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.

Non-intubated subxiphoid uniportal video-assisted thoracoscopic thymectomy.

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

Heterotopic Ossification of the Xiphoid After Chest Compressions.

This report describes the case of a 56-year-old woman with a 6-year history of severe epigastric pain after chest compressions for cardiac arrest. A comprehensive gastrointestinal workup was negative. However, an abdominal computed tomographic scan demonstrated an elongated xiphoid process. After a xiphoid trigger point injection, she experienced pain relief lasting 4 days, and thus her symptoms were attributed to xiphoidalgia secondary to heterotopic ossification after trauma. She underwent open resection of the xiphoid process. Heterotopic ossification of the xiphoid process is rare. This report documents a case of heterotopic ossification secondary to trauma from chest compressions.

[Experience with Wang procedure for treatment of pectus excavatum in young children].

OBJECTIVE: To review the experience with Wang procedure for treatment of pectus excavatum in young children. METHODS: The clinical data of 21 children with a mean age of 3.3 ± 1.1 years (ranging from 1.5-6 years) undergoing Wang procedure for pectus excavatum were analyzed. A longitudinal incision (1 to 2 cm) was made in the front of the xiphoid, and two tunnels were created using steel bars beneath the muscles on two sides of the chest wall. The fibrous tissue between the diaphragm and the sternum was dissociated, and the steel wires were sutured through the deformed chest wall. After the steel bar was placed in the tunnels, the wires were pulled and fixed in the middle of the bar, and the incision was sutured. RESULTS: All the operations were performed using 3 wires and 1 steel bar. The operation time was 25 to 51 (38.1 ± 9.6) min with an intraoperative bleeding volume of 5 to 10 (7.1±1.5) mL. The time of hospitalization of the patients ranged from 6 to 10 days (mean 8.1±1.3 days). In all the patients, the incision healed smoothly without serious pain or obvious complications. All the patients were followed up for 1 to 13 months after the operation. During the follow- up, no recess recurred and no such complications as bar displacement or transposition occurred. According to the evaluation criteria after pectus excavatum operation, 13 cases had a total score of 9, and 8 had a total score of 8. The overall effect was satisfactory, and there were no cases rated as basically satisfactory or unsatisfactory. CONCLUSIONS: Wang procedure is a good option for treatment of pectus excavatum in young children.

Uniportal Subxiphoid Video-Assisted Thoracoscopic Anatomical Segmentectomy: Technique and Results.

BACKGROUND: Performing sublobar resection for early stage non-small cell lung carcinoma is becoming increasingly popular, with studies suggesting equivalent outcomes to lobectomy when sufficient lymph node sampling is performed. Furthermore, there has been a move to minimally invasive thoracic surgery facilitating enhanced recovery and reduced postoperative morbidity. The subxiphoid video-assisted thoracic surgery (SVATS) approach is a novel technique that is becoming increasingly popular, with evidence of reduced postoperative pain. Here, we report experience and the technique of performing segmentectomy by the uniportal SVATS approach. METHODS: The uniportal SVATS approach was used to perform all possible segmentectomies. Specific instruments were designed to facilitate performing surgery through this approach, and the operative technique is described and demonstrated with videos. RESULTS: Between September 2014 and April 2017, 242 segmentectomies were performed by uniportal SVATS. Twenty-nine of the patients underwent bilateral procedures. The mean duration of surgery was 2.14 ± 0.78 hours. Lymph node stations were accessible, and a mean of 4.00 ± 1.00 lymph node stations and 10.64 ± 3.38 lymph nodes were sampled. The mean postoperative hospital length of stay was 4.67 ± 9.54 days. Only 4 cases required conversion to thoracotomy, and 3 required conversion to full lobectomy. There were no perioperative deaths, with 30-day survival of 100%. CONCLUSIONS: This report demonstrates that the uniportal SVATS approach can be safely and effectively utilized to perform pulmonary segmentectomies. Our series demonstrates that it is possible to access and resect all segments by this novel approach to VATS.

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.

Xiphoidectomy for Intractable Xiphodynia.

