Video-assisted Thoracic Surgery Cases Research Articles

Training Cardiothoracic Residents in Robotic Lobectomy Is Cost-Effective With No Change in Clinical Outcomes

Objective: Our objective was to evaluate for any changes in quality or cost when robotic lung resection is used with significant trainee participation. Methods: All anatomic lung resections between January 2006 and June 2016 were identified from a prospectively maintained database. Clinical data were recorded by double entry. Cost and cancer-related data were gathered from the business analytics department and tumor registry. Robotic outcomes were compared to an ongoing thoracotomy and video-assisted thoracic surgery (VATS) experience. Propensity scores using age, sex, and comorbidities were assigned for statistical analysis. Survival was evaluated using the Kaplan-Meier method. Results: Of 523 consecutive cases, 483 were included (211 robotic, 210 thoracotomy, 62 VATS). There were 74 robotic cases (35%) performed by trainees as the console surgeon. Length of stay was shortest for robotics (3 days) compared to thoracotomy (7 days, P < 0.001) and VATS (5 days, P = 0.010). Complications occurred in 33% of robotic cases, 42% of VATS cases (P = 0.854), and 52% of thoracotomy cases (P < 0.001). Stage I non-small cell lung cancer 3-year overall survival for robotics, thoracotomy, and VATS was 79.5%, 74.3%, and 74.0%, respectively (P > 0.25). There was no significant difference in negative margin rates. Total cost related to the hospitalization for surgery was $5,721 less for robotics compared to thoracotomy (P = 0.003) but comparable to VATS. Trainees served as console surgeon in 0% of cases in the first 2 years of robotics but increased to 79% in the last year of the study. Conclusions: Robotic lung resection can be safely performed and taught in an academic medical center without sacrificing quality or cost.

Learning curve in robotic-assisted lobectomy for non-small cell lung cancer is not steep after experience in video-assisted lobectomy; single-surgeon experience using cumulative sum analysis

BackgroundRobotic assistance in lung lobectomy has been suggested to enhance the adoption of minimally invasive techniques among surgeons. However, little is known of learning curves in different minimally invasive techniques. We studied learning curves in robotic-assisted versus video- assisted lobectomies for lung cancer. MethodsA single surgeon performed his first 75 video-assisted thoracic surgery (VATS) lobectomies from April 2007 to November 2012, and his 75 first robotic-assisted thoracic surgery (RATS) lobectomies between August 2011 and May 2018. A retrospective chart review was done. Cumulative sum (CUSUM) analysis was used to identify the learning curve. ResultsNo operative deaths occurred for VATS patients or RATS patients. Conversion-to-open rate was significantly lower in the RATS group (2.7% vs. 13.3%, p = 0.016). Meanwhile, 90-day mortality (1.3% vs. 5.3%, p = 0.172), postoperative complications (24% vs. 24%, p = 0.999), re- operation rates (4% vs. 5.3%, p = 0.688), operation time (170±56 min vs. 178±66 min, p = 0.663) and length of stay (8.9 ± 7.9 days vs. 8.2 ± 5.8 days, p = 0.844) were similar between the two groups. Based on CUSUM analysis, learning curves were similar for both procedures, although slightly shorter for RATS (proficiency obtained with 53 VATS cases vs. 45 RATS cases, p = 0.198). ConclusionsRobotic-assisted thoracoscopic lung lobectomy can be implemented safely and efficiently in an expert center with earlier experience in VATS lobectomies. However, there seems to be a learning curve of its own despite the surgeon's previous experience in conventional thoracoscopic surgery.

Trans-sternotomy versus video-assisted thoracic surgery for early-stage thymoma patients: a meta-analysis.

