Thoracoscopic sleeve resection-the better approach?

Effect of preoperative three-dimensional modeling on uniportal video-assisted thoracoscopic bronchial sleeve resection and early postoperative outcomes

Background

The aim of this study was to evaluate the effects of preoperative three-dimensional (3D) modeling on the performance of uniportal video-assisted thoracoscopic bronchial sleeve resection and early postoperative outcomes.

Methods

A total of 10 patients (5 males, 5 females; mean age: 53.8±16.9 years; range, 18 to 75 years) who underwent uniportal video-assisted thoracoscopic bronchial sleeve resection with preoperative 3D modeling between April 2021 and November 2023 were retrospectively analyzed. Preoperative 3D modeling was prepared using computed tomography with an open-source 3D software program. Demographic, clinical, intraoperative, and postoperative data of the patients were recorded. Anatomical landmarks identified by preoperative 3D modeling were compared with intraoperative findings.

Results

The anatomical landmarks created with the 3D model were in 100% agreement with the intraoperative findings. The procedures performed were three left lower lobes, three right upper lobes, one middle lobe, one right lower lobe, and one parenchyma-sparing intermediate bronchial sleeve resection. Bronchial sleeve resection was completed using uniportal video-assisted thoracoscopic technique in 90% of patients, with only one patient requiring conversion to open thoracotomy. The mean resection time was 264.2±40.5 min, and the mean anastomosis time was 86.0±20.3 min. Anastomosis times decreased with increasing experience (p=0.008). Postoperative atelectasis was observed in two patients, and there was no mortality. The mean follow-up duration was 12.2±11.8 months.

Conclusion

Preoperative 3D modeling significantly contributed to the successful implementation of uniportal video-assisted thoracoscopic bronchial sleeve resection surgery. In the future, with advancements in simulation programs, patient-specific 3D modeling is expected to benefit the identification of anatomical landmarks for bronchial sleeve resections.

Recent developments in video-assisted thoracoscopic surgery for pulmonary nodule management

In the modern era when screening and early surveillance of pulmonary nodules is increasing in importance, the management of the pulmonary nodule represents a different challenge to thoracic surgeons. The difficulty lies in the merging of sound surgical and oncological principles with more minimally invasive and appropriate lung sparing surgery. Furthermore, the intra-operative identification and surgical management of small and sometimes multi-focal pulmonary lesions remain challenging. There have been many developments and innovations in the field of video-assisted thoracoscopic surgery (VATS) to cater for the demands from increasing incidence of pulmonary nodules with associated paradigm shift in their surgical management. Recently, uniportal VATS and non-intubated VATS represent an even less invasive alternative to the conventional multiport VATS. The emergence of image guided VATS, hybrid operating theatre and fluorescence thoracoscopy have all contributed to improved precision of VATS lung resection, and are becoming important adjuncts to lung sparing surgery. In this chapter, some of these recent developments in VATS with emphasize on their importance in surgical management of the pulmonary nodule will be discussed.

Bronchoplasty using continuous suture in complete monitor view: a suitable method of thoracoscopic sleeve lobectomy for non-small cell lung cancer

Background

Our study aims to determine the value of bronchial anastomosis using complete continuous suture.

Methods

Six patients diagnosed with central lung carcinoma who were candidates for right-sided sleeve lobectomy and underwent sleeve resection of the right upper lobe by thoracoscopic surgical procedure.

Results

The mean surgical time was 182 min (range, 110 to 260 min). The mean time of bronchial anastomosis was 49 min (range, 18 to 76 min). The mean bleeding was 110 mL (range, 50 to 260 mL). Median chest tube drainage was 305 mL (range, 200 to 600 mL). No perioperative deaths or major complications occurred. The postoperative bronchoscopy confirmed no stenosis. The mean follow-up time was 19.2 months (range, 7 to 34 months), and six patients were alive.

Conclusions

Bronchial anastomosis using complete continuous suture may be a suitable method in thoracoscopic sleeve lobectomy.

Uniportal video-assisted thoracoscopic bronchoplastic and carinal sleeve procedures

Despite of the recent advanced with the video-assisted thoracoscopic surgery (VATS), the most common approach for bronchial and carinal resection is still the open surgery. The technical difficulties, the steep learning curve and the concerns about performing an oncologic and safe reconstruction in advanced cases, are the main reasons for the low adoption of VATS for sleeve resections. Most of the authors use 3-4 incisions for thoracoscopic sleeve procedures. However these surgical techniques can be performed by a single incision approach by skilled uniportal VATS surgeons. The improvements of the surgical instruments, high definition cameras and recent 3D systems have greatly contributed to facilitate the adoption of uniportal VATS techniques for sleeve procedures. In this article we describe the technique of thoracoscopic bronchial sleeve, bronchovascular and carinal resections through a single incision approach.

Robot-assisted thoracoscopic bronchoplasty

BACKGROUND

Robotic systems have been used to enhance the surgeon's dexterity and visualization in endoscopic surgery and thus facilitate refined dissection, suturing, and knot tying. We describe use of the da Vinci surgical system for robotic-assisted thoracoscopic bronchoplasty in patient with centrally located lung cancer.

METHODS

We used three robotic ports (a 12-mm trocar for the 30°-down camera and two 8-mm trocars for the robotic instrument arms) and one utility incision for assistance and specimen retrieval. Lung isolation were achieved using double-lumen endotracheal tube without carbon dioxide inflation. The bronchoplasty was performed by using 4/0 polydioxanone suture (PDS).

RESULTS

Three cases of robotic-assisted thoracoscopic bronchoplasty (n=3) were performed. Case 1: right upper lobe lobectomy with right main bronchus primary closure; case 2: right upper lobe lobectomy with the anterior wall of the right main bronchus re-anastomosis; case 3: left upper lobe sleeve lobectomy. The surgery and post-operative course were smooth without complication.

CONCLUSIONS

We suggest that robotic-assisted thoracoscopic surgery offers specific advantages over conventional thoracoscopic surgery with accuracy and safety when doing bronchoplasty.

Uniportal video-assisted thoracoscopic right upper sleeve lobectomy

BACKGROUND

The development of minimally invasive thoracic surgery in recent years is undeniable, VATS has evolved from the conventional three-port technique to an uniportal approach, without compromising the type of cases that can be operated successfully.

METHODS

Thanks to the continuous progress of uniportal video-assisted thoracoscopic surgery (VATS) the complexity of cases performed by this approach has improved remarkably since the first procedures were made, recent advances in surgical thoracoscopic technology had made feasible to achieve vascular and bronchial sleeve lobectomies. Anatomic variants in patients can increase the technical difficulty of the procedure making the process more challenging.

RESULTS

In this case the sleeve right upper lobectomy was performed by uniportal VATS despite the obstruction of the right pulmonary artery (PA) for the bronchial anastomosis.

CONCLUSIONS

In the hands of experienced surgeons in uniportal VATS with background in thoracoscopic suturing, sleeve lobectomies are feasible and safe to perform even when anatomic variants increase the complexity of the case.