Hybrid operating room with ceiling mounted imaging system assisted pre-operative and intra-operative lung nodule localization for thoracoscopic resections: a 5-year case series

BACKGROUND

Video-assisted thoracoscopic (VATS) lung resections are increasingly popular and localization techniques are necessary to aid resection. We describe our experience with hybrid operating room (OR) cone-beam computed tomography (CT) assisted pre-operative and intra-operative lesion localization of lung nodules for VATS wedge resections, including our novel workflow using the hybrid OR cone-beam CT to re-evaluate patients who have undergone pre-operative localization for those who are unsuitable for intra-operative localization.

METHODS

Retrospective analysis of all consecutive patients with small (≤ 20 mm), deep (≥ 10 mm distance from pleura) and/or predominantly ground-glass nodules selected for lesion localization in the Interventional Radiology suite followed by re-evaluation with cone-beam CT in the hybrid OR (pre-operative), or in the hybrid OR alone (intra-operative), prior to intentional VATS wedge performed by a single surgeon at our centre from January 2017 to December 2021.

RESULTS

30 patients with 36 nodules underwent localization. All nodules were successfully resected with a VATS wedge resection, although 10% of localizations had hookwire or coil dislodgement. The median effective radiation dose in the pre-operative group was 10.4 mSV including a median additional radiation exposure of 0.9 mSV in the hybrid OR for reconfirmation of hookwire or coil position prior to surgery (p = 0.87). The median effective radiation dose in the intra-operative group was 3.2 mSV with a higher mean rank than the intra-operative group, suggesting a higher radiation dose (p = 0.01).

CONCLUSIONS

We demonstrate that our multidisciplinary approach utilizing the hybrid OR is safe and effective. Intra-operative localization is associated with lower radiation doses. Routine use of cone-beam CT to confirm the position of the physical marker prior to surgery in the hybrid OR helps mitigate consequences of localization failure with only a modest increase in radiation exposure.

Sub-axillary cosmetic incision versus single-incision thoracoscopic surgery for primary spontaneous pneumothorax

BACKGROUND

In recent years, single-incision thoracoscopic surgery (SITS) has been increasingly applied as an optimal treatment option for primary spontaneous pneumothorax (PSP). However, most SITS techniques are used in the fourth to sixth intercostal space between the anterior axillary and mid axillary lines. To find out more concealed incisions, this study performed PSP surgery via the sub-axillary cosmetic incision (SACI) technique.

METHODS

A total of 128 PSP patients were subjected to video-assisted thoracoscopic surgery (VATS) between January 2017 and January 2019 at our institution. These patients were evaluated and assigned into SACI (n = 21) and SITS (n = 57) groups. Propensity score matching (PSM) was performed based on patients' backgrounds, and the enrolled cohort was divided into 21 pairs. The incision satisfaction was assessed at 2 weeks and 6 months post-surgery.

RESULTS

The 21 pairs with matching baseline characteristics in the two groups did not exhibit significant differences in their backgrounds and surgical results. However, compared with the SITS group, the operation time was longer in the SACI group (p = 0.013). There were no post-operative complications in both groups. At 2 weeks and 6 months, incision satisfaction scores in the SACI group were significantly lower than those in the SITS group (p = 0.022 and p = 0.039, respectively). There were no recurrences of ipsilateral pneumothorax in both groups.

CONCLUSIONS

SACI is a safe and feasible surgical method for PSP treatment. In addition, incision concealment can be used for patients with incision needs.

Three-dimensional CT angiography facilitates uniportal thoracoscopic anatomic lung resection for pulmonary sequestration: a retrospective cohort study

Background

Pulmonary sequestration (PS) is a rare lesion with independent blood supply from an anomalous systemic artery. A timely resection is considered as the best treatment for PS. Three-dimensional computed tomography angiography (3D-CTA) has been widely utilized for precise thoracic surgery. This study aimed to investigate the role of preoperative 3D-CTA and resection simulation in uniportal video-assisted thoracoscopic surgery (VATS) anatomical lung surgery for PS.

Methods

The data of 20 consecutive PS patents undergoing anatomic lung resection between April 2011 and May 2021 in a single centre were retrospectively reviewed. These patients were divided into the 3D-CTA group (10 patients) and the control group (10 patients) according to the initial surgical planning with or without 3D-CTA. The perioperative parameters regarding safety and fluency such as the incidence of conversion to open thoracotomy, operation time, blood loss, complications and chest tube duration were analyzed.

Results

This cohort included 12 female and 8 male patients, with a mean age of 45 years old (range 24–60 years). Nine cases demonstrated recurrent febrile, cough, or hemoptysis; whereas the other 11 patients were asymptomatic on admission. Eighteen (90.0%) intralobar and 2 extralobar PS were confirmed, whereas 18 (90.0%) lesions were located in the left thorax. The feeding vessels originated from the thoracic aorta in 16 patients (80.0%), the abdominal aorta in 3 (15.0%), and the inferior phrenic artery in 1 patient (5.0%). There was no major bleeding or 30 days mortality. The initial surgical planning included 9 uniportal and 1 two-port VATS in the 3D-CTA group, as compared with 10 two-port VATS in the control group. Thirteen lobectomies, 5 segmentectomies and 2 mass excisions were performed. However, no conversion was needed in the 3D-CTA group; whereas 6 (60.0%) conversions (4 to multiple-port and 2 to thoracotomy) occurred in the control group, indicating a significant difference (P = 0.003). In addition, the operation time in the 3D-CTA group was significantly shorter than those in the control group [(108.5 ± 24.9) min vs. (154.5 ± 39.4) min, P = 0.006]. The other surgery-related outcomes were similar between the two groups.

