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Case Reports, subxyphoid approach

Case Study: Thymectomy by Uniportal subxyphoid approach

Article originally published October 31, 2015

We report the case of a thymectomy performed through a subxyphoid vertical single incision port carried out in a 51 years old female myasthenic patient presenting a Masaoka stage I thymoma.

The subxhyphoid approach permits an excellent view of the mediastinal anterior region and of the two pleural spaces giving the surgeon the possibility to perform a very radical and safe dissection of the thymic and peri-thymic fatty tissues.

Considering the position and the 3.5 cm length of the port, it is esthetically excellent. Without a sternal incision, or VATS – associated intercostal nerve injury, the recovery can be faster and less painful than the sternotomy approach or other vats approaches carried out through the intercostal spaces.

Technique

We performed extended thymectomy through a uniportal subxiphoid approach in a 51 years old female presenting a thymoma of 2.5 cm and myasthenia gravis.

The patient was informed about the risks and the benefits of the procedure and the consent to carry on with the operation was obtained.

Under general anesthesia, the patient was intubated with a double-lumen endotracheal tube and artificial ventilation was applied.

The patient was placed in a supine position with a silicon roll positioned below the lower part of the chest in order to lift the subxiphoid region.

The operating surgeon stood on the right side of the patient, the assistant stood on the patient’s left side and operated the endoscope. The  monitor was positioned at the right side of the patient toward the cranial side of the bed.

A 3.5-cm longitudinal muscle sparring incision was made below the xiphoid process between through the linea alba.

the incision

the incision

The xiphoid process was exposed,  the inferior part of the sternum was lifted up with a retractor and a blunt dissection was carried out in order to find the pericardial plane.

A SILS port (Covidien, Mansfield, MA) was then inserted into the port, and CO2 was insufflated at a maximal pressure of 8 mm Hg. The CO2 insufflation within the mediastinum generates a very useful  amount of extra working space within the anterior-superior mediastinum allowing an easier dissection and a better visualization of the mediastinal structures especially toward the cranial part of the mediastinum cephalad to the left innominate vein including the upper poles of the thymus.

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Under visual guidance provided through a 10-mm EndoCAMeleon® Telescope, the operator utilized grasping forceps designed for single-incision surgery with his left (SILS Hand Instruments Endo Clinch™ II (Covidien) and performed dissection, coagulation, and division of tissue mainly using  the Sonicision™ cordless ultrasonic dissection device (Covidien, Mansfield, MA) and occasionally using a normal straight hook cautery.

The bilateral phrenic nerves and the bilateral mammary arteries and veins were always under optimal control as well as the cranial part of the mediastinum permitting a safe dissection en bloc of the  thymus, thymic tumor, and surrounding fatty tissue anterior to the phrenic nerves.

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The operation time was about 2 hours and 30 minutes, and blood loss was minimal.

crops

No complications occurred during or after the operation, the drain was taken out after one day and the patient was discharged home 2 days after surgery.

closed incision

closed incision

Postoperative pain was very low requiring just 1 g  X 3 daily of paracetamol during the hospital stay, and no analgesic administration after the discharge.

 Case study submitted by:

Dr. Giuseppe Aresu

University Hospital of Udine

Udine, Italy

Dr. Guiseppe Arescu

Dr. Giuseppe Aresu

This case was later published (Dec 14, 2015) at CTSnet.  Congratulations Dr. Aresu!

Additional Reading

Suda, T. (2016). Single-port thymectomy using a subxiphoid approach-surgical technique. Ann Cardiothorac Surg. 2016 Jan;5(1):56-8. doi: 10.3978/j.issn.2225-319X.2015.08.02. Review. Free fulll text discussion of a similar case by Japanese surgeon.  This article includes a video presentation and a in-depth discussion of technical aspects of the case such as surgeon position and camera access.

 

About K Eckland

World of Thoracic Surgery is a blog about the work, research, and practices of thoracic surgeons around the world. It includes case studies, [sometimes] dry research, interviews with thoracic surgeons along with patient perspectives, and feedback.

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