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. However, the choice of the specific minimally invasive technique of thymectomy is a specific unsolved problem. There are several operative approaches for minimally invasive thymectomy including unilateral video-assisted thoracic surgery (VATS), bilateral VATS, robotic videoassisted techniques (RATS), transcervical thymectomy and subxiphoid thymectomy (7)(8)(9)(10)(11)(12). This last approach was introduced by Kido et al., who performed thymectomy within the mediastinum, without opening of the mediastinal pleura (12). During the last decade the uniportal subxiphoid approach was used successfully. However, with exception of Suda et al. who described their experience in several publications in the other two studies only case reports were presented (13-15). Our team was the second one using the subxiphoid approach but out policy was quite different from the method of Kido et al. We used the technique combining the transcervical and subxiphoid incisions with double elevation of the sternum with use of the Rochard frame and bilateral single VATS ports and performed thymectomy in the maximally extended technique, similar to this described by Jaretzki et al. who use the transcervical-transsternal approach (2,16). Subsequently, we modified our technique by introduction of the subxiphoid-right VATS approach, the subxiphoid-bilateral VATS approach and, finally by the uniportal subxiphoid approach, which will be described in this article (17,18). Keywords Patients selection and work-upAll patients with nonthymomatous MG are the candidates for this kind of procedure. In case of the advanced stage III thymomas the transsternal approach is preferred. In case of nonthymomatous MG the operation is proposed primarily to patients in the MGFA class I-IIIb (mild to moderate ocular, bulbar and extremities muscles affected) (19). In case of severe MG the operation is postponed until the patient's clinical improvement after preoperative preparation with steroids, immunosuppres...
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.
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