Subxiphoid Incision Research Articles

Surgical pericardial adhesions do not preclude minimally invasive epicardial pacemaker lead placement in an infant porcine model.

Pericardial adhesions in infants and small children following cardiac surgery can impede access to the epicardium. We previously described minimally invasive epicardial lead placement under direct visualization in an infant porcine model using a single subxiphoid incision. The objective of this study was to assess the acute feasibility of this approach in the presence of postoperative pericardial adhesions. Adhesion group piglets underwent left thoracotomy with pericardiotomy followed by a recovery period to develop pericardial adhesions. Control group piglets did not undergo surgery. Both groups underwent minimally invasive epicardial lead placement using a 2-channel access port (PeriPath) inserted through a 1 cm subxiphoid incision. Under direct thoracoscopic visualization, pericardial access was obtained with a 7-French sheath, and a pacing lead was affixed against the ventricular epicardium. Sensed R-wave amplitudes, lead impedances and capture thresholds were measured. Eight piglets underwent successful pericardiectomy and developed adhesions after a median recovery time of 45 days. Epicardial lead placement was successful in adhesion (9.5 ± 2.7 kg, n = 8) and control (5.6 ± 1.5 kg, n = 7) piglets. There were no acute complications. There were no significant differences in capture thresholds or sensing between groups. Procedure times in the adhesion group were longer than in controls, and while lead impedances were significantly higher in the adhesion group, all were within normal range. Pericardial adhesions do not preclude minimally invasive placement of epicardial leads in an infant porcine model. This minimally invasive approach could potentially be applied to pediatric patients with prior cardiac surgery.

P1425Complication rate and incidence of esophageal injury after minimally invasive convergent procedure for treatment of atrial fibrillation

Abstract Funding Acknowledgements None Introduction Convergent procedure is a minimally invasive surgical approach for treatment of atrial fibrillation (AF) combining epicardial and endocardial radiofrequency (RF) ablation. However, there is conflicting data regarding the rate of major complications after convergent treatment of AF. Apart from common complications the esophageal injury incidence after convergent procedure is not well documented. Purpose Our aim was to assess major complication occurrence after convergent procedure with additional emphasis on the incidence of esophageal injury. Methods One hundred forty-seven consecutive patients (113 male, mean age 59 ± 9 years, BMI 29 ± 5 kg/m2) with persistent (122, 83%) and paroxysmal (25, 17%) AF were treated with convergent procedure that included epicardial RF ablation with coagulation devices (12 lesions, each for 90 s, with 30 W power), combined with endocardial RF catheter ablation for pulmonary vein isolation. The approach for epicardial ablation was diaphragmatic pericardial window through subxiphoid incision. Infusion of cooled saline into the pericardial space during epicardial ablations and monitoring of esophageal temperature with temperature probe were additional precautions to avoid esophageal overheating. All patients had endoscopy of the esophagus at least 2 days after the procedure to assess for presence of esophageal injury. Adverse events resulting in additional intervention or causing long-term disability were defined as major complication. Results During short-term follow-up (minimum of 5 months) major complication rate was 6.1%. Three patients had cardiac tamponade, 4 had abdominal bleeding, 1 had ischemic stroke and 1 had arterial pseudoaneurysm. Esophageal mucosal lesions were observed in 11 patients (7.5%) that did not result in major complication. All lesions were followed with additional endoscopies and resolved without any intervention. Conclusions Complication rate after minimally invasive convergent procedure for treatment of AF in our patient cohort is low. Prevention of esophageal overheating resulted in absence of major esophageal injury.

