Subxiphoid mediastinal lymphadenectomy

Abstract

Video-assisted thoracoscopic surgery (VATS) has experience an exponential growth in lung anatomic resections. Since its beginnings in early 90s with the conventional multiport VATS to the more recent uniportal approach, a continuous search for a less invasive procedure has fueled the development of minimally invasive thoracic surgery. In this sense, subxiphoid uniportal VATS has surge as a uniportal option that avoids damage to the intercostal nerve created in a transthoracic approach. In order for this technique to become as an acceptable choice for lung cancer, oncologic principles must be respected, including a feasible and safe mediastinal lymphadenectomy. Although technically more difficult than other VATS approaches, a complete lymphadenectomy is possible in the hands of expert VATS surgeons through a subxiphoid approach.

Uniportal Subcostal Video-Assisted Thoracoscopic Surgery: A Feasible Approach for a Challenging Middle Lobectomy in an Obese Patient

“…Exclusion criteria for using the uniportal subcostal approach were chest wall tumor involvement, central masses, previous thoracic surgery, adhesion, body mass index BMI>30 kg/m 2 [3, 6, 7], cardiomegaly, cardiac comorbidities due to compression on the heart specially on the left side, and enlarged lymph nodes with confirmed N1 or N2 disease [7].…”

“…It was reported that patients with obesity are not good candidate for subcostal approach [7]; therefore the challenging point also in obese patients is high location of the diagram, because of the abdominal pressure effect; therefore we compromise that, by resection both xiphoid process, mediastinal and pericardial fatty tissue, these steps allow enlarging the space for instruments manipulation.…”

“…(4) Energy devices like Harmonic Scalpel (Ethicon, Inc.) can be used for dissection and maintaining hemostasis at the same time [7].…”

Subxiphoid complex uniportal video-assisted major pulmonary resections

“…The view is caudal-cranial and anterior to posterior, so the access for the view of the posterior mediastinum is difficult, resulting in the need for the lung requiring more traction to assess the lesions in this area. The complete dissection of the subcarinal lymph nodes is more difficult to accomplish than transthoracic approach, especially on the left side (13). When a bleeding is difficult to control by this approach, an extension of the subxiphoid incision is unlikely to be useful so an additional thoracic port must be performed (3-4 cm utility incision).…”

Subxiphoid or subcostal uniportal robotic-assisted surgery: early experimental experience

“…However, the longer distance from the subxiphoid or subcostal incision to the hilum makes this approach more difficult to perform major pulmonary resections. Nevertheless, in expert hands this technique allows the possibility to perform complex resections (6), lymph node dissection (7) and anatomic segmentectomies (8).…”