Non-Intubated Subxiphoid Multiport VATS Thymectomy

This is a video of a non-intubated subxiphoid multiport VATS thymectomy. The patient was a 40-year-old man who was an asymptomatic chronic smoker. On incidental evaluation, HRCT thorax was suggestive of anterior mediastinal lesions, which on further MRI thorax was confirmed to be cystic and 1.8 x 0.8c m. Awake ventilation anesthesia without muscle relaxant was given under LMA. Tubeless principles were adopted. The patient was placed in a supine position, keeping legs wide apart with the surgeon standing in the center in between the legs and the first assistant to the left of the operating surgeon. Lidocaine block to the vagus nerve and sprays on the pleural cavity were done for adequate anesthesia.

A 3-port VATS was performed with the camera port first in the subxiphoid region using a 12 mm incision. The remaining subcostal ports were done under guidance of finger dissection. During dissection, internal mammary vessels and phrenic nerve were identified and safeguarded sequentially, first on the right side and then on the left. The thymus was completely dissected off from the pericardium along with the superior horns. Supra-innominate dissection of the thymus was completed, including the superior horns. The thymic vein was identified and cauterized with harmonic. The specimen was removed from the subxiphoid route. The chest tube was removed on-table once no air leak was confirmed on negative suction. Ropivacaine infiltration to the intercostal nerves was done to ensure adequate postoperative analgesia. Postoperative chest X-ray was uneventful and the patient was discharged on day two. Histopathology was confirmed as a bronchogenic cyst.

Reference

Cui F, Liu J, Li S, Yin W, Xin X, Shao W, et al. Tubeless video-assisted thoracoscopic surgery (VATS) under non-intubated, intravenous anesthesia with spontaneous ventilation and no placement of chest tube postoperatively. J Thorac Dis. 2016;8(8):2226‐2232.

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