Surgical technique for subxiphoid-subcostal bilateral thoracoscopic thymectomy: how we do it

Minimally invasive thymectomy has comparable outcomes to open thymectomy for myasthenia and non-myasthenia related indications. There is no consensus however, on the best minimally invasive approach to thymectomy. Several variations of transthoracic and subxiphoid techniques have been reported in literature with the transthoracic approach still the most commonly used. The subxiphoid approach has been validated as a safe and feasible alternative to the more traditional transthoracic thoracoscopic approach and avoids the postoperative complication of intercostal neuropathy, negates the need for lung isolation, and allows visualization of the entire course of both phrenic nerves. We describe here, our adaptation of the subxiphoid approach to thymectomy which includes subxiphoid and subcostal ports for better access and visualization. We detail the technical aspects and also discuss our experience and patient outcomes with our subxiphoid-subcostal approach to thymectomy, including our ability to maximize the extent of thymectomy with this approach. We discuss our preoperative evaluation and anesthetic management for these operations. We include a step-by-step approach to the surgical technique starting from positioning to closure. We also discuss our perspective of the utility of the subcostal ports and camera hopping. We detail the pearls and pitfalls of this approach with an intention of making the approach more reproducible for the reader.