Over the years, video-assisted thoracic surgery (VATS) thymectomy has progressively replaced trans-sternotomy (TS) in early-stage thymoma (Masaoka stage I and stage II). This meta-analysis aimed to confirm the differences in the efficacies of VATS and TS approaches in early-stage thymoma patients. A thorough literature search of the following online databases was performed: PubMed, Cochrane Library, Web of Science, and EMBASE. Appropriate search terms, such as "thymoma or thymus neoplasms or Thymic Carcinoma" and "Video-Assisted Thoracic Surgeries or Video-Assisted Thoracoscopic", were used with MeSH search methods. Heterogeneity was assessed first with the Q-test and inconsistency index and sensitivity analysis and subgroup analysis were then used to find the source of heterogeneity. We retrieved 1,228 articles, 11 articles were selected as the subjects of our research, and 1,222 patients were included in the research (666 VATS cases versus 556 TS cases). VATS caused less blood loss (P=0.02), and required shorter hospital stay (P<0.001), shorter duration of chest tube drainage (P=0.03) than TS. No obvious difference was found in operative time (P=0.14), postoperative recurrence (OR =0.81, 95% CI: 0.35-1.85, P=0.613), postoperative complications (OR =0.60, 95% CI: 0.31-1.16, P=0.129) and R0 resection (OR =0.35, 95% CI: 0.12-1.04, P=0.06), but the trend showed that more patients in the TS group achieved R0 resection. For early-stage thymoma patients, VATS thymectomy seems to provide many advantages to be considered as a legitimate alternative to TS; however, when performing VATS, surgeons should pay special attention to ensure that R0 resection is achieved.

Decortication as an Option for Empyema Thoracis.

To analyse the outcome and morbidity associated with decortication in empyema thoracis. A case series. Departments of Surgery, Combined Military Hospitals (CMH) of Rawalpindi, Quetta and Lahore, from January 2006 to March 2018. This is a retrospective study of 812 cases of open and VATS (video-assisted thoracic surgery) decortication for empyema thoracis, operated by the same consultants. Only patients with established empyema were included. Those who were unfit for one-lung ventilation, undergoing local anesthesia procedures like rib resection, clagget window or tube windows, with clotted hemothorax and malignant pathology were excluded. Posterolateral serratus sparing thoracotomy was used in open decortications. Multiportal or uniport VATS was employed for video-assisted thoracoscopic decortications (VATD). Histopathology and microbiological sampling was also done in all cases. There were 537 (66.1%) males and 275 (33.9%) females. Age ranged from 1 to 80 years with a mean of 37 years. Open decortication was done in 650 (80%), standard decortication with posterolateral thoracotomy in 458 (56.4%), minithoracotomy was done in 69 (8.4%) patients with loculated empyema, thoracotomy and open decortication with conventional thoracoplasty was done in 21 patients. Twenty-two patients required open decortications with tailored thoracoplasty and muscle flap. Open decortication with intercostal muscle (ICM) flap or primary closure of bronchopleural fistula was performed in 55 patients. VATD was done in 162 cases, out of which 120 were early empyema, and 42 were of chronic empyema; of which 22 required a further utility thoracotomy. Decortication with lung resection and muscle flap reinforcement to bronchial stump was done in 25 patients. Blood transfusion was required in 331 (40.7%). Twenty-six (3.4%) patients developed residual space and collection requiring intervention; and 384 (47.3%) patients had a histopathology diagnostic for tuberculosis. There were 11 (1.3%) deaths. Open decortication is still one of the preferred procedures in developing countries. VATD is also increasingly utilised for empyema.

Techniques of uniportal video-assisted thoracic surgery—esophageal and mediastinal indications

Uniportal approach for esophagus and mediastinum is gaining popularity. While a transthoracic approach is applied for esophagus frequently from the 5th or 6th intercostal space on the posterior axillary line, approach to anterior mediastinum is variable with access through right/left chest, cervical and subxiphoid regions. The results of uniportal approach for esophagus and mediastinum are comparable with multiport video-assisted thoracic surgery (VATS) and open approach in terms of bleeding, oncologic adequacy and operation times. Indications are similar with open and multiportal VATS cases, however large mediastinal tumors (>5 cm) and T3-4 esophageal cancers can be challenging in the beginning in terms of oncologic adequacy of the operations. Uniportal approach for esophagus and mediastinum is utilized more frequently and initial reports show that it is feasible and its applicability and advantages will become apparent in the coming years.

