7%), P=0.046) and the incision satisfaction degree was significantly improved (45 (79.0%) vs 61 (53.5%), P=0.001). In females, there were no statistical differences in intraoperative blood loss, postoperative drainage amount, chest tube drainage duration, postoperative hospital day and the incision satisfaction degree (P>0.05). Compared to control group B, the operation time was obviously prolonged (57.67 ± 5.72 vs 42.91 ± 7.82, P=0.000), the VAS score of the 1st and 2nd postoperative day was significantly lower (2.13 ± 1.06 vs 3.84 ± 1.69, P=0.001; 2.60 ± 1.24 vs 4.18 ± 1.56, P=0.001) and the incision discomfort in 30th and 90th postoperative day was reduced (4 (26.7%) vs 34 (75.6%), P=0.001; 4 (26.7%) vs 28 (62.2%), P=0.017). In single-port VATS surgery for some pulmonary diseases, we choose "individualized" incision location--trans-areola incision in males and subxiphoid incision in females--according to different gender and varieties of diseases, which was considered to raise incision satisfaction degree in males and reduce postoperative pain in females, it warrants further clinical practice.