Single-incision subxiphoid approach for bilateral metastasectomy

One-Stage Bilateral Pulmonary Nodule Resection via Unilateral Thoracic Cavity Access: A Single-Center Experience of 12 Cases

BACKGROUND

Surgical intervention remains the primary therapeutic modality for managing multiple pulmonary nodules. However, in cases with bilateral pulmonary nodules, one-stage bilateral resection is discouraged due to tumor aggressiveness and surgical invasiveness. In light of this, we investigated an innovative approach, termed one-stage bilateral pulmonary nodule resection via unilateral thoracic cavity access.

METHODS

From July 2022 to September 2024, a cohort of 12 patients with bilateral pulmonary nodules were enrolled in this study. This technique involves initial unilateral transcostal incision for segmental or lobectomy of a nodule on one side, followed by bilateral mediastinal pleura incision through the anterior mediastinum, facilitating subsequent wedge resection of the contralateral nodule. Clinical and pathological data, along with perioperative imaging findings and follow-up information, were systematically collected and subjected to a comprehensive retrospective analysis.

RESULTS

A total of 25 nodules were resected from 12 patients. Regarding surgical approaches, nine patients underwent right thoracic incision, while three patients underwent left thoracic incision. Intraoperatively, seven patients received bilateral wedge resections, whereas five patients underwent segmentectomy on one side combined with wedge resection on the contralateral side. R0 resection of the contralateral nodules was successfully achieved during the procedures. The average distance between the surgical margin and the contralateral nodules was 12.5 mm, ranging from 5 mm to 25 mm. Of the 12 patients, one (Patient 6) was lost to follow-up, while the remaining 11 patients underwent postoperative chest CT examinations. The median follow-up duration for these 11 patients was 105 days (range: 36-857 days). No evidence of bilateral pleural effusion or tumor recurrence was detected on follow-up chest CT scans.

CONCLUSIONS

This study offers the potential to concurrently address bilateral pulmonary nodules, thereby sparing patients from the need for a subsequent hospitalization for surgical intervention.

Subxiphoid Single-Port Robotic Thymectomy Using the Single-Port Robotic System versus VATS: A Multi-Institutional, Retrospective, and Propensity Score-Matched Study

Subxiphoid thymectomy is a novel alternative to the transthoracic approach and sternotomy, with potential benefits, such as reduced postoperative pain and faster recovery. We previously reported the initial experience with subxiphoid single-port robotic-assisted thoracic surgery (SRATS) thymectomy using the single-port robotic system (SPS). However, the efficacy of this technique remains unknown. Thus, this study examined the multi-institutional experience with SRATS thymectomy and compared the perioperative outcomes of this technique to those of subxiphoid single-port video-assisted thoracic surgery (SVATS) thymectomy. The data of patients who underwent subxiphoid SRATS and SVATS thymectomy, performed by three thoracic surgeons at three institutions between September 2018 and May 2024, were retrospectively collected. In total, 110 patients were included, with 85 and 25 undergoing SRATS and SVATS thymectomy, respectively. After propensity score matching, 25 patients were included in each group. The SRATS group was associated with a lower conversion rate to multi-port surgery (0% vs. 20%, p = 0.05), shorter chest tube drainage duration (1.32 ± 0.75 vs. 2.00 ± 1.29 days, p = 0.003), and a shorter postoperative hospital stay (2.52 ± 1.00 vs. 5.08 ± 5.20 days, p = 0.003). Subxiphoid SRATS thymectomy using the SPS is feasible and is a good alternative to conventional thymectomy. Further studies are necessary to confirm its benefits.

Comparison of short-term results of subxiphoid and conventional video-assisted thoracoscopic surgery in diagnostic wedge resections

BACKGROUND

This study aimed to compare early results in patients who underwent subxiphoid wedge resection with those operated on using a multiportal approach.

METHODS

We retrospectively evaluated 151 patients who underwent diagnostic wedge resection for suspected interstitial lung disease. Patients who underwent wedge resection via subxiphoid video-assisted thoracoscopic surgery and conventional video-assisted thoracoscopic surgery were compared.

RESULTS

The study included 90 men (59.6%) and 61 women (40.4%) with a mean age of 54.8 ± 12 years. Of these, 127 patients underwent conventional video-assisted thoracoscopic surgery and 24 patients underwent subxiphoid video-assisted thoracoscopic surgery. Postoperative complications occurred in 13 patients (8.6%), with no significant difference according to surgical technique. Sex was a significant factor in the rate of complications (12.2% in men vs. 3.2% in women). There was no intraoperative mortality; the 30-day mortality rate was 4% (n = 6). Five nonsurviving patients were in the conventional video-assisted thoracoscopic surgery group and 1 was in the subxiphoid video-assisted thoracoscopic surgery group (p = 0.95).

CONCLUSION

The results of this study indicate that the subxiphoid approach reduced procedure time and length of hospital stay in the early period, while there was no significant difference between the techniques in terms of complications or mortality. Based on these findings, we conclude that surgical outcomes were as successful with the subxiphoid approach as with conventional video-assisted thoracoscopic surgery.