The erector spinae plane block in 4 cases of video-assisted thoracic surgery

Multimodal anaesthesia, combining epidural catheter and general anaesthesia, is a common technique in thoracic surgery, however, epidural catheter placement is not always possible. Recently, erector spinae plane block has been described, which provides analgesia like that of the epidural block, although unilateral, and which has been used in various procedures at thoracic level. At present, there are no studies comparing the efficacy or safety of this block with those commonly used in thoracic surgery. However, its safety profile and contraindications seem different from those of the epidural catheter, since its placement is done under ultrasound view, the needle introduction is done in plane and the ultrasound target, the transverse process, is easily identifiable and is relatively remote from major neural or vascular structures and the pleura. Unlike other blockages made by anatomical references, erector spinae plane block can be done with the patient in different positions. We describe our experience with erector spinae plane block as part of a multimodal anaesthetic approach in thoracic surgery.

Five Hundred Seventy-Six Cases of Video-Assisted Thoracic Surgery Using Local Anesthesia and Sedation: Lessons Learned

General anesthesia and endotracheal intubation are a luxury rather than a necessity for many video-assisted thoracic surgery (VATS) operations. Twenty-three years ago, I began using local anesthesia and sedation for pleural disease and subsequently, for pericardial and lung disease. The records of all patients undergoing VATS using local anesthesia and sedation at hospitals of the Geisinger Health System (Danville and Wilkes-Barre, PA), from June 1, 2002 to June 30, 2011, and the Lifebridge Health System (Baltimore, MD) from July 1, 2011 to March 1, 2017, were retrospectively reviewed. There was 1 unsuccessful attempt at this technique, and it was eligible for inclusion. No patient was excluded based on age, BMI, or comorbidities. No patient had endotracheal intubation, laryngeal mask airway, or epidural or nerve block analgesia; all patients breathed spontaneously. Five hundred twenty-nine patients ranging in age from 21 to 104 years (mean 67 years) underwent 576 procedures: pleural biopsy-drainage with or without talc (n= 368); drainage of empyema (n= 112); lung biopsy (n= 56); evacuation of chronic hemothorax (n= 23); pericardial window (n= 10); treatment of chylothorax (n= 2); lung abscess draining (n=2); treatment of pneumothorax (n= 2); and mediastinal mass biopsy (n= 1). No patient required intubation or conversion to thoracotomy. There were 12 complications (2%). There were no deaths due to operation. Video-assisted thoracic surgery using local anesthesia and sedation is safe and effective for many indications. A review of the lessons learned caring for 529 patients will allow any thoracic surgeon and any anesthesiologist to practice this technique.

P1.08-052 Comparison Study of Perioperative Outcomes in Robotic, Video-Assisted Thoracic Surgery, and Thoracotomy Approaches for Lung Cancer

Robotic surgery for lung cancer has not widely spread because of the lack of definitive advantage compared to conventional approaches, specifically video-assisted thoracic surgery (VATS). Some studies have reported that postoperative complication in robotic surgery is superior for unclear reasons. The aim of this study is to compare the perioperative outcomes, particularly pointing out postoperative complication among robotic, video-assisted thoracic surgery (VATS) and thoracotomy approach in non-small cell lung cancer (NSCLC). We performed a retrospective review of NSCLC patients who underwent curative anatomical resection in our hospital from January 2011 to April 2016. There were 346 lobectomy cases and 76 segmentectomy cases. The patients were classified into four groups (robotic, VATS, open conversion from VATS, and thoracotomy) and were compared for differences in perioperative outcomes. Total 422 patients (43 robotic, 265 VATS, 30 open conversion from VATS, and 84 thoracotomy) were included in the analysis. Clinical and pathological stage showed earlier in robotic and VATS cases. Operative time (min), bleeding amount (gram) and drainage period (days) for robot, VATS, conversion and thoracotomy were 247/20/2, 188/10/2, 246/100/2, 225/ 92.5/2 respectively (p<0.0001). In the incidence of all, over G3, respiratory over G3 postoperative complications robotic surgery showed significantly lowest among them and there were neither conversion to thoracotomy nor operative/hospital mortality in robotic surgery. In our initial results of robotic surgery, lower incidence of operative morbidities is one of the advantageous features. Important issue whether robotic surgery is established as a minimally invasive approach for NSCLC or not should be verified.

