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Risk factors for diaphragmatic injury in subxiphoid video-assisted thoracoscopic surgery

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Abstract

Background

Subxiphoid video-assisted thoracoscopic surgery (VATS) is considered a safe and feasible operation for anterior mediastinal mass resection. However, diaphragmatic injury, presented as tearing or puncturing, may occur during subxiphoid VATS despite of low incidence. This study aims to explore risk factors for diaphragmatic injury in subxiphoid VATS, as well as strategies to reduce occurrence of the injury.

Methods

We retrospectively reviewed clinical records of 44 consecutive adult patients who underwent subxiphoid VATS. These patients were divided into two groups: diaphragmatic injury group and non-injury group. Perioperative outcomes and anatomic features derived from 3D CT reconstructions were compared between the two groups.

Results

Significant differences were observed in operation time (223.25 ± 92.57 vs. 136.28 ± 53.05, P = 0.006), xiphoid length (6.47 ± 0.85 vs. 4.79 ± 1.04, P = 0.001) and length of the xiphoid below the attachment point on the diaphragm (24.86 ± 12.02 vs. 14.61 ± 9.25, P = 0.029). Odds ratio for the length of the xiphoid below the attachment point on the diaphragm was 1.09 (1.001–1.186), P = 0.048 by binary logistic regression analysis.

Conclusions

We identified the length of the xiphoid below the attachment point on the diaphragm as an independent risk factor for diaphragm injury during subxiphoid VATS. Prior to subxiphoid VATS, a 3D chest CT reconstruction is recommended to assess the patients’ anatomic variations within the xiphoid process. For patients with longer xiphoid process, a higher incision at the middle and upper part of the xiphoid process, and partial xiphoid process resection or xiphoidectomy is preferred.

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Acknowledgements

We thank Yaruo Zhang, Clinical Skills Center, Zhujiang Hospital, Southern Medical University, for providing Fig. 5.

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Authors and Affiliations

  1. Department of Thoracic Surgery, Zhujiang Hospital, Southern Medical University, No. 253 Gongye Middle Avenue, Haizhu District, Guangzhou, Guangdong, China

    Maodan Chen, Yang Huang, Juyi Hu, Longfei Jia, Yuanzhou Wu, Jing Feng, Fuwei Zhang, Jian Tong, Qunqing Chen & Hui Li

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  1. Maodan Chen
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Correspondence to Hui Li.

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Maodan Chen, Yang Huang, Juyi Hu, Longfei Jia, Yuanzhou Wu, Jing Feng, Fuwei Zhang, Jian Tong, Qunqing Chen, and Hui Li have no conflicts of interest or financial ties to disclose.

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Chen, M., Huang, Y., Hu, J. et al. Risk factors for diaphragmatic injury in subxiphoid video-assisted thoracoscopic surgery. Surg Endosc 38, 2795–2804 (2024). https://doi.org/10.1007/s00464-024-10789-9

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