International Society For Minimally Invasive Cardiothoracic Surgery

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Subxiphoid Non-intubated Uniportal Vats Right Lower Lobectomy
Haisam Saad, Giuseppe Aresu, Kunal Bhakhri, Mohamed Mohamed Moneer Elsaegh, Chinmay Patvardhan, Andrew Roscoe, Adam Peryt, Aman Coonar.
Royal Papworth Hospital NHS Foundation Trust, Cambridge, United Kingdom.

OBJECTIVE: Minimally invasive thoracic surgery has witnessed a tremendous evolution over the last 2 decades. VATS gained a lot of interest among thoracic surgeons with potential benefits and advantages over conventional thoracotomy approach. Subxiphoid VATS presented itself as an alternative due to the lack of intercostal nerve in the subxiphoid area which can prevent the chronic chest wound pain. Combining the least invasive VATS approach with least invasive anesthesia, we demonstrate subxiphoid uniportal VATS lobectomy in a non-intubated patient.
METHODS: We present a case of a 74-year-old male with CT chest finding of 14 mm right lower lobe nodule with positive uptake in PET scan. Anaesthesia was induced and size 5 laryngeal mask airway (LMA Classic ) was inserted with the patient breathing spontaneously on a circle circuit. Single shot bilateral subcostal TAP blocks were given each side. A single shot right paravertebral block was inserted at level T5/6. A 3 cm subxiphoid incision was made in the midline and a retrosternal tunnel was created into right hemithorax. Dissection of the pleural and diaphragmatic adhesions was conducted followed by dissection of inferior pulmonary ligament. A wedge resection of the nodule revealed the presence of squamous cell carcinoma. Right lower lobectomy with commenced with dissection and resection of inferior pulmonary vein followed by dissection of the anterior part of the fissure and resection of right lower lobe arteries. Dissection of right lower lobe bronchus followed, with resection and completion of the posterior part of the fissure and lymphadenectomy.
RESULTS: Patient was taken to the ward from recovery 2 and half hours after leaving theatre, achieved independent mobility with return to baseline within the first 24 hours following surgery and was discharged home within the first 48 hours following surgery.
CONCLUSIONS: Based on our experience and according to the limited literature, This is the first reported non-intubated subxiphoid uniportal VATS lobectomy procedure which has proven to a safe procedure and technically feasible. It combines the advantages of subxiphoid approach which is less invasive than conventional or uniportal VATS and the less invasive non-intubated anesthesia.

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