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Background: Surgical approach in the treatment of thymoma is varied. This retrospective study aimed to evaluate the outcomes of different surgical approaches in the treatment of thymoma. Methods: From January 2020 to December 2023, a total of 208 patients underwent thoracoscopic surgical treatment and were diagnosed with thymoma by postoperative pathological result in our institution. We collected and then analysed potential factors including general conditions, surgical approaches, preoperative clinical symptoms, surgical procedures, postoperative hospital stay, postoperative drainge, postoperative pain score, postoperative complications and postoperative follow-up. Results: Of the 208 patients, 98 patients underwent surgery via subxiphoid approach (47.1%) and 110 patients via lateral intercostal approach (52.8%). The duration of the surgical procedure (P = 0.02), intraoperative blood loss (P = 0.045), total postoperative drainage (P = 0.021), postoperative drainage per day (P = 0.004) and Postoperative pain score (Day1 P = 0.010 and Day2 P = 0.002)showed a significant difference between these two groups. 31 patients (14.9%) received postoperative radiotherapy. One patient died due to postoperative radiotherapy. No recurrence occurred in one-year follow-up. Conclusions: The present study not only showed that subxiphoid approach was a safe and feasible technique for thymoma, with a potentially faster postoperative recovery and less postoperative pain. [ABSTRACT FROM AUTHOR]

OBJECTIVES The da Vinci single-port system is a novel robotic system that has gained popularity and demonstrated favourable outcomes in various surgical fields. Nevertheless, its application in thoracic surgery is relatively rare. In this study, we report our initial experiences with the da Vinci single-port system via a subxiphoid approach in patients with an anterior mediastinal mass. METHODS We retrospectively reviewed patients with an anterior mediastinal mass who underwent surgery using the da Vinci single-port system via a subxiphoid approach between October 2020 and April 2024. Clinicopathological, intraoperative, and postoperative data were retrospectively collected. RESULTS A total of 14 patients were included in this study. The median age was 55 years (interquartile range 48–62 years), with 4 (28.6%) patients being male. All patients underwent complete resection without conversion to multiport or open surgery. The median operation time was 135 min (interquartile range 113–155 min). Nine (64.3%) patients were diagnosed with thymoma, and 2 (14.3%) patients had myasthenia gravis. The median pathologic size of the mass was 32.5 mm (interquartile range 25.3–38.0 mm), and the median peak Numerical Rating Scale score was 3 (interquartile range 2–4). The median duration of chest drainage and hospital stay were 2 (interquartile range 1–3) and 3 (interquartile range 2–3) days, respectively. No complications were reported following surgery. CONCLUSIONS The da Vinci single-port system for anterior mediastinal mass was deemed safe and feasible. To expand indications in thoracic surgery, further accumulation of experience and additional technological advancements are necessary. [ABSTRACT FROM AUTHOR]

Objective: To compare the application effects of thoracoscopic assisted anterior mediastinal tumor resection by lateral thoracic approach or subxiphoid approach. Methods: According to the random number table method, 115 patients undergoing thoracoscopic assisted anterior mediastinal tumor resection were divided into group A (n=57, lateral thoracic approach) and group B (n=58, subxiphoid approach). The perioperative related indexes, stress response indexes and inflammatory factors were compared between two groups, and the occurrence of postoperative complications was observed. Results: Compared with group A, group B had longer operation time, less intraoperative blood loss and postoperative drainage volume, shorter postoperative hospital stay and drainage tube indwelling time (P<0.05). 1 day after operation, neuropeptide Y (NPY), 5-hydroxytryptamine (5-HT), substance P (SP) and prostaglandin E2 (PGE2) in two groups increased, but group B were lower than those of group A (P<0.05). 1 day after operation, C-reactive protein (CRP), white blood cell count (WBC) and neutrophils increased in two groups, but group B were lower than those of group A (P<0.05). The total incidence of complications in group A was 12.28%, and that in group B was 6.90%, there was no difference between two groups (P>0.05). Conclusion: During thoracoscopic assisted anterior mediastinal tumor resection, although the subxiphoid approach takes longer than the lateral thoracic approach, which can reduce intraoperative injury, reduce stress response and inflammatory response, and promote postoperative recovery. [ABSTRACT FROM AUTHOR]

Abstract Background Surgical approach in the treatment of thymoma is varied. This retrospective study aimed to evaluate the outcomes of different surgical approaches in the treatment of thymoma. Methods From January 2020 to December 2023, a total of 208 patients underwent thoracoscopic surgical treatment and were diagnosed with thymoma by postoperative pathological result in our institution. We collected and then analysed potential factors including general conditions, surgical approaches, preoperative clinical symptoms, surgical procedures, postoperative hospital stay, postoperative drainge, postoperative pain score, postoperative complications and postoperative follow-up. Results Of the 208 patients, 98 patients underwent surgery via subxiphoid approach (47.1%) and 110 patients via lateral intercostal approach (52.8%). The duration of the surgical procedure (P = 0.02), intraoperative blood loss (P = 0.045), total postoperative drainage (P = 0.021), postoperative drainage per day (P = 0.004) and Postoperative pain score (Day1 P = 0.010 and Day2 P = 0.002)showed a significant difference between these two groups. 31 patients (14.9%) received postoperative radiotherapy. One patient died due to postoperative radiotherapy. No recurrence occurred in one-year follow-up. Conclusions The present study not only showed that subxiphoid approach was a safe and feasible technique for thymoma, with a potentially faster postoperative recovery and less postoperative pain.