Surgical removal of bilateral lung metastases from Wilms tumor via subxiphoid approach video-assisted thoracic surgery: a case report

BACKGROUND

Lung is the most common site of metastasis in pediatric patients with Wilms tumor (WT). For such patients, neoadjuvant chemotherapy before nephrectomy is recommended now. A considerable proportion of metastases will shrink in size after the chemotherapy. However, there are still some of them that are not sensitive to chemotherapy and require subsequent surgical resection. For pediatric patients with bilateral lung metastases from WT which are not sensitive to chemotherapy, the simultaneous surgical removal of bilateral lung tumors via one-stage surgery is problematic. These children typically require 2 separate surgeries to remove the bilateral lung metastases and improve their 5-year event-free survival (EFS) rate. There is no precedent in pediatric thoracic surgery for one-stage, bilateral, lung wedge resection via subxiphoid approach video-assisted thoracic surgery (SA-VATS).

CASE DESCRIPTION

In this article, we report on a successful SA-VATS performed on an 8-year-old boy whereby all of the bilateral lung metastases were completely resected. The operation was performed through 3 incisions under the xiphoid process and costal arch. No complications occurred after surgery. The patient's intraoperative blood loss was approximately 20 mL. Drainage tubes were indwelled in both pleural cavities which were removed on post-operative day (POD) 5 and POD 6. There was no recurrence at follow-up of about 4 months.

CONCLUSIONS

This case presents a new option for thoracoscopic surgery which is safe and less invasive for patients with bilateral lung metastases from WT. Similar patients may benefit from the shorter time frame between the operation and other postoperative treatment.

Current opinion and comparison of surgical procedures for the treatment of primary spontaneous pneumothorax

INTRODUCTION

Although three-port video-assisted thoracoscopic surgery (VATS) is the standard radical treatment for primary spontaneous pneumothorax (PSP), several issues need to be addressed as the postoperative recurrence rate remains relatively high. Although bullectomy is effective in preventing the postoperative recurrence of PSP, recurrent pneumothorax often occurs, requiring additional methods such as pleural covering with absorbable mesh sheets, surgical chemical pleurodesis, pleural abrasion, or pleurectomy. In addition, minimally invasive approaches that exceed three-port VATS are required according to the social demand. These approaches, such as uniportal VATS, reduced port surgery, and needlescopic surgery, have cosmetic merits, lower postoperative pain, and similar surgical results as three-port VATS.

AREAS COVERED

We focused on conventional and novel treatments for PSP in this article.

EXPERT OPINION

Effective methods that prevent postoperative recurrence and minimally invasive approaches will become popular in the near future.

A subxiphoid uniportal video-assisted thoracoscopic surgery for synchronous bilateral pulmonary metastasis: A case report

The subxiphoid incision has been widely used in videothoracoscopic surgery in recent years. This minimally invasive technique allows to reach both lungs from a single port. With the future development of the surgical instruments required for the technique, it is expected to become more commonly used. Herein, we report the first case of bilateral pulmonary metastasectomy performed with a subxiphoid single incision in Turkey.

Subxiphoid uniportal bilateral lung wedge resection

Subxiphoid uniportal bilateral lung wedge resection, in which all manipulations are performed via a 3-cm wound positioned below the xiphoid process, can be performed in the supine position without the patient having to change positions. It also enables one-stage bilateral lung resection. We report the surgical procedure and initial results of subxiphoid uniportal bilateral lung wedge resection. A 3-cm transverse incision was made 1 cm caudally below the xiphoid process. A port for uniportal surgery was inserted. After CO2 insufflation at 8 mmHg, the lung was grasped and lifted with bent grasping forceps, and by bending the tip of a stapler, the surgeon resected the affected portion of the bilateral lungs. In this approach, there is one incision, no intercostal nerve damage and bilateral surgery can be performed in the same procedure; therefore, the technique may have the benefit of lesser invasiveness for the patient. Furthermore, a detailed comparison of subxiphoid uniportal bilateral lung wedge resection with the one-stage lateral intercostal approach with a larger subject sample is needed.

Feasibility of the single-incision subxiphoid approach for video-assisted thoracoscopic surgery in dogs

OBJECTIVES

To report early results of uniportal video-assisted thoracoscopic surgery in dogs using a single-incision subxiphoid approach.

MATERIALS AND METHODS

Retrospective study of 10 client-owned dogs with: pyothorax (n=5), pericardial effusion (n=2), bilateral pneumothorax (n=1), retained surgical swab (n=1), cranial mediastinal mass (n=1). With the dog in dorsal recumbency a 3-4 cm incision was made over the xiphoid process. After resection of the xiphoid process, a tunnel was created towards the pleura and open access maintained with an Alexis™ wound retractor. The pleural cavity was explored with a 10 mm 30° or 5 mm 0° telescope and straight laparoscopic instruments.

RESULTS

Median surgical time was 75 minutes. The SISA technique was performed successfully in five of 10 cases and allowed easy and adequate inspection of the intra-thoracic structures. One case was converted to lateral thoracotomy after laceration of the vena cava and one converted to median sternotomy because of adhesions. An additional port was placed in three cases to facilitate triangulation and surgical manipulation. No other intra-operative complications were encountered.

CLINICAL SIGNIFICANCE

In this initial report of uniportal thoracic approach in dogs, this technique allowed excellent access and treatment of mediastinal structures. Further cases are required to assess its suitability for pulmonary surgery.