P3.04-047 The Incidence and Outcome of Hoarseness after Systematic Upper Mediastinal Nodal Dissection by Radical Surgery for Primary Lung Cancer: Topic: Miscellaneous II

Recurrent laryngeal nerve (RLN) paralysis can occur following systematic upper mediastinal nodal dissection by radical surgery for primary lung cancer. However, there have been very few reports. We retrospectively reviewed the clinical data of 365 consecutive patients who underwent radical surgery for primary lung cancer with an over 6-month observation period in our institution from July 2010 to August 2015. There were 22 cases that experienced hoarseness after lung cancer surgery (6.0%). We could identify the movement of the vocal folds with a laryngoscope in 21 out of 22 cases (95.5%), because one patient refused to have the examination. Categorical variables were analyzed with Fisher’s exact test and continuous variables with the student’s-t test. P < 0.05 was considered statistically significant for all tests. Hoarseness subsequent to radical surgery for primary lung cancer arose in 16 out of 308 (5.2%) cases of video-assisted thoracic surgery (VATS) including robotic VATS, in contrast with six out of 88 cases (6.8%) of open thoracotomy. All patients who experienced hoarseness had received upper mediastinal nodal dissection. Patients who had received right upper nodal dissection experienced hoarseness in eight out of 150 cases (5.3%), in contrast to 14 out of 84 cases (16.3%, P = 0.020) for left upper lymph node dissection. Laryngoscopic examination revealed that five patients (23.8%) were diagnosed with right RLN paralysis and 15 (71.4%) as left. One patient who underwent VATS right upper lobectomy with upper mediastinal and subcarinal nodal dissection had left RLN paralysis. There was a patient (4.8%) who did not suffer from RLN paralysis, and one patient refused to undergo the examination. Eleven out of 18 patients (61.1%) were identified to improve the diagnosis of disorders of the vocal cords with the laryngoscope. It took one to 24 months (average 6.5 months) to improve the movement of the vocal cords observed with the laryngoscope. In addition, fourteen out of 19 cases (73.7%) were recognized for the improvement of their hoarseness. It took one to 28 months (average 10.4 months) to improve the voice disorder after surgery. In our cohort, 8.4% of patients who underwent systematic upper mediastinal lymph node dissection had hoarseness as a subjective symptom. However, 73.7% of patients who suffered from hoarseness and 62.5% of patients who were identified as having disorders of the vocal cords improved in more than two years.

VATS lobectomy, a standardised approach?

The article by French and colleagues (1) published in Annals of Cardiothoracic Surgery has the merit of being the first published article on the transition from multiple port video-assisted thoracic surgery (VATS) to single port surgery (S-VATS) in minimally invasive anatomic pulmonary resections. The authors have carefully designed and conducted a comparative study to evaluate the safety and feasibility of this transition and to assess its impact on intraoperative and early postoperative outcomes. They add to the existing literature a series of 50 consecutive S-VATS anatomical lung resections which were compared to an equal, historical and prospective cohort of multiple port VATS cases; all of them were performed at the same institution and by the same surgeon. Its main clinical message is that the transition from multiple port VATS to S-VATS lung resection is safe, efficient and with good surgical quality. However they failed in their attempt to find differences in perioperative outcomes between approaches, specifically in patient reported pain in favor of S-VATS.

Transition from multiple port to single port video-assisted thoracoscopic anatomic pulmonary resection: early experience and comparison of perioperative outcomes.