This trial was to evaluate the efficacy of subxiphoid approach thoracoscopic thymectomy for postoperative pain control and length of hospital stay compared with a lateral intercostal approach thoracoscopic thymectomy. This multicenter, open-label, randomized clinical superiority trial enrolled 101 eligible participants clinically diagnosed with Masaoka-Koga I-II thymoma between August 15, 2021, and February 15, 2022. Each enrolled participant was randomized and underwent subxiphoid approach thoracoscopic thymectomy or lateral intercostal approach thoracoscopic thymectomy. A per-protocol analysis for each coprimary outcome was performed in addition to the main intention-to-treat analysis. In the analysis for the coprimary outcomes, the pain Visual Analog Scale score area under the curve at 0 to 7 days was lower in the subxiphoid approach thoracoscopic thymectomy group than in the lateral intercostal approach thoracoscopic thymectomy group (difference, −4.82; 98.3% CI, −8.84 to −0.80). However, there was no significant difference between the 2 groups in the length of hospital stay (difference, 0.318; 98.3% CI, −0.190 to 0.825) or cumulative opioid consumption after surgery (difference, −4.630; 98.3% CI, −9.530 to 0.272). All patients underwent complete resection, and there was no significant difference (7.84% vs 8.00%, P = 1.000) in the rate of complications between the 2 groups. No recurrence or death occurred in the postoperative 6 months. This study found improved pain and similar length of hospital stay associated with the subxiphoid approach compared with the lateral intercostal approach in patients with suspected Masaoka-Koga I-II thymoma. [Display omitted] [ABSTRACT FROM AUTHOR]

Background: Subxiphoid video-assisted thoracoscopic surgery (VATS) is considered a safe and feasible operation for anterior mediastinal mass resection. However, diaphragmatic injury, presented as tearing or puncturing, may occur during subxiphoid VATS despite of low incidence. This study aims to explore risk factors for diaphragmatic injury in subxiphoid VATS, as well as strategies to reduce occurrence of the injury. Methods: We retrospectively reviewed clinical records of 44 consecutive adult patients who underwent subxiphoid VATS. These patients were divided into two groups: diaphragmatic injury group and non-injury group. Perioperative outcomes and anatomic features derived from 3D CT reconstructions were compared between the two groups. Results: Significant differences were observed in operation time (223.25 ± 92.57 vs. 136.28 ± 53.05, P = 0.006), xiphoid length (6.47 ± 0.85 vs. 4.79 ± 1.04, P = 0.001) and length of the xiphoid below the attachment point on the diaphragm (24.86 ± 12.02 vs. 14.61 ± 9.25, P = 0.029). Odds ratio for the length of the xiphoid below the attachment point on the diaphragm was 1.09 (1.001–1.186), P = 0.048 by binary logistic regression analysis. Conclusions: We identified the length of the xiphoid below the attachment point on the diaphragm as an independent risk factor for diaphragm injury during subxiphoid VATS. Prior to subxiphoid VATS, a 3D chest CT reconstruction is recommended to assess the patients' anatomic variations within the xiphoid process. For patients with longer xiphoid process, a higher incision at the middle and upper part of the xiphoid process, and partial xiphoid process resection or xiphoidectomy is preferred. [ABSTRACT FROM AUTHOR]

Objective To compare the perioperative efficacy and safety of da Vinci robot-assisted thoracoscopic surgery (RATS) for treatment of anterior mediastinal tumors through subxiphoid versus lateral thoracic approaches under the laryngeal mask anesthesia. Methods We retrospectively analyzed the clinical data of 102 patients with anterior-mediastinal tumors treated by RATS under laryngeal mask anesthesia completed by the same operator. Forty-five patients underwent the subxiphoid approach (subxiphoid group), and 57 patients were treated with the lateral thoracic approach (lateral thoracic group). The operating time, intraoperative bleeding, and total postoperative drainage volume in the two groups were compared and analyzed. Results All patients successfully completed resection of the anterior mediastinal tumor without the occurrence of perioperative death. In terms of total postoperative drainage volume, postoperative drainage time, postoperative hospital stay, and VAS pain on postoperative days 2 and 3, the subxiphoid group was more advantages (P < 0.05). No statistically significant difference was found between the two groups in terms of operative time, docking time, total operative time, intraoperative bleeding volume, postoperative day 1 VAS pain score, or postoperative complications (P > 0.05). Conclusion The subxiphoid approach of RATS is safe and feasible for resection of anterior mediastinal tumors. Compared with the lateral thoracic approach, the subxiphoid approach has advantages in terms of rapid postoperative recovery and postoperative pain.

Objective: The purpose of this article is to evaluate the security and effectiveness of subxiphoid and subcostal robot-assisted thoracoscopic thymectomy (S-RATT) and compare it with subxiphoid and subcostal video-assisted thoracoscopic thymectomy (S-VATT) in terms of short-term perioperative results and costs. Methods: A retrospective study was carried out on 62 individuals who had undergone successful complete thymectomy for anterior mediastinal disease using subxiphoid and subcostal arch approaches. Propensity score-matching analysis was utilized between the two groups, and the perioperative outcomes were compared. Results: The S-RATT group exhibited less intraoperative blood loss (20 ± 15.35 versus 69.55 ± 69.54, P < .001), lower levels of C-reactive protein (112.38 ± 68.08 versus 72.58 ± 42.62, P = .027), and lower postoperative pain scores (2.09 ± 1.54 versus 4.27 ± 1.28, P < .001). However, the hospitalization costs of patients in the S-VATT group were found to be lower than those in the S-RATT group (33,802.41 ± 8785.05 versus 49,977.53 ± 20,221.79, P < .001). Conclusions: S-RATT appears to be a viable and secure method for managing anterior mediastinal tumors. [ABSTRACT FROM AUTHOR]

