Innovations and technologies in thoracic surgery

Video-assisted thoracoscopy for lung cancer: who is the future of thoracic surgery?

As the computer processing technique and display technology evolved dramatically, the surgical approach to early-stage non-small cell lung cancer (NSCLC) has made a rapid progress within the past few years. Currently, the gold standard for NSCLC is lobectomy. After the introduction of video-assisted thoracoscopic surgery (VATS), lung resection can now be conducted mini-invasively, enabling better prognosis for patients and better operation condition for surgeons. At the very beginning, the conventional two-dimensional (2D) system enabled operators to have a closer, magnified and illuminated view inside the body cavity than open thoracotomy. With the introduction of the glasses-assisted three-dimensional (3D) and glasses-free 3D display system, multiple viewing angles were further enhanced, thus a more stable, easier to master and less invasive video-assisted thoracoscopic surgery (VATS) appeared. However, given that the standard VATS is associated with limited maneuverability and stereoscopy, it restricts the availability in more advanced cases. Hopefully, most of the limitations of standard VATS can be overcome with the robotic-assisted thoracic surgery (RATS). The RATS system consists of a remote console and a robotic unit with 3 or 4 arms that can duplicate surgeons’ movements. Also, it provides a magnified, 3D and high definition (HD) operation field to surgeons, allowing them to perform more complicated procedures. Apart from these, some new technologies are also invented in combination with the existing surgery system to solve difficult problems. It is hoped that the higher costs of innovative surgical technique can be offset by the better patient outcomes and improved benefits in cost-effectiveness.

The comparison of electromagnetic with virtual bronchoscopic navigation accuracy at hybrid operating room in patient with sternal wires

We describe a case of a 63-year-old lady with an incidental small right upper lobe ground glass opacity (GGO) lesion, who had history of open-heart surgery with bypass grafts for coronary artery disease. Video-assisted thoracic surgery (VATS) excisional biopsy with pre-operative localization was planned. Localization by percutaneous approach is challenging due to position of GGO shielded by both the scapular and ribs. Electromagnetic navigation accuracy may be affected by steel sternal wires but its effect has not been reported on literature. Both virtual and electromagnetic navigation bronchoscopy platforms were used with real-time cone-beam CT confirmation in the hybrid operating room to perform dye marking. Both navigation methods successfully marked the GGO for lung resection. Our case demonstrated that the accuracy of electromagnetic navigation in the presence of steel sternal wire is satisfactory for dye marking and the use of intra-operative cone-beam CT in hybrid operating room is invaluable for the success of navigational bronchoscopy.

Potential of the glasses-free three-dimensional display system in shortening the learning curve of video-assisted endoscopic surgery: a self-controlled ex-vivo study

Background

One of the largest challenges in endoscopic surgical training is adapting to a two-dimensional (2D) view. The glasses-free three-dimensional (GF-3D) display system was designed to integrate the merits of both 2D and conventional 3D (C-3D) displays, allowing surgeons to perform video-assisted endoscopic surgery under a stereoscopic view without heavy and cumbersome 3D glasses.

Methods

In this study, 15 junior thoracic surgeons were divided to test one routine and one complex task three times each via traditional high-definition 2D (HD-2D) and GF-3D to determine whether there was any advantage when using the GF-3D system to acquire endoscopic skills. The duration, numbers of stitches, and distance between every two stitches were recorded for every procedure.

Results

Seven participants were enrolled in the HD-2D group and eight participants were enrolled in the GF-3D group. All 15 participants successfully completed porcine skin continuous suture and tracheal continuous anastomosis procedures three times each. For skin continuous suture, there was no significant difference between the two groups in terms of the learning curve for speed (P=0.683) and accuracy (P=0.556). For tracheal continuous anastomosis, there was a significant difference between the two groups in terms of the learning curve for speed (P=0.001), but no significant difference was observed between the two groups in terms of the learning curve for accuracy (P=0.211).

Conclusions

In summary, both HD-2D and GF-3D display systems are efficient for routine and complex endoscopic surgery. With the help of GF-3D, surgeons can acquire new complex endoscopic skills faster than HD-2D and be free from burdensome polarized glasses. More comparative studies in a clinical setting are needed to further explore the feasibility, necessity, and economic aspects of the GF-3D display system.

Glasses-free 3D versus 2D video-assisted thoracoscopic thymectomy: a single-center short-term comparative study

Background

Thymectomy is widely used to for the treatment of thymomas, thymic cysts, thymic adenocarcinomas, and other thymic diseases. The development of video-assisted thoracoscopic surgery (VATS) thymectomy by our team offers the advantages of a glasses-free 3D thoracoscopic system for pulmonary surgery. The aim of the present retrospective study was to compare the advantages and short-term outcomes of glasses-free 3D VATS vs. 2D VATS for the treatment of thymic diseases.