Comparison of post-operative pain and quality of life between uniportal subxiphoid and intercostal video-assisted thoracoscopic lobectomy

Background

Uniportal video-assisted thoracoscopic surgery (VATS) although considered less invasive than the multi-port techniques, is still an intercostal approach, resulting in intercostal nerve injury. Recently, some surgeons have tried to address this problem by attempting a subxiphoid approach. The aim of our study was to assess and compare results between intercostal and subxiphoid uniportal VATS lobectomy in terms of postoperative pain and quality of life (QoL).

Methods

Patients from January 2014 to January 2018 undergoing subxiphoid and intercostal VATS lobectomy were prospectively assessed for pain and QoL at 1, 3, and 6 months following discharge. Postoperative pain was measured using a numeric rating scale (NRS) and QoL was assessed with the EuroQoL 5-dimension questionnaire (EQ5D)

Results

Eight hundred and thirty-three patients undergoing lobectomy were included: 373 in the intercostal VATS group and 459 in the subxiphoid group. The proportion of patients with moderate or worse clinical pain was significantly lower at 1 and 3 months after subxiphoid VATS (P<0.01) compared with intercostal VATS. QoL was significantly higher following subxiphoid VATS at these same time points (P<0.001).

Conclusions

Uniportal subxiphoid VATS is a safe and feasible minimally invasive approach for undertaking pulmonary lobectomy that may result in reduced postoperative pain compared to conventional VATS. There may also be earlier return of QoL. A randomized controlled trial examining this further would provide further insight into our observations.

Hemothorax: A Review of the Literature

Hemothorax is a collection of blood in the pleural cavity usually from traumatic injury. Chest X-ray has historically been the imaging modality of choice upon arrival to the hospital. The sensitivity and specificity of point-of-care ultrasound, specifically through the Extended Focal Assessment with Sonography in Trauma (eFAST) protocol has been significant enough to warrant inclusion in most Level 1 trauma centers as an adjunct to radiographs.^1,2 If the size or severity of a hemothorax warrants intervention, tube thoracostomy has been and still remains the treatment of choice. Most cases of hemothorax will resolve with tube thoracostomy. If residual blood remains within the pleural cavity after tube thoracostomy, it is then considered to be a retained hemothorax, with significant risks for developing late complications such as empyema and fibrothorax. Once late complications occur, morbidity and mortality increase dramatically and the only definitive treatment is surgery. In order to avoid surgery, research has been focused on removing a retained hemothorax before it progresses pathologically. The most promising therapy consists of fibrinolytics which are infused into the pleural space, disrupting the hemothorax, allowing for further drainage. While significant progress has been made, additional trials are needed to further define the dosing and pharmacokinetics of fibrinolytics in this setting. If medical therapy and early procedures fail to resolve the retained hemothorax, surgery is usually indicated. Surgery historically consisted solely of thoracotomy, but has been largely replaced in non-emergent situations by video-assisted thoracoscopy (VATS), a minimally invasive technique that shows considerable improvement in the patients' recovery and pain post-operatively. Should all prior attempts to resolve the hemothorax fail, then open thoracotomy may be indicated.

The Feasibility and Advantages of Subxiphoid Uniportal Video-Assisted Thoracoscopic Surgery in Pulmonary Lobectomy

BACKGROUND

Uniportal video-assisted thoracoscopic surgery (VATS) lobectomy has emerged as a promising and exciting approach for minimally invasive thoracic surgeries. However, nearly all reported uniportal VATS lobectomies are performed via an intercostal route, and chest wall trauma remains an issue. Here, we report the use of a novel uniportal VATS technique involving a subxiphoid route for pulmonary lobectomies.

METHODS

We retrospectively analyzed perioperative data for patients who underwent subxiphoid uniportal and traditional three-port VATS lobectomies from January 2016 to January 2017 at our hospital.

RESULTS

During the study period, 37 patients successively underwent subxiphoid uniportal VATS lobectomies, including three synchronous bilateral pulmonectomies; 68 patients underwent traditional three-port VATS. There were no surgical or 30-day postoperative mortalities, and no significant between-group differences were found in the number of retrieved lymph nodes, number of explored nodal stations, blood loss, drainage time, postoperative complications, or length of hospital stay. Operative time was longer in the subxiphoid uniportal VATS group than in the traditional three-port VATS group (P < 0.001). Visual analog scale (VAS) pain scores after surgery were significantly lower in the subxiphoid uniportal VATS group (P < 0.05).

CONCLUSIONS

Subxiphoid uniportal VATS lobectomy is a safe and feasible surgical procedure associated with reduced surgical trauma and postoperative pain as well as improved cosmetic results compared with traditional VATS. Moreover, this procedure is better suited for patients receiving synchronous bilateral pulmonectomy. Further long-term follow-up analyses involving more patients are ongoing.

TRIAL REGISTRY NUMBER

ClinicalTrials.gov NCT03051438.

Surgical management of colorectal lung metastases

Pulmonary metastasectomy for colorectal cancer is an established means of treatment for select patients. This article will highlight the recent evidence published in the literature related to current practices for the surgical management of colorectal lung metastases and propose a diagnostic algorithm for use in clinical practice. It will also discuss controversies related to pulmonary metastasectomy, including the optimal timing of surgery, the extent of lymph node sampling/dissection, and the extent of surgical resection.