BACKGROUND: Xiphodynia is a rare condition with hardly any data published regarding xiphoidectomy as a valid treatment option for intractable disease. It is necessary to bear this syndrome in mind after having filtered out other differential diagnoses. METHODS: Between 2003 and 2015, 11 patients underwent xiphoidectomy for intractable xiphodynia at our institution. Patients' charts were reviewed including preoperative workup, operative technique, and results. Every patient had routine follow-ups, 4 weeks after the procedure and 1 year after surgery. RESULTS: The main symptom was chest pain in the area of the xiphoid. Conservative treatment trials with different combinations of analgesics over at least 1 year did not lead to insufficient and long-term improvement, which is why the decision for a surgical xiphoidectomy was eventually made. No postoperative complications occurred. Significant pain relief was achieved in eight out of ten patients; one patient was lost to long-term follow-up. Both patients with insufficient pain relief have had previous surgery in form of a sternotomy and upper median laparotomy. CONCLUSIONS: Xiphodynia is a diagnostic conundrum, which is why reports on its treatment including surgical resection of the xiphoid are even sparser. So far, this is the largest reported series of surgically treated xiphodynia. Correct diagnosis remains the key factor for success. While tenderness over the tip of the xiphoid process combined with protrusion of the xiphoid with a xiphisternal angle of <160° are good indications for surgery, patients after previous operations affecting the xiphoid process are less likely to benefit from xiphoidectomy.

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.

Xiphoidectomy for xiphoid process-induced pain in a surfer.

A 53-year-old man who had been surfing for more than 30 years was referred to our hospital with upper abdominal wall pain. Computed tomography showed that his xiphoid process was protruding forward and the overlying skin was thickened. We diagnosed chronic abdominal wall pain due to repeated compression between the surfboard and his xiphoid process. To relieve the pain, we performed a xiphoidectomy. The pain resolved after surgery and he resumed surfing 26 days postoperatively. Xiphoidectomy is effective for treating xiphoid process-induced pain in surfers.

Trans-subxiphoid robotic thymectomy.

Minimally invasive surgery has replaced median sternotomy for resectable anterior mediastinal masses and is performed by various approaches. We developed a new minimally invasive surgical procedure by combining the subxiphoid approach performed through a midline camera port with the use of a robotic surgery system (Intuitive Surgical, Sunnyvale, CA, USA). A 3-cm transverse incision was made 1 cm below the xiphoid process. Then, a port designed for single-port surgery was inserted. Through this port, CO2 gas was injected at 8 mmHg. The thymus was then detached from the back of the sternum. A 1-cm skin incision was made bilaterally in the sixth intercostal space, followed by insertion of a port for the robotic system. A camera port was inserted into the subxiphoid port, to which the camera scope was mounted, and thymectomy was performed. We have performed the operation in 3 patients. In our experience, this procedure provides a good operative view in the neck region and makes verification of the phrenic nerve easy. Furthermore, with the da Vinci surgical system, which enables surgical manipulation from a correct angle due to the multijoint robotic arms, trans-subxiphoid robotic thymectomy may be a promising new thymectomy procedure.

Subxyphoid thyroidectomy: a feasibility study.

OBJECTIVE: The cultural desire to avoid cervical incisions and increasing concern for cosmetic outcomes has motivated surgeons to develop alternative approaches to thyroid surgery. The Direct Drive Endoscopic System (DDES) platform combines a flexible endoscope with a pair of separately controlled articulating instruments through a single, flexible, access system. We hypothesized that the DDES platform would permit single-incision minimally invasive thyroid lobectomy without robotic assistance. METHODS: This is a single-cadaver feasibility study. A single, 2.2-cm subxyphoid incision was used for access. The platform's 55-cm flexible sheath was secured to the operating table rails and introduced into the subcutaneous space. A flexible pediatric endoscope was simultaneously introduced with 2 interchangeable 4-mm instruments. Blunt dissection and electrocautery were used to create the tunnel in the otherwise free central plane. The thyroid was dissected using a superior to inferior technique while maintaining the critical steps of traditional thyroid surgery. A Veress needle introduced through the lateral neck provided additional retraction. RESULTS: The total operating time was 2.5 hours. The subcutaneous tunnel was safe and accommodated the DDES well. Visualization was adequate. Graspers, scissors, and hook cautery were used to complete the lobectomy. The ergonomics, articulation, and strength of the instrumentation were sufficient. CONCLUSIONS: Subxyphoid thyroidectomy is technically possible and avoids the difficulties inherent to a transaxillary approach while still avoiding cosmetically unappealing cervical scars. Continued technological refinement will only expand the therapeutic possibilities of flexible endoscopy while minimizing the physical insult to patients and maximizing aesthetics for patients.