Conclusion

Preoperative 3D-CTA facilitates the safe and fluent performance of uniportal VATS anatomical lung resection for PS with shortened operation time and lessened surgical conversions.

Uniportal video-assisted thoracic surgery for major lung resection is associated with less immunochemokine disturbances than multiportal approach

Multiportal video-assisted thoracic surgery (VATS) for major lung resection causes less immunochemokine production compared to thoracotomy. Whether uniportal VATS is similarly associated with lower early postoperative circulating levels of immunochemokines compared to multiportal VATS have not been studied. Selected patients who received uniportal or multiportal VATS major lung resection were recruited. Blood samples were collected preoperatively and on postoperative days 1 and 3 for enzyme linked immunosorbent assay of serum levels of Tissue Inhibitor of Metalloproteinase (TIMP)-1, Insulin Growth Factor Binding Protein (IGFBP)-3, and Matrix Metalloproteinase (MMP)-9. A linear mixed-effects models were used to analyze the effects of uniportal VATS on the postoperative circulating chemokine levels. From March 2014 to April 2017, 68 consecutive patients consented for the prospective study and received major lung resection by either uniportal VATS (N = 29) or multiportal VATS (N = 39) were identified. Uniportal VATS major lung resection was associated with lower post-operative levels of TIMP-1 and MMP-9 compared to multiportal VATS after controlling for the effects of the corresponding baseline level and the time of follow-up measurement. No difference was observed for the level of IGFBP-3. Less immunochemokine disturbances was observed after uniportal VATS major lung resection compared to multiportal VATS.

Nonintubated Uniportal Video-Assisted Thoracoscopic Surgery for Intrathoracic Diseases: Initial Results in Vietnam

OBJECTIVE

Nonintubated uniportal video-assisted thoracoscopic surgery (VATS) is a recent controversial procedure in many countries. Hence, the authors would like to present the experience in performing this approach and evaluate its initial results in the treatment, particularly, of intrathoracic diseases in Vietnam.

METHODS

A prospective, descriptive study was conducted on 17 patients with intrathoracic diseases treated with nonintubated uniportal VATS from February to July 2019. Preoperative, intraoperative, and postoperative parameters were gathered and analyzed by SPSS Statistics, Version 18.0.

RESULTS

Patients had an average age of 49.2 ± 20.5 (range 6 to 71) years. Regarding operative indications and methods, there were 3 ground glass opacity (17.6%) and 1 bullous lung disease receiving wedge resection (5.9%); 8 mediastinal tumors (47.1%) having resection, and 5 non-small-cell lung cancers receiving lobectomy combined with node dissection (29.4%). The average operative time and pleural drainage time were 108.6 ± 28.17 min (range 60 to 160) and 3.7 ± 1.18 days (range 2 to 8), respectively. The average hospitalization time was 4.9 ± 1.76 (range 3 to 12) days. No mortalities or major complications were recorded postoperatively.

CONCLUSIONS

Nonintubated uniportal VATS is a safe and considerable surgical choice for appropriate intrathoracic conditions.

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.

Partial lung resection by uniportal video-assisted thoracoscopic surgery: technique and pitfalls

The use of uniportal video-assisted thoracoscopic surgery (VATS) has increased worldwide. The number of facilities introducing this simple and cost-effective surgical procedure in Japan has also increased. Partial lung resection is performed to diagnose or treat various cases and surgeons are required to flexibly deal with it. This report describes the technique and pitfalls of partial lung resection by uniportal VATS.

Hybrid Theater and Uniportal Video-Assisted Thoracic Surgery: The Perfect Match for Lung Nodule Localization

Cone-beam computed tomography provides unparalleled real-time imaging of the patient within the hybrid theater, which can be used for simultaneously diagnosing and localizing small pulmonary lesions for resection. Hybrid theater can guide more precise placement of electromagnetic navigation bronchoscopy tools, thereby increasing the diagnostic yield in biopsy procedures while reducing diffusion artifact in dye marking for nodule localization. Furthermore, hook-wires implantation that is widely used to assist in lesion localization for uniportal thoracoscopic surgery can take place in the hybrid suite, eliminating the common complications and discomfort associated with the conventional workflow carried out in the radiology suite.