Non-intercostal access for video-assisted thoracic surgery-analysis of technical advantages and disadvantages

Background

Video-assisted thoracoscopic surgery (VATS) lobectomy has become an accepted method for the treatment of early-stage non-small-cell lung cancer (NSCLC). The standard VATS approach is an intercostal one which is often followed by postoperative pain due to injury of the intercostal nerve. The non-intercostal techniques of VATS include the subxiphoid, transcervical, transdiaphragmatic and transoral procedures.

Methods

The technical difficulty of operative management of the anatomical structures during VATS anatomical resection are compared for the intercostal, subxiphoid and transcervical approaches.

Results

Some operative steps have different range of difficulty, which are analyzed in detail.

Conclusions

The clearest advantages of the non-intercostal approaches include less postoperative pain and superradial bilateral mediastinal lymphadenectomy in case of the transcervical approach. However, the non-intercostal approaches are more technically demanding procedures, which therapeutic role has to be clarified in the future.

Minimally invasive thoracic surgery: beyond surgical access

Thoracic surgery has evolved throughout the decades. The difficulty of accessing the intrathoracic organs through the bony rib-cage has been a challenge for thoracic surgeons. In the past, large incisions stretching across the chest, such as posterolateral thoracotomies with rib spreading was the standard approach to access the lungs. These methods cause large amounts of trauma to the patient, with high rates of mortality and morbidity. However, with the advances in technology and the improvements in surgical technique, thoracic surgery has progressed to minimise trauma to the patient while still maintaining oncological and surgical principles. State-of-the-art technology, combined with wide variety of old and new surgical techniques give the thoracic surgeon a formidable armamentarium. Although there has been a focus on reducing the number and size of surgical wounds, considerations other than surgical approach can reduce the trauma suffered by the patient. Preservation of pulmonary function via organ preservation and anaesthetic techniques to further minimise the systemic inflammation such as non-intubated anaesthesia have also been shown to improve patient outcomes. This article aims to review the recent advances in minimally invasive thoracic surgery.

Subxiphoid approach for video-assisted thoracoscopic surgery: an update

The transthoracic video-assisted thoracoscopic surgery (VATS) is considered as standard operation for various thoracic diseases. With the development of single-incision VATS, the thoracic surgery becomes less traumatic. However, chronic chest wound pain still an issue despite the less invasive approach. Therefore, subxiphoid VATS was proposed to overcome this problem. In this article, we review current applications, pros and cons, and potential developments of VATS through subxiphoid approach.

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.

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 uniportal video-assisted thoracoscopic surgery for synchronous bilateral lung resection

OBJECTIVES

With advancements in medical imaging and current emphasis on regular physical examinations, multiple pulmonary lesions increasingly are being detected, including bilateral pulmonary lesions. Video-assisted thoracic surgery is an important method for treating such lesions. Most of video-assisted thoracic surgeries for bilateral pulmonary lesions were two separate operations. Herein, we report a novel technique of synchronous subxiphoid uniportal video-assisted thoracic surgery for bilateral pulmonary lesions.

METHODS

Synchronous bilateral lung resection procedures were performed through a single incision (~4 cm, subxiphoid).

RESULTS

This technique was used successfully in 11 patients with bilateral pulmonary lesions. There were no intraoperative deaths or mortality recorded at 30 days.

CONCLUSIONS

Our results show that the subxiphoid uniportal thoracoscopic procedure is a safe and feasible surgical procedure for synchronous bilateral lung resection with less surgical trauma, postoperative pain and better cosmetic results in qualifying patients. Further analysis is ongoing, involving a larger number of subjects.

Uniportal video-assisted thoracoscopic surgery in hemothorax

The management of hemothorax (spontaneous or, more often, due to thoracic trauma lesions), follows basic tenets well-respected by cardiothoracic surgeons. In most, a non-operative approach is adequate and safe, with a defined group of patients requiring only tube thoracostomy. Only a minority of patients need a surgical intervention due to retained hemothorax, persistent bleeding or incoming complications, as pleural empyema or entrapped lung. In the early 1990s, the rapid technological developments determined an increase of diagnostic and therapeutical indications for multiport video-assisted thoracoscopic surgery (VATS) as the gold standard therapy for retained and persistent hemothorax, allowing an earlier diagnosis, total clots removal and better tubes placement with less morbidity, reduced post-operative pain and shorter hospital stay. There is no consensus in the literature regarding the timing for draining hemothorax, but best results are obtained when the drainage is performed within the first 5 days after the onset. The traditional multi-port approach has evolved in the last years into an uniportal approach that mimics open surgical vantage points utilizing a non-rib-spreading single small incision. Currently, in experienced hands, this technique is used for diagnostic and therapeutic interventions as hemothorax evacuation as like as the more complex procedures, such as lobectomies or bronchial sleeve and vascular reconstructions.

Microlobectomy: A Novel Form of Endoscopic Lobectomy

Objective

Microlobectomy is a novel form of videoscopic-assisted thoracic surgery lobectomy. Strict inclusion criteria consist of the following: no intercostal incisions greater than 5 mm, 12 mm subxiphoid port, subxiphoid removal of the specimen, total endoscopic technique with CO2 insufflation, vision through a 5-mm camera, stapling via the subxiphoid port, or with 5-mm stapling devices.

