Subxiphoid approach, a new prospective to see the minimally invasive thoracic surgery

In 1995 the treatment guidelines of the American Society of Clinical Oncology considered an improvement in Quality Of Life to be a necessary objective in justifying the recommendation of a new therapeutic strategy for patients with cancer.

In this view the development of the minimally invasive thoracic surgery had the purpose to achieve the same oncological results in a less traumatic way leading to an improvement of several post operatory quality of life determinants.

From the first thoracoscopic procedures introduced in the first years of the 20^th century, we have assisted a constant evolution of techniques and technologies but the real revolution started in the early 90’s when the first VATS major anatomic lung resection was performed by Roviaro.

From that point a new way has opened and, after a slow diffusion plenty of difficulties and detractors, in the last fifteen years the VATS techniques have spread worldwide.

Many studies have shown the minimally invasive approach benefits and in the last years even the official guidelines have recommended it the preferred option even in the case of lung cancer resection.

In parallel with the increased experience in this field an important number of variations have come to light especially regarding the number, the position and the size of the ports. Needlescopic, biportal and uniportal VATS have been introduced with the aim to reduce the invasiveness and the traumatic injury of the intercostal bundles and therefore to improve the outcome. However, analyzing the results, we can recognize that we have room to improve as patients undergoing VATS still complain of some acute and chronic postoperative pain.

In this context the promise land of an almost painless incision has been the new aim of a group of pioneer minimally invasive thoracic surgeons that have proposed to reach the chest cavity and operate into it without passing through the rib cage giving birth to the subxiphoid video-assisted thoracic surgery.

The subxiphoid approach has been proposed as a less invasive alternative for minor and major procedures such as lung lobectomies and segmentectomies thymectomies and bilateral lung resections.

This special issue provides a summary of different procedures carried out using the subxiphoid approach. Furthermore we have given space to hot topics in this field like lymphadenectomy, bilateral procedures and learning curve.

Some of the best world experts in this technique have been involved in this Journal of Visualized Surgery (JOVS) edition, I hope that their experience and their futuristic vision will help to spread subxiphoid VATS all over the thoracic surgery community making our work less invasive and less painful for our patients.

Giuseppe Aresu