Transaxillary uniportal video assisted thoracoscopic surgery for right upper lobectomy

Uniportal video-assisted thoracic surgery (VATS) was growing popular since its first introduction. Based on the conventional uniportal VATS, we modified the technique and introduced transaxillary uniportal VATS lobectomy in this case report. In March 2017, transaxillary uniportal VATS was firstly attempted on a patient suffering from right upper lobe lesion at the Department of Thoracic Surgery, Zhongshan Hospital, Fudan University. A 4-cm single incision was made at the fossa axillaris paralleled to the skin folds, to which a soft wound protector was applied to reach the third intercostal space along the anterior axillary line. The right upper lobectomy was performed through the transaxillary incision. The surgery was accomplished without conversion to thoracotomy or application of extra incision. The truncus anterior artery, the upper lobe bronchus and upper pulmonary vein was mobilized and dissected in order. The target lobe was removed through the fossa axillaris incision. The operation duration was 110 minutes with limited blood loss. The patient was discharged 3 days post-operatively. Transaxillary uniportal VATS lobectomy is safe and feasible, and the procedure showed cosmetic advantages. Further studies based on larger population are required to determine these findings.

Video-assisted thoracic surgery for tiny pulmonary nodules with real-time image guidance in the hybrid theatre: the initial experience

Background

Localization of tiny lung nodules during video-assisted thoracic surgery (VATS) resection can be challenging. Real-time image-guided hookwire localization of the target lesions immediately followed by VATS lung resection in the hybrid operating theatre setting is an emerging approach.

Methods

We retrospectively reviewed our experience with this form of hybrid operating theatre image-guided VATS (iVATS) for lung nodules 1.5 cm or less, or soft in consistency. These patients were compared with matched cohort who received standard hookwire localization in the radiology department.

Results

From February 2014 to September 2017, lung nodules of indeterminate nature in 32 consecutive patients with mean size 9.1±4.6 mm underwent iVATS. All were accurately localized by hookwire and successfully resected. There was no postoperative mortality. There were 21 (66%) malignant lesions, all with adequate resection margins. Major outcomes were compared with a comparable cohort of 8 patients who received standard hookwire localization and VATS (sVATS) performed at separate departments operation suites. sVATS groups has significantly longer 'at-risk' period for pneumothorax progression and hookwire dislodgement (109.5±57.1 minutes for sVATS vs. 41.1±15.0 minutes for iVATS, P=0.011), and a higher risk of hookwire dislodgement (25% for sVATS vs. 0 for iVATS, P=0.036).

Conclusions

Real-time image-guided hookwire localization in the hybrid theatre setting is an effective facilitator of VATS resection of tiny lung nodules in selected patients, and may have added advantages in terms of safety and localization accuracy over the conventional sVATS method.

Single-incision versus multiport video-assisted thoracoscopic surgery in the treatment of lung cancer: a systematic review and meta-analysis

OBJECTIVES

Recent studies compared single-incision thoracoscopic surgery (SITS) with more widely used conventional multiport video-assisted thoracoscopic surgery in the treatment of lung cancer. To establish the safety and feasible of SITS in the treatment of lung cancer, we conducted this systematic review and meta-analysis.

METHODS

Eleven studies were identified from the databases of PubMed, Cochrane Library, SpringerLink, and ScienceDirect. The randomized controlled trials (RCTs) and non-randomized studies evaluated the outcomes of SITS compared with multiport video-assisted thoracoscopic surgery in the treatment of lung cancer were included for analysis. Odds ratio (OR, used to compare dichotomous variables) and weight mean difference (WMD, used to compare continuous variables) were calculated with 95% confidence intervals (CIs) based on intention-to-treat analysis.

RESULTS

Eleven studies including 1314 patients were included for analysis. Our analysis showed that the operative time, blood loss amount, mean duration of chest tube, lymph nodes retrieved were similar between two approaches, the SITS pulmonary resection might be associated with shorter hospital stay (p = .008) and lower complication rate (p = .009) when compared with conventional multiport video-assisted thoracoscopic surgery approaches.

CONCLUSIONS

In selected patients SITS is safe, feasible and may be considered an alternative to multiport VATS.

The feasibility of electromagnetic navigational bronchoscopic localization with fluorescence and radiocontrast dyes for video-assisted thoracoscopic surgery resection

Recently, some groups have reported the utilization of electromagnetic navigational bronchoscopy (ENB) for localization of pulmonary lesion. Its application for intraoperative visual localization with dyes to determine the target area has been increasing. In this paper, we reviewed the feasibility of ENB utilization for video-assisted thoracoscopic surgery (VATS) or robotic sublobar resection as a localization tool, and its future application in minimally invasive thoracic surgery.

Simple covering technique in thoracoscopic bullectomy for spontaneous pneumothorax

Reduced-port thoracoscopic surgery for pneumothorax has been well reported. However, the optimum method for preventing postoperative recurrence in reduced-port thoracoscopic bullectomy remains unclear. We investigated ways to improve the covering technique with reduced-port thoracoscopic bullectomy for spontaneous pneumothorax. From April to December 2016, we performed a simple covering technique with reduced-port thoracoscopic bullectomy on six patients and evaluated the surgical results and patient outcomes. All of the patients were successfully treated with the simple covering technique, and none had a postoperative ipsilateral recurrence of pneumothorax. Our method is a simple and easy technique involving the wide reinforcement of the staple line and may be effective in reducing the risk of postoperative recurrence in reduced-port thoracoscopic bullectomy.