Single port thoracoscopy is an approach aimed at minimizing trauma to the chest wall during lung resection. The objectives of this study were to describe early experience in the transition from multiple port video-assisted thoracic surgery (VATS) to single port surgery (S-VATS) and to compare perioperative outcomes between approaches. Consecutive anatomic lung resections using S-VATS were reviewed and compared to a historical, prospective cohort of multiple port VATS cases. Outcomes analysis was focused on the use of operating room resources and postoperative recovery. Over 12 months, 50 S-VATS procedures were completed by one surgeon and compared to an equal number of VATS patients. The groups were similar in age, gender, BMI, comorbidity, tumor size and pulmonary function. There was no statistically significant difference in operative time. All tumors were completely resected (R0) and the median number of lymph nodes evaluated pathologically was equivalent {S-VATS=7 [4-10]; VATS=7 [4-10]; P=0.92}. There was no significant difference in conversion rate {S-VATS=2 (4%); VATS=1 (2%); P=0.56}. The median length of stay was similar in both groups {S-VATS=4 [3-7]; VATS=4 [3-7]; P=0.99}. There was no mortality and no significant difference in the rate of major complications {S-VATS=10/50 [20%]; VATS=5/50 [10%]; P=0.26}. There was no difference in patient reported pain as measured by a visual analog scale at 24 hours {S-VATS=4 [2-5]; VATS=4 [3-5]; P=0.63}. Early experience in the transition from multiple port VATS to S-VATS lung resection indicates that safety, efficiency and surgical quality are preserved. More long-term data are required. Alternative approaches to perform thoracoscopic lung resection should be carefully evaluated and compared to established minimally invasive techniques.

Video-assisted thoracic surgery in a Nigerian teaching hospital: Experience and challenges.

Video-assisted thoracic surgery (VATS) is well established. Its application in Nigeria has however been limited and not been reported. The aim of this study was to describe our institutional experience and challenges with VATS. This was a retrospective cross-sectional study of all patients that underwent VATS in our institution between March 2008 and June 2013. Data were extracted from a prospectively maintained database. Two hundred and sixty-one patients were assessed as potential VATS cases. VATS was initiated in 26 patients, but completed in 25 patients (9.6%) as there was one case of conversion of a planned VATS bullectomy due to the failure of one lung ventilation. There were 12 males and 13 females. Mean age was 40.7 ± 13.9 years. The indication was interstitial lung disease in 9 patients (36%), malignant pleural effusion in 6 patients (24%), spontaneous pneumothorax in 5 patients (20%), indeterminate pulmonary nodule in 2 patients (8%), pleural endometriosis in 2 patients (8%) and bronchogenic cyst in one patient (4%). Procedures performed were lung biopsy in 13 patients (52%), pleural biopsy and pleurodesis in 6 patients (24%), bullectomy and pleurodesis in 5 patients (20%) and excision of bronchogenic cyst in one patient (4%). Mean hospital stay was 4 ± 0.7 days. There were no complications and no mortalities. VATS is being performed in our institution with successful outcomes. The use of VATS in Nigeria is encouraged. The relatively high cost of VATS is, however, a major limitation to more widespread use.

Uniportal Videothoracoscopic Surgery: Our Indications and Limits.

