Feasibility of transumbilical anatomic "Lung" segmentectomy in a canine model

BACKGROUND

Transumbilical approach has been shown to be feasible to perform lung wedge resection and anatomic lobectomy. This study uses a canine model to assess the feasibility of transumbilical segmentectomy.

METHODS

Transumbilical segmentectomy was performed in 10 beagle dogs using a 3-cm umbilical incision combined with a 2.5-cm diaphragmatic incision. We evaluated the surgical outcomes, operative complications, physiologic changes, hemodynamic changes, and inflammatory changes of the procedures.

RESULTS

Transumbilical segmentectomy was successfully completed in eight of ten animals. There was one mortality complication related to lung injury causing hemodynamic collapse. Another animal required conventional thoracotomy to complete the surgery due to limited working space. There were no notable events in the postoperative period for all eight dogs that completed the segmentectomy via the transumbilical approach.

CONCLUSION

This animal study demonstrates that the pulmonary segmentectomy can be performed with current standard endoscopic instruments via a single transumbilical incision.We believe that advancing surgical innovation and good collaboration between multi-disciplinary research teams will further establish clearer roles for transumbilical segmentectomy in thoracic surgery.

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 During the history of VATS, the classical 10 mm 0° or 30° rigid rod lens system, has been replaced by new thoracoscopes providing a variable angle technology and allowing 0° and 120° range of vision.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.

Electrocautery device does not provide adequate pulmonary vessel sealing in transumbilical anatomic pulmonary lobectomy

INTRODUCTION

Safe pulmonary vessel sealing device plays a crucial role in anatomic lung resection. In 2014, we reported high rates of massive bleeding complications during transumbilical lobectomy in a canine model due to difficulty in managing the pulmonary vessel with an endostapler. In this animal survival series, we aimed to evaluate the outcome of pulmonary vessel sealing with an electrocautery device to simplify the transumbilical thoracic surgery.

METHODS

Under general anesthesia, a 3-cm longitudinal incision was made over the umbilicus. Under video guidance, a bronchoscope was inserted through the incision for exploration. The diaphragmatic wound was created with an electrocautery knife and used as the entrance into the thoracic cavity. Using the transumbilical technique, anatomic lobectomy was performed with electrosurgical devices and endoscopic vascular staplers in 15 canines.

RESULTS

Transumbilical endoscopic anatomic lobectomy was successfully completed in 12 of the 15 animals. Intraoperative bleeding developed in three animals during pulmonary hilum dissection, where one animal was killed due to hemodynamic instability and the other two animals required thoracotomy to complete the operation. There were five delayed bleeding and surgical mortality cases caused by inadequate vessel sealing by electrosurgical devices. Postmortem examination confirmed correct transumbilical lobectomy in the twelve animals that survived the operations.

CONCLUSION

Transumbilical anatomic lobectomy is technically feasible in a canine model; however, the electrosurgical devices were not effective in sealing the pulmonary vessel in the current canine model.

Hemodynamic and inflammatory responses following transumbilical and transthoracic lung wedge resection in a live canine model

BACKGROUND

Single-port transumbilical surgery is a well-established platform for minimally invasive abdominal surgery. The aim of this study was to compare the hemodynamics and inflammatory response of a novel transumbilical technique with that of a conventional transthoracic technique in thoracic exploration and lung resection in a canine model.

METHODS

Sixteen dogs were randomly assigned to undergo transumbilical thoracoscopy (n = 8) or standard thoracoscopy (n = 8). Animals in the umbilical group received lung resection via a 3-cm transumbilical incision in combination with a 2.5-cm transdiaphragmatic incision. Animals in the standard thoracoscopy group underwent lung resection via a 3-cm thoracic incision. Hemodynamic parameters (e.g., mean arterial pressure, heart rate, cardiac index, systemic vascular resistance, and global end-diastolic volume index) and inflammatory parameters (e.g., neutrophil count, neutrophil 2',7' -dichlorohydrofluorescein [DCFH] expression, monocyte count, monocyte inducible nitric oxide synthase expression, total lymphocyte count, CD4+ and CD8+ lymphocyte counts, the CD4+/CD8+ratio, plasma Creactive protein level, interleukin-6 level) were evaluated before surgery, during the operation, and on postoperative days 1, 3, 7, and 14.