Advantages and disadvantages of single incision VATS in major anatomical resection for lung cancer

Safety and feasibility of lung resections by single incision thoracoscopy have been confirmed in large number of studies. As proponents claim its lesser invasive nature caused by lacking of additional intercostal port(s), opponents question the outcome measures of the approach especially in oncological manner. Since there is no major discussion regarding the superiority of video-assisted thoracoscopic surgery (VATS) on lung resections over the open technique in the surgical management of lung cancer today, advantage and disadvantage of single incision VATS lung resections was reviewed with the comparison of standard, multi-port VATS approach in this article. Overall, results of comparative studies confirm that single incision and multiportal thoracoscopy are similar, or single incision thoracoscopy has more advantages in the lung resection for lung cancer. Currently, the main disadvantage of single incision approach is the lacking of long-term oncological results.

Single-staged uniportal VATS in the supine position for simultaneous bilateral primary spontaneous pneumothorax

BACKGROUND

Simultaneous bilateral primary spontaneous pneumothorax (SBPSP) is rare, but requires surgery on both sides, in patients with definite bilateral bullae to prevent life-threatening conditions. Recently, uniportal video-assisted thoracoscopic surgery (VATS) has been widely accepted as a less invasive technique for the treatment of pneumothorax. Thus, we introduced single-staged uniportal VATS technique in the supine position, for the management of two cases of SBPSP.

CASE PRESENTATION

A 17-year-old boy presented with bilateral spontaneous pneumothorax and he underwent single-staged uniportal VATS in the supine position. Single wide draping in consecutive bilateral approaches removes the needs of changing patients' position. Whole thoracoscopic procedure for wedge resection of bullae lesions was conducted without difficulty. The total operation time took 65 min and the patient discharged 3 days after the operation. The patient was followed for 24 months without recurrence of both sides. Another 18-year-old boy was admitted with bilateral spontaneous pneumothorax and single-staged uniportal VATS was also performed in the supine position. The total operation time took 79 min and the patient discharged on postoperative day 4. He was followed for 19 months without recurrence of both sides.

CONCLUSIONS

Single-staged uniportal VATS approach yielded satisfactory results from simplicity that not requires position change compared to conventional multi-ports VATS in the lateral position, and with better cosmetics. This technique is thought to be a feasible procedure in selective patients with SBPSP or with contralateral bullae for preventive role.

Laser resection of pulmonary nodule via uniportal thoracoscopic surgery

Uniportal video-assisted thoracic surgery (VATS) lung wedge resection usually requires three devices, thoracoscope, lung retracting instrument and an endo-stapler cutter to perform the procedure. With advances in miniaturization of the thoracoscope and lung retracting instruments, a major limitation to operating through a smaller uniportal incision has become the endo-stapler. We describe the surgical technique for uniportal VATS laser lung resection which uses a much narrower laser catheter device to replace the endo-stapler for resection. The new approach to limited lung resection can potentially reduce instrument fencing and the uniportal incision wound size, while achieving satisfactory hemostasis and pneumostasis.

From full thoracotomy to uniportal video-assisted thoracic surgery: lessons learned

Over the last two decades, conventional video-assisted thoracic surgery (VATS) has established itself as the preferred approach for almost all thoracic surgical procedures. The procedure provides a safe and easy approach with undisputed patient benefit at a cost acceptable to the healthcare system all over the world, in large hospitals as well as underprivileged rural areas. VATS has effectively addressed the patients' right to less scarring, trauma (both of access and intrathoracic manipulation), medication, pain, hospitalization, and early return home and work. These improvements have been further stressed by the introduction of uniportal VATS (uniVATS). Single port surgery is a very exciting new modality in the field of minimal access surgery which aims at further reducing scars of standard vats and towards an hypothetical prospective of scarless surgery.

Technological aids in uniportal video-assisted thoracoscopic surgery

With the evolution of uniportal video-assisted thoracoscopic surgery (VATS), the technological aids have come to help skill surgeons to improve the results in thoracic surgery and feasible to perform a complex surgery. The technological aids are divided into three important groups, which make surgical steps easy to perform, besides reducing surgical time and surgical accidents in the hands of experienced surgeons. The groups are: (I) conventional thoracoscopic instruments; (II) sealing devices using in uniportal VATS; (III) high definition cameras, robotic arms prototype and the future robotic aids for uniportal VATS surgery. Uniportal VATS is an example of the continuing search for methods that aim to provide the patient a surgical cure of the disease with the lowest morbidity. That is the reason companies are creating more and new technologies, but the surgeon have to choose properly and to know how, when and where is the moment to use each new aids to avoid mistakes. The future of the thoracic surgery is based on evolution of surgical procedures and innovations to try to reduce even more the surgical and anesthetic trauma. This article summarizes the technological aids to improve and help a thoracoscopics surgeons perform a uniportal VATS feasible and safe.

