Subxiphoid Incision Research Articles

Subxiphoid single-port thymectomy procedure: tips and pitfalls

We previously described a subxiphoid single-port thymectomy procedure with CO 2 insufflation of the mediastinum and removal of the thymus via a single incision below the xiphoid process. This report describes an endoscopic subxiphoid, single-port thymectomy procedure, with tips to ensure success and pitfalls to avoid. The patient is placed in the supine position with the legs apart. A vertical or horizontal incision of approximately 3 cm is made 1 cm caudal to the xiphoid process. A finger is inserted behind the sternum via the subxiphoid wound to blindly detach the caudal side of the thymus from the sternum. A port for single-port surgery is inserted. CO 2 insufflation is performed at 8 mmHg. The trick to safe use of the vessel sealing device is to perform separation by opening and closing the jaw tips before dissection, passing one of the jaws through the separated area, and then dissecting. In a subxiphoid single-port thymectomy, the thymic vein is sectioned last because it runs tangential to the subxiphoid wound and shifts laterally on the traction of the thymus. The thymus is removed from the body through the subxiphoid incision. The subxiphoid approach affords a cervical field of view that is superior to other approaches and makes it easy to identify the bilateral phrenic nerves. Furthermore, it is a minimally invasive approach that reduces the extent of intercostal nerve damage compared with the lateral intercostal approach. Thymectomy using the subxiphoid approach is a surgical technique that should be learned by respiratory surgeons.

Subxiphoid robotic thymectomy procedure: tips and pitfalls

Recently, robot-assisted surgery has gained popularity for thymectomy. The advantages of robot-assisted surgery include true three-dimensional (3D) imaging with binocular glasses and the use of multiarticular forceps that allow the performance of high-precision operations. Furthermore, the presence of devices with multiple articulations within the thoracic cavity enables detachment procedures to be achieved in a natural manner. In the subxiphoid robotic thymectomy, the camera scope was inserted through a midline subxiphoid incision, which provides an operative visual field like that obtained during median sternotomy, making it easy to identify the neck structures and the location of the bilateral phrenic nerves and to observe the entire left brachiocephalic vein. This report described the surgical indications and techniques of subxiphoid robot-assisted thymectomy (SRT). The patient is in the supine position with the arms and legs apart. A 3 cm vertical incision is made approximately 1 cm caudal to the xiphoid process. CO 2 insufflation is performed at 8 mmHg. The mediastinal pleura is sectioned bilaterally to expose the thoracic cavity. A 1 cm skin incision is made along each of the bilateral anterior-axillary lines at the sixth intercostal space of the precordium to insert the port for the da Vinci system arm. When using the retraction arm, a port is inserted at least 6 cm from the port on the anterior-axillary line to the mid-axillary line in the right sixth intercostal space. Robot-assisted surgery is performed with multi-articulated forceps that move like human joints. This allows safe clamping of the left brachiocephalic vein even if it is in contact with the tumor. Subxiphoid robotic thymectomy allows for minimally invasive surgery in some patients previously considered unsuitable for thoracoscopic surgery such as in those with brachiocephalic vein involvement or with pericardial invasion requiring a more complicated surgery.

Subxiphoid Minimally Invasive Epicardial Ablation (Convergent Procedure) With Left Thoracoscopic Closure of the Left Atrial Appendage

The Convergent Procedure is a combined epicardial and endocardial ablation performed by a cardiac surgeon and electrophysiologist to treat symptomatic persistent and long standing persistent atrial fibrillation. The epicardial ablation is performed on the entire width of the posterior left atrial wall using monopolar radiofrequency via a subxiphoid incision. There is no sternotomy and cardiopulmonary bypass is not utilized. The surgical ablation is then followed by endocardial voltage mapping and ablation, allowing for complete lesion set creation. Left atrial appendage exclusion can be performed via left thoracoscopic approach at the same time as the surgical ablation. The Convergent Procedure is a truly hybrid, collaborative procedure which combines the strengths of minimally invasive cardiac surgery and percutaneous electrophysiologic techniques to treat a challenging disease process.

Microlobectomy—where do we stand?

