Background: Video-assisted (VATS) lung lobectomy can be associated with stronger postoperative pain than is commonly believed. It is generally accepted to introduce multimodal analgaesic strategies based on regional blockade, opioids and non-steroidal anti-inflammatory drugs. However, there is still no consensus regarding the optimal regional technique. The aim of this study was to compare the analgaesic efficacy of continuous thoracic epidural block (TEA) and percutaneous continuous paravertebral block (PVB) in patients undergoing video-assisted lung lobectomy. Methods: Fifty-one patients undergoing VATS lobectomy were enrolled in the present prospective, randomised clinical trial. The same analgaesic regimen in both groups included continuous infusion of 0.25% bupivacaine with epinephrine, intravenous ketoprofen and paracetamol. The doses of local anaesthetics were determined to achieve the spread of at least 4 segments in both groups. Postoperative static and dynamic visual analogue pain scores, as well as patient-controlled morphine usage, were used to compare the efficacy of analgaesia. Side effects and failure rates of both blocks were analysed. Results: Static and dynamic pain scores at 24 postoperative hours were significantly lower in the paravertebral group, as were the static pain score at 36 and 48 postoperative hours (P < 0.05). No difference between the treatment groups was identified regarding postoperative morphine usage. The failure rate was higher in the epidural group than in the paravertebral group. No complications were noted in either group, but side effects (urinary retention, hypotension) were more frequent in the epidural group (P < 0.05). Conclusions: Postoperative pain following VATS lung resection procedures is significant and requires the application of complex analgaesic techniques. Percutaneous paravertebral block is equally effective as thoracic epidural block in providing analgaesia in patients undergoing VATS lobectomy. Paravertebral block has a better safety profile than thoracic epidural block.

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...

The presence of OM in the mediastinal LNs was associated with decreased total and disease-free survival rates in stages I and II NSCLC patients. Immunohistochemical staining of mediastinal LNs obtained preoperatively improved the accuracy of staging and allowed for the identification of patients with a poorer prognosis.

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Background: Video-assisted thoracoscopic surgery (VATS) lobectomy has become an accepted method for the treatment of early-stage non-small-cell lung cancer (NSCLC). The standard VATS approach is an intercostal one which is often followed by postoperative pain due to injury of the intercostal nerve. The non-intercostal techniques of VATS include the subxiphoid, transcervical, transdiaphragmatic and transoral procedures. Methods: The technical difficulty of operative management of the anatomical structures during VATS anatomical resection are compared for the intercostal, subxiphoid and transcervical approaches. Results: Some operative steps have different range of difficulty, which are analyzed in detail. Conclusions: The clearest advantages of the non-intercostal approaches include less postoperative pain and superradial bilateral mediastinal lymphadenectomy in case of the transcervical approach. However, the non-intercostal approaches are more technically demanding procedures, which therapeutic role has to be clarified in the future.

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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