Technological innovation in video-assisted thoracic surgery

The popularity of video-assisted thoracic surgery (VATS) which increased worldwide due to the recent innovations in thoracic surgical technics, equipment, electronic devices that carry light and vision and high definition monitors. Uniportal VATS (UVATS) is disseminated widely, creating a drive to develop new techniques and instruments, including new graspers and special staplers with more angulation capacities. During the history of VATS, the classical 10 mm 0° or 30° rigid rod lens system, has been replaced by new thoracoscopes providing a variable angle technology and allowing 0° and 120° range of vision. Besides, the tip of these novel thoracoscopes can be positioned away from the operating side minimize fencing with other thoracoscopic instruments. The curved-tip stapler technology, and better designed endostaplers helped better dissection, precision of control, more secure staple lines. UVATS also contributed to the development of embryonic natural orifice transluminal endoscopic surgery. Three-dimensional VATS systems facilitated faster and more accurate grasping, suturing, and dissection of the tissues by restoring natural 3D vision and the perception of depth. Another innovation in VATS is the energy-based coagulative and tissue fusion technology which may be an alternative to endostaplers.

Magnetic anchoring guidance system in video-assisted thoracic surgery

The magnetic anchoring guidance system (MAGS) is one of the most promising technological innovations in minimally invasive surgery and consists in two magnetic elements matched through the abdominal or thoracic wall. The internal magnet can be inserted into the abdominal or chest cavity through a small single incision and then moved into position by manipulating the external component. In addition to a video camera system, the inner magnetic platform can house remotely controlled surgical tools thus reducing instruments fencing, a serious inconvenience of the uniportal access. The latest prototypes are equipped with self-light-emitting diode (LED) illumination and a wireless antenna for signal transmission and device controlling, which allows bypassing the obstacle of wires crossing the field of view (FOV). Despite being originally designed for laparoscopic surgery, the MAGS seems to suit optimally the characteristics of the chest wall and might meet the specific demands of video-assisted thoracic surgery (VATS) surgery in terms of ergonomics, visualization and surgical performance; moreover, it involves less risks for the patients and an improved aesthetic outcome.

Staged bilateral single-port thoracoscopic lung volume reduction surgery: A report of 11 cases

The aim of the present study was to investigate the feasibility and efficacy of staged bilateral single-port thoracoscopic lung volume reduction surgery (LVRS) for patients with chronic obstructive pulmonary emphysema (COPE). Eleven male patients with a mean age of 60.27±12.11 years with bilateral COPE and bullae were admitted to the Department of Thoracic Surgery, Xuzhou Central Hospital from January 2013 to June 2014. The patients underwent staged bilateral single-port thoracoscopic LVRS. The hyperinflated bullae were resected using endoscopic staplers (Endo-GIA), followed by continuous suture and biological glue for reinforcement of the margin. In addition, pulmonary function, blood gas assay, 6-min walk distance (6MWD) and life quality evaluated by a short form 36-item health survey questionnaire (SF-36) were recorded before and after LVRS, respectively. All the patients survived after surgery. The chest tube drainage time was 9.09±1.31 days and postoperative hospital stay was 15.73±2.75 days, with 5 cases of persistent air leakage and 7 cases of pulmonary infection which were finally cured. The patients were followed up for 3 to 12 months, and the pulmonary function, partial pressure of oxygen (pO₂), 6MWD and life quality after unilateral or bilateral LVRS were improved compared to these parameters before surgery. However, there was no significant difference between unilateral and bilateral LVRS in terms of life quality. In conclusion, staged bilateral single-port thoracoscopic LVRS may improve the short-term life quality of patients with COPE.

Non-grasping en bloc mediastinal lymph node dissection through uniportal video-assisted thoracic surgery for lung cancer surgery

Uniportal video-assisted thoracic surgery (VATS) has been demonstrated to be feasible, safe, and effective for lung cancer surgery compared with traditional multi-portal VATS. However, complete mediastinal lymph node dissection (MLND) through uniportal VATS is still a difficult work due to more limited access, and most thoracic surgeons use strategies of grasping, accompanied with which are complicated instrumentation and mutual interference among them. To simplify the instrumentation and make MLND more comfortable, we developed the method of "non-grasping en bloc MLND" and applied it during uniportal VATS lung cancer surgery. Two main instruments (suction and energy devices) were developed with diversified use. And only the two instruments were used during MLND following the strategy of "non-grasping". This technique incorporates with several advantages, such as: simplified instrumentation, decreased risk of damages to lymph nodes, and en bloc dissection. Considering the limited access, this technique fits well with the uniportal procedure and truly interprets the concept of "less is more" during uniportal VATS MLND.

Stepwise approaches to optimize strategy for holding thoracoscope during single port video-assisted thoracoscopic surgery

Coordination between the thoracoscope assistant and the surgeon was difficult during single port video-assisted thoracoscopic surgery (SP-VATS). What's more, holding the thoracoscope was an exhausting work for the assistant and optimized strategies were intensely needed. This paper aims to share our experience in making the thoracoscope assistant feel comfortable by illustrating the stepwise approaches in optimizing the strategies for holding the thoracoscope during our practice of SP-VATS. The evolution of techniques were divided into four stages: stage I, traditional 10-mm 30° thoracoscope placed at the posterior part of the incision; stage II, 5-mm thoracoscope towed and fixed via a silk suture; stage III, 5-mm thoracoscope placed outside of a plastic wound protector; stage IV, 5-mm thoracoscope introduced into the thoracic cavity through a 5-mm laparoscopic trocar outside of a plastic wound protector and the assistant stood at a foot-stool. After stepwise improvement, the thoracoscope assistant felt more labor saving and comfortable, and coordination with the surgeon has become smoother.