Methods

The medical records of patients who underwent traditional 2D and glasses-free 3D video-assisted thoracoscopic thymectomy at the First Affiliated Hospital of Guangzhou Medical University from May 2015 to December 2018 were retrospectively reviewed, while focusing on the collection, evaluation, and comparison of clinical data and perioperative manifestations.

Results

A total of 152 patients were included, of which 71 patients underwent glasses-free 3D VATS and 81 underwent 2D VATS. There were no significant differences in demographic characteristics and baseline variables between the two groups (P>0.05). The overall surgical duration was significantly shorter in the 3D group than the 2D group (105.08±4.08 vs. 119.93±4.81 min, respectively, P=0.022). Further intergroup comparisons revealed that the median estimated intraoperative blood loss volume (10 vs. 20 mL, respectively, P=0.038) was less, postoperative thoracic tube indwelling rate (43/71 vs. 64/81, respectively, P=0.013) was lower, and the median duration of postoperative hospitalization (3 vs. 4 days, respectively, P=0.034) was shorter in the 3D group than the 2D group. Although no patient had died, complications occurred in 5 (7.0%) patients in the 3D group and 9 (11.1%) in the 2D group (P=0.387).

Conclusions

As compared with traditional 2D thoracoscopy, glasses-free 3D VATS thymectomy is both safe and effective, and can shorten the surgical duration, reduce blood loss, decrease the indwelling rate of thoracic tube, and shorten the postoperative length of hospitalization.

Precise anesthesia in thoracoscopic operations

Purpose of review

The current review focuses on precise anesthesia for video-assisted thoracoscopic surgery (VATS) with the goal of enhanced recovery.

Recent findings

VATS has become an established and widely used minimally invasive approach with broad implementation on a variety of thoracic operations. In the current environment of enhanced recovery protocols and cost containment, minimally invasive VATS operations suggest adoption of individualized tailored, precise anesthesia. In addition to a perfect lung collapse for surgical interventions with adequate oxygenation during one lung ventilation, anesthesia goals include a rapid, complete recovery with adequate postoperative analgesia leading to early discharge and minimized costs related to postoperative inpatient services. The components and decisions related to precise anesthesia are reviewed and discussed including: letting patients remain awake versus general anesthesia, whether the patient should be intubated or not, operating with or without muscle relaxation, whether to use different separation devises, operating with different local and regional blocks and monitors.

Conclusion

The determining factors in designing a precise anesthesic for VATS operations involve consensus on patients’ tolerance of the associated side effects, the best practice or techniques for surgery and anesthesia, the required postoperative support, and the care team's experience.

Catheter-based alternative treatment for early-stage lung cancer with a high-risk for morbidity

The mainstream treatment modality for early stage non-small cell lung cancer (NSCLC) is surgery; however, many patients are deemed inoperable and warrant alternative therapeutic options. Several minimally invasive catheter-based therapies are emerging as viable alternatives. In this review, we evaluate the outcomes from radiofrequency ablation (RFA), microwave ablation (MWA), cryoablation (CRA) and photodynamic therapy (PDT) for early-stage lung cancer. Novel technical developments have allowed for endobronchial thermal ablation to be conducted in a hybrid theatre setting, which may optimize treatment outcomes and minimise treatment-related complications.

Innovative surgical endoscopes in video-assisted thoracic surgery

In the past three decades, rod lens endoscopes had facilitated the development and wide spread applications of video-assisted thoracic surgery (VATS). With the rise of uniportal VATS in recent years, innovations in surgical instruments should once again complement the advancement in surgical technique. While articulated flexible endoscopes have expand the field of view, and can alter viewing direction with minimal maneuvers, they still suffer from problems like trocar crowding and interference with other instruments. Magnetic anchored endoscopes, on the other hand, may provide unique benefits to VATS by replacing the endoscope rigid rod body with magnetic linkage, thus overcoming the challenge of port crowding in single incision surgery. Most magnetic anchored endoscopes reported in literature are not designed for thoracic surgeries. Many of these designs do not allow tilting of endoscopic view, rely on micromotors for actuation, or are ergonomically unfit to be operated within the spatial constraints seen in VATS application. Considering these limitations, we have designed two novel magnetic anchored and steered endoscopes targeted for uniportal VATS. Both designs could be wirelessly actuated by magnetic interaction. One has a silicone rubber formed soft body for compactness, lightweight and safety, while another is a 40 mm long capsule optimized for VATS spatial constraints.

Multi-dimensional printing in thoracic surgery: current and future applications

Three-dimensional (3D) printing has been gaining much attention in the medical field in recent years. At present, 3D printing most commonly contributes in pre-operative surgical planning of complicated surgery. It is also utilized for producing personalized prosthesis, well demonstrated by the customized rib cage, vertebral body models and customized airway splints. With on-going research and development, it will likely play an increasingly important role across the surgical fields. This article reviews current application of 3D printing in thoracic surgery and also provides a brief overview on the extended and updated use of 3D printing in bioprinting and 4D printing.