Video-assisted thoracoscopic surgery (VATS) have been shown to be superior to open procedures, particularly with regards to pain and post-operative recovery, though high-levels of pain may still be reported due to large intercostal port sizes. Microlobectomy is a novel endoscopic lobectomy technique building on VATS lobectomies, with the principle that there are no intercostal ports larger than 5 mm. CO 2 insufflation is used to improve access to the chest and a 12 mm subxiphoid port is created to function as a utility port and can be extended further to facilitate specimen removal. All instruments utilized are 5 mm in size, including a 5 mm camera. However, a standard 12 mm stapler can be used through the subxiphoid incision, which provides excellent access to all the hilar structures bilaterally. Additionally, newer instruments are being developed to facilitate easier improved dissection of vascular structures and lymph nodes, such as the FlexDex needle holder, which is an articulated endoscopic needle holder facilitating movements in all directions, similar to a robotic instrument. The main advantage of a microlobectomy is reduced post-operative pain and shorter time to mobilisation, enabling a faster recovery. In our experience of microlobectomies, we have had patients successfully discharged on the first post-operative day. The development of a greater variety of 5 mm instruments that are similar to conventional VATS instruments may enable more surgeons globally to adopt the microlobectomy approach.

Subxiphoid uniportal video-assisted bilateral surgery: right upper lobectomy and left upper wedge resection S3.

Traditional approach of bilateral lesions usually involves bilateral approaches instead of classical thoracotomy or video-assisted thoracoscopic surgery (VATS) surgery, and often at two different times. During visit of Dr. Gonzalez Rivas at Master Class to Málaga, we performed right upper lobectomy and S3 wedge resection left upper lobe of a two synchronous bilateral lung lesions case with subxiphoid single incision approach. We are reporting the first case of a lobectomy combined with a wedge resection performed through an uniportal subxiphoid bilateral VATS in Spain.

Subxiphoid incision, elevation of the sternum, opening of the right mediastinal pleura, dissection of the mediastinal tissue from the sternum, introduction of the percutaneous hook elevating the sternal manubrium

Subxiphoid incision, elevation of the sternum, opening of the right mediastinal pleura, dissection of the mediastinal tissue from the sternum, introduction of the percutaneous hook elevating the sternal manubrium

Subxiphoid uniportal VATS thymectomy.

To present the technique of minimally invasive extended thymectomy performed through the uniportal subxiphoid approach, with double elevation of the sternum for nonthymomatous myasthenia gravis (MG). Operative technique: the whole dissection was performed through the 4-7 cm transverse or longitudinal subxiphoid incision with use of videothoracoscope. The sternum was elevated with two hooks connected to the sternal frame (Rochard bar, Aesculap-Chifa, Nowy Tomysl, Poland). The lower hook was inserted through the subxiphoid incision and the superior hook was inserted percutaneously, after the mediastinal tissue including the major mediastinal vessels were dissected from the inner surface of the sternum. The fatty tissue of the anterior mediastinum and the aorta-pulmonary window was completely removed. There were four patients in the period 1.1.2017-30.4.2017. There was no mortality and morbidity. The uniportal subxiphoid approach combined with double elevation of the sternum enabled very extensive thymectomy in case of thymoma.

Definitions and standard indications of minimally-invasive techniques in thymic surgery.

The minimally invasive thoracic procedures are those performed through the intercostal, subxiphoid, subcostal or transcervical incisions. In most of these procedures (with exception of some transcervical procedures) the video-assisted thoracic surgery (VATS) technique is used for performance of an operation under guidance of a video monitor. According to the definition the minimally invasive procedures do not include the sternal manubriotomy (upper sternal split), transverse sternotomy and subcutaneous longitudinal sternotomy. Currently, a minimally invasive extended thymectomy became a widespread procedure advised for nonthymomatous myasthenia gravis (MG) and early-stage thymomas. The definition of an extended thymectomy is a removal of the whole thymus with the surrounding adipose tissue. Instead of the term "extended thymectomy" some authors recommended a term "complete thymectomy", which means total removal of the whole thymus, without the adjacent fatty tissue. There are a lot of doubts about the definition of extended thymectomy. There have been no prospective randomized trials comparing the transsternal and minimally invasive approaches for MG or thymomas. Possible scenarios for such trials are analyzed in this paper. There are several issues of a minimally invasive thymectomy for MG and thymomas necessitating further clarifications.

