Thymoma Resection Using Subxiphoid Uniportal Approach

There are different types of anterior mediastinal tumors, such as thymoma, germ cell tumors, ectopic parathyroid tumors, and lymphoid tumors. Completeness of tumor resection has been considered the most important determinant of long-term survival, therefore surgical resection of these tumors should be both safe and radical. Subxiphoid access is a novel approach for anterior mediastinal tumor resection. To perform surgery via this access, specially designed long instruments are required. Subxiphoid access provides excellent visualization of the mediastinum. There are reports of prolonged port-site pain and chest wall numbness with single or multiple video-assisted thoracoscopic surgery (VATS), and hence subxiphoid is proposed as an alternative access to deal with this.The subxiphoid approach is technically more demanding than VATS due to the longer subcutaneous tunnel, smaller operative angle, and more instrument interference. The presumed advantages are more mediastinal multiangle surgical exposure on both sides, less tissue trauma, swift recovery, minor wound infection, reduced operative time and blood loss, lower pain scores due to avoidance of damage to the intercostal nerves, and reduced length of hospital stay. As the subxiphoid incision is away from the breast, it is cosmetically more acceptable. Subxiphoid incision is a “true” thoracic wound, ie, the surgical wound is below the sternocostal triangle and above the diaphragm, therefore herniation of the viscera through the incision is rare.Disadvantages of this approach:In case of accidental bleeding during surgery, an emergency conversion to open the chest through sternotomy would be necessary. Also, the anterior mediastinal space is narrow, especially in obese patients, so the instruments may interfere with and crowd each other.Patient Selection and Preoperative EvaluationThe patients who are candidates for this kind of surgery:Clinically diagnosed anterior mediastinal tumorNonthymomatous myasthenia gravisThymoma of Masaoka stage 1-3Normal heart and pulmonary function testBody mass index (BMI) 5 cmMasaoka thymoma stage IVEnlargement of lymph nodesPrevious thoracic operationThoracic cage deformityBMI >30CardiomegalyPreoperative evaluation:Blood testPulmonary function testContrast-enhanced chest computed tomography scanStabilization of myasthenia gravis before surgeryOperative StepsDouble lumen ventilation was used. The patient was positioned supine with