Methods

The combined early experiences of six hospitals from three countries were combined from September 2014 to May 2016. During that time, the study represents a consecutive cohort study of this technique.

Results

Seventy-two patients underwent microlobectomy. The median (range) age was 66 (27–82). Half of the patients were female. There were 48 right-sided resections and 24 on the left. There were four segmental resections and there was one right pneumonectomy. Four operations were performed robotically (with 8-mm intercostal incisions). The median (range) operative time was 180 (94–285) minutes and the blood loss was 118 (5–800) mL. There were three conversions to thoracotomy and two conversions to videoscopic-assisted thoracic surgery by means of an intercostal utility incision to complete the operation. The median (range)length of stay was 3(1–44) days and 30 patients (42%) when home by day 2 and 16 patients (22%) were discharged on day 1. There were no deaths. Five patients (7%) had a prolonged airleak. There were no wound infections and there was one incisional hernia.

Conclusions

We believe that microlobectomy is an interesting novel form of videoscopic-assisted thoracic surgery lobectomy and has several theoretical advantages. We have presented our early results and hope that this will stimulate others to investigate this type of videoscopic-assisted thoracic surgery lobectomy further.

Uniportal subxiphoid video-assisted thoracoscopic bilateral segmentectomy for synchronous bilateral lung adenocarcinomas

Uniportal subxiphoid video assisted bilateral segmentectomy is a minimally invasive option for the treatment of synchronous bilateral lung lesions. Its advantages over conventional multiportal or uniportal video assisted thoracoscopic surgery include avoidance of damage to the intercostal neurovascular bundle and allowance of bilateral lesion resection as a combined procedure via a single incision. This article presents a case from our centre to describe our surgical technique for this procedure.

Learning curve and subxiphoid lung resections most common technical issues

BACKGROUND

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.

METHODS

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).

RESULTS

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.

CONCLUSIONS

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.

Initial experience in uniportal subxiphoid video-assisted thoracoscopic surgery for major lung resections

OBJECTIVES

Uniportal subxiphoid video-assisted thoracoscopic (SVATS) surgery for major lung resections is a new approach, but clinical evidence is lacking. The aim of this study was to examine our experience with the use of the uniportal subxiphoid approach in video-assisted thoracoscopic (VATS) major lung resections and lymph node dissections.

METHODS

From October 2014 to August 2015, 153 patients with early-stage non-small-cell lung carcinoma (NSCLC) and benign disease underwent uniportal subxiphoid VATS major lung resections. Patients were placed in a lateral position with 60-70° inclination, and a 4- to 5-cm midline median or transverse incision was made below the sternocostal triangle. A 10-mm 30° video camera and VATS instruments were used through the same single incision. Perioperative variables and outcomes were collected prospectively and analysed retrospectively.

RESULTS

Of the 153 patients who underwent surgery with the uniportal subxiphoid VATS approach, 105 had lobectomies and 48 had segmental resections; 135 cases of lung cancer and 18 cases of benign pulmonary disease were noted. Right upper lobectomy was the most common procedure (51%), and left upper lobectomy was the most time-consuming procedure (190 ± 21 min). The mean operating time was 166.9 ± 12.6 min; the average volume of blood loss was 127.5 ± 27.6 ml. In patients with lung cancer, the mean total number of lymph node stations explored was 3.4 ± 0.8. The duration of chest drain use was 2.6 ± 0.2 days. The length of hospital stay was 4.3 ± 0.4 days. Perioperative arrhythmia was the most common complication (13% of cases). Prolonged air leak was the cause of prolonged hospital stay. Five cases were converted to conventional VATS due to technical difficulties, and eight cases were converted to thoracotomy due to major bleeding. Postoperative 30-day mortality was zero and there were no re-admissions. All cases had a R0 complete cancer resection on histology.

CONCLUSIONS

Uniportal subxiphoid VATS lobectomy/segmentectomy is a feasible and safe procedure for early-stage lung cancer and benign disease.

Subxiphoid single-port video-assisted thoracoscopic surgery

Background

We report the feasibility and safety of chest surgery through the subxiphoid single port approach based on our preliminary experience.

Methods

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.

Results

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.

Conclusions

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.

Single port VATS mediastinal tumor resection: Taiwan experience

BACKGROUND

To present the technique of single-port video-assisted thoracoscopic mediastinal tumor resection, which includes limited thymectomy, extended thymectomy, cyst excision and posterior mediastinal tumor excision, and the early results of resection with the use of this technique.

METHODS

Forty patients with mediastinal tumors were treated with single-port thoracoscopic mediastinal resection at Chang Gung Memorial Hospital between April 2014 and September 2015. The surgical intervention was performed through the fourth or fifth intercostal space at the anterior axillary line. A 5 or 10 mm 30 degree video camera and working instruments were employed simultaneously at this incision site throughout the surgery.

