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Experiences of Single-port VATS thymectomy through the sub-xiphoidal incision without CO2 insufflation
Do Kyun Kang, InHa Kim, Woon Heo, Sung Kwang Lee, Ho-ki Min, Hee Jae Jun, Youn-ho Hwang.
Haeundae Paik Hospital, Busan, Korea, Republic of.

OBJECTIVE: Single-port VATS thymectomy through the sub-xiphoidal incision was introduced by some authors. They reported that CO2 insufflation to the mediastinum was needed for securing the retrosternal space with an air-tight trocar sleeve. It is useful, however sometimes it causes hypotension due to extrinsic compression of the heart and cannot provide the optimal space for the surgery. We present our experiences of single-port VATS thymectomy through the sub-xiphoidal incision using a wire and Kent retractor under the one-lung ventilation without CO2 insufflation.
METHODS: Single-port VATS thymectomy through the sub-xiphoidal incision was attempted in 8 patients in our institute from August 2014 to November 2015. Two patients were converted to sternotomy or bilateral VATS thymectomy because of uncontrollable bleeding due to injury of the internal mammary artery and technical difficulties. Six patients underwent the surgery as planned. Surgical procedure performed in the supine position and under the general anesthesia using a double lumen endotracheal tube. A sub-xiphoidal incision (about 4cm) was made on the xiphoid process. The xiphoid process was resected. After blunt dissection of the retrosternal space, an X-small sized wound retractor was applied. The mediastinal pleura were opened bilaterally and a wire was passed the retrosternal space through the bilateral 4th intercostal space. The wire was lifted up using Kent retractor for securing the retrosternal space. After examining the bilateral phrenic nerves, the thymectomy was performed with an ultrasonic scalpel and 5mm-30degree thoracoscpe under the one-lung ventilation.
RESULTS: We performed the thymectomy in 4 patients with thymoma and extended thymectomy in 2 patients with thymic hyperplasia and myasthenia gravis successfully. The mean operation time was 180 minutes. The mean duration of the chest tube drainage was 3.7 days. The mean duration of the hospital stay was 7.5 days. There was no surgical mortality and complication.
CONCLUSIONS: In our experiences, single-port VATS thymectomy through the sub-xiphoidal incision using a wire and Kent retractor under one-lung ventilation without CO2 insufflation was feasible.To evaluate the feasibility of single port VATS thymectomy through the sub-xiphoidal incision, more experiences would be required.


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