Abstract Background The purpose of this study was to compare the perioperative efficacy and safety of da Vinci robot-assisted thoracoscopic surgery (RATS) for treating anterior mediastinal tumors through the subxiphoid and lateral thoracic approaches under the anesthesia of nontracheal intubation (i.e., laryngeal mask airway). Methods We retrospectively analyzed the clinical data of 116 patients with anterior mediastinal tumors treated by RATS under laryngeal mask anesthesia completed by the same operator in the Department of Thoracic Surgery, Gansu Provincial People’s Hospital, from October 2016 to October 2022. There were a total of 52 patients including 24 males and 28 females, with an average age of 45.40±4.94 years, in the subxiphoid approach (subxiphoid group). On the other hand, there were a total of 64 patients including 34 males and 30 females, with a mean age of 46.86±5.46 years in the lateral thoracic approach (lateral thoracic group). Furthermore, we have detailedly compared and analyzed the operating time, intraoperative bleeding, and total postoperative drainage in the two groups. Results All patients in both groups successfully completed resection of the anterior mediastinal tumor without occurring perioperative death. Compared with the lateral thoracic group, the subxiphoid group has more advantages in terms of total postoperative drainage (P=0.035), postoperative drainage time (P=0.015), postoperative hospital stay (P=0.030), and visual analog scale (VAS) pain on postoperative days 2 (P=0.006) and 3 (P=0.002). However, the lateral thoracic group has more advantages in the aspect of docking time (P=0.020). There was no statistically significant difference between the two groups in terms of operative time (P=0.517), total operative time (P=0.187), postoperative day 1 VAS pain score (P=0.084), and postoperative complications (P=0.715). Conclusion The subxiphoid approach of RATS under laryngeal mask anesthesia is safe and feasible for resecting anterior mediastinal tumors. Compared with the lateral thoracic approach, the subxiphoid approach has advantages in terms of rapid postoperative recovery and postoperative patient pain, and patient acceptance is also higher and thus is worth promoting in hospitals where it is available.

Objective To compare the perioperative efficacy and safety of da Vinci robot-assisted thoracoscopic surgery (RATS) for treatment of anterior mediastinal tumors through subxiphoid versus lateral thoracic approaches under the laryngeal mask anesthesia. Methods We retrospectively analyzed the clinical data of 102 patients with anterior-mediastinal tumors treated by RATS under laryngeal mask anesthesia completed by the same operator. Forty-five patients underwent the subxiphoid approach (subxiphoid group), and 57 patients were treated with the lateral thoracic approach (lateral thoracic group). The operating time, intraoperative bleeding, and total postoperative drainage volume in the two groups were compared and analyzed. Results All patients successfully completed resection of the anterior mediastinal tumor without the occurrence of perioperative death. In terms of total postoperative drainage volume, postoperative drainage time, postoperative hospital stay, and VAS pain on postoperative days 2 and 3, the subxiphoid group was more advantages (P<0.05). No statistically significant difference was found between the two groups in terms of operative time, docking time, total operative time, intraoperative bleeding volume, postoperative day 1 VAS pain score, or postoperative complications (P>0.05). Conclusion The subxiphoid approach of RATS is safe and feasible for resection of anterior mediastinal tumors. Compared with the lateral thoracic approach, the subxiphoid approach has advantages in terms of rapid postoperative recovery and postoperative pain. [ABSTRACT FROM AUTHOR]

Minimally invasive strategies are increasingly popular in patients with myasthenia gravis (MG)-associated thymomas. Within the context of video-assisted thoracoscopic surgery (VATS) as a widely known minimally invasive option, the most recent achievement is uniportal subxiphoid VATS. In MG patients, it is mandatory (1) to minimize perioperative interference with administered anesthetics to avoid complications and (2) to achieve a complete surgical resection, as the prognosis essentially depends on radical tumor resection. In order to fulfill these criteria, we merged this surgical technique with its anesthesiologic counterpart: regional anesthesia with the maintenance of spontaneous ventilation via a laryngeal mask. Non-intubated uniportal subxiphoid VATS for extended thymectomy allowed radical thymectomy in all MG patients with both rapid symptom control and fast recovery.

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. [ABSTRACT FROM AUTHOR]

Purpose: Thymectomy is an important treatment for myasthenia gravis (MG). We conducted this study to compare the clinical outcomes of the recently introduced subxiphoid and subcostal arch thymectomy (SASAT) approach with those of the standard unilateral video-assisted thoracoscopic surgery (VATS). Methods: We analyzed, retrospectively, the perioperative, and long-term outcomes of 179 consecutive MG patients (age 18–65 years), who underwent SASAT or unilateral VATS-extended thymectomy between July, 2012 and May, 2019. Results: All demographic and clinical characteristics were comparable in the two groups. The median surgical time, estimated blood loss, thoracotomy conversion rate, total and chest drainage, and complications did not differ significantly between the groups. The visual analog scale (VAS) score was significantly lower in the SASAT group. Complete stable remission (CSR) was achieved in a significantly larger proportion of the SASAT group patients and was significantly higher in women than in men. The Quantitative MG score was significantly lower in the SASAT group. Patients in the MG Foundation of America Clinical Classification groups I and II achieved better remission rates than those in groups III–V. Conclusions: SASAT is a safe and feasible MG treatment, which may yield better outcomes than unilateral VATS and improve the quality of treatment. [ABSTRACT FROM AUTHOR]

