The Zakopane Pulmonary Hospital experience on subxiphoid thymectomy.

BACKGROUND: To present the technique of minimally invasive extended thymectomy performed through the subxiphoid-bilateral subcostal video-assisted thoracoscopic surgery (VATS) approach, with double elevation of the sternum for nonthymomatous myasthenia gravis (MG). METHODS: The whole dissection was performed through the 4-7 cm transverse subxiphoid incision with single 10 mm extra-long bariatric laparoscopy ports inserted subcostally to the right and left chest cavities for videothoracoscope and subsequently for chest tubes. 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 were 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 147 patients (62 patients operated on for thymomas, 75 patients for nonthymomatous MG and 10 for rethymectomies) in the period 1.1.2009-30.3.2016. There was no mortality and morbidity. The mean operative time was 109.1 min (range, 75-150 min). CONCLUSIONS: The subxiphoid approach combined with bilateral single port subcostal VATS and double elevation of the sternum enables very extensive thymectomy in case of nonthymomayous MG.

Uniportal transcervical video-assisted thoracoscopic surgery (VATS) approach for pulmonary lobectomy combined with transcervical extended mediastinal lymphadenectomy (TEMLA).

BACKGROUND: To present the technique of uniportal transcervical video-assisted thoracoscopic surgery (VATS) approach for pulmonary lobectomy combined with transcervical extended mediastinal lymphadenectomy (TEMLA). METHODS: Transcervical extended approach utilizes a typical a 5-8 centimeters collar incision in the neck. The critical technical point enabling a wide access to the chest is an elevation of the sternal manubrium with a special retractor (modified Rochard frame, Asculap-Chifa Company). A bilateral visualization of the laryngeal recurrent and vagus nerves is usually performed to avoid injury of these structures. The uniportal transcervical VATS lobectomy for NSCLC is preceded by TEMLA to enable optimal intraoperative staging of the mediastinal nodes and perform extensive bilateral lymphadenectomy, which theoretically might affect survival. VATS lobectomy is the next step after obtaining results of intraoperative examination of the nodes. Ventilation of the operated lung is disconnected and the mediastinal pleura is opened. Pleural adhesions are divided. The branches of the pulmonary artery and vein and the lobar bronchus are sequentially dissected and managed with endo staplers. The fissure is divided with endo stapler and the resected lobe is removed in endobag. RESULTS: There were 9 patients operated on in the period 1.2.2016-30.7.2016. In one patient with left lower lobe tumor we had to convert to uniportal VATS left lower lobectomy due to extensive adhesions. There was no mortality and complications occurred in 2 patients. The mean operative time was 258.1 min (200-385 min) for the whole TEMLA procedure with imprint cytology and lobectomy and 168.1 min (110-295 min) for a lobectomy solely. CONCLUSIONS: A uniportal transcervical video-assisted thoracoscopic surgery (VATS) approach for pulmonary lobectomy combined with TEMLA provides an opportunity for radical pulmonary resection and super radical extensive mediastinal lymphadenectomy.

Subxiphoid uniportal VATS thymectomy.

BACKGROUND: To present the technique of minimally invasive extended thymectomy performed through the uniportal subxiphoid approach, with double elevation of the sternum for nonthymomatous myasthenia gravis (MG). METHODS: Operative technique: the whole dissection was performed through the 4-7 cm transverse or longitudinal subxiphoid incision with use of videothoracoscope. 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 were 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 four patients in the period 1.1.2017-30.4.2017. There was no mortality and morbidity. CONCLUSIONS: The uniportal subxiphoid approach combined with double elevation of the sternum enabled very extensive thymectomy in case of thymoma.

[Surgical strategy and outcome in multiple cerebral aneurysms]. / Taktyka postepowania chirurgicznego i wyniki leczenia tetniaków mnogich mózgu.

INTRODUCTION: Multiple aneurysms of the brain are a more dangerous disorder than single aneurysms. Most of patients have evidence of aneurysmal rupture, but rebleeding remains an additional danger because of co-existing aneurysms. These "silent" aneurysms also have to be operated--the risk of following subarachnoid haemorrhage (SAH) is about 2% annually. AIM: The purpose of this study was to assess of the surgical outcome in multiple aneurysmal SAH in regard to chosen risk factors. MATERIAL AND METHOD: Retrospective analysis of 608 patients treated within three years (2001-2003) for cerebral aneurysms in the Department of Neurosurgery, Jagiellonian University in Kraków, was carried out. 14% patients had multiple aneurysms: 72--two aneurysms, 10 patients three aneurysms, and three patients four and more. The mean age was 50, with slight predominance of women (58%). Most patients were operated on via pterional craniotomy, and posterior circulation aneurysms were clipped by means of suboccipital approach. "Silent" aneurysms being clipped in the first stage, if were available via the same craniotomy, another--in the next stage. We analyzed short-term outcome of multiple aneurysms in comparison to the single (literature data). We presented the outcome (according to the Glasgow Outcome Scale) with regard to preoperative condition, age, location of the most frequent "bleeding" aneurysms (middle cerebral artery, anterior communicating artery), and in patients operated on in the 1st and 2nd stage. Accuracy of the preoperative detection of "bleeding" aneurysm was checked based on CT, MRI, angio-CT, angio-MRI and DSA. RESULTS AND CONCLUSIONS: Out of all 85 treated patients, 64 (75.3%) presented very good and good condition on discharge. Five (5.9%) were severe disabled, and 16 (18.8%) died. Good preoperative condition, age less than 55, and "bleeding" aneurysms of the middle cerebral artery (compared with anterior communicating artery) are good prognostic factors in surgically treated multiple aneurysms. Outcome in single and multiple aneurysms is similar, excluding perioperative losses, which are 5% higher in the multiple aneurysms group. In our series in each case of "bleeding" aneurysm was correctly detected preoperatively.