Image-guided localization of small lung nodules in video-assisted thoracic surgery

The advancement of imaging technology has recently facilitated single port minimally-invasive thoracic surgery techniques. Cone-beam computed tomography (CBCT) shows promising results in visualizing the target lesion and its surrounding critical anatomy, with an error of less than 2 mm. The integration of CBCT with the operating room (OR) to form the hybrid OR, provides unparalleled real-time imaging of the patient, which can be used with electromagnetic navigation bronchoscopy to confirm successful navigation and increase procedural accuracy particularly for small peripheral pulmonary targets. Furthermore, implantation of hookwires or microcoils that are widely used to localize the lesion can take place in the hybrid suite, eliminating the common complications and discomfort associated with the conventional workflow carried out in the radiology suite. Displacement leading to localization failure can be also reduced, and sublobar resection will be performed without resecting a larger area of parenchyma than desired. This one-stop, paradigm-shifting concept for simultaneously diagnosing and managing small pulmonary lesions in the hybrid OR can lead to reduced invasiveness and improved patient care.

Uniportal video-assisted thoracoscopic right upper lobectomy with systematic lymphadenectomy

Over the past decade, uniportal video-assisted thoracic surgery (VATS) has been reported to be a promising, less invasive alternative with potentially better cosmesis and less postoperative pain and paraesthesia. Although uniportal VATS has now evolved into a sophisticated technique capable of performing some of the most complex thoracic procedures, this approach to lobectomy is not standardized, and the surgical procedure still varies between surgeons. Here, we describe our uniportal VATS procedure during right upper lobectomy in a patient with a nodule in the right upper lobe. Subsequent mediastinal lymphadenectomy was performed to remove lymph nodes from the 2(nd), 3(rd), 4(th), 7(th), 8(th), and 9(th) groups. Although there are some details that are different compared to the conventional VATS approach, as experience with uniportal VATS has grown, this approach is a viable alternative approach for lobectomy in selected patients.

Modular 3-cm uniportal video-assisted thoracoscopic left upper lobectomy with systemic lymphadenectomy

Uniportal video-assisted thoracoscopic lobectomy for non-small-cell lung cancer is accepted worldwide, with incisions ranging from 4 to 6 cm. We believed in less invasive and more precise that uniportal video-assisted thoracoscopic lobectomy could be. Therefore, we performed modular uniportal thoracoscopic lobectomy with systemic lymphadenectomy on left upper lobe using a 3-cm-diameter port. And the modular surgical route was arranged in seven modules. Anesthesia, patient positioning and instruments play an important role in the surgery. From October 2014 to June 2015, 96 patients underwent this modular surgery and all patient were discharged uneventfully with no postoperative deaths. Compared with multi-port VATS, the operation time were longer than multiport video-assisted thoracoscopic surgery (VATS) (164.70±12.50 vs. 160.70±11.60 min, P>0.05), and the mean lymphadenectomy station was 6.00±0.77, and the mean lymphadenectomy number was 17.58±5.33. There is no significant difference on lymphadenectomy. Thus, modular uniportal video-assisted thoracoscopic lobectomy with systemic lymphadenectomy on left upper lobe using a 3-cm-diameter port is a safe, feasible, and less painful technique for select patients with lung disease.

Learning curve of single-incision thoracoscopic surgery for primary spontaneous pneumothorax

BACKGROUND

Single-incision thoracoscopic surgery (SITS) requires extensive time and practice to achieve satisfactory technical skills. The aim of this study was to evaluate the learning curves of SITS for primary spontaneous pneumothorax (PSP).

METHODS

This study included a total of 274 consecutive patients who underwent PSP surgery by a single operator between May 2011 and February 2014. During this period, SITS was applied as a routine approach. Learning curves were made by the cumulative sum (CUSUM) method using the number of cases and four surgical technique-related factors, including operation time, postoperative complication, non-SITS rate, and ipsilateral PSP recurrence.

RESULTS

Among the 274 patients, 16 patients who were presented with a previous 3-port wound scar or inadequate chest tube site before surgery were not eligible for SITS. Hence, SITS was attempted on 258 patients and performed successfully in 251 patients. For these successful SITS patients, the mean age was 22.9 ± 8.1 years, the mean operation time was 65.6 ± 22.2 min, the mean chest tube indwelling time was 1.5 ± 1.1 days, and the mean postoperative hospital stay was 1.7 ± 1.1 days. The mean operation time decreased from 84.0 to 47.6 min when a comparison was made between patients operated in the initial 6 months and the last 6 months of the study period. As revealed by the CUSUM technique, more than 50 % of the cases experienced an operation time of <70 min after the first 92 cases. After 57 cases, the postoperative complication rate was maintained at <5 %. The non-SITS rate was achieved to be lower than 5 % after 112 cases. The ipsilateral PSP recurrence rate was maintained at below 8 % after 102 cases.

CONCLUSIONS

Although PSP is the most applicable scenario for the beginner of SITS, at least 100 cases of experience are needed to achieve optimal technical level.