We carried out the systematic review of the domestic and foreign literature focusing on surgical treatment of patients with thymic pathology. Special attention was paid to the discussion of the advantages of minimally invasive surgery, particularly, video endoscopic thymectomy from subxiphoid access. Pubmed, Medline and E-library databases were searched for retrospective and prospective randomized trials. Based on the analysis of literature sources, we presented the data on tumor and non-tumor pathology of the thymus gland, clarified indications for surgical treatment in different types of thymic pathology. Variants of thymectomy were described, a brief historical review of the use of the surgical method in patients with thymus gland pathology was conducted. The technique of surgeries, advantages and weak points of various surgical approaches were described. We focused our attention on minimally invasive interventions, listed its advantages in comparison with the standard “open” surgical approach. The contemporary trends in surgical approaches in thymus pathology were discussed. Minimally invasive thymectomy is modern, safe and feasible variant of surgical treatment of patients with tumor and non-tumor pathology of the thymus gland. The subxiphoid approach allows to reduce postoperative pain, provides an excellent view of mediastinal structures and both pleural cavities, which improves the safety of operation with satisfactory cosmetic results.

BackgroundThe subxiphoid approach has been widely used recently. However, there is little data focusing on neurological outcomes in patients with thymomatous myasthenia gravis (MG) who underwent subxiphoid thoracoscopic thymectomy. The purpose of this study was to compare the neurological outcomes of patients with thymomatous MG who underwent extended thymectomy with a subxiphoid or transthoracic approach 1 year postoperatively.MethodsThe records of patients with Masaoka stage I and II thymomas who underwent extended thymectomy from January 2019 to December 2020 with tumor size less than 5 cm and thymomatous MG were retrospectively reviewed and evaluated. Neurological outcomes were measured by a quantitative myasthenia gravis score (QMGS), with a 2.3-point reduction in QMGS associated with improvement in clinical MG status. The clinical efficacy and variables affecting the outcomes were assessed using the Kaplan–Meier method and Cox proportional hazard regression analysis.ResultsA total of 89 patients were included in the analysis, of which 44 had a subxiphoid approach and 45 had a trans-sternal approach. Mean QMGS decreased from 12 at initial diagnosis to 8.7 preoperatively and 5.6 at 12 months postoperatively in the subxiphoid group and from 12.1 to 8.9 to 6.0 in the transthoracic group. Thirteen patients (28.9%) who underwent the trans-sternal approach and 10 (22.7%) who underwent the subxiphoid approach did not have an improved clinical status compared with their preoperative status. The median time to clinical improvement was 3 months (95% CI, 2.15–3.85) for the subxiphoid approach and 6 months (95% CI, 5.54–6.46) for the trans-sternal approach. Univariate results showed that the subxiphoid approach was associated with a faster improvement in clinical status (HR = 1.701, 95% CI, 1.044–2.773, P

Background: The subxiphoid single-port approach for thymectomy has advantages compared with conventional lateral transthoracic approaches. Most of centers use CO2 insufflation to secure an appropriate surgical field during subxiphoid thymectomy, which causes fighting between surgical instruments and restrictions on the types of surgical instruments. The objective of this study is to introduce an effective method to establish the subxiphoid approach without CO2 insufflation using a retractor and steel wire. Methods: All consecutive 59 patients undergoing subxiphoid single-port thymectomy between August 2014 and August 2021 were reviewed retrospectively. Results: We analyzed data of 59 patients (31 male and 28 female) with a median age of 59 years (range 50–68). Two (3.4%) patients presented postoperative complications. The conversion to a different approach was required in 4 (6.8%) cases. The median follow-up time was 23 months (range 10–41) and loco-regional recurrence was observed in one patient (1.7%). There were no intraoperative deaths and the postoperative mortality. No complications related to sternal wiring occurred. Conclusions: Subxiphoid single-port thymectomy without CO2 using a retractor and steel wire insufflation is a technically feasible method. [ABSTRACT FROM AUTHOR]

BackgroundAccumulating researches show potential advantages of video-assisted thoracoscopic surgery (VATS) via the subxiphoid approach, and this meta-analysis aims to investigate the efficacy and safety of the subxiphoid approach for anterior mediastinal surgery.MethodsRelevant studies were retrieved by searching Embase and PubMed databases (from the inception to October 1, 2021). Primary outcomes included postoperative pain, intraoperative blood loss, operation time, chest tube duration, and hospital length of stay. All meta-analyses were performed by using random-effects models.ResultsOverall, 14 studies with 1,279 patients were included, with 504 patients undergoing anterior mediastinal surgery via subxiphoid approach and 775 via other approaches. The pooled results indicated that the subxiphoid approach was associated with reduced postoperative pain indicated by visual analog scale [weight mean difference (WMD): 24 h: −2.27, 95% CI, −2.88 to −1.65, p

