P06: A new surgical method for anterior mediastinum tumors: a 3-hole approach

Thoracic Surgery, Fourth Military Medical University, Xi’an 710032, China

Background: This study was to introduce a new surgical method for resecting anterior mediastinum tumors through a subxiphoid incision, which accurately combines the advantages of both video-assisted thoracic surgery and standard sternotomy for a minimally-invasive procedure with fewer complications.

Methods: From January to August 2014, 58 patients underwent surgery using this new method, 34 of whom had myasthenia gravis and had an extended thymectomy. The following surgical procedures were used: (I) with the patient in a supine position and legs apart at 45°–60°, a 2.0-cm incision was made below the xiphoid process to be used as the observation hole. Two 0.5-cm surgery holes were made along the bilateral rib arch at the midclavicular line, and two trocars were inserted into these holes using B-ultrasound guidance. Carbon dioxide (CO₂) was pumped into the anterior mediastinum, the pressure was maintained at 8.0 mmH₂O, and an ultrasound scalpel and a grasping forceps were inserted through the two surgery holes; (II) the retrosternal space, including the bilateral lower poles of thymus, internal mammary arteries, and phrenic nerves, were exposed using both blunt and sharp dissection. The thymus and its surrounding fat tissue were separated and the thymic veins were severed using an ultrasound scalpel; (III) for myasthenia gravis patients, the bilateral mediastinal pleurae and the affected adipose tissues (around the lower pole of thyroid, left innominate vein, aortic window, sulci venae cavae cranial is of the ascending aorta and bilateral phrenic nerves, and so on) were completely removed. During the entire procedure, the innominate vein, bilateral phrenic nerves, vagus nerves, and left recurrent laryngeal nerve were protected from injury; (IV) at the end of the surgery, the lungs were dilated to exhaust the CO₂ and a latex tube was inserted through the observation hole to draw off all gas in the mediastinum. Drainage was not necessary.

Results: The mean bleeding volume was 20 mL, the mean surgery time was 90 min, and the average postoperative hospital stay was 2 d. There were two cases (3.45% of the total) of sternotomy that were necessary because the affected sites could not be freed from the left innominate vein. No massive hemorrhage occurred in any of the cases. The postoperative mortality rate was 0, and no recurrence was observed in follow-up.

Conclusions: This new 3-hole surgical method combines the effectiveness and safety of a standard sternotomy with the minimal invasion and quick recovery of thoracoscopy. It can also thoroughly remove the affected sites using accurate and controllable steps with less postoperative pain, fewer complications, less economic burden, shorter postoperative hospital stay.

Keywords: Anterior mediastinum tumors; new surgical method; 3-hole approach