A uniport subxiphoid approach with a modified sternum retractor is safe and feasible for anterior mediastinal tumors

BACKGROUND: Minimally invasive surgery has been used to treat anterior mediastinal tumors. This study sought to describe a single team’s experience of uniport subxiphoid mediastinal surgery using a modified sternum retractor. METHODS: Patients who underwent uniport subxiphoid video-assisted thoracoscopic surgery (USVATS) or unilateral video-assisted thoracoscopic surgery (LVATS) from September 2018 to December 2021 were retrospectively enrolled in this study. A 5-cm vertical incision approximately 1-cm caudal to the xiphoid process was usually made followed by the installment of a modified retractor, which was able to raise the sternum by 6–8 cm. Next, the USVATS was performed. In the unilateral group, 3 1-cm incisions were usually made, among which, 2 are made in the 2(nd) or 3(rd) and 5(th) intercostal anterior axillary line, and the 3(rd) was made in the 5(th) intercostal midclavicular line. In some instances, an additional subxiphoid incision was made to remove the large tumors. All the clinical and perioperative data, including the prospectively recorded visual analogue scale (VAS) score, were analyzed. RESULTS: In total, 16 patients who underwent USVATS and 28 patients who underwent LVATS were enrolled in this study. With the exception of tumor size (USVATS 7.9±1.6 cm vs. LVATS 5.1±2.4 cm, P<0.001), the baseline data of the patients in the 2 groups were comparative. Blood loss in surgery, conversion, draining duration, postoperative stay, postoperative complications, pathology and tumor invasion were similar between the 2 groups. Although the operation time was significantly longer in the USVATS group than the LVATS group (115±19 vs. 83±30 min, P<0.001), the VAS score at 1st postoperative day (1.9±1.1 vs. 3.1±1.1, P<0.001) and moderate pain level (a VAS score >3) (6.3% vs. 32.1%, P=0.049) were better in the USVATS group than the LVATS group. CONCLUSIONS: Uniport subxiphoid mediastinal surgery is a feasible and safe procedure, especially for large tumors. Our modified sternum retractor is especially helpful during uniport subxiphoid surgery. Compared to lateral thoracic surgery, this approach has the advantages of less injury and lower postoperative pain, which may lead to a faster recovery. However, its long-term follow-up outcomes need to be observed.