Feasibility and Advantages of a Modified Subxiphoidal Video-Assisted Thoracoscopy Procedure Compared to Established Traditional Video-Assisted Thoracoscopy Procedures in Intercostal Access

Abstract

Background: Minimally invasive thoracic surgical techniques are under continual development, especially the subxiphoidal approach, which until recently could only be done in a few centers across the world, due mainly to the many challenges associated with this method. There are ongoing discussions around minimally invasive methods including the instrument sizes and types, the incision position and expected outcomes. Robotic surgery using the subxiphoidal approach is still under discussion and is expected to be one of the methods of the future. In this study we aim to demonstrate the advantages of our subxiphoidal technique using a modified incision position and size, combined with a separate 5-10 mm camera incision in the 6-7 midaxillary line. Methods: This is a retrospective review of our clinical data obtained from modified subxiphoid procedures performed between July 2018 and March 2020. In total, 50 cases (30 Female, and 20 Male) were identified in which our modified subxiphoid video-assisted thoracoscopic surgery (VATS) was applied including cases of lobectomy, segmentectomy, wedge resection, hemothorax, chylothorax, and biopsies from mediastinal tumors and lymph nodes. Institutional Review Board (IRB) and ethics commission approval of our study have been given by the University of Erlangen and patient consent gained. Results: 50 modified subxiphoid VATS procedures were performed between July 2018 March 2020, including lobectomy, segmentectomy such as apical tri-segmentectomy of the left upper lobe, the basal segmentectomy of both sides, wedge resection, hemothorax, chylothorax, and biopsies from mediastinal tumors and lymph nodes. There were no mortalities, no complications of postoperative bleeding, one case of surgical chylothorax, and three cases of parenchymal air leakage which were treated with pleurodesis, and postoperative arrhythmia. Conclusions: The modified subxiphoid incision, combined with a separate camera incision showed many advantages for the patients, such as a smaller subxiphoid incision even for lobectomy (3.5 cm), less pain, more space in which to apply the instruments in situ, accurate view of the posterior mediastinum for the completion of subcarinal lymph node dissection and the dissection of adhesions. No pain was reported by patients at the position of the camera incision, no abdominal muscle layer weakness or herniation, shorter recovery and stay in hospital and no wound disorders.