Future of uniportal video-assisted thoracoscopic surgery-emerging technology

Uniportal VATS poses unique difficulties to the surgeon, mainly as a consequence of operating through a small single incision. The instruments in uniportal VATS have limited movement through the small incision. In addition, the approach to the surgical operating site is unidirectional, which may restrict vision and retraction, and unavoidably suffers from instrument fencing. Recent thoracoscopic technology in the form of a wide variable angled lens has to some extent improved these shortcomings. The development of an extendable flexible thoracoscope and wireless steerable endoscope (WSE) systems can further improve the visualization for surgery and reduce or even remove fencing between endoscope and instruments. New single incision access platforms both derived from Natural orifice transluminal endoscopic surgery (NOTES) and robotic surgery approaches are on the horizon. These may allow uniportal VATS to be performed through an even smaller ultra-minimally invasive incision, with improved vision, more freedom of movement of the instruments and greater precision. However, a number of problems remain to be resolved, including provision of a stable platform and payload, applied force limitations and equipment sterilization. Advances in uniportal VATS major lung resection techniques have not only challenged the surgeon to acquire new skills and knowledge, but at the same time have rekindled the collaborative spirit between industry and clinician in developing novel equipment and technology to push the boundaries of minimally invasive surgery. These technological improvements and innovations may improve operating efficiency and safety during uniportal VATS surgery.

Subxiphoid uniportal video-assisted thoracoscopic middle lobectomy and anterior anatomic segmentectomy (S3)

The video-assisted thoracoscopic surgery (VATS) approach for combined lobectomy and segmentectomy in the same lung is an infrequent procedure, rarely reported in the literature. Currently, Most of the surgeons still use 2-3 thoracic incisions for thoracoscopic anatomic resections. However, the uniportal approach is gaining worldwide acceptance in the recent years. The main advances of uniportal VATS during the last years are related to improvements in surgical technique by implementing new technology. The experience acquired with the uniportal technique allows expert uniportal VATS surgeons to explore new approaches in order to minimize even more the surgical invasiveness. Recently the aim to avoid the intercostal nerve damage created by the transthoracic incision has led to the creation of a novel procedure entitled uniportal VATS subxiphoid approach. Here we report the first case of a lobectomy combined with anatomic segmentectomy performed through a uniportal subxiphoid approach.

Uniportal lobectomy in Africa: a beginning

Report of the first uniportal wet lab run in South Africa. This included four university centers involving live surgery. Lobectomies as well as other video assisted procedures were performed. The results are the introduction of thorascopic programs in all four centers. The next stage in this program is to extend the outreach to the other centers in the country as well as in the neighboring countries. During 2016 a beginning will be made in Namibia as well as in Botswana.

Comparing the postoperative outcomes of video-assisted thoracoscopic surgery (VATS) segmentectomy using a multi-port technique versus a single-port technique for primary lung cancer

BACKGROUND

Single-port video-assisted thoracoscopic surgery (VATS) has attracted much attention recently; however, it is still very challenging to perform especially on more technically demanding sublobar anatomic resection procedures such as segmentectomy. Therefore we conducted a retrospective study on the perioperative results of single-port segmentectomy using a propensity-matched method for comparison with multi-port segmentectomy in patients with primary lung cancer.

METHODS

For procedures of anatomic segmentectomy performed between May 2006 and March 2014, we retrieved data on patients' demographic information, medical history, cancer information, and postoperative outcomes from our surgical database of thoracoscopic lung cancer surgery. Outcome variables included the number of lymph nodes retrieved during the surgery, the amount of blood loss, the duration of hospitalization, the length of the wound, the operation duration in minutes, and incidence and types of complication. The t-test and Chi-squared test were used to compare demographic and clinical variables between single- and multi-port approaches.

RESULTS

A total of 98 consecutive patients who underwent VATS segmentectomy for lung cancer treatment were identified in our database: 52 (53.1%) underwent a single-port segmentectomy and 46 (46.9%) had a multi-port segmentectomy. After propensity score matching, the differences in patients' age, pulmonary function tests, tumor size, and operating surgeons were no longer significant between the two sample groups. The length of the wound was the only surgical outcome for which single-port segmentectomy had a significantly better outcome than multi-port segmentectomy (P value <0.001).

CONCLUSIONS

This study showed that single-port VATS segmentectomy yielded comparable surgical outcomes to multi-port segmentectomy despite technique difficulties and smaller wound in our setting.

Hybrid DynaCT-guided electromagnetic navigational bronchoscopic biopsy†

Electromagnetic navigational bronchoscopy-guided biopsy of small pulmonary nodules can be challenging. Navigational error of the system and movement of the biopsy tool during its deployment adversely affect biopsy success. Furthermore, conventional methods to confirm navigational success such as fluoroscopy and radial endobronchial ultrasound become less useful for the biopsy of small lesions. A hybrid operating theatre can provide unparalleled real-time imaging through DynaCT scan to guide and confirm successful navigation and biopsy of difficult-to-reach or small lesions. We describe our technique for DynaCT image-guided electromagnetic navigational bronchoscopic biopsy of a small pulmonary nodule in the hybrid operating theatre. The advantages, disadvantages and special considerations in adopting this approach are discussed.