We present our experience with uniportal videothoracoscopic surgery (VATS-U), examining its indications, limits, and results. Since January 2009, 66 patients underwent VATS-U for the following indications: pneumothorax (n = 25), lung nodule (n = 15; n = 10 with preoperative radiolocalization), wedge biopsy (n = 15), hyperhidrosis (n = 10), and chest wall schwannoma (n = 1). The conversion rate to conventional video-assisted thoracic surgery (VATS), postoperative pain, complications, residual paraesthesia, and hospitalization were analyzed. Operative time, postoperative pain, and paraesthesia were retrospectively compared with a cohort of 172 cases of conventional multiportal VATS, performed in the same period. Conversion to traditional VATS was necessary in two cases (pulmonary nodule, n = 1; pneumothorax, n = 1). The mean pain score was 0.8, the mean operation time was 42 minutes, and 10 patients had postoperative paraesthesia that lasted a mean of 7 days. No postoperative complications were reported, and the mean postoperative hospital stay was 3 days (range, 1-6 days). The comparison between the VATS-U and the standard multiportal VATS group showed in the VATS-U group a lower but not statistically significant pain score and paraesthesia as well as a lower and statistically significant operative time. Uniportal videothoracoscopic surgery has a wide range of indications: lung apex resections and pleurodesis for spontaneous pneumothorax treatment; pulmonary nodule assessment with or without preoperative localization; lung biopsy for interstitial diseases; unilateral or bilateral sympathectomy to treat hyperhidrosis; benign chest wall tumor evaluation. The limits of this technique are linked to pleural adhesions or lung nodules in difficult positions. In our experience, VATS-U results in minimal postoperative pain, allowing for fast functional recovery and a consequent short hospital stay; thus, we suggest that VATS-U is a valid alternative to traditional multiportal VATS for indications beyond cosmetic benefits. Prospective randomized trials are necessary to validate the advantages of uniportal VATS.

Long-Term Survival Outcomes of Video-assisted Thoracic Surgery (VATS) Lobectomy After Transitioning from Open Lobectomy

Open lobectomy continues to be more commonly performed than video-assisted thoracic surgery (VATS) lobectomy. We previously described the short-term safety of an approach for transitioning from open lobectomy to VATS. We now assess its long-term safety by evaluating survival results of the initial VATS cases after transition. From a prospective database, survival of stage I non-small cell lung cancer was compared between the first 40 VATS lobectomy and the 40 open lobectomy performed just before the transitioning to VATS. All patients underwent staging by positron emission tomographic scan and mediastinoscopy. Survival was estimated by the Kaplan-Meier method and compared by the log-rank test. Patient and intraoperative characteristics were not different between the two groups, except for operative time, which was longer for VATS (median 132 vs. 150min, p=0.023) and tumor size, which was smaller for VATS (median 2 vs. 2.5cm, p=0.002). There was no difference in morbidity and mortality. Median follow-up was 118months for the open group and 81months for the VATS group. The 5-year disease-free survival for stage IA (90% open vs. 97% VATS, p=0.439) and IB (74% open vs. 79% VATS, p=0.478) were not different. The 5-year overall survival for stage IA (91% open vs. 97% VATS, p=0.152) and IB (55% open vs. 67% VATS, p=0.198) were also not different. The transition from open to VATS lobectomy is safe with regards to both short-term morbidity and long-term survival. Surgeons currently performing open lobectomy should consider transitioning to the VATS procedure.

Preliminary results of anatomic lung resection using energy-based tissue and vessel coagulative fusion technology

Mechanical stapling devices have been established as the mainstay of therapy in the selective isolation and division of bronchial and vascular structures during anatomic lung resection. Few data are available regarding the application of energy-based tissue fusion technology during anatomic lung resection. In the present study, we evaluated the use of energy-based instruments for the division of the pulmonary arterial and venous branches during anatomic lung resection. Anatomic lung resection (segmentectomy or lobectomy) was performed using energy-based coagulative fusion technology. A low-profile jaw can be used to facilitate dissection in both open and video-assisted thoracic surgery cases, applying a seal 6 mm wide by 22 mm in length. Two energy applications were applied to the arterial and venous branches before vessel division. The bipolar tissue fusion system was used in 211 patients between 2008 and 2010 (104 lobectomies and 107 anatomic segmentectomies). Initially, we used a device with a smaller, curved jaw (n=12), producing a 3.3- to 4.7-cm seal. No arterial dehiscences and 2 partial venous dehiscences that were recognized and controlled intraoperatively occurred. For the remaining cases, we used a new device with a larger jaw that applied a seal 6 mm wide by 22 mm in length. No arterial or venous dehiscences (vessel size range, 0.4-1.2 cm) occurred. The bipolar tissue fusion system provided safe and reliable control of pulmonary arterial and venous branches during anatomic lung resection. The use of energy-based tissue fusion technology represents a reasonable alternative to mechanical stapling devices during anatomic lung resection.

