Tips and tricks for success in subxiphoid video-assisted thoracic surgery

The subxiphoid approach to video-assisted thoracic surgery (VATS) has been introduced as an alternative to intercostal VATS. There is some evidence that avoiding intercostal incision and instrumentation leads to reduced pain and facilitates early mobilisation and enhanced recovery. Access of the pleural cavities and anterior mediastinal space through a subxiphoid incision presents some challenges, particularly when accessing posterior pulmonary lesions. With increasing experience, a large range of thoracic surgical operations performed through the subxiphoid approach have been reported including anatomical segmentectomies, thymectomies. Another attraction is that bilateral procedures can be performed through a single incision. The experience of several surgeons passing through the learning curve of subxiphoid VATS surgery has resulted in overcoming many of the early challenges faced. In this paper, a series of tips and tricks are presented to enable surgeons considering adopting this technique into their practice to do so safely and with an appreciation of the difficulties that they may face.