Subxiphoid tyhmectomy under CO2 insufflation

This post describes our technique for subxiphoid uniportal thymectomy under CO2 insufflation using a sterile glove to create an extra external space.

The patient is placed in supine decubitus with abducted legs in order to let the main surgeon and the assistant stand in front of the incision, but the possibility to move to both sides.

General anesthesia, single-lumen tracheal tube and mechanical ventilation

were employed. A 3 cm transverse incision is made 1-2 cm below the lower edge of xiphoid.

Blunt dissection is performed in the reverse side of the sternum without removing the xiphoid process. A soft retractor is placed in the incision, and a sterile glove attached to this in order to keep CO2 insufflation, as it’s conventionally used for most thoracoscopic thymectomies

At the beginning, a 11 mm trocar is placed in the glove´s thumb for the thoracoscope, another 11 mm trocar in the 4th finger, and a 5 mm port is placed in the 2nd finger for the rest of instrumental. With two 11 mm trocarse we can use both ports for the thoracoscope, and switch the vision between both of them depending on the step of the surgery. This detail makes possible to exchange surgeon and assistant position to decrease the instruments crashing during the procedure through the uniportal incision.

We secure the ports to the glove by using silk sutures. The sterile glove attached to the wound retractors allows us to place the ports outside the patient incision (ports remain in the insufflated glove) decreasing the continuous crashing between ports within the uniportal incision and increasing the working angles of the surgical tools. Under CO2 insufflation with median positive pressure between 8-11 mmHg, a comfortable surgical space is achieved.

Initially, dissection of retrosternal space is executed preserving bilateral mammary vessels, and then we perform the opening of mediastinal right pleura near sternal surface. When the right phrenic nerve is visualized, we continue opening that right mediastinal pleura until the junction between left innominate vein and superior cava vein. Once the right side is completely exposed, the opening of left mediastinal pleura is equally performed, we visualize left phrenic nerve and open that mediastinal pleura until the most apical portion of left hemithorax. In that moment, the dissection of thymus and mediastinal fat over the pericardium can be performed, and afterwards dissection from the big vessels (superior vena cava, ascending aorta) until reaching the left innominate vein. Small thymic veins are carefully dissected and sectioned with bipolar energy, and both superior thymic horns are dissected without incidences.

The specimen can be removed by an endoscopic retrieval bag. We leave one thoracic drainage in each pleural cavity through the uniportal incision.

Video 1 shows the main steps of the procedure.