Compared to the intercostal group, the subxiphoid single-port thoracoscopy group exhibited significantly better postoperative catheter placement time (
P = 0.013), total thoracic drainage volume (
P = 0.018), visual analog scale pain scores at 24 and 48 h after the operation (
P < 0.000 and
P < 0.000), and incision pain and numbness at 1 and 3 months after the operation (
P = 0.006 and
P = 0.003). There were no significant differences in operation time, intraoperative blood loss, or postoperative complications between the two groups (all
P > 0.05) (Table
2).
Table 2
Comparison of intraoperative and postoperative data
Operative time (min, x ± s) | 66.972 ± 13.246 | 64.139 ± 15.262 | t = 0.841 | 0.403 |
Intraoperative blood loss (ml, x ± s) | 51.528 ± 17.921 | 49.722 ± 19.159 | t = 0.413 | 0.681 |
Intubation time (d) | 3.0(2.0,4.0) | 3.0(3.0,5.0) | U = 436.500* | 0.013 |
total thoracic drainage(ml, x ± s) | 261.944 ± 69.850 | 308.611 ± 91.843 | t = 2.427 | 0.018 |
complications (n) | 2 | 2 | χ2 = 0.000** | 1.000 |
Arrhythmia | 0 | 2 | | |
Prolonged air leak | 1 | 0 | | |
Incision fat liquefaction | 1 | 0 | | |
Postoperative pain score (VAS scale) |
24 h after surgery | 2.667 ± 0.926 | 4.750 ± 1.628 | t = 6.675 | < 0.000 |
48 h after surgery | 2.917 ± 1.251 | 4.389 ± 1.591 | t = 4.365 | < 0.000 |
Discharge follow-up for pain or numbness in the incision |
1 month after surgery | 2 | 11 | χ2 = 7.604 | 0.006 |
3 month after surgery | 1 | 10 | χ2 = 8.692 | 0.003 |
There were no cases of perioperative mortality, conversion to thoracotomy, or increased surgical incision, and no serious complications (e.g., intrathoracic hemorrhage or pulmonary embolism) after the operation throughout the study population. In the subxiphoid group, one case of postoperative pulmonary air leakage was resolved after intrathoracic injection of erythromycin, and one case of incision fat liquefaction was resolved by intensive incision dressing changes. In the intercostal group, there were two cases of arrhythmia after the operation: atrial fibrillation and atrial premature beat (one case each). All patients were discharged after successful treatment of symptoms.
Traditional intercostal single-port thoracoscopic treatment of pulmonary lesions has the advantage of reduced trauma, rapid recovery, and high patient satisfaction [
1,
2]. However, for thoracoscopic surgery to concurrently remove lesions in both lungs, it remains necessary to enter the thoracic cavity through both sides of the intercostal space for surgery. Regardless of whether both sides are treated using single-port thoracoscopic surgery, two surgical incisions are required; this inevitably causes damage to the intercostal nerves on both sides. In addition, the body position must be changed and the drape must be re-sterilized during the operation, thus increasing both the use of surgical consumables and the corresponding amounts of time and effort. With the development of minimally invasive thoracoscopic techniques, there has been considerable interest in identifying a less invasive surgical approach for the simultaneous resection of bilateral lung lesions [
3‐
5]. Many thoracic surgeons have attempted subxiphoid single-port thoracoscopic lobectomy since it was first reported in 2014 by Liu et al. [
6]. There have been reports of single-port thoracoscopic resection of single-lung lesions, but there have been few reports of simultaneous resection of double-lung lesions; the efficacy and safety of the surgery have remained uncertain.
The subxiphoid approach has multiple advantages in comparison with the bilateral intercostal approach to resection of bilateral lung lesions. First, the subxiphoid approach avoids damage to the bilateral intercostal nerves, thereby avoiding the potential for acute nerve pain in the thoracic incision. In this study, the pain scores in the subxiphoid group at 24 and 48 h after the operation were lower than the corresponding pain scores in the intercostal group (
P < 0.05). The relief of pain in the subxiphoid incision enables patients to more easily cough and expectorate after surgery, promotes lung recruitment, and enhances the drainage of pleural effusion; these benefits can lead to early extraction of the chest catheter. The total drainage volume significantly differed between the subxiphoid and intercostal groups in the present study (
P < 0.05). Second, compared with two chest incisions, one incision under the xiphoid process greatly reduces the occurrence of long-term intractable pain and improves long-term quality of life for patients; consistent with this perspective, we observed significant differences in the incidences of incision pain or numbness at 1 and 3 months after the operation between the two groups (
P < 0.05). Third, with one incision, only one position is required to remove the bilateral lung lesions. Thus, there is no need to reposition the patient during surgery; this shortens the operation and anesthesia times, while reducing the use of medical consumables. However, we observed no significant difference in the operation time between the two groups in this study (
P > 0.05), presumably because of the longer learning curve for subxiphoid single-port thoracoscopic surgery than for traditional intercostal single-port thoracoscopic surgery [
7‐
10].
Because of the learning curve, subxiphoid single-port thoracoscopic surgery is carried out only in larger medical centers. There is considerable distance between the surgical incision in the subxiphoid approach and the lung tissue; thus, the surgical path becomes obliquely long and the surgical field of view changes, leading to necessary operator adaptation [
11,
12]. Because of cardiac pulsation, the operation is difficult in the left lung; operations involving the outer and posterior basal segments of the left lower lung are generally considered to be contraindicated.
However, the learning curve may be shortened by accumulating more cases and continuously reporting experience with the subxiphoid approach. Longer double-joint instruments with a curved head should be used where possible to facilitate the operation [
13]. A sternum retractor should be used to increase the retrosternal space, and an incision protection sleeve should be used to ensure thoracoscopic lens clarity. The lens should be kept at the top of the incision, with 30° oblique illumination of the thoracic cavity from top to bottom, double joint oval forceps and straight cut stapler are used in the operation through the lower end of the incision, which can avoid interference between surgical instruments and the lens [
14,
15].
There are still many limitations in this study. It included few cases and the follow-up time was short, so further research is needed for large samples and long-term follow-up. The selection bias can also affect study results. At the same time, the recurrence was not observed in this study. In the future study, the observation time will be extended, various indicators will be improved.
In summary, suitable patient selection and simultaneous surgical resection of bilateral lung lesions with subxiphoid single-port thoracoscopic surgery can reduce the intubation time, relieve acute and chronic incision pain, and improve the long-term safety and efficacy of the operation. This can improve patient quality of life and overall acceptance by patients.