Resumen: Introducción: La estimulación epicárdica permanente es una alternativa cuando existen contraindicaciones para el abordaje endocavitario. Métodos y resultados: Se presentan 2 casos, con bloqueo auriculoventricular completo y contraindicación para la estimulación endocavitaria, a quienes se les implantó electrodo epicárdico por cirugía subxifoidea mínima invasiva. Se empleó anestesia endovenosa e infiltración local (lidocaína 2%), pero sin necesidad de entubación endotraqueal. Se abordó por vía subxifoidea con incisión cutánea de 2-3 cm y sin resección del apéndice xifoides. Se resecó el pericardio, y el electrodo epicárdico unipolar modelo 5071 [Medtronic (Minneapolis, Minnesota)] se avanzó hasta la cara diafragmática del ventrículo derecho y con buen apoyo se liberó el mecanismo de fijación; posteriormente, se midieron los parámetros de estimulación. Se realizó un bolsillo subcutáneo en la zona abdominal pararrectal izquierda, submuscular y se colocó el marcapasos unicameral VVIR Efecta [Biotronik (Berlín, Alemania)]. Se realizó profilaxis antibiótica según el protocolo del servicio. Al mes de seguimiento los parámetros de estimulación eran estables y no se reportaba infección en los sitios quirúrgicos. Conclusiones: El implante de marcapasos epicárdico por técnica mínima invasiva subxifoidea es eficaz, seguro y reproducible. Abstract: Introduction: Permanent epicardial stimulation is an alternative when there are contraindications to the endocavitary approach. Methods and results: Two cases are presented with complete ventricular atrial block and contraindication for endocavitary stimulation. In both cases, an epicardial electrode was implanted using minimally invasive subxiphoid surgery. Intravenous anaesthesia and local infiltration (lidocaine 2%) were used; endotracheal intubation was not required. Subxiphoid approach was performed with a 2-3 cm skin incision and without resection of the xiphoid appendix. The pericardium was resected and the unipolar epicardial electrode model 5071 [Medtronic (Minneapolis, Minnesota)] was advanced to the diaphragmatic face of the right ventricle and with good support, the fixation mechanism was released. The stimulation parameters were then measured. A subcutaneous pocket was made in the left para-rectal, sub-muscular abdominal area, and the VVIR Efecta unicameral pacemaker [Biotronik (Berlin, Germany)] was inserted. Antibiotic prophylaxis was given according to the service protocol. At one month of follow-up, the stimulation parameters were stable, and no infection was reported at the surgical sites. Conclusions: The implantation of an epicardial pacemaker using minimally invasive subxiphoid technique is effective, safe, and reproducible.

The standard treatment for primary mediastinal yolk sac tumour involves neoadjuvant chemotherapy followed by residual tumour resection, typically performed through a median sternotomy or a thoracotomy. However, in this case, a 16-year-old patient with a large anterior mediastinal tumour underwent less invasive, subxiphoid, robot-assisted surgery using a 4-arm da Vinci Xi system with CO2 insufflation at 8 mmHg. The tumour, located in the right thymic lobe, was dissected using a technique similar to blunt dissection, bipolar electrocautery and vessel sealer. Pericardiotomy was performed suspecting tumour invasion, with the thickened pericardial border incised circularly from the left side. Preservation of the right phrenic nerve involved careful separation from the densely adherent tumour. A pulmonary wedge resection was also performed using a stapler. The pericardial defect was reconstructed using an expanded polytetrafluoroethylene sheet, sutured together with nylon threads, and the resected tumour was extracted with a retrieval bag. This subxiphoid robot-assisted approach is a minimally invasive option for malignant mediastinal tumours., (© The Author 2024. Published by MMCTS on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Competing Interests: Disclosures The authors have no conflicts of interest to disclose.

Objectives: The study was designed to evaluate the superiority of the subxiphoid approach compared with the lateral intercostal approach during the operation and other perioperative indices., Methods: Patients diagnosed with anterior mediastinal disease in our hospital between January 2018 and October 2019 were prospectively assigned to 2 groups; 1 group underwent the lateral intercostal approach and 1 group underwent the subxiphoid approach of video-assisted thoracoscopic surgery to resect the diseased tissue. The PaCO2, SaO2, PaO2 and circulation changes were recorded during the operation; the neutrophil-to-lymphocyte ratio and other perioperative outcomes, including clinical and surgical results, operating time, blood loss, postoperative complication and postoperative pain score were compared., Results: A total of 59 patients diagnosed with an anterior mediastinal tumour or myasthenia gravis underwent a video-assisted thoracoscopic resection. Thirty-one patients were treated via the subxiphoid approach, and 28 patients were treated via the lateral intercostal approach. The PaCO2 increased significantly and the SaO2 remained stable in the subxiphoid group during the operation, whereas PaCO2 increased significantly and SaO2 decreased at the same time in the lateral intercostal group. Operations were more frequently interrupted for the hypoxia or circulation disturbance during the process of dissecting the thymus in the lateral intercostal approach. Compared with the lateral intercostal approach, patients treated via the subxiphoid approach experienced less inflammation and exhibited lower pain scores and shorter postoperative hospital stays. There were no significant differences in postoperative complications between the 2 groups. All of the patients recovered well when discharged., Conclusions: Our study results suggested that the subxiphoid approach has less of an influence on the pulmonary circulation than the lateral intercostal approach, that the whole procedure is safer and easier and that the subxiphoid approach may be the ideal choice for patients with anterior mediastinal disease., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery.)

