Video-assisted thoracic surgery thymectomy: subxiphoid approach
Marcin Zieliński1, Pawel Gwozdz1, Katarzyna Solarczyk-Bombik1, Michal Wilkojc1, Wojciech Czajkowski1, Sylweriusz Kosinski2, Edward Fryzlewicz2, Tomasz Nabialek2, Malgorzata Szolkowska3, Juliusz Pankowski4
1Department of Thoracic Surgery, 2Department of Anesthesiology and Intensive Care, Pulmonary Hospital, Zakopane, Poland; 3Department of Pathology, Tuberculosis Institute, Warsaw, Poland; 4Department of Pathology, Pulmonary Hospital, Zakopane, Poland
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.