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Subxiphoid Uniportal Thoracoscopic Thymectomy Without Carbon Dioxide Insufflation
Min Kyun Kang, Do Kyun Kang, Ji Yong Kim, Inha Kim, Ho-ki Min, Youn-Ho Hwang.
Haeundae Paik Hospital, Busan, Korea, Republic of.

BACKGROUNDS Thymectomy is the most important treatment for anterior mediastinal mass and myasthenia gravis. Until now, different surgical approaches have been described to perform thymectomy, from median sternotomy to robotic thymectomy. But there is no consensus on the best approach of thymectomy. Depending on approach to perform thymectomy, the advantages and disadvantages are different. Currently, the lateral intercostal approach in video-assisted thoracoscopic surgery thymectomy(VATS thymectomy) is the most frequently performed surgical approach for thymectomy. But this approach has difficulty to identify the contralateral phrenic nerve and intercostal nerve impairment. Recently, to overcome shortcomings of VATS thymectomy, subxiphoid sigle-port thymectomy(SPT) was introduced. We have perfomed modified subxiphoid SPT using our own manufacturing sternal retractor without carbon dioxide insufflation under one-lung ventilation. We report the initial operative results of modified subxiphoid SPT . METHODS Subjects of this study were patients who underwent thymectomy or extended thymectomy at Inje University Haeundae Paik Hospital between July 2016 and November 2018. We reviewed the medical records of these patients retrospectively. Indication of thymectomy is anterior mediastinal mass without tumor invasion. In our department, we performed thymectomy for anterior mediastinal mass in the absence of myasthenia gravis . And extended thymectomy, which involves the removal of all adipose tissue involve anterior to the phrenic nerve, was performed for myasthenia gravis. Subxiphoid uniportal thoracoscopic thymectomy was attempted first in July 2016. From this time, thymectomy for anterior mediatinal mass or extended thymectomy for MG were preformed via SPT with sternal retraction. All surgical procedures were performed by a single surgeon. 29 patients who underwent thymectomy or extended thymectomy were enrolled. Information of patient demographics, intraoperative, postoperative data were collected and retrospectively evaluated.
RESULTS The patient's demographics are presented in table 1. The results of operative outcome of subxiphoid SPT are presented in table 2 and table 3.
CONCLUSIONS The benefit of subxipohid approach with sternal retraction is that it makes it easier to identify the contra-lateral phrenic nerve. Also, our procedure has 3 advantages when compared with carbon dioxide insufflation subxiphoid single-port thymectomy. First, because we do not insufflate carbon dioxide, there is no need to worry about hypotension. Second, we do not use air tight trocar, so we use more instruments and have more flexibility in them. Finally, sternum retraction provides more optimal space for the surgery. Single-port thymectomy through the subxiphoidal incision using sternal retractor under one-lung ventilation without carbon dioxide insufflation was feasible. LEGEND Table 1. patient's demographics, Table 2. Operative outcomes, Table 3. Pathologic diagnosis

Table 1

	Thymectomy	Extended thymectomy
No. of patients	21	8
Age (years)	55.23±13.04	44.62±16.47
Sex (male/female)	10/11	3/5
BMI	24.72±3.60	24.87±3.57
Mass size(cm)	3.85±1.73	2.13±0.38

Table 2

	Thymectomy	Extended thymectomy
Operative time(min)	143.57±51.96	184.38±43.30
Blood loss in operation(ml)	246.90±262.76	183.75±147.45
Drain after operation(ml)	488.67±308.05	1506.13±1203.80
Duration of chest tube(day)	2.81±1.12	5.00±2.39
HD after operation(day)	6.05±2.87	8.38±2.39
Conversion to other approach	3	0

Table 3

Thymoma	Thymic cyst	Thymic hyperplasia	Other
13	6	5	5

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