Resection of thymomas with use of the new minimally-invasive technique of extended thymectomy performed through the subxiphoid-right video-thoracoscopic approach with double elevation of the sternum.

OBJECTIVES: To present the new technique of minimally invasive extended thymectomy performed through the subxiphoid-right video-thoracoscopic (VATS) approach with double elevation of the sternum and the early results of resection of thymomas with the use of this technique. OPERATIVE TECHNIQUE: whole dissection was performed through a 4- to 7-cm transverse subxiphoid incision, and a single 5-mm port was inserted into the right chest cavity for the video thoracoscope and subsequently for the chest tube. The sternum was elevated with two hooks connected to the sternal frame (Rochard bar, Aesculap-Chifa, Nowy Tomysl, Poland). The lower hook was inserted through the subxiphoid incision, and the superior hook was inserted percutaneously after the mediastinal tissue including the major mediastinal vessels was dissected from the inner surface of the sternum. The fatty tissue of the anterior mediastinum and the aorta-pulmonary window was completely removed. RESULTS: There were 24 patients operated on for the Masaoka Stage I-III thymoma in the period from 1 January 2009 to 30 March 2012. There was no mortality and complications occurred in 1 patient necessitating revision for bleeding (morbidity rate 4.2%). The median operative time was 105.0 (range 70-195) min. In 2 patients it was possible to completely resect Masaoka Stage III tumour infiltrating the right lung, which was resected with the use of an endostapler. The dimensions of the thymomas ranged from 1.8 × 1.5 × 1.5 to 12 × 9 × 5 cm. CONCLUSIONS: In our opinion, the presented technique is probably the least invasive and the most complete technique of VATS thymectomy with excellent cosmetic results and is a valid alternative to sternotomy approach for the Masaoka Stage I-III thymomas.

The efficiency of surgical subxiphoid pericardial drainage and percutaneous pericardial drainage in pericardial effusions associated with cardiac tamponade.

OBJECTIVES: The optimal management for pericardial effusions with cardiac tamponade remains controversial. This study compares the results after two commonly performed techniques: subxiphoid surgical pericardial drainage (DPSS) and percutaneous catheter drainage (DPPK). MATERIAL AND METHODS: We conducted a 5-year retrospective study to analyse the outcome after DPSS and DPPK in patients with non-traumatic pericardial effusions with cardiac tamponade. OUTCOMES: Patients with non-traumatic cardiac tamponade were treated with DPSS (N=138) and DPPK (N=54). There were no statistical differences between groups regarding: age, drainage volume and duration of drainage. The etiology was malignant in 72 patients and benign in 120 patients. The 2-year survival was statistically non-significant: 55,1% in the surgical group and 44,4% in the percutaneous group, but there was a slight prevalence of malignant diagnosis in the first group (38% versus 35%). The 1-year survival in patients with proved cyto- hystological malignancy was statistically poorer than in patients with malignant diagnosis and with both negative cytology and hystology (7% versus 33%). The 1-year freedom of re-intervention for recurrence of pericardial effusion was statistically better in the surgical group as in the percutaneous one (92.8% versus 79,6%). CONCLUSIONS: DPSS and DPPK can be both safely performed. DPSS appears to decrease intervention-necessitating recurrence, but it brings a minimal advantage for the malignant diagnosis over cytology alone.

Análise dos resultados estéticos na reconstrução mamária com TRAM ipsilateral vs. contralateral / Comparison of the aesthetic outcomes of breast reconstruction by using ipslateral or contralateral TRAM flaps", "_e": "n

INTRODUÇÃO: A reconstrução mamária com retalho do músculo reto abdominal (TRAM, do inglês transverse rectus abdominis myocutaneous) tem se tornado um procedimento comumente realizado desde a década de 1990. O TRAM ipsilateral vem demonstrando ser tão seguro quanto o retalho contralateral na reconstrução mamária. Entretanto, estudos avaliando o resultado estético com as duas técnicas são escassos na literatura. A proposta deste estudo é comparar os resultados cosméticos entre os retalhos pediculados ipsilateral e contralateral. MÉTODO: Foi realizada avaliação prospectiva de 29 pacientes submetidas a reconstrução imediata com TRAM ipsilateral e contralateral. Os grupos foram comparados entre si, analisando-se os resultados estéticos. RESULTADOS: O estudo incluiu 29 pacientes, com média de idade foi 43 + 7 anos. O grupo 1 (TRAM ipsilateral) apresentou o sulco inframamário bem definido em 91,7% dos casos, comparativamente a 52,9% no grupo 2 (TRAM contralateral). Observou-se abaulamento na região xifoide em 8,3% dos pacientes do grupo 1 e em 23,5% dos pacientes do grupo 2. A diferença na forma global da mama reconstruída não foi importante, com 66,7% e 70,6% de simetria nos grupos 1 e 2, respectivamente. CONCLUSÕES: O TRAM ipsilateral demonstrou melhor manutenção do sulco inframamário e menor abaulamento na região xifoide. Entretanto, a forma global da mama e a projeção do polo inferior da mama foram similares entre os dois grupos.