Uniportal subxiphoid approach for resection of an intra-thymic parathyroid adenoma: a case report

Ectopic parathyroid glands are frequently encountered. When patients develop hyperparathyroidism, a parathyroidectomy may be indicated. Normally, this is feasible through a cervical incision; however, a few patients may require a trans-sternal or trans-thoracic approach due to deeply located adenomas. Most surgeons currently use a thoracoscopic approach; however, this can cause postoperative neuropathic pain because of the trauma to the intercostal nerves. In the Video, we describe a uniportal subxiphoid approach for resection of an intra-thymic parathyroid adenoma causing hyperparathyroidism. We report the case of a 44-year-old woman who was referred for primary hyperparathyroidism. She had recurrent renal lithiasis, gastritis, fatigue and loss of concentration. Corrected serum calcium level was 2.9 mmol/L and parathormone 25 pmol/L. A scintigraphy scan localized an ectopic adenoma in the anterior mediastinum, below the left innominate vein. Under general anesthesia, a subxiphoid transverse incision was made and the retrosternal space was entered. A GelPOINT ® Mini advanced access platform was placed and all the thoracoscopic instrumentations were inserted through this single port. Carbon dioxide was insufflated. During dissection, the ectopic adenoma was localized inside the thymus gland. This was confirmed by intra- operative angiography with Indocyanine green and a subtotal thymectomy was then performed. Intra- operative parathormone levels confirmed biological cure of primary hyperparathyroidism. The patient was discharged with normal serum calcium level and parathormone, without any pain medication. Uniportal subxiphoid technique might be considered as valid alternative to the standard thoracoscopic resection, possibly resulting in more favorable outcomes.

Extracardiac Mechanical Support Device Placement by a Minimally Invasive Approach is Safe and Effective

All current short-term mechanical cardiac assist devices are placed intravascularly and are associated with relatively high rates of thrombosis and infection. We examined a non-blood-contacting extracardiac device that can be inserted with a minimally invasive technique. The CorInnova cardiac assist device consists of 2 polyurethane chambers and a nitinol wire frame. It surrounds the left and right ventricles (fig 1). Its low-profile allows actuation within the pericardium. Air chambers pressurize cyclically to compress the heart during systole. Minimally invasive implantation was assessed in ovine studies. In a beating-heart procedure under general anesthesia, cardiac access was via a 2-3 inch subxiphoid incision. A small pericardial incision was made at the cardiac apex. Under fluoroscopy, the device was advanced to surround the ventricles within the pericardial space (fig 2). After chest closure, fluid was infused into the device's innermost chamber to conform the device to the epicardium. Minimally invasive deployment and attachment was successful for 55 devices in 25 acute studies. No animal sustained any cardiac injury as confirmed by necropsy. The wire frame allowed the device to self-flare around the heart. The intact pericardium kept the device intimately attached to the myocardium. Device-heart coupling was enhanced by the fluid chamber. This feature was verified in several (25+) acute studies and one 5-day study as documented by fluoroscopic imaging and subsequent explant. A novel extracardiac assist device can be placed safely using a minimally invasive procedure.

An Auxiliary Subxiphoid Incision in Nuss Procedure for the Treatment of Complex Pectus Excavatum.

An auxiliary subxiphoid incision was utilised to facilitate pectus bar placement and minimise operative risks in complex pectus excavatum. A series of 33 patients with recurrent or severe pectus excavatum underwent Nuss procedure with this incision from March 2013 to March 2016. The median age of the cohort was 6.9 years (9 females vs. 24 males). The mean Haller index was 5.22. There were 12 redo cases and 18 cases with a Haller index >6. Four cases underwent double bar correction. There was no perioperative death or major complication. Twenty-one cases had already the bars removed when this study was initiated. During follow-up (6-30 months), three cases presented with mild depression of lateral chest wall; while in the rest, the shapes of the chest wall remained satisfactory. The application of the auxiliary subxiphoid incision in Nuss procedure can make it safer in recurrent and severe pectus excavatum with favourable postoperative cosmetic effects.

MS03.03 Minimally Invasive Surgical Strategies and Considerations for Small Anterior Mediastinal Lesions