Minimally invasive surgical procedures for thymic disease in Asia.

Video-assisted thoracic surgery (VATS) procedures for thymic tumors and myasthenia gravis were introduced in Asia in the middle 1990s in at least two regions, Hong Kong and Japan. To overcome difficulties in obtaining a wide view of the anterior mediastinum, several methods for lifting the sternum or anterior chest wall have been presented, mainly by Japanese surgeons. More recently, single port VATS through a subxiphoid incision was also introduced in Japan. The long-term outcome of a VATS extended thymectomy for myasthenia gravis has been shown to be comparable to that of a trans-sternal extended thymectomy, while the long-term outcome of a VATS thymectomy for thymic epithelial tumors remains to be elucidated. Nevertheless, its indication for tumors in an early stage is now widely accepted, and the number of VATS procedures is steadily increasing in Japan and China. Single-port VATS through a subxiphoid incision was developed in Japan and might become accepted as a useful approach in the near future when combined with robot-assisted thoracoscopic surgery. In addition, robot-assisted thoracoscopic surgery for the thymus has also been introduced in some areas in Asia. Although few of those surgical procedures for the thymus have been performed, results obtained thus far indicate that it might be preferable to lung resection. Several novel minimally invasive thymectomy techniques have been invented and developed in Asia, and further advancements in this field by Asian surgeons are anticipated.

Minimally invasive, pericardial implantable cardioverter-defibrillator placement in a young child

We report the successful minimally invasive placement of a pericardial implantable cardioverter-defibrillator (ICD) in a 16-kg child. A transvenous ICD dual coil was advanced through a small subxiphoid incision and screwed into the oblique sinus pericardium under fluoroscopic guidance. An additional sense-pace lead was sutured onto the right ventricular apex, and the generator was placed in the upper abdominal wall through the same incision. Threshold testing demonstrated successful defibrillation at 15J. After implantation, the patient had two episodes of appropriate shock for ventricular fibrillation. The ICD system continues to show stable impedance at 6 months of follow-up.

Subxiphoid Exchange of HeartMate II Left Ventricular Assist Device

With increasing use of left ventricular assist devices (LVADs) for long-term circulatory support comes a growing need for device exchange. The conventional surgical approach for device exchanges has been a reoperative median resternotomy. Less-invasive HeartMate II LVAD exchange via a nonmuscle-dividing subxiphoid incision as an alternative to a left subcostal incision may reduce pain burden and facilitate recovery. From November 2006 to June 2015, 292 patients underwent HeartMate II LVAD placement, of which 30 (10.3%) required an exchange. Twenty-four (80%) LVAD exchanges were performed through a subxiphoid sternal-sparing approach and six (20%) through reoperative sternotomy. Predominant indication for device exchange was suspected or confirmed pump thrombus (73.3%), followed by electromechanical pump dysfunction (16.7%). The subxiphoid approach resulted in significantly shorter median intensive care unit (7 vs. 37 days, p = 0.01) and hospital stay (29 vs. 107 days, p = 0.01) compared with reoperative sternotomy. Kaplan-Meier analysis showed comparable survival between the subgroups (p = 0.15) as well as between the patients with device exchange and the rest of the HeartMate II LVAD patients at our institution (p = 0.12). Subxiphoid device exchange is a viable option, resulting in low operative morbidity and mortality with no adverse effect on late survival.

Single-incision percutaneous pericardial ICD lead placement in a piglet model.