Objective: Our previous study demonstrated that modified subxiphoid video-assisted thoracic surgery thymectomy with an auxiliary sternal retractor is feasible for locally invasive thymic malignancies. This study aimed to compare perioperative and oncological outcomes of modified subxiphoid video-assisted thoracoscopic surgery thymectomy versus median sternotomy thymectomy for locally advanced thymic malignancies., Methods: In total, 221 patients with T 2-3 thymic malignancies who underwent modified subxiphoid video-assisted thoracoscopic surgery thymectomy or median sternotomy thymectomy between 2015 and 2020 were enrolled in our prospectively maintained database. A 1:1 propensity score-matching analysis was performed to balance the bias. Surgical difficulty was evaluated with a modified resection index. Perioperative and oncological results were compared between the modified subxiphoid video-assisted thoracoscopic surgery thymectomy group and the median sternotomy thymectomy group., Results: There were 72 patients in each group in the final analysis. Our results showed that the modified subxiphoid video-assisted thoracoscopic surgery thymectomy group had a shorter operative duration (98 vs 129 minutes, P < .001), less blood loss (40 vs 100 mL, P < .001), shorter drainage duration (3 vs 5 days, P < .001), shorter length of hospital stay (5 vs 6 days, P < .001), and fewer postoperative complications (5.6% vs 23.6%; P = .005). No significant difference was detected in complete resection (98.6% vs 98.6%, P = 1.000) between the 2 groups. Conversion occurred in 5 of 106 patients (4.7%). Survival analyses indicated similar recurrence-free survival (hazard ratio, 0.94; 95% CI, 0.40-2.20; P = .883) and overall survival (hazard ratio, 0.52; 95% CI, 0.05-5.02; P = .590) between the 2 groups., Conclusions: Modified subxiphoid video-assisted thoracoscopic surgery thymectomy was safe and effective for T 2-3 thymic malignancies and could be an alternative for selected patients with locally advanced thymic diseases. Further prospective studies are needed to evaluate the long-term survival of those undergoing modified subxiphoid approach thoracoscopic thymectomy., Competing Interests: Conflict of Interest Statement The authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest., (Copyright © 2024. Published by Elsevier Inc.)

Objective: This study aimed to report the initial experiences of 115 patients who underwent robotic thoracic surgery using the da Vinci single-port robotic surgical system (Intuitive Surgical)., Methods: Robotic thoracic surgery using the da Vinci single-port robotic surgical system was performed on 115 patients between November 2020 and June 2023. Patient characteristics, intraoperative outcomes, and postoperative outcomes were analyzed retrospectively., Results: The type of surgeries included thymectomy, mediastinal mass excision, anatomical pulmonary resection (including lobectomy and segmentectomy), esophagectomy, and enucleation of esophageal submucosal tumors in 41, 13, 54, 5, and 2 patients, respectively. The mean total operative time and chest tube duration for different procedures were as follows: thymectomy, 152.9. ± 6.7 minutes and 1.2 ± 0.5 days; mediastinal mass excision, 93.3 ± 26.5 minutes and 1.0 ± 0 days; anatomical pulmonary resection, 187.2 ± 55.8 minutes and 2.5 ± 1.5 days; esophagectomy, 485 ± 111.9 minutes and 12 ± 4.6 days; and enucleation of esophageal submucosal tumors, 170 ± 30 minutes and 5.5 ± 0.5 days, respectively. Conversion to a thoracotomy or sternotomy was not required. Conversion to video-assisted thoracic surgery occurred in 1 patient, and an additional port was applied in 2 patients. Two patients experienced postoperative complications greater than grade IIIa., Conclusions: Robotic thoracic surgery using the da Vinci single-port robotic surgical system is feasible and safe in various fields of thoracic surgery, including complex procedures such as anatomical pulmonary resection and esophagectomy. More complex thoracic surgeries can be performed with the continuous advancement and innovation of instruments in robotic systems., Competing Interests: Conflict of Interest Statement The authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest., (Copyright © 2024 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Introduction: Pericardial effusion develops due to different etiologies. The main goals of our study are to understand the etiology and determine whether the amount of pericardial effusion is significant in terms of malignancy.Material and Methods: 142 patients with pericardial effusion, who met the criteria between 1 January 2014 and 1 January 2019, were retrospectively analyzed. All of these patients underwent operation with the subxiphoidal approach. The fluid samples were sent to the microbiology and pathology laboratories for evaluation. Patients underwent follow-up after 1 month.Results: Of the patients included in this study, 72 (61%) of 118 patients were operated on under general anesthesia with a laryngeal mask, and 46 (39%) underwent sedation and local anesthesia. The etiologies found in patients were as follows: effusions resulting from malignancy in 27 (22.9%), idiopathic in 24 (20.3%), cardiac causes (depending on the use of anticoagulants or postoperation) in 22 (18.6%), uremia in 20 (16.9%), infection in 18 (15.3%), and heart failure in 7 patients. The amount of fluid drained from the patients was 661.61 ± 458.34 mL. Out of 27 patients with malignancy, 21 (77.8%) had drainage over 500 mL of effusion fluid, and 6 (22.2%) had drainage under 500 mL. Patients who had positive results tended to have drainage over 500 mL compared with patients who had negative results in terms of malignancy (P = .033).Conclusion: The subxiphoidal approach to pericardial effusion is an easily applicable operation, whether therapeutic or diagnostic. The advantages of the subxiphoidal approach include drainage of all of the fluid and ease of sampling the pericardial fluid. We believe that the amount of fluid drained can lead us to consider malignancy as an etiology. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide Open in new tab Download slide OBJECTIVES We previously reported a transthoracic approach using the da Vinci Single-Site™ platform. This study describes the outcomes of robotic single-site thymectomy via a subxiphoid approach based on our previous experiences. METHODS This study included patients, who underwent single-site robotic thymectomy via the subxiphoid approach between September 2018 and October 2019. A 3- to 4-cm vertical incision was made over the subxiphoid area, and the Lapsingle port with CO2 gas was introduced. After docking at the single site, a 5-mm curved cannula, 5-mm cardiere grasper and Maryland bipolar forceps or permanent cautery hook was inserted. The single-site robotic platform was used to conduct all surgical procedures except the dissection around the inferior portion of the thymic tissue performed via a thoracoscopic approach through the same incision. RESULTS Overall, 13 patients, including 2 with myasthenia gravis, were enrolled. The mean duration of the surgery and chest drainage were 167.3 ± 52.8 (range 73–253) min and 2.2 ± 0.9 (range 1–5) days, respectively. All surgeries were successfully completed without conversion to an open surgery, and there were no major post-surgical complications. The diagnoses based on histopathology included thymoma in 10 patients, thymolipoma in 2 patients and atypical carcinoid tumour in 1 patient with free resection margin. CONCLUSIONS This study demonstrated that robotic single-site-assisted thymectomy via the subxiphoid approach is a safe and technically feasible procedure. Although this initial series comprised relatively simple cases, more advanced and complex procedures can soon be performed with the advent of single-port robotic platform. [ABSTRACT FROM AUTHOR]