Thymomas are the most common anterior mediastinal masses. These are slow growing relatively indolent tumors that are often curable with surgical resection. Thymomas are often detected in asymptomatic patients who had a computed tomography of the chest for other reasons. Until recently, the surgical standard of care for curative surgery was resection of the thymus en-bloc with the mass through an open sternotomy. Advances in video surgery have allowed resection of the thymus and the anterior mediastinal masses through small incisions. Currently, there are multiple minimally invasive approaches to the anterior mediastinum, including thoracoscopy though the chest wall, thoracoscopy through a subxiphoid incision, and robotic assisted thoracoscopy. Although data comparing the techniques is sparse, there is no reason to believe that one has oncologic or survival advantages over the other. Data comparing minimally invasive approaches with open approaches have shown better short-term outcomes such as postoperative complications and blood loss, and similar long-term survival. Several authors have questioned the need for a complete thymectomy in patients with small anterior mediastinal lesions, hence the term thymomectomy. Thymomectomy involves the removal of the thymoma only, with margins around it, but without a formal complete thymectomy. Data comparing complete thymectomy with thymomectomy is sketchy and likely unreliable. Another area of intense investigation is the role of nodal dissection or sampling in the surgical management of thymomas. Data from multiinstitutional database suggests that the incidence of nodal metastases is higher than previously thought. Although data is lacking, removal of enlarged nodes, or sampling of nodes in the anterior mediastinum is likely indicated. In summary, small anterior mediastinal masses can be removed using minimally invasive techniques. The need for complete thymectomy, and nodal sampling are areas of investigation. Until more data is available, complete thymectomy with nodal sampling appears prudent. THYMOMA, minimally invasive surgery, Robotic Surgery

Non-intubated subxiphoid uniportal video-assisted thoracoscopic thymectomy.

This report describes a non-intubated, subxiphoid, uniportal approach to video-assisted thoracoscopic thymectomy. A laryngeal mask was used as a safety precaution for ventilatory management, and thymectomy was accomplished through a single transverse incision below the lower edge of the xiphoid. Patients were uneventfully discharged with fast recovery. This novel surgical approach may merge the potential benefits of a subxiphoid incision for treatment of anterior mediastinum lesion and adoption of a non-intubated anaesthesia protocol.

Subxiphoid uniportal video-assisted thoracoscopic surgery in lung cancer resection

Exponential advances in surgical technology have enabled moving to less invasive technique. Achievement of radical resection whatever the chosen approach is the fundamental integral part of oncological surgical principles. In 2014, Liu et al. (1) described the first uniportal video-assisted thoracoscopic surgery (VATS) lobectomy through subxiphoid incision harnessing that to decrease pain score by avoidance a traumatic insult to the intercostal nerve. Subxiphoid access is a novel approach for unilateral or bilateral lung tumor resection. The subxiphoid approach is safe, oncological achievable, it can alleviate postoperative pain and reduce hospital stay (2). Furthermore, it allows patients to resume physical activity quicker, which makes this approach preferable in selected patients.

Sternal elevation techniques during the minimally invasive repair of pectus excavatum.

The aim of the review was to evaluate the routine use of sternal elevation techniques (SETs) during minimally invasive repair of pectus excavatum (MIRPE, the Nuss procedure). We performed a review of the literature between January 1998 and September 2018 with focus on different methods of SET during MIRPE. Reported effects and side effects were evaluated and compared with our own experience concerning the routine use of the vacuum bell for sternal elevation during MIRPE during the last 13 years. SET is more often used in adult patients than in adolescents. SET improves visualization and safety of MIRPE. Advancement of the pectus introducer, retrosternal dissection and placement of the pectus bar are easier. The risk of cardial and/or pericardial lesion is reduced significantly. Different types of retractors, a crane combined with a wire and/or customized hooks are reported to be used as SET. Furthermore, routine use of a subxiphoid incision is reported. However, more technical equipment, and in some SETs additional incisions are necessary. In contrast, no additional skin incision is necessary for the vacuum bell. The routine intraoperative use of the vacuum bell was safe and effective in 131 patients. It facilitates the retrosternal dissection and the insertion of the pectus bar like other SETs. Besides a temporary mild hematoma, no relevant side effect was observed. In conclusion, an increasing number of authors report on the routine use of SET during MIRPE to improve safety of the procedure. We recommend the routine intraoperative use of the vacuum bell during MIRPE.