Cirugía toracoscópica monoportal utilizando el instrumento SILS® como un método novedoso en el tratamiento quirúrgico del neumotórax

Single Incision Laparoscopic Surgery (SILS) has recently been used by general surgeons to perform cholecystectomies and pre-peritoneal hernia repairs with mesh using minimally invasive surgery, thus decreasing post-operative pain and a more cosmetic result of the surgery being obtained. We describe the first cases of video-assisted thoracic surgery (VATS) in spontaneous pneumothorax using the SILS system. There are no previous reports on the use of the SILS system in VATS for spontaneous pneumothorax. This system also allows us to obtain a more cosmetic surgical result, as well as decreasing the mean post-operative hospital stay and the need for analgesics to improve the post-operative pain.

The two-incision approach for video-assisted thoracoscopic lobectomy: an initial experience

The video-assisted thoracoscopic approach (video-assisted thoracic surgery (VATS)) to lobectomy for non-small-cell lung cancer (NSCLC) is not standardised. Although three to four incisions are usually made, with the right surgical technique, the operation can be successfully carried out using only two incisions. We have analysed retrospectively, the characteristics and postoperative evolution of patients undergoing VATS lobectomies using two ports. From June 2007 to November 2009, we carried out 131 major pulmonary resections by VATS, of which 40 (February 2009 to November 2009) were realised using only two incisions: one 1-cm incision through the 7th/8th intercostal space in the mid-axillary line, and a 3-5-cm anterior utility incision in the 5th intercostal space. The patients' mean age was 60.8±11.4 years (75% male, 25% female). The conversion rate was 10% (four patients). Of the remaining 36 cases, the diagnosis in six patients was benign, and in four was metastatic disease. Of the 26 cases with NSCLC, the most frequent stage was that of interactive application (IA) (58%) and histology mostly revealed adenocarcinoma (33%). Mean duration of surgery in the 36 resections completed by VATS was 168.6±54.0 min (range 80-300 min). The median chest tube duration was 2.5 days and the median length of stay in hospital was 3 days. There was no perioperative mortality in completed VATS cases, and no patient needed to be re-operated. Those patients with chronic obstructive pulmonary disease (COPD) needed longer hospital stays (p=0.046). Similarly, extreme cases of adhesion during surgery needed more days of thoracic drainage (p=0.040) and longer hospital stays (p=0.011), as well as displaying a higher percentage of postoperative complications (p=0.008). If the group of patients is divided in two periods (February to July 2009 and August to November 2009), more extended lymphadenectomies are observed among those performed during the latter period. VATS lobectomy with two incisions is a safe and reliable procedure producing good postoperative results. As we obtain more experience over time, results improve, especially in the performance of more extended lymphadenectomies.

Single Port Thorascopic Surgery Using the SILS ® Tool as a Novel Method in the Surgical Treatment of Pneumothorax

Single Incision Laparoscopic Surgery (SILS) has recently been used by general surgeons to perform cholecystectomies and pre-peritoneal hernia repairs with mesh using minimally invasive surgery, thus decreasing post-operative pain and a more cosmetic result of the surgery being obtained. We describe the first cases of video-assisted thoracic surgery (VATS) in spontaneous pneumothorax using the SILS system. There are no previous reports on the use of the SILS system in VATS for spontaneous pneumothorax. This system also allows us to obtain a more cosmetic surgical result, as well as decreasing the mean post-operative hospital stay and the need for analgesics to improve the post-operative pain.

