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Page 4 of 5 Abu Akar et al. Mini-invasive Surg 2020;4:10 I http://dx.doi.org/10.20517/2574-1225.2019.65

Figure 4. The subxiphoid wound, one week after surgery

who developed the multiportal VATS technique for pediatrics over the last three decades [1,2,9] . Besides the
cosmetic and early postoperative morbidity concerns, some of the crucial benefits of thoracoscopic surgery
in children (which may not affect the adult patients) are decreasing the risk of musculoskeletal deformity
(asymmetric chest wall, scoliosis, rib fusion, and winged scapula) that may be noted after posterolateral
thoracotomy in younger patients [10-12] . In adult patients, a natural progression and evolving of thoracoscopic
techniques resulted recently in the evolution of uniportal VATS technique [3-6,13] . Mastering the technique
of uniportal VATS in adults requires intensive training to pass the learning curve to be applied safely in
[6]
adults . The subxiphoid approach is a new addition to the uniportal VATS technique. The subxiphoid
area is distinguished from the intercostal by being nerveless, which allows avoiding injury to the intercostal
nerve during operation [14,15] . Besides, the proper angles for the instruments and staplers, which intersect at
a 90° angle with the hilar structures, are more streamlined and comfortable to the operator. However, the
subxiphoid approach is not devoid of challenges; the need to compress the pericardium occasionally during
surgery and the distance of the work area from the incision requires specialized training and experience. In
children, this technique may require additional skills. It could be more challenging to the surgeon for many
reasons, including the difficulty of obtaining isolated lung ventilation due to the lack of a double-lumen
endotracheal tube in young children, in addition to the lack of appropriate instruments with the curved tip
specially designed for uniportal VATS operations. A few reports and studies have recently been published
on the utilization of uniportal VATS for anatomical resections in pediatrics [7,16-18] . However, the literature
does not yet contain a report on subxiphoid uniportal VATS anatomical resection in a pediatric patient. To
our knowledge, this is the first case in which an anatomical resection was performed for a patient of this age
and weight via subxiphoid uniportal VATS approach.

In conclusion, in expert hands, subxiphoid uniportal VATS lobectomy in pediatrics may be safe and may
have benefits to the patient. The surgeon’s experience in this type of surgery in adults is crucial before
starting to apply it to pediatrics. There is a need to design suitable instruments and staplers for this type of
surgery in pediatrics. There is, of course, also a need to run a comparative study with an appropriate cohort
of patients before determining the safety and feasibility of this technique in pediatrics.

DECLARATIONS
Authors’ contributions
Conception and design of the study and performed data analysis and interpretation: Abu Akar F, Shaqqura B
Performed data acquistion, as well provided administrative, technical, and material support: Abu Akar F,
Jiang L, Rumman N