Robotic subxiphoid thymectomy: techniques, tips, and tricks

We describe the surgical techniques for robotic subxiphoid thymectomy when using the da Vinci surgical system. A 3-cm vertical incision is made approximately 1 cm below the xiphoid process on the caudal side. A space is then created to allow for port insertion blindly by the finger around the layer at the back of the rectus abdominis muscle. The wound retractor that comes with the GelPOINT Mini ® , which is a port designed for single-port surgery, is inserted through the subxiphoid incision. Insufflation and exhaustion tubes are connected to the three-way stopcock of the platform, and CO2 gas is injected at 8 mmHg. The bilateral mediastinal pleura is dissected to bilaterally open the chest cavity. A 1-cm skin incision is made on either side of the 6th intercostal space precordial axillary line, followed by insertion of a robotic surgery port. If a retraction arm is used, the port should be inserted 4–6 cm away from the main port along the anterior to the midaxillary line at the right 6th intercostal space. Bilateral phrenic nerves can be located easily by robotic subxiphoid thymectomy while easily securing a clear view of the operative field. We expect this approach to be applied to more complicated surgeries, such as combined resection of adjacent organs in thymectomy.

Tips and tricks for success in subxiphoid video-assisted thoracic surgery.

The subxiphoid approach to video-assisted thoracic surgery (VATS) has been introduced as an alternative to intercostal VATS. There is some evidence that avoiding intercostal incision and instrumentation leads to reduced pain and facilitates early mobilisation and enhanced recovery. Access of the pleural cavities and anterior mediastinal space through a subxiphoid incision presents some challenges, particularly when accessing posterior pulmonary lesions. With increasing experience, a large range of thoracic surgical operations performed through the subxiphoid approach have been reported including anatomical segmentectomies, thymectomies. Another attraction is that bilateral procedures can be performed through a single incision. The experience of several surgeons passing through the learning curve of subxiphoid VATS surgery has resulted in overcoming many of the early challenges faced. In this paper, a series of tips and tricks are presented to enable surgeons considering adopting this technique into their practice to do so safely and with an appreciation of the difficulties that they may face.

Video-assisted thoracoscopic surgery lingular segmentectomy with pericardial resection and reconstruction

We describe a patient with a metastatic lung mass who underwent video-assisted thoracoscopic surgery (VATS) lingular segmentectomy with pericardial resection and reconstruction as minimally invasive surgery. There was a metastatic mass arising from cervical cancer in the lingular segment. Because the mass was obviously larger than the intercostal space, we made a subxiphoid incision besides usual ports for VATS segmentectomy to remove a specimen. Intraoperatively, we found pericardial invasion by the mass. The pericardium was safely resected with the use of a bipolar vessel sealing system. To reconstruct the pericardium under thoracoscopy, we devised two techniques. One was the use of a thread to measure the defect size. A stretched thread was placed on the defect to determine its length. By referring to the defect length, we could cut a covering material of proper size. The other technique was that the needle tip should not be pointed towards the heart to ensure that the pericardium can be sutured safely. These techniques allowed us to reconstruct the pericardium relatively easily and safely.

Initial experience with a combined sequential left-sided and subxiphoid video-assisted thoracic surgery approach for resection of large anterior mediastinal tumors

Background: There is no standard surgical approach to deal with anterior mediastinal disorders specially tumors with a diameter larger than 4 cm. Radical resection and speciment retrieval in minimally invasive surgery can be challenging. Methods: We describe the first 4 cases of our initial experience dealing with large anterior mediastinal masses in a minimally invasive way. We combined the left side video-assisted thoracic surgery (VATS) approach with a single subxiphoid incision to achieve radical resection and remove the specimen at the end of the procedure without rib spreading. Results: The operative time ranged from 117 to 151 minutes. Blood loss was less than 150 mL during the procedures. Patients were discharged at the third post-operative day with minimal discomfort at the subxiphoid region. No morbidity/mortality was observed. Conclusions: Such procedure offers a safe option to deal with lesions without apparent invasion of other organs (mainly thymic tumors), allowing a good exposure for safe radical resection and for preserving both phrenic nerves. In the future we will consider this combined approach for lesions with a diameter of more than 4 cm and no radiological signs of infiltration.

Subxiphoid video-thoracoscopy.

