Uniportal VATS Lobectomy: Subxiphoid Approach.

INTRODUCTION: Interest in uniportal video-assisted thoracic surgery (VATS) is rapidly growing worldwide because it represents the surgical approach to the lung with the least possible trauma and in recent years the subxiphoid approach has been used in the field of thoracic surgery as it is associated with lesser pain because there is no intercostal nerve damage and it provides excellent cosmetic outcomes. This technique was recently introduced for major pulmonary resections and even bilateral approaches in selected patients.

METHODS: We present a case of a 66 years old male, former smoker (45 unit pack year) who had a thorax CT (computorized tomography) scan for worsening complaints of cough with sputum production. The CT scan revealed a right upper lobe nodule (16x14mm) with ground glass density and fissure retraction. The pulmonary function tests showed mild bronchial and bronchiolar obstruction. It was decided to undergo surgical treatment. The surgical approach was a subxiphoid uniportal lung resection.

RESULTS: The patient was positioned in a left lateral position with 60 degrees of inclination. The surgeon and scrub nurse were located in front of the patient and the assistant in the opposite side. A 3cm midline vertical incision was made below the sterno-costal triangle. The rectus abdominis was divided and the xiphoid process was partially resected. The right pleura was opened by finger dissection. The pericardial fatty tissue was removed and a soft tissue retractor was placed. A 10- mm, 30-degrees video camera and double articulated instruments combined with several specific longer VATS instruments were used through the same subxiphoid incision.It was performed a wedge resection and after the diagnosis of adenocarcinoma in the intraoperative histological examination, the patient underwent a right upper lobectomy and complete mediastinal lymphadenectomy by the same approach.The post-operative period was uneventful, the chest tube was removed in the third postoperative day. The pain control was excellent, with a maximum of pain grade 1 in the Visual Analogue Scale.The patient was discharged in the fourth postoperative day.

CONCLUSION: The subxiphoid approach is a variant of uniportal VATS approach without opening the intercostal space with its striking advantages in terms of pain control and cosmetics in selected patients. However, this technique has yet some limitations such as the control of major bleeding and the performance of a complete oncologic lymph node dissection related to its surgical complexity expected in emerging techniques. Further studies are necessary to certify the feasibility, safety and benefits of this approach.