Giuseppe Aresu

Subxiphoid single incision thoracoscopic surgery approach for thymectomy: a case report

Thoracic surgery is rapidly evolving with minimally invasive strategies now dominating. Thymectomy has traditionally been performed through a sternotomy, but more recently video-assisted thoracoscopic surgery (VATS) approaches have become increasingly popular. To further minimise surgical impact, the uniportal subxiphoid VATS technique has recently been described, using a muscle sparing incision that avoids intercostal nerve injury. A potential advantage that makes this approach particularly suited to thymectomy includes the ability to access both sides of the chest with a single incision. There is also the potential for reduced post-operative pain and chronic thoracostomy neuralgia. Here we describe the management of a patient with thymoma, reporting our procedure and technique for performing uniportal subxiphoid VATS thymectomy.

Subxiphoid approach for spontaneous bilateral pneumothorax: a case report

The development of video-assisted thoracoscopic surgery (VATS) has contributed to reduced pain and improved recovery following thoracic surgery. However, pain remains a major issue. Patients with bilateral pulmonary pathology requiring operative intervention may have even more pain due to bilateral transthoracic incisions. The recently described uniportal subxiphoid VATS approach provides an opportunity to undertake bilateral thoracic surgery through a single incision that avoids the bilateral intercostal nerve damage caused by transthoracic incision and drainage. Here we report a case of a patient requiring bilateral bullectomy and pleurectomy for the management of pneumothorax that was performed successfully by the subxiphoid VATS approach.

Uniportal subxiphoid video-assisted thoracoscopic approach for thymectomy: a case series

Background Minimally invasive techniques are becoming increasingly popular in thoracic surgery. Although median sternotomy is the traditional approach for thymectomy, video-assisted thoracoscopic surgery (VATS) approaches now predominate. This study reports a case series of the novel uniportal subxiphoid-VATS approach to extended thymectomy. Methods Over the period of study (October 2014-January 2017) 17 patients underwent uniportal subxiphoid-VATS extended thymectomy for a thymic nodule at the Shanghai Pulmonary Centre. Ten patients were female, and the mean age of the cohort was 55 years. The mean size of nodule was 23.6 mm. Results The mean operative duration was 2.5 hours, with one conversion to thoracotomy for bleeding. The mean operative blood loss was 115 mL. The median length of hospital stay was 4 days. There were no episodes of phrenic nerve palsies. The 30-day survival was 100%. Conclusions Uniportal subxiphoid-VATS is a feasible and safe surgical approach to extended thymectomy in selected patients, with good post-operative outcomes.

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.

Subxiphoid pneumonectomy: the new frontier?

Over the last decade there has been a significant drive towards minimally invasive thoracic surgery. The reported benefits of video-assisted thoracic surgery (VATS) over open surgery include reduced postoperative pain, reduced postoperative complications, reduced length of hospital-stay and period of recovery to normal function (1-4). With increased experience, more advanced procedures are now reportedly performed by VATS in high volume centres, including sleeve and carinal resections (5,6).

Long term and disease-free survival following surgical resection of occult N2 lung cancer

Background Despite systematic investigation with computed tomography (CT), positron emission tomography (PET)/CT, CT or magnetic resonance imaging (MRI) brain imaging and supplementary investigation using endobronchial ultrasound guided biopsy (EBUS), endo-oesophageal ultrasound guided biopsy (EUS), fine needle aspiration (FNA), mediastinoscopy or mediastinotomy, there is an approximately 10% rate of occult N2 disease identified at pathological staging. It has been hypothesised that such occult disease, too small or inactive to be identified during pre-operative multi-modality staging, may represent low volume disease that may have equivalent survival to patients with similar stage at clinical, pre-operative assessment. We compared the long-term survival and disease-free survival of patients with the same clinical TNM stage with and without occult N2 disease. Methods We retrospectively analysed a database that prospectively captured information on all patients assessed and treated for lung cancer in our surgical unit. We reviewed data on patients who underwent lung cancer surgery with curative intent between January 2006 and August 2010. Results A total of 312 lung cancer resections were performed [mean age 68 (range, 42-86) years old and male:female ratio 1.14:1]. Occult N2 disease was identified in 28 (8.7%) of 312 patients. There was no difference in the rate of N2 disease for different tumour histological types. Five-year survival with occult N2 disease was 35.8% vs. 62.5% without. Median survival was 34 months with occult N2 disease vs. 84 months without. Conclusions With contemporary staging techniques, so-called occult N2 disease, even with low volume and PET non-avid disease, does not have an indolent course and should still be considered a risk factor for poorer prognosis.