Video-assisted thoracoscopic thymectomy versus subxiphoid single-port thymectomy: initial results†

OBJECTIVES

Compared with conventional median sternotomy, approaches used in thymectomy for myasthenia gravis and anterior mediastinal tumours have become much less invasive in recent years. We previously developed a surgical technique called single-port thymectomy (SPT) to excise the thymus through a single opening made below the xiphoid process. In this study, to show the utility of SPT, we compared factors contributing to low surgical invasiveness between SPT and conventional video-assisted thoracoscopic surgery (VATS) thymectomy.

METHODS

Between January 2005 and December 2014, 146 patients underwent surgery for anterior mediastinal tumour or myasthenia gravis at our hospital. After excluding patients diagnosed with tumour invasion of nearby organs or those who had undergone concurrent removal of nearby organs, 81 patients were enrolled in this retrospective study as subjects. Patients were divided into the VATS thymectomy group (VATS group, n = 35) and the SPT group (n = 46). Surgical duration, blood loss, duration of hospital stay and the amount and duration of postoperative oral analgesics were compared between the groups.

RESULTS

Operating time did not vary significantly between the VATS and SPT groups (P = 0.0853). The amount of blood loss was higher in the VATS group than in the SPT group (P < 0.0001). The duration of hospital stay was longer in the VATS group than in the SPT group (P = 0.0008). The amount of postoperative oral analgesics was significantly higher in the VATS group than in the SPT group (P = 0.0092). Similarly, the duration of postoperative oral analgesics was significantly longer in the VATS group than in the SPT group (P = 0.0312).

CONCLUSIONS

Compared with VATS thymectomy, SPT required a similar operating time, was associated with less blood loss and enabled postoperative analgesics to be discontinued earlier. Therefore, it could be considered a less invasive surgical approach.

A novel narrow profile articulating powered vascular stapler provides superior access and haemostasis equivalent to conventional devices†

OBJECTIVE

Current endoscopic transection devices are not optimized to meet the unique challenges posed by the task of vessel transection in difficult-to-access locations within the pleural cavity. The ECHELON FLEX™ powered vascular stapler (PVS) has been designed with four rows of staples instead of six, to decrease its size and enable more precise placement on fragile pulmonary vessels, using a narrower anvil than other commercially available transecting devices. This study was performed to determine whether the reduced number of staple rows affects haemostasis, and to assess surgeons' initial impression of the smaller stapler during in vivo usage.

METHODS

The new four-row stapler was compared with commercially available six-row articulating staplers via expert graders using a validated scale of haemostasis in vivo after application on porcine gastroepiploic pedicles and other thin- and thick-walled vessels. The new stapler was then compared with current products by practising thoracic surgeons (n = 27) during in vivo usage of simulated pulmonary procedures in a porcine model. The surgeons were also surveyed on the key attributes of the four-row stapler in relation to the six-row predicates.

RESULTS

Haemostasis evaluated on an ordered scale was clinically equivalent between the test and predicate staplers, and was deemed acceptable for all thin- and thick-vascular tissue applications. Surgeons found no difference in haemostasis between the four- and six-row staplers (P = 0.486), and judged the four-row stapler superior in terms of access, reduced need for dissection, reduced stress of surgeon and precise control (P < 0.001 for all).

CONCLUSIONS

The new ECHELON FLEX™ PVS provides haemostasis equivalent to six-row staplers. With a smaller anvil, narrower shaft and wider angle of articulation, the PVS demonstrated improved access capability for pulmonary vessel procedures.

Single- versus multiple-port thoracoscopic lobectomy for lung cancer: a propensity-matched study†

OBJECTIVES

In this retrospective study, we aimed to compare single-port (SP) and multiport (MP) video-assisted thoracoscopic surgery (VATS) for the surgical resection of non-small-cell lung cancer (NSCLC).

METHODS

Between October 2013 and October 2014, a total of 411 consecutive NSCLC patients who underwent VATS lobectomy in the Department of Thoracic Surgery, Zhongshan Hospital of Fudan University, were enrolled. Propensity-matched analysis, incorporating preoperative clinical features, was used to compare the perioperative outcomes and analyse the safety and efficacy between SP and MP VATS lobectomies for NSCLCs.

RESULTS

There were 115 patients in the SP group, and 296 patients in the MP group from October 2013 to October 2014. Propensity matching produced 100 pairs in this retrospective study. During the operation, the lobectomy took less time in the SP than in the MP (65.7 ± 14.8 vs 81.3 ± 13.6, P < 0.001) group, while the duration of lymphadenectomy was longer in the SP group (29.6 ± 16.7 vs 17.4 ± 13.3, P < 0.001). The total operation duration, the volume of estimated blood loss (55.1 ± 9.0 ml vs 58.7 ± 7.1 ml, P = 0.22) and the length of postoperative hospital stay (4.7 ± 1.2 days vs 5.3 ± 1.4 days, P = 0.05) were similar between the two groups. Postoperatively, SP and MP groups showed similar results in terms of morbidity and mortality.

CONCLUSIONS

In comparison with conventional VATS, SP VATS lobectomy showed better safety and efficacy in the surgical resection of NSCLCs. Further studies based on larger populations and better methodology are required to determine its further benefits towards patients.