BACKGROUND: Breast reconstruction by using the rectus abdominis muscle (transverse rectus abdominis myocutaneous, TRAM) flaps is a common procedure that has been performed since the 1990s. Ipsilateral TRAM flaps were proven to be as safe as contralateral flaps for breast reconstruction. However, studies comparing the aesthetic outcomes of the two procedures are poorly described in the literature. The aim of this study was to compare the cosmetic outcomes of ipsilateral and contralateral pedicled flaps. METHODS: We prospectively evaluated 29 cases of immediate reconstruction with ipsilateral (group 1) or contralateral (group 2) TRAM flaps. The aesthetic outcomes were analyzed and the two groups were compared. RESULTS: The average age of the patients was 43 ± 7 years. In group 1 (ipsilateral TRAM), 91.7% of the patients presented a well-defined inframammary fold, as compared to 52.9% of the patients in group 2 (contralateral TRAM). In group 1, 8.3% of patients showed xiphoid bulges, whereas they were observed in 23.5% of patients in group 2. The difference in the overall shape of the reconstructed breast was not significant; symmetry was observed in 66.7% and 70.6% of patients in groups 1 and 2, respectively. CONCLUSIONS: Ipsilateral TRAM flaps allow better preservation of the inframammary fold and cause less xiphoid bulge. However, the overall shape of the breast and the projection of its lower pole were similar between the two groups.

Postoperative elongation of the xiphoid process --report of a case--.

We report a case of a 66-year-old man who presented with an abnormal sensation, tenderness, and pain in the middle of his chest in May 2006, two years after a mitral valve replacement for severe mitral regurgitation and a MAZE operation for chronic atrial fibrillation elective cardiac. He was immediately admitted, and the x-ray examination revealed an abnormal elongation of the xiphoid process. At the time of discharge after the initial operation in 2004, x-rays indicated that the length of the xiphoid process was 3 cm; however, in 2006 it had elongated to 6 cm and was prominent in the anterior view. The patient underwent surgical extirpation of the xiphoid process while he was under local anesthesia. Histological examination of the resected xiphoid process revealed no signs of neoplastic or maligant change. The cause of the elongation of the xiphoid process was believed to be distraction tissue neogenesis. The xiphoid process, which fractured and separated from the sternum at the initial operation, was pulled down inferiorly by the rectus abdominis muscles, following which the xiphoid process became elongated and reconnected with the sternum. In cases of a fractured or amputated xiphoid process after median sternotomy, the xiphoid process should be resected to avoid its neogenesis.

Hybrid combination of small subxiphoid incision and thoracoscopic thymectomy for juvenile myasthenia gravis.

BACKGROUND/PURPOSE: Myasthenia gravis is an autoimmune disease that usually responds positively to treatment with thymectomy. Various approaches via video-assisted thoracic thymectomy as a substitute for conventional sternotomy have been reported. We reported a less invasive technique for thymectomy in pediatric groups. METHODS: Four adolescents with juvenile myasthenia gravis all underwent hybrid combination of small subxiphoid incision and thoracoscopic thymectomy at our institute. Clinical characteristics and surgical outcome were consecutively collected. RESULTS: In these 4 patients, 2 presented with Osserman class III and 2 with class IIb. The mean operative time was 180 minutes. There was no conversion to sternotomy, and there was only minimal blood loss. Follow-up duration was 3 to 64 months. Postoperatively, 1 patient had complete remission and 3 patients had improvement in clinical symptoms. CONCLUSION: Hybrid combination of small subxiphoid incision and thoracoscopic thymectomy may be an effective alternative with low surgical invasiveness for treating juvenile myasthenia gravis.