Our group has demonstrated the feasibility of percutaneous pericardial ICD lead placement in a piglet model utilizing direct visualization from a lateral thoracoscopic approach. Development of a novel delivery tool that incorporates visualization allows for the procedure to be performed with a 1 cm subxiphoid incision. A 1 cm incision is made in the subxiphoid area and a novel self-anchoring delivery tool is inserted. A rigid thoracoscope and needle are inserted into two crossed working channels of the tool. After needle visualization, pericardial needle access, followed by sheath access is obtained. A modified side-biting ICD lead is inserted and fixated to the ventricular epicardial surface. The lead is connected to an ICD generator and lead testing followed by defibrillation threshold testing (DFT) is performed. Single-incision ICD lead placement was performed in 6 piglets without acute complications. Median time from subxiphoid incision to DFT testing was 64 minutes; median time from thoracoscope insertion to lead fixation was 16.5 minutes (range 9-30). All had adequate ventricular sensing and pacing at implant and underwent successful defibrillation (range 3-5 J). Survival period ranged from 1 to 16 weeks. Two piglets had survival periods of 12 and 16 weeks with mean weight gain of 7 kg; both had successful repeat DFT at 10 J. All survival animals had stable lead impedances and R-wave amplitudes throughout the survival period. Percutaneous pericardial placement of an ICD lead using our novel access tool can be safely performed through a 1 cm incision without complications.

Subxiphoid thymectomy—technical variants

The aim of this article is to review technical variants of minimally invasive extended thymectomy performed through the subxiphoid approach. These approaches include the sole subxiphoid with use of Video-Assisted-Thoracic Surgery (VATS) technique or the subxiphoid incision might be combined with the transcervical, intercostal, subcostal single or bilateral VATS. The use of CO2 insufflation or the elevation of the sternum are the options to facilitate an access to the chest. The technical details of all these variants are described in detail. The advantages of the subxiphoid approach in comparison to the other approaches for thymectomy including a transcervical approach, unilateral VATS, bilateral VATS, VATS combined with transcervical incision, are analyzed. The operative technique of the new procedure, subxiphoid uniportal extended thymectomy with double elevation of the sternum is described.

Subxiphoid incision, elevation of the sternum, opening of the right mediastinal pleura, dissection of the mediastinal tissue from the sternum, introduction of the percutaneous hook elevating the sternal manubrium

Subxiphoid incision, elevation of the sternum, opening of the right mediastinal pleura, dissection of the mediastinal tissue from the sternum, introduction of the percutaneous hook elevating the sternal manubrium

The Zakopane Pulmonary Hospital experience on subxiphoid thymectomy.

To present the technique of minimally invasive extended thymectomy performed through the subxiphoid-bilateral subcostal video-assisted thoracoscopic surgery (VATS) approach, with double elevation of the sternum for nonthymomatous myasthenia gravis (MG). The whole dissection was performed through the 4-7 cm transverse subxiphoid incision with single 10 mm extra-long bariatric laparoscopy ports inserted subcostally to the right and left chest cavities for videothoracoscope and subsequently for chest tubes. The sternum was elevated with two hooks connected to the sternal frame (Rochard bar, Aesculap-Chifa, Nowy Tomysl, Poland). The lower hook was inserted through the subxiphoid incision and the superior hook was inserted percutaneously, after the mediastinal tissue including the major mediastinal vessels were dissected from the inner surface of the sternum. The fatty tissue of the anterior mediastinum and the aorta-pulmonary window was completely removed. There were 147 patients (62 patients operated on for thymomas, 75 patients for nonthymomatous MG and 10 for rethymectomies) in the period 1.1.2009-30.3.2016. There was no mortality and morbidity. The mean operative time was 109.1 min (range, 75-150 min). The subxiphoid approach combined with bilateral single port subcostal VATS and double elevation of the sternum enables very extensive thymectomy in case of nonthymomayous MG.

Subxiphoid VATS approach for the mediastinum

The technique of subxiphoid video-assisted thoracoscopic surgery (VATS) approach for thymectomy for thymomas, non thymomatous myasthenia gravis and rethymectomies is described. This technique combines a subxiphoid incision with bilateral insertion of single intercostal, or subcostal VATS ports and elevation of the sternum with two hooks connected to the Rochard frame. The extended thymectomy is performed with opening of both pleural cavities, visualization of both phrenic nerves and the lower poles of the thyroid gland and en bloc removal of the whole thymus, parathymic fatty tissue, both epiphrenic fat pad and the sheets of right and left anterior mediastinal pleura covering the thymus and mediastinal fatty tissue. The variants of the subxiphoid VATS approach for the mediastinum and the applications of this approach are described.