RESULTS

Among the 40 cases included in the final analysis, 10 extended thymectomies, 7 limited thymectomies, nine cyst excisions and 14 tumor excisions were performed successfully without the need for conversion. For the 40 patients who underwent single-port video-assisted thoracoscopic surgery (VATS), the mean operation time was 97.3±31.2 min and the average blood loss was 29.75±39.77 mL. The average length of the incision wound was 3.22±0.79 cm and the average length of postoperative hospital stay was 3.72±1.63 days. There were no mortalities and mobility was achieved within 30 days postoperatively.

CONCLUSIONS

Our preliminary report suggests that uniportal VATS for mediastinal tumor resection is a promising and safe technique within a short-term period.

Overview of uniportal video-assisted thoracic surgery (VATS): past and present

Single incision video-assisted thoracic surgery (VATS), better known as uniportal VATS, has taken the world of thoracic surgery by storm over the previous few years. Through advances in techniques and technology, surgeons have been able to perform increasingly complex thoracic procedures utilizing a single small incision, hence avoiding the inherent morbidity of the standard open thoracotomy. This was a natural extension of what most recognize as the standard of care for early stage lung cancer, the VATS lobectomy, generally performed through a three- or four-incision technique. Improved camera optics have allowed the use of smaller cameras, making the uniportal approach technically easier. Improvement in articulating staplers and the development of other roticulator instruments have also aided working through a small single access point. The uniportal technique further brings the operative fulcrum inside the chest cavity, enabling better visualization, and creates working conditions similar to the open thoracotomy. Currently, uniportal VATS is being used for minor thoracic procedures and lung resections up to complex thoracic procedures typically requiring open approaches, such as chest wall resections, pneumonectomy, and bronchoplastic and pulmonary artery sleeve resections. Uniportal VATS is a clear advance in the field of general thoracic surgery and provides but a glimpse into the untold future.

Subxiphoid uniportal video-assisted thoracoscopic middle lobectomy and anterior anatomic segmentectomy (S3)

The video-assisted thoracoscopic surgery (VATS) approach for combined lobectomy and segmentectomy in the same lung is an infrequent procedure, rarely reported in the literature. Currently, Most of the surgeons still use 2-3 thoracic incisions for thoracoscopic anatomic resections. However, the uniportal approach is gaining worldwide acceptance in the recent years. The main advances of uniportal VATS during the last years are related to improvements in surgical technique by implementing new technology. The experience acquired with the uniportal technique allows expert uniportal VATS surgeons to explore new approaches in order to minimize even more the surgical invasiveness. Recently the aim to avoid the intercostal nerve damage created by the transthoracic incision has led to the creation of a novel procedure entitled uniportal VATS subxiphoid approach. Here we report the first case of a lobectomy combined with anatomic segmentectomy performed through a uniportal subxiphoid approach.

Single port VATS: recent developments in Asia

Single port video-assisted thoracic surgery (VATS) is the most recent evolution in minimally invasive thoracic surgery. With increasing global popularity, the single port VATS approach has been adopted by experienced thoracic surgeons in many Asian countries. From initial experience of single port VATS lobectomy to the more complex sleeve resection procedures now forming part of daily practice in some Asia institutes, the region has been the proving ground for single port VATS approaches' feasibility and safety. In addition, certain technical refinements in single port VATS lung resection and lymph node dissection have also sprung from Asia. Novel equipment designed to facilitate single port VATS allowing further reduce access trauma are being realized by the partnership between surgeons and the industries. Advanced thoracoscopes and staplers that are narrower and more maneuverable are particularly important in the smaller habitus of patients from Asia. These and similar new generation equipment are being applied to single port VATS in novel ways. As dedicated thoracic surgeons in the region continue to striving for excellence, innovative ideas in single incision access including subxiphoid and embryonic natural-orifice transluminal endoscopic surgery (e-NOTES) have been explored. Adjunct techniques and technology used in association with single port VATS such as non-intubated surgery, hybrid operating room image guidance and electromagnetic navigational bronchoscopy are all in rapid development in Asia.

Thoracoscopic surgery via a single-incision subxiphoid approach is associated with less postoperative pain than single-incision transthoracic or three-incision transthoracic approaches for spontaneous pneumothorax

BACKGROUND

Comparison of the degree of postoperative pain associated with different thoracoscopic surgical techniques for spontaneous pneumothorax has never reported. In this study we compared perioperative outcomes and degrees of postoperative pain associated with single-incision subxiphoid thoracoscopic surgery, single-incision transthoracic thoracoscopic surgery and three-incision transthoracic thoracoscopic surgery for spontaneous pneumothorax.

METHODS

During the period August 2013 to September 2015, fifty-seven consecutive patients with spontaneous pneumothorax were treated via single-incision subxiphoid thoracoscopic surgery, single-incision transthoracic thoracoscopic surgery or three-incision transthoracic thoracoscopic surgery. Demographic data, operative time, operative blood loss, length of hospital stay, duration of chest tube drainage, postoperative complications, and numeric pain rating scale scores were collected from the medical records for analysis.

RESULTS

Among the 57 patients, 14 received single-incision subxiphoid thoracoscopic surgery, 26 underwent single-incision transthoracic surgery and 17 received three-incision thoracoscopic surgery. In all patients, surgeries were completed without the need for conversion to open surgery. Patients who underwent the single-incision subxiphoid procedure had significantly lower 1-, 8-, 24- and 32-hour postoperative pain scale scores than patients who underwent the other two procedures. The average and maximum pain scale scores during the first 24 hours were lowest in the single-incision subxiphoid group (P<0.0001).