This case report describes two patients that underwent successful video-assisted thoracoscopic surgery (VATS) lung resections under spontaneous ventilation using the uniportal subxiphoid approach. The authors performed lung wedge resection in both patients under local anesthesia without using of a Foley catheter, arterial line, or intercostal chest drain. Only intravenous drugs and an oxygen mask with reservoir bag were used. The postsurgical course for both patients was uneventful. Both were discharged on postoperative day 2 and were doing well at 1- and 3-month follow-ups. [ABSTRACT FROM AUTHOR]

Background: Thymectomy is increasingly being performed via minimally invasive approaches. The present study aimed to assess the safety and feasibility of the subxiphoid approach to video-assisted thoracic surgery (VATS) compared with the lateral intercostal approach VATS.Methods: Patients who underwent VATS thymectomy via subxiphoid and lateral intercostal approaches in our hospital between 2015 and 2018 were retrospectively analyzed. A series of perioperative outcomes, including clinical and surgical results, postoperative pain scores and cosmetic results, was compared in a propensity score matching analysis.Results: A total of 98 patients diagnosed with non-myasthenic early-stage thymoma underwent complete thymectomy by VATS. Propensity score analysis revealed that 28 patients treated with the subxiphoid approach and 28 patients treated with the lateral intercostal approach had the same baseline characteristics. Compared with those in the lateral intercostal approach group, patients in the subxiphoidapproach group yielded lower pain scores and shorter postoperative hospital stays. Other advantages of the subxiphoid approach included decreased inflammatory cytokine response and superior cosmesis. There were no significant differences in postoperative complications between the two groups. All these patients recovered well when discharged. There were no perioperative deaths.Conclusions: Our data suggest that subxiphoid and subcostal arch thoracoscopic radical thymectomy is a less invasive procedure for the treatment of non-myasthenic early-stage thymoma and provides a satisfactory cosmetic effect. Owing to the limitation ofour retrospective study, further prospective studies are needed to evaluate long-term and oncologic outcomes of subxiphoid approach VATS thymectomy. [ABSTRACT FROM AUTHOR]

An open approach by sternotomy is still selected for locally advanced anterior mediastinal tumors. Technical and instrumental improvements to video-assisted thoracic surgery (VATS) have enabled the treatment of anterior mediastinal tumor in the last decade, and the indications of VATS for an anterior mediastinal tumor are thus expanding. Recently, a single-port thymectomy procedure using the subxiphoid approach has gained popularity worldwide because of its low invasiveness. Improvements to the thoracoscopic instruments and the development of a single-port device are expanding the adoption of single-port VATS in the thoracic surgical field, including resection of anterior mediastinal tumors. We, herein, report a case of thymothymectomy with pulmonary partial resection using the subxiphoid approach. This approach is useful for extended operation for anterior mediastinal tumors and provides favorable results regarding postoperative pain and cosmetic outcomes. [ABSTRACT FROM AUTHOR]

Objectives: The purpose of this study was to explore the safety and feasibility of video-assisted thoracic surgery (VATS) total thymectomy via the single-port subxiphoid approach compared with the intercostal approach., Methods: From January 2018 to May 2022, patients who underwent VATS total thymectomy via the subxiphoid or unilateral intercostal approach and diagnosed with Masaoka-Koga stage I-II, non-myasthenic thymoma were included in this study. Perioperative outcomes, immediate and long-term pain evaluations were compared in a propensity score-matching analysis., Results: In total, 95 patients were included and underwent the subxiphoid approach (n = 37) and the intercostal approach (n = 58). Propensity score yielded 2 well-matched cohorts of 30 patients and there was no significant demographical imbalance between the 2 groups. Compared with the intercostal approach, the subxiphoid group demonstrated favourable perioperative outcomes including the intraoperative blood loss (P = 0.025) and the median duration of hospital stay (P = 0.083). The immediate and long-term pain evaluations revealed that the subxiphoid group reported lower visual analogue scales at postoperative 24 h and lower total doses of fentanyl bolus infusions during hospitalization (P = 0.004 and 0.018, respectively), along with lower long-term neuropathic pain scale scores (P = 0.005) than patients in the intercostal group., Conclusions: VATS thymectomy via the single-port subxiphoid approach showed favourable perioperative outcomes compared to the intercostal approach. Moreover, the subxiphoid approach seemed both to cause minimal immediate postoperative pain and to have advantages in reducing long-term neuropathic pain compared with the intercostal approach., (Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery 2023.)