Use of a subxiphoid incision for pectus bar placement in the repair of pectus excavatum.

BACKGROUND: Since the first description of the Nuss repair for pectus excavatum, many technical variations have been described. Over the past 10 years, we have used a subxiphoid incision to allow finger guidance to protect the mediastinum which obviates the need for thoracoscopy. METHODS: A retrospective review was conducted on all our patients who have undergone pectus excavatum repair from December 1999 to March 2009. Demographic, treatment, and outcome variables were recorded. All operations were performed with 2 lateral incisions, one subxiphoid incision, and 2 stabilizers. RESULTS: During this timeframe, 307 patients underwent pectus bar placement. Mean age was 14.0 +/- 3.3 years, and 78% were male. Mean operating time was 50.0 +/- 15.9 minutes, length of hospitalization was 4.1 +/- 1.1 days, and time to bar removal was 33.0 +/- 7.3 months. There were no intraoperative events. Postoperative complications included a bar infection in 13 patients (4.2%), stabilizer displacement/discomfort requiring removal in 5 patients (1.6%), and bar rotation in 4 patients (1.3%). Rotation required operative correction in 3 cases and early removal in the other owing to a cracked sternum. No reoperations have been done for recurrence. CONCLUSIONS: The subxiphoid guided technique is a simple, safe, and reproducible method for the minimally invasive repair of pectus excavatum that obviates the need for thoracoscopy.

A new animal model for assessing cartilage repair and regeneration at a nonarticular site.

The aim of this study was to establish a critical-sized nonjoint chondral defect animal model and to evaluate its feasibility for testing cartilage regeneration strategies. Dermal biopsy punches 1-4 mm in diameter were used to create cylindrical full-thickness defects in the center of athymic rat xiphoids. The 3 and 4 mm defects remained unhealed 35 days postsurgery, with a large area in the center that had low proteoglycan content based on contrast-enhanced microCT (EPIC-microCT), radiographic, and histological analyses. In a second step, tissue-engineered cartilage was synthesized by culturing primary bovine articular chondrocytes on poly-L-lactic acid (PLA) scaffolds in a perfusion-shear bioreactor for 28 days. These chondrocyte/PLA constructs or primary bovine chondrocytes were implanted into 3-mm-diameter defects. Empty defects and defects implanted with empty PLA scaffolds were used as controls. Xiphoids were harvested 28 days after surgery and examined with faxitron, microCT, and histology using hematoxylin and eosin and safranin-O staining. Both chondrocyte/PLA constructs and chondrocytes alone formed neocartilage. The results indicate that a 3 mm cylindrical defect in a rat xiphoid is an economic, feasible, and reproductive model to evaluate the potential of various constructs for nonjoint cartilage repair.

Xiphoid lower-sternotomy approach for multivessel revascularization of the left internal mammary artery to the left anterior descending artery and right internal mammary artery inflow to the other vessels.

BACKGROUND: We describe the technical details and the preliminary results of a new surgical approach for multivessel disease that involves using a lower T sternotomy, grafting of the left internal mammary artery (LIMA) to the left anterior descending coronary artery (LAD) and use of the right internal mammary artery (RIMA) as inflow to the other vessels. OPERATIVE TECHNIQUE: The sternotomy was made from the xiphoid up to the fourth intercostal space and then was continued transversally (T incision). The LIMA was harvested for a length of approximately 8 cm, with preservation of the distal part. The vein was simultaneously taken from the leg. The RIMA was dissected for a length of approximately 5 cm, and the distal part was occluded. Then, 3 mg/kg heparin was given. The anastomosis between the vein and the RIMA was performed. The distal venous anastomoses were done either singly or sequentially. The anterior or posterior route was chosen according to the patient's anatomy. The LIMA was then anastomosed to the LAD. One drain was placed. The sternum was closed with 4 wires, 2 for the T incision and 2 for the sternum. RESULTS: Between September and December 2008, 9 patients underwent their operations with this technique. The mean age was 60 years (range, 55-68 years). The mean number of grafts was 2.8. The mean hospital stay was 5.2 days. Operative mortality was 0%. All patients were reevaluated with 16-slice multislice computed tomography, and all grafts were patent. At the 3-month follow-up, all patients were alive and free of symptoms. CONCLUSION: This minimally invasive technique is a useful alternative for complete revascularization. The sternal mammary supply and the upper part of the sternum are preserved.