RESULTS

Lung resections were successfully performed in all 16 animals. There were 2 surgery-related mortality complications (1 animal in each group). In the transumbilical group, 1 death was caused by early extubation before the animal fully recovered from the anesthesia. In the thoracoscopic group, 1 death was caused by respiratory distress and the complication of sepsis at 5 days after surgery. There was no significant difference between the two techniques with regard to the hemodynamic and immunologic impact of the surgeries.

CONCLUSION

This study suggests that the hemodynamic and inflammatory changes with endoscopic lung resection performed by the transumbilical approach are comparable to those after using the conventional transthoracic approach. This information is novel and relevant for surgeons interested in developing new surgical techniques in minimally invasive surgery.

Transumbilical Thoracoscopy Versus Conventional Thoracoscopy for Lung Wedge Resection: Safety and Efficacy in a Live Canine Model

PURPOSE

Transumbilical single-port surgery has been associated with less postoperative pain and offers better cosmetic outcomes than conventional 3-port laparoscopic surgery. This study compares the safety and efficacy of transumbilical thoracoscopy and conventional thoracoscopy for lung wedge resection.

METHODS

The animals (n = 16) were randomly assigned to the transumbilical thoracoscopic approach group (n = 8) or conventional thoracoscopic approach group (n = 8). Transumbilical lung resection was performed via an umbilical incision and a diaphragmatic incision. In the conventional thoracoscopic group, lung resection was completed through a thoracic incision. For both procedures, we compared the surgical outcomes, for example, operating time and operative complications; physiologic parameters, for example, respiratory rate and body temperature; inflammatory parameters, for example, white blood cell count; and pulmonary parameters, for example, arterial blood gas levels. The animals were euthanized 2 weeks after the surgery for gross and histologic evaluations.

RESULTS

The lung wedge resection was successfully performed in all animals. There was no significant difference in the mean operating times or complications between the transumbilical and the conventional thoracoscopic approach groups. With regard to the physiologic impact of the surgeries, the transumbilical approach was associated with significant elevations in body temperature on postoperative day 1, when compared with the standard thoracoscopic approach.

CONCLUSIONS

This study suggests that both approaches for performing lung wedge resection were comparable in efficacy and postoperative complications.

Feasibility of transumbilical anatomic pulmonary lobectomy in a canine model

PURPOSE

Transthoracic thoracoscopic lobectomy is the preferred method of surgical treatment for early lung cancer. Current methods require a transthoracic approach and are associated with chronic postoperative pain in up to 25% of patients. Single-port transumbilical uniport surgery may offer advantages over multiport surgery with less postoperative pain and better cosmetic results. The aim of this study was to evaluate the feasibility of a transumbilical anatomic lobectomy of the lung (TUAL) in a canine model.

METHODS

TUAL was performed in 12 beagle dogs using a 3-cm umbilical incision combined with a 2.5-cm diaphragmatic incision. Variables evaluated for surgical outcomes were operating time, operative complications, body rectal temperature, respiratory rate, white blood cell count, and arterial blood gases.

RESULTS

TUAL was successfully completed in ten animals. There were six bleeding complications related to surgery. In four animals, an avulsion of pulmonary vessel causes intraoperative bleeding, requiring simultaneous pulmonary artery and bronchus resections. In one animal, slipping of endoclip after vessel clipping caused perioperative bleeding. The other animal encountered bleeding complication during dissection of inferior pulmonary vein. Both animals required conventional thoracotomy to complete the surgery.

CONCLUSIONS

TUAL in the canine model is feasible but associated with significant morbidity. With further development and refinement of instruments, comparative studies between the novel transumbilical lobectomy and the current video-assisted transthoracic lobectomy will clarify the role of transumbilical lobectomy in thoracic surgery.