When enlarged cardiophrenic lymph nodes (CPLN) are resected the impact on survival is still uncertain, but resection contributes to accurate staging and complete gross resection in advanced ovarian cancer. CPLN resection can be performed via video-assisted thoracic surgery or transabdominally through the subxiphoid or transdiaphragmatic routes. The subxiphoid approach is used to reach the prepericardiac nodes located in the anterior mediastinum. The transdiaphragmatic route is used to remove the costophrenic and supradiaphragmatic paracaval lymph nodes located in the middle and posterior mediastinum, respectively. However, the transdiaphragmatic approach necessitates diaphragm opening and, in most cases, liver mobilization. Costophrenic nodes can be resected through the subxiphoid route in appropriate patients without opening the diaphragm. Thus, the subxiphoid approach may be preferred to remove the costophrenic lymph nodes, in cases in whom diaphragm resection is not anticipated, and especially when the resection procedure is planned to include the prepericardiac nodes. In this video article, we present the method of resecting both prepericardiac and costophrenic lymph nodes using only the subxiphoid approach in a case of advanced ovarian cancer. The subxiphoid virtual space between the pericardium and diaphragm was developed. The observed and palpated CPLNs were dissected and excised from the prepericardiac and right latero-cardiac spaces. Thereafter, diaphragm peritoneum beneath the right costophrenic nodes was dissected. After identifying any enlarged costophrenic nodes by palpation, the sternal and costal diaphragmatic attachments were incised and the right latero-cardiac space was extended. When the single enlarged node was reached, it was grasped and pulled with curved-ring forceps and ultimately resected. [ABSTRACT FROM AUTHOR]

Objective: To describe the surgical technique of a subxiphoid approach to remove cardiophrenic lymph nodes in women with advanced ovarian cancer. Materials and methods: The first step is to dissect and separate the anterior insertions of the diaphragm at the xiphoid appendix. Thus, the parietal peritoneum and the upper fibres of the transversus abdominis muscle are incised. Then, the anteroinferior mediastinum is identified and dissected. Diaphragmatic deinsertion may be extended 5-7 cm laterally to the xiphoid appendix following the inferior costal margin according with the localization of the enlarged lymph nodes. Thus, the dissection of the anterolateral cardiophrenic space allows the identification of both pleura. In addition, the vertical dissection of the anterior cardiophrenic space allows the removal of enlarged lymph nodes. However, it is important to bear in mind at this time that the unintentional opening of the pleura is possible. To reduce this risk, a careful dissection of the anterior cardiophrenic fat tissue is essential. Moreover, a careful dissection will avoid damage at the left phrenic nerve as well as the left pericardiophrenic artery and vein. After removing the cardiophrenic fat tissue, the diaphragm is sutured at the lower costal margin by using separated stiches of absorbable 2-0 suture. Conclusion: The subxiphoid approach to resect cardiophrenic lymph nodes is a feasible surgical technique. In addition, it reduces the possibility of opening the pleural cavity, while avoiding a diaphragmatic incision, in comparison with the standard trans-diaphragmatic surgical approach. [ABSTRACT FROM AUTHOR]

Background: Epicardial ablation is often necessary for the treatment of complex arrhythmias refractory to endocardial ablation. Conventional needle access to the pericardial space is considered quite challenging, and it is often associated with several potential complications, particularly inadvertent right ventricular puncture. The novel EpiAccess needle tip is embedded with a pressure sensor able to report the pressure waveform in real time when used with the EpiAccess System.Objective: We prospectively evaluated the feasibility and safety of the EpiAccess System by EpiEP, Inc., with a novel epicardial access needle in a multicenter study.Methods: Twenty-five patients with a clinical need for epicardial access were enrolled. The EpiAccess needle and EpiAccess System were used for epicardial access in each case. Successful epicardial access, defined as the ability to introduce a guidewire into the epicardial space, was assessed via the device and confirmed with fluoroscopy. Significant pericardial bleeding was defined as >80 mL of blood by using peer review article definitions.Results: Patients were men (76%) with a mean age of 62 years (range 28-84 years). Epicardial access for ventricular tachycardia ablation was indicated in 80% of the patients. Successful epicardial access was obtained in all cases, with pressure monitoring guiding pericardial wire access in all cases. One delayed pericardial effusion occurred.Conclusion: Epicardial access with the novel EpiAccess needle and System with real-time pressure monitoring is feasible and safe. The pressure monitoring capability identifies successfully the epicardial space, facilitating access and potentially minimizing complications. This has relevant clinical implications. [ABSTRACT FROM AUTHOR]

Bidirectional Glenn procedure outcomes are very good; therefore, extracorporeal membrane oxygenation use as extracorporeal cardiopulmonary resuscitation is uncommon. We describe a 13-month-old female who required extracorporeal cardiopulmonary resuscitation for ventricular tachycardia provoked by transient myocarditis 6 months post-bidirectional Glenn procedure. After extracorporeal membrane oxygenation induction with cannulation on the cervical vessels, small skin incision was created on the subxiphoid area without sternotomy and the atrium was cannulated. With adequate venous drainage and ventricular unloading, ventricular tachycardia eventually converted to sinus rhythm. The patient withdrew from extracorporeal membrane oxygenation and was discharged successfully. Our results suggest that for successful post-bidirectional Glenn extracorporeal cardiopulmonary resuscitation, quick atrial access and ventricular unloading are essential. [ABSTRACT FROM AUTHOR]