Surgical procedures of pleural cavity are crucial to complete the diagnoses or planning treatment of pleural effusions with an unknown aetiology. Traditionally, the transthoracic approach has been the most used procedure to study the pleural cavity. The subxiphoid video-thoracoscopy is becoming an alternative to the transthoracic approach. Subxiphoid video-thoracoscopy is a minimally invasive technique that allows us to study both pleural cavities with a single subxiphoid incision. In the supine decubitus, through a small subxiphoid incision, a rigid video-mediastinoscope is introduced. Once all the tissues are dissected, mediastinal pleura can be identified and incised. A 30° thoracoscopy is then inserted into the pleural cavity through the video-mediastinoscope to obtain samples of pleural fluid and biopsies of the parietal pleura and lung nodules if present. Subxiphoid approach has some advantages compared with the traditional transthoracic approach. On the one hand, contrary to traditional thoracoscopy, in subxiphoid video-thoracoscopy it is not necessary to do a transthoracic approach even for the insertion of a chest tube. Avoidance of intercostal ports probably decreases the risk of post-operative pain and the patients can be discharged 24 hours after surgery with no increase in surgical risk. On the other hand, we can explore both pleural cavities at the same time through a single incision, in case of bilateral pleural effusion. If malignancy is confirmed by frozen-section or by macroscopic evidence of intrapleural tumour infiltration or implants, a pleurodesis to avoid recurrence can be performed prior to tube insertion and closure.

Subxiphoid video-thoracoscopy

Surgical procedures of pleural cavity are crucial to complete the diagnoses or planning treatment of pleural effusions with an unknown aetiology. Traditionally, the transthoracic approach has been the most used procedure to study the pleural cavity. The subxiphoid video-thoracoscopy is becoming an alternative to the transthoracic approach. Subxiphoid video-thoracoscopy is a minimally invasive technique that allows us to study both pleural cavities with a single subxiphoid incision. In the supine decubitus, through a small subxiphoid incision, a rigid video-mediastinoscope is introduced. Once all the tissues are dissected, mediastinal pleura can be identified and incised. A 30° thoracoscopy is then inserted into the pleural cavity through the video-mediastinoscope to obtain samples of pleural fluid and biopsies of the parietal pleura and lung nodules if present. Subxiphoid approach has some advantages compared with the traditional transthoracic approach. On the one hand, contrary to traditional thoracoscopy, in subxiphoid video-thoracoscopy it is not necessary to do a transthoracic approach even for the insertion of a chest tube. Avoidance of intercostal ports probably decreases the risk of post-operative pain and the patients can be discharged 24 hours after surgery with no increase in surgical risk. On the other hand, we can explore both pleural cavities at the same time through a single incision, in case of bilateral pleural effusion. If malignancy is confirmed by frozen-section or by macroscopic evidence of intrapleural tumour infiltration or implants, a pleurodesis to avoid recurrence can be performed prior to tube insertion and closure.

The Evolution of the Minimally Invasive Approach and Conventional Median Sternotomy for Coronary Artery Fistula Correction

Minimally invasive cardiac surgery has become a safe and cosmetic alternative to standard median sternotomy. This retrospective study reviews our results and experience with the minimally invasive approach for congenital coronary artery fistula correction, compared with conventional approach. From February 2001 to June 2016, 110 patients with isolated coronary artery fistula (CAF) in our centre underwent correction through minimally invasive approach (MIA) (n=65) or standard median sternotomy (SMS) (n=45). Cardiopulmonary bypass (CPB) was used in 16 patients in the SMS group, and all the other patients underwent the procedure without CPB through a standard median sternotomy or minimally invasive approach. There was no in-hospital mortality and no patients reverted to a median sternotomy in the MIA group. Subxiphoid incision (32 cases) and parasternal incision (28 cases) were the most common approaches used for the procedure. The operative time was 67.82±14.4minutes in MIA group and 107.04±27.91minutes (p=0.0001) in the SMS group. The intubation time was 3.58±2.33hours in the MIA group and 6.1±3.26hours in the SMS group (p=0.0001); the intensive care unit (ICU) stay was 10.04±7.95hours in the MIA group and 19.74±7.81hours in the SMS group (p=0.0001). Three patients (two in MIA Group vs one in SMS Group, p=0.787) were identified with a trivial residual shunt during the procedure, which had disappeared by discharge. Minimally invasive approach can provide an excellent surgical exposure for CAF ligation in selective patients compared with SMS. It is a safe and cosmetic alternative to conventional treatment and minimised the length of stay.

