title: Subxiphoid and subcostal arch thoracoscopic extended thymectomy: a safe and feasible minimally invasive procedure for selective stage III thymomas.
abstract: BACKGROUND
  Video-assisted thoracoscopic surgery (VATS) has been applied to resection of small and well-encapsulated thymomas. However, few data are available regarding to the application of VATS in stage III thymomas.
  
  
  METHODS
  A novel subxiphoid and subcostal arch approach for thoracoscopic extended thymectomy was developed by us. From January 2014 to August 2015, 14 patients with stage III thymoma were treated by using this new technique in the Department of Thoracic Surgery, Tangdu hospital, Xi'an, China. These patients were retrospectively reviewed and analyzed.
  
  
  RESULTS
  Among the 14 patients, 1 patient was converted to transsternal approach owning to invasion of the superior vena cava. The other 13 patients with thymomas invading the pericardium, lung tissues and left innominate vein (LIV), were successfully operated on by using this new technique. The average operation time was 120.0±32.7 min (80-170 min), the average volume of estimated blood loss was 51.5±44.8 min (10-150 mL) and the average postoperative hospital stay was 4.8±1.5 days (3-9 days). There was no perioperative death. Two patients suffered postoperative complications including one patient with atrial fibrillation (AF) and the other one with myasthenic crisis (MC). The postoperative pain score decreased dramatically from 3.8±1.0 [3-6] at 24 hours to 1.5±0.9 [0-6] at 48 hours, and finally to 0 at 3 months after surgery (P=0.000). The patients reported a higher cosmetic score of 92.6±2.7 [90-96]. There was no tumor recurrence and the five patients with myasthenia gravis had improvement and did not need any medication until follow-up.
  
  
  CONCLUSIONS
  Based on our limited experience, the subxiphoid and subcostal arch thoracoscopic extended thymectomy is safe and feasible for selective stage III thymoma, and might reduce the postoperative pain and provide satisfied cosmetic effect.
authors.affiliation: Department of Thoracic Surgery, Tangdu Hospital, the Fourth Military Medical University, Xi'an 710038, China.
authors.forename: Jinbo
authors.initials: J
authors.lastname: Zhao
authors.affiliation: Department of Thoracic Surgery, Tangdu Hospital, the Fourth Military Medical University, Xi'an 710038, China.
authors.forename: Juzheng
authors.initials: J
authors.lastname: Wang
authors.affiliation: Department of Thoracic Surgery, Tangdu Hospital, the Fourth Military Medical University, Xi'an 710038, China.
authors.forename: Zhengwei
authors.initials: Z
authors.lastname: Zhao
authors.affiliation: Department of Thoracic Surgery, Tangdu Hospital, the Fourth Military Medical University, Xi'an 710038, China.
authors.forename: Yong
authors.initials: Y
authors.lastname: Han
authors.affiliation: Department of Thoracic Surgery, Tangdu Hospital, the Fourth Military Medical University, Xi'an 710038, China.
authors.forename: Lijun
authors.initials: L
authors.lastname: Huang
authors.affiliation: Department of Thoracic Surgery, Tangdu Hospital, the Fourth Military Medical University, Xi'an 710038, China.
authors.forename: Xiaofei
authors.initials: X
authors.lastname: Li
authors.affiliation: Department of Thoracic Surgery, Tangdu Hospital, the Fourth Military Medical University, Xi'an 710038, China.
authors.forename: Qiang
authors.initials: Q
authors.lastname: Lu
authors.affiliation: Department of Thoracic Surgery, Tangdu Hospital, the Fourth Military Medical University, Xi'an 710038, China.
authors.forename: Yongan
authors.initials: Y
authors.lastname: Zhou
keywords: Invasive thymoma; subxiphoid approach; thymectomy; video-assisted thoracic surgery (VATS)