CONCLUSIONS

Single-incision subxiphoid thoracoscopic surgery is associated with significantly lower postoperative pain intensity than transthoracic approaches and therefore may provide an alternative surgical technique for patients with spontaneous pneumothorax.

Thymectomy via a subxiphoid approach: single-port and robot-assisted

BACKGROUND

We have previously reported on single-port thymectomy (SPT), which involves performing thymectomy via a single subxiphoid incision, and trans-subxiphoid robotic thymectomy (TRT), which is performed using the da Vinci surgical system. The aim of this study was to investigate the early surgical outcomes of thymectomy using the SPT and TRT subxiphoid approaches and to discuss their appropriate uses.

METHODS

The subjects included 80 patients who underwent thymectomy via a subxiphoid approach. These patients were selected from among 99 surgical cases of myasthenia gravis or anterior mediastinal tumors at Fujita Health University Hospital between March 2011 and November 2015. The patients were divided into a SPT group (n=72) and a TRT group (n=8).

RESULTS

The operative time was shorter in the SPT group compared with that in the TRT group (135±48 and 20±40 min, respectively; P=0.0004). There were no significant differences between the groups in terms of blood loss volume (5.9±16.8 and 5.4±4.6 mL, respectively; P=0.48), postoperative hospital stay duration (4.0±2.0 and 4.3±3.6 days, respectively; P=0.21), or the period of postoperative oral analgesic use (10.7±5.4 and 10.1±3.4 days, respectively; P=0.89). There were no intraoperative complications, such as intraoperative bleeding, in either group. In the SPT group, there was one case (1.4%) of postoperative left phrenic nerve paralysis and one case (1.4%) of transient paroxysmal atrial fibrillation. No one died during or after the surgery.

CONCLUSIONS

TRT may be as equally minimally invasive as SPT. In cases where the thymoma has infiltrated the surrounding organs, the extent of the infiltration should be used to determine whether to select TRT, or median sternotomy.

Physiologic and immunologic effects of subxiphoid pulmonary lobectomy compared with transthoracic pulmonary lobectomy in a canine survival model

BACKGROUND

Subxiphoid thoracoscopic surgery has been used in various thoracic surgical procedures. The aim of this study is to compare the physiological and inflammatory responses between subxiphoid thoracoscopic surgery and standard transthoracic thoracoscopic surgery for anatomic pulmonary lobectomy in a canine model.

METHODS

Nineteen dogs were assigned to subxiphoid (n=10) or standard thoracoscopy (n=9). Animals in the subxiphoid and standard thoracoscopy group received anatomic lobectomy via a 3-cm xiphoid and thoracic incision, respectively. Physiological and inflammatory parameters were compared between the two groups before surgery, during the operation, and on postoperative days 1, 3, 7, and 14. The animals were sacrificed and necropsied at 2 weeks after surgery.

RESULTS

All procedures were performed successfully with no conversion nor complication. The physiologic changes were similar in both groups. There was no observable different between the two groups in terms of C-reactive protein (CRP) level, interleukin-6 (IL-6) level, neutrophil count, neutrophil 20,70-dichlorodihydrofluorescein (DCFH) expression, monocyte count, monocyte inducible nitric oxide synthase (iNOS), and CD4/CD8 ratios. However, the reduction of total lymphocyte count, CD4, and CD8 lymphocyte counts were observed in the subxiphoid anatomic lobectomy group on postoperative day 7, which was significantly lower than that of the standard transthoracic thoracoscopic approach.

CONCLUSIONS

Subxiphoid thoracoscopic surgery resulted in similar physiologic impact and surgical outcome to those of standard transthoracic thoracoscopic surgery. Nevertheless, subxiphoid thoracoscopic surgery is associated with more pronounced immunosuppression than the standard transthoracic thoracoscopic approach.

Video-assisted thoracoscopic microthymectomy

There are many techniques for performing video-assisted thoracoscopic (VATS) thymectomy. This article describes one particular technique that we employ in thymectomies as well as lobectomies. The principles of both operations are as follows, and have been presented in greater detail for lobectomies previously: (I) the use of ports no greater than 5-mm in the intercostal spaces; (II) the use of a 12-mm subxiphoid port; (III) subxiphoid removal of the specimen; (IV) carbon dioxide (CO2) insufflation; (V) vision enabled through a 5-mm camera; (VI) in microlobectomies, the use of a 5-mm stapling device. These principles are particularly suited to thymectomy, as there are no large vascular structures that require stapling and a large number of the instruments required for thymectomy are already 5-mm in diameter, including energy devices, graspers, clip applicators and suction devices. We believe that this technique, which eliminates the need for large incisions in the intercostal spaces, is less painful than other techniques that we have employed, including intercostal uniportal surgery. It also allows the use of CO2 insufflation, which is very useful indeed in endoscopic thymectomies. Furthermore, microthymectomy is technically easier than subxiphoid-only techniques, in that it requires little modification compared to a more conventional VATS thymectomy. We describe this technique in detail in this article.

