Wojciech Czajkowski

Resection of thymomas with use of the new minimally-invasive technique of extended thymectomy performed through the subxiphoid-right video-thoracoscopic approach with double elevation of the sternum

OBJECTIVES To present the new technique of minimally invasive extended thymectomy performed through the subxiphoid-right video-thoracoscopic (VATS) approach with double elevation of the sternum and the early results of resection of thymomas with the use of this technique. METHODS OPERATIVE TECHNIQUE whole dissection was performed through a 4- to 7-cm transverse subxiphoid incision, and a single 5-mm port was inserted into the right chest cavity for the video thoracoscope and subsequently for the chest tube. 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 was 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 24 patients operated on for the Masaoka Stage I-III thymoma in the period from 1 January 2009 to 30 March 2012. There was no mortality and complications occurred in 1 patient necessitating revision for bleeding (morbidity rate 4.2%). The median operative time was 105.0 (range 70-195) min. In 2 patients it was possible to completely resect Masaoka Stage III tumour infiltrating the right lung, which was resected with the use of an endostapler. The dimensions of the thymomas ranged from 1.8 × 1.5 × 1.5 to 12 × 9 × 5 cm. CONCLUSIONS In our opinion, the presented technique is probably the least invasive and the most complete technique of VATS thymectomy with excellent cosmetic results and is a valid alternative to sternotomy approach for the Masaoka Stage I-III thymomas.

Technique of the transcervical-subxiphoid-videothoracoscopic maximal thymectomy

Background: The aim of this study is to present the new technique of transcervical-subxiphoid-videothoracoscopic “maximal”thymectomy introduced by the authors of this study for myasthenia gravis. Materials and Methods: Two hundred and sixteen patients with Osserman scores ranging from I–III were operated on from 1/9/2000 to 31/12/2006 for this study. The operation was performed through four incisions: a transverse 5–8 cm incision in the neck, a 4–6 cm subxiphoid incision and two 1 cm incisions for videothoracoscopic (VTS) ports. The cervical part of the procedure was performed with an open technique while the intrathoracic part was performed using a video assisted thoracoscopic surgical (VATS) technique. The whole thymus with the surrounding fatty tissue containing possible ectopic foci of the thymic tissue was removed. Such an operation can be performed by one surgical team (the one team approach) or by two teams working simultaneously (two team approach). The early and late results as well as the incidence and localization of ectopic thymic foci have been presented in this report. Results: There were 216 patients in this study of which 178 were women and 38 were men. The ages of the patients ranged from 11 to 69 years (mean 29.7 years). The duration of myasthenia was 2–180 months (mean 28.3 months). Osserman scores were in the range of I–III. Almost 27% of the patients were taking steroids or immunosuppressive drugs preoperatively. The mean operative time was 201.5 min (120–330 min) for a one-team approach and it was 146 (95–210 min) for a two-team approach (P < 0.05). While there was no postoperative mortality, the postoperative morbidity was 12%. The incidence of ectopic thymic foci was 68.4%. The rates of complete remission after one, two, three, four and five years of follow-up were 26.3, 36.5, 42.9, 46.8 and 50.2%, respectively. Conclusion: Transcervical-subxiphoid-VTS maximal thymectomy is a complete and highly effective treatment modality for myasthenia gravis. The need for sternotomy is avoided while the completeness of the operation is retained.

Current evidence on transcervical mediastinal lymph nodes dissection

In the last decade, we witnessed the development of two new, fascinating techniques of mediastinal exploration: the video-assisted mediastinoscopic lymphadenectomy (VAMLA) and the transcervical extended mediastinal lymphadenectomy (TEMLA). During this time, several articles were published, providing a substantial body of evidence regarding different aspects of these techniques. Based on this evidence, we discuss the operative technique, its applications and results as well as questions to be answered and possible future development. The aim of this review is to provide the readers who have no personal experience with these techniques, with the key information regarding the usefulness, advantages and drawbacks of VAMLA and TEMLA.

Video-assisted thoracic surgery thymectomy: subxiphoid approach

Background: To describe the use of the subxiphoid approach for thymectomy and to present a variant of the technique of minimally invasive extended thymectomy for thymoma or myasthenia gravis (MG) without thymoma done via a sole (uniportal) subxiphoid incision with aid of the sternal lifting. Methods: The infrasternal (subxiphoid) technique was used. The whole specimen containing the thymus surrounded by the right and left mediastinal pleural sheets and the fat of the anterior mediastinum and the lower neck region was resected en bloc through the incision made above the xiphoid process for insertion of a videothoracoscope [video-assisted thoracic surgery (VATS)] and, finally for introduction of chest drains. The sternum was lifted by two hooks attached to the Zakopane bar (B.Braun, Aesculap-Chifa, Nowy Tomysl, Poland). The lower hook was elevating the lower sternal angle and the upper hook was inserted through a puncture made above the sternal notch while the major mediastinal structures were pressed down toward the spine to avoid injury. Results: The entire group of patients in whom the subxiphoid approach was used for thymectomy included 611 patients, overall (80 patients with thymomas, 516 patients with MG without thymoma and 15 patients with repeated thymectomy) operated on from Sep 2000 to Sep 2017. There were 5 uniportal subxiphoid-VATS extended thymectomies (for non-thymomatous MG in 2 patients and for thymic tumors in 2 patients). The mean time of the operation 118.5 min (range, 85–130 min). For the whole group of 611 patients there was no mortality and less than 5% morbidity. The complete remission rate 53.1% for the transcervical-subxiphoid-VATS maximal thymectomy approach for non-thymomatous MG was reported. Conclusions: The subxiphoid uniportal incision with sternal lifting facilitates performance of extended thymectomy for thymomas or MG without thymoma.

Subxiphoid uniportal VATS thymectomy

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.

The Zakopane Pulmonary Hospital experience on subxiphoid thymectomy

BACKGROUND To present the technique of minimally invasive extended thymectomy performed through the subxiphoid-bilateral subcostal video-assisted thoracoscopic surgery (VATS) approach, with double elevation of the sternum for nonthymomatous myasthenia gravis (MG). METHODS The whole dissection was performed through the 4-7 cm transverse subxiphoid incision with single 10 mm extra-long bariatric laparoscopy ports inserted subcostally to the right and left chest cavities for videothoracoscope and subsequently for chest tubes. 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 147 patients (62 patients operated on for thymomas, 75 patients for nonthymomatous MG and 10 for rethymectomies) in the period 1.1.2009-30.3.2016. There was no mortality and morbidity. The mean operative time was 109.1 min (range, 75-150 min). CONCLUSIONS The subxiphoid approach combined with bilateral single port subcostal VATS and double elevation of the sternum enables very extensive thymectomy in case of nonthymomayous MG.

Uniportal transcervical video-assisted thoracoscopic surgery (VATS) approach for pulmonary lobectomy combined with transcervical extended mediastinal lymphadenectomy (TEMLA)

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.