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.

Monitorización neurofisiológica intraoperatoria del nervio frénico: utilidad y descripción de la técnica / Intraoperative neurophysiological monitoring of the phrenic nerve: utility and descriptions of the technique

En procedimientos quirúrgicos de las regiones supraclaviculares y laterales cervicales, así como en cirugías cardíacas y mediastínicas, la función diafragmática puede comprometerse desde la base del riesgo de lesión del nervio frénico y/o la raíz C4. Son escasas las publicaciones que tratan la estimulación intraoperatoria de estas estructuras nerviosas para evaluar su funcionalidad y, en nuestro conocimiento, hasta ahora no se ha hipotetizado acerca de si es posible reducir las tasas de lesión situadas en hasta el 26% en algunos estudios de cirugía cardíaca. Describimos la técnica empleada para la monitorización neurofisiológica del nervio frénico. Asimismo, se discute su utilidad y ventajas respecto a otras técnicas. Concluimos que con la incorporación creciente de la monitorización neurofisiológica intraoperatoria en los últimos años, es posible su aplicación al nervio frénico en los procedimientos en los que se considere que existe riesgo de lesión del mismo y, con ella, puede ser factible la reducción de las tasas de lesión iatrógena

In surgical procedures of the supraclavicular and lateral cervical regions, as well as in cardiac and mediastinal surgeries, diaphragm function can be compromised by the risk of injury to the phrenic nerve and/or the C4 root. There are few publications that treat the intraoperative stimulation of these nerve structures to evaluate their functionality and, to our knowledge, until now it has not been hypothesized about whether it is possible to reduce the injury rates, which reach 26% in some cardiac surgery studies. We describe the technique used for the neurophysiological monitoring of the phrenic nerve. Also, its usefulness and advantages over other techniques are discussed. We conclude that, with the increasing incorporation in recent years of intraoperative neurophysiological monitoring, its application to the phrenic nerve is possible in procedures with a risk of injury and, thus, the reduction of iatrogenic injury rates may be feasible

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.

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.

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.

Timectomía transesternal ampliada en forma de alas de mariposa / "Butterfly wings" shape maximal trans sternal thymectomy

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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.

Xiphodynia Mimicking Acute Coronary Syndrome.

A 79-year-old man with diabetes and partial gastrectomy visited our hospital due to gradually worsening epigastric pain on exertion. Unstable angina was suspected and coronary angiography was performed, which revealed severe stenosis of the left ascending artery. Despite successful intervention, the pain persisted. A careful physical examination finally revealed the point of tenderness on the xiphoid process, and the patient was diagnosed with xiphodynia. The severe epigastric pain resolved immediately after xiphoidectomy. This case demonstrates that symptoms of xiphodynia may mimic those of various types of disorders, such as angina, and that careful palpation is warranted during routine physical examinations.

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.