Feasibility of Subxiphoid Anatomic Pulmonary Lobectomy in a Canine Model

Purpose. Transthoracic thoracoscopic approach is the gold standard in surgical treatment for thoracic disease. However, it is associated with significant chronic postoperative wound discomfort. Currently, limited data are available regarding the subxiphoid approach to the thoracic cavity. The present study is aimed to evaluate the performance of a subxiphoid anatomic pulmonary lobectomy (SAPL) in a canine model. Methods. The SAPL procedure was performed in 10 beagle dogs using a 3-cm incision over the xiphoid process. After thoracic exploration, SAPL was performed under flexible bronchoscopy guidance. The pulmonary vessel was divided with Ligasure and secured with a suture ligature. The bronchus was divided with endostapler. Surgical outcomes were evaluated by the success of SAPL and operative complications. Results. SAPL was successfully completed in 9 animals. One animal required conventional thoracotomy to resuture the pulmonary artery stump. Another animal encountered small middle lobe laceration after SAPL and died at 8 days postoperation due to respiratory distress. Conclusion. Subxiphoid anatomic pulmonary lobectomy is technically feasible. Refinement of endoscopic instruments combined with more research evidences may facilitate the development of subxiphoid platform in thoracic surgery.

Video-assisted thoracoscopic thymectomy versus subxiphoid single-port thymectomy: initial results†

OBJECTIVES

Compared with conventional median sternotomy, approaches used in thymectomy for myasthenia gravis and anterior mediastinal tumours have become much less invasive in recent years. We previously developed a surgical technique called single-port thymectomy (SPT) to excise the thymus through a single opening made below the xiphoid process. In this study, to show the utility of SPT, we compared factors contributing to low surgical invasiveness between SPT and conventional video-assisted thoracoscopic surgery (VATS) thymectomy.

METHODS

Between January 2005 and December 2014, 146 patients underwent surgery for anterior mediastinal tumour or myasthenia gravis at our hospital. After excluding patients diagnosed with tumour invasion of nearby organs or those who had undergone concurrent removal of nearby organs, 81 patients were enrolled in this retrospective study as subjects. Patients were divided into the VATS thymectomy group (VATS group, n = 35) and the SPT group (n = 46). Surgical duration, blood loss, duration of hospital stay and the amount and duration of postoperative oral analgesics were compared between the groups.

RESULTS

Operating time did not vary significantly between the VATS and SPT groups (P = 0.0853). The amount of blood loss was higher in the VATS group than in the SPT group (P < 0.0001). The duration of hospital stay was longer in the VATS group than in the SPT group (P = 0.0008). The amount of postoperative oral analgesics was significantly higher in the VATS group than in the SPT group (P = 0.0092). Similarly, the duration of postoperative oral analgesics was significantly longer in the VATS group than in the SPT group (P = 0.0312).

CONCLUSIONS

Compared with VATS thymectomy, SPT required a similar operating time, was associated with less blood loss and enabled postoperative analgesics to be discontinued earlier. Therefore, it could be considered a less invasive surgical approach.

Pulmonary metastasectomy: outcomes and issues according to the type of surgical resection

According to a recent report by the Committee for Scientific Affairs of the Japanese Association for Thoracic Surgery, pulmonary metastasectomy accounted for as many as 10.2 % of all entry cases of general thoracic surgery, and its use is increasing year by year. Accordingly, many studies have examined the surgical procedures used during pulmonary metastasectomy for metastases from primary tumors affecting various organs as well as the outcomes of and indications for such procedures, but some problems remain. In this article, the following questions related to the surgical approach and the type of resection used during pulmonary metastasectomy are reviewed: (1) Wedge resection--what is a safe margin for preventing local recurrence? (2) What is the clinical significance of node sampling/dissection during pulmonary metastasectomy? and (3) When is segmentectomy necessary? In addition, we discuss: (4) open thoracotomy vs. video-assisted thoracoscopic surgery (VATS), (5) repeated metastasectomy for pulmonary metastases, (6) the surgical approach for bilateral pulmonary metastasectomy, (7) pneumonectomy, and (8) pulmonary metastasectomy combined with resection of the neighboring organs.

Subxiphoid single-incision thoracoscopic bilateral ablative sympathectomy for hyperhidrosis

We describe the first case of severe palmar hyperhidrosis treated with single-incision subxiphoid thoracoscopic ablative sympathectomy, bilaterally, at T3 level. The single-incision subxiphoid thoracoscopic approach required only a 2-cm incision in the upper abdomen. In addition, the technique does not cause postoperative intercostal neuropathy and postoperative pain is minimal as the intercostal space is bypassed. Total operative time was ∼60 min and the volume of blood loss was 10 ml. The patient was discharged from the hospital the next day with complete remission of her symptoms. Excess palmar sweating released after operation and there was no compensatory sweating after a 6-month follow-up.

Subxyphoid single-incision thoracoscopic pulmonary metastasectomy

Single-incision thoracoscopic surgery has increasingly attracted public interest and been applied in numerous thoracic procedures. However, single-incision thoracoscopic surgery is associated with requiring subsequent procedures, such as intercostal neuralgia. Herein, we extend the single-port technique of pulmonary metastasectomy through a single subxiphoid approach, and report the first two cases of this procedure to date.