AB056. PS02.20: Left sided VATS + subxiphoid for radical thymectomy

: Technical difficulties during thymic surgery usually represent conversion to not minimal invasive approaches. In centers where minimal invasive left side approach is established, the tissue removal at the right cardiophrenic angle remains a technical problem to be solved. Also non infiltrative tumors with large sizes required a non-minimal invasive approach for correct dissection and specimen retrieval. We present an alternative approach to try to solve both technical issues adding a subxiphoidal port to the conventional left side minimal invasive one. Special importance was given to a careful dissection of both phrenic nerves, which was easily accomplished, adding a higher radicality at the right cardiophrenic tissue removal. Four patients were operated following such approach in our institution achieving a radical thymectomy in all cases. Tumors larger than 5 cm could be retrieved through the subxiphoid incision. No mortality/morbidity is reported.

Subxiphoid incision, opening of the right pleural cavity and introduction of the bariatric port through the subcostal space

Subxiphoid incision, opening of the right pleural cavity and introduction of the bariatric port through the subcostal space

Hybrid Nuss Procedure for Pectus Excavatum With Severe Retrosternal Adhesions After Sternotomy

The most striking feature of pectus excavatum (PE) after previous congenital heart disease (CHD) surgery through a median sternotomy is the postsurgical adhesions between the sternum and heart. For patients with severe adhesions, passing the introducer can be difficult and hazardous when performing a Nuss repair. We describe a hybrid Nuss procedure using a small subxiphoid incision for blunt and sharp anterior mediastinal dissection and using a thoracoscope to ensure the whole process of dissection is under direct visualization. A retrospective case review was conducted of PE patients (previous CHD operation) who had undergone the hybrid Nuss procedure between January 2012 and June 2015. Demographic, treatment, and outcome variables were recorded. Eleven patients were included. The mean age was 4.7 ± 1.7 years (range, 3.2 to 8.9). The mean Haller index based on computed tomography was 4.15 ± 0.78 (range, 3.2 to 5.8). All cases were the symmetric type. Mean operating time was 95.5 ± 8.4 minutes (range, 80 to 110); mean blood loss was 15 ± 2.3 mL; and mean length of hospitalization was 6.0 ± 1.4 days (range, 4 to 8). There was no pneumothorax, cardiac injury, wound infection, discomfort requiring removal, or bar rotation at the average 27-month (range, 9 to 50) follow-up. Two patients had the bars removed. No reoperations were performed owing to recurrence. The hybrid Nuss procedure is a safe, simple modification of the Nuss repair for patients with severe retrosternal adhesions. This procedure achieves dissection with direct visualization. Hence, the risk of death due to cardiac perforation can be prevented.

Minimally invasive repair of pectus excavatum in children: Results of a modified Nuss procedure

Pectus excavatum (PE) is the most common deformity of the anterior thoracic wall. The Nuss technique allows the thorax to be reshaped with the aid of a retrosternal metallic bar. The aim of this study is to evaluate and compare the complication rate between the original Nuss technique and a lightly modified approach. We performed a retrospective single-center observational study based on the medical files of patients operated for PE in the Pediatric Surgery Unit between July 2004 and July 2015. We divided two patient groups according to the operating technique employed: the Nuss group (NG) and the modified Nuss group (MNG) with supplementary subxiphoid incision and bilateral thoracoscopy. Twenty-seven patients were included: sixteen in the NG and eleven in the MNG. No significant differences were found between the two groups for all kinds of complications: total complication rate (50% for the NG versus 54% for the MNG, P>0.05), early (31% vs 46%, P>0.05), late (19% vs 9%, P>0.05), non-serious (37% vs 36%, P>0.05) or serious (13 vs 18%, P>0.05). There was no life threatening complication in the MNG, contrary to the NG. In the two groups, a significant difference was found (P=0.029) regarding the operating time: longer operating times (80±25min) were correlated with a higher complication rate. The modified Nuss technique does not cause more complications than the original technique described by Nuss and it has the advantage to minimize the risk of heart damage.