Video-assisted thoracic surgery thymectomy: subxiphoid approach

Background: To describe the use of the subxiphoid approach for thymectomy and to present a variant of the technique of minimally invasive extended thymectomy for thymoma or myasthenia gravis (MG) without thymoma done via a sole (uniportal) subxiphoid incision with aid of the sternal lifting. Methods: The infrasternal (subxiphoid) technique was used. The whole specimen containing the thymus surrounded by the right and left mediastinal pleural sheets and the fat of the anterior mediastinum and the lower neck region was resected en bloc through the incision made above the xiphoid process for insertion of a videothoracoscope [video-assisted thoracic surgery (VATS)] and, finally for introduction of chest drains. The sternum was lifted by two hooks attached to the Zakopane bar (B.Braun, Aesculap-Chifa, Nowy Tomysl, Poland). The lower hook was elevating the lower sternal angle and the upper hook was inserted through a puncture made above the sternal notch while the major mediastinal structures were pressed down toward the spine to avoid injury. Results: The entire group of patients in whom the subxiphoid approach was used for thymectomy included 611 patients, overall (80 patients with thymomas, 516 patients with MG without thymoma and 15 patients with repeated thymectomy) operated on from Sep 2000 to Sep 2017. There were 5 uniportal subxiphoid-VATS extended thymectomies (for non-thymomatous MG in 2 patients and for thymic tumors in 2 patients). The mean time of the operation 118.5 min (range, 85–130 min). For the whole group of 611 patients there was no mortality and less than 5% morbidity. The complete remission rate 53.1% for the transcervical-subxiphoid-VATS maximal thymectomy approach for non-thymomatous MG was reported. Conclusions: The subxiphoid uniportal incision with sternal lifting facilitates performance of extended thymectomy for thymomas or MG without thymoma.

Right VATS thymectomy, utilising a subxiphoid incision and the LigaSure retractable L-hook

We describe a technique of right sided video-assisted thoracoscopic surgery (VATS) thymectomy in a lady who had a large 7 cm mass which was adherent to the pericardium, extended into the superior poles of the thymus and had adhesions to the lung bilaterally. We utilized 3 mm × 5 mm ports from the right-hand side and a 12 mm subxiphoid incision which was used to retrieve the tumour at the end of the case. Due to the bulky nature of the tumour we also added a 5 mm port to the left chest to visualize the left phrenic nerve towards the end of the case. The pericardium is widely excised in this case as the tumour is adherent to it. The LigaSure L-hook is demonstrated which was particularly useful in this case. This device can grasp, blunt dissect, cut and seal as usual like any other LigaSure, but there is a switch that can retract the LigaSure back and advance a hook diathermy without removing the instrument from the chest. We hope this video and description demonstrates that endoscopic thymectomy is safe and feasible even in more difficult cases and provides the same completeness of resection as open surgery.

Subxiphoid incision, elevation of the sternum, opening of the right mediastinal pleura, dissection of the right epiphrenic fat pad from the diaphragm and the pericardium

Subxiphoid incision, elevation of the sternum, opening of the right mediastinal pleura, dissection of the right epiphrenic fat pad from the diaphragm and the pericardium

Nonintubated Subxiphoid Bilateral Redo Lung Volume Reduction Surgery

This report describes a nonintubated, bilateral thoracoscopic redo lung volume reduction surgery procedure through a single subxiphoid access in a patient who previously underwent one-stage bilateral volume reduction for upper lobe-predominant heterogeneous emphysema 19 years earlier. The patient was uneventfully discharged on postoperative day 2, and meaningful improvement in respiratory function and exercise tolerance occurred at 3 months postoperatively. This novel surgical approach may merge the potential benefits of a subxiphoid incision for bilateral treatment, nonintercostal passage of chest drains, and adoption of a nonintubated anesthesia protocol.