Left cardiac sympathetic denervation for the treatment of long QT syndrome and catecholaminergic polymorphic ventricular tachycardia using video-assisted thoracic surgery

Long QT syndrome (LQTS) and catecholaminergic polymorphic ventricular tachycardia (CPVT) are two of the most common, potentially lethal, cardiac channelopathies. Treatment strategies for the primary and secondary prevention of life-threatening polymorphic ventricular tachycardia/fibrillation include pharmacotherapy with beta-blockers, implantable cardioverter defibrillators, and left cardiac sympathetic denervation (LCSD). This study sought to report our institutional experience with LCSD using video-assisted thoracic surgery (VATS). From November 2005 through November 2008, 20 patients (8 female, average age at surgery 9.1 +/- 9.7 years, range 2 months to 42 years) underwent LCSD via either a traditional approach (N = 2) or VATS (N = 18). A total of 12 patients had genotype-positive LQTS (7 LQT1, 2 LQT2, 1 LQT3, 2 LQT1/LQT2), 2 had JLNS, 4 had genotype-negative LQTS, and 2 had CPVT1. Electronic medical records were reviewed for patient selection, perioperative complications, and short-term outcomes. LCSD was performed as a secondary prevention strategy in 11 patients (8 LQTS patients, average QTc 549 ms) and as primary prevention in 9 patients (average QTc 480 ms). There were no perioperative complications, including no intraoperative ectopy, no uncontrolled hemorrhage, and no VATS cases requiring conversion to a traditional approach. The average length of available follow-up was 16.6 +/- 9.5 months (range 4 to 40 months). Among the 18 patients who underwent VATS-LCSD, the average time from operation to dismissal was 2.6 days (range 1 day to 15 days), the majority being next-day dismissals. Among those receiving LCSD as secondary prevention, there has been a marked reduction in cardiac events. We present a series of 20 patients with LQTS and CPVT who underwent LCSD, 18 using VATS. The minimally invasive VATS surgical approach was associated with minimal perioperative complications, including no intraoperative ectopy and excellent immediate and short-term outcomes. Videoscopic denervation surgery, in addition to traditional LCSD, offers a safe and effective treatment option for the personalized medicine required for patients with LQTS/CPVT.

Optimal Technique for Primary Spontaneous Pneumothorax in Children

Surgery| March 01 2009 Optimal Technique for Primary Spontaneous Pneumothorax in Children AAP Grand Rounds (2009) 21 (3): 29. https://doi.org/10.1542/gr.21-3-29 Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Facebook Twitter LinkedIn MailTo Tools Icon Tools Get Permissions Cite Icon Cite Search Site Citation Optimal Technique for Primary Spontaneous Pneumothorax in Children. AAP Grand Rounds March 2009; 21 (3): 29. https://doi.org/10.1542/gr.21-3-29 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search toolbar search search input Search input auto suggest filter your search All PublicationsAll JournalsAAP Grand RoundsPediatricsHospital PediatricsPediatrics In ReviewNeoReviewsAAP NewsAll AAP Sites Search Advanced Search Topics: primary spontaneous pneumothorax, thoracic surgery, video-assisted, pleurodesis, blister Source: Bialas R, Weiner T, Phillips D. Video-assisted thoracic surgery for primary spontaneous pneumothorax in children: is there an optimal technique? J Pediatr Surg. 2008;43(12):2151–2155; doi:10.1016/j.jpedsurg.2008.08.041 To assess outcomes and compare different techniques using video-assisted thoracic surgery (VATS) for the treatment of primary spontaneous pneumothorax (PSP) in children, investigators from the University of North Carolina reviewed the records of 32 children treated from 1999 to 2007 by a single group of surgeons. The indications for VATS were either presence of persistent air leak after placement of a chest tube, recurrent ipsilateral pneumothorax, or occurrence of a contralateral pneumothorax. Children with underlying lung disease (such as cystic fibrosis), trauma, or cancer were excluded. The surgical technique via thoracoscopy was determined by the operating surgeon. Bleb resection was performed using an endoscopic stapling device. Pleurodesis was done either mechanically via cautery scratch pad abrasion and/or pleural stripping, or chemically by coating the pleura with a fine dust of sterile talc powder. A chest tube was placed at the conclusion of the procedure and only removed when air leak ceased and postoperative chest radiographs showed no residual pneumothorax. The study population consisted of 32 patients who had 41 procedures. Mean age of patients in the study was 16.5 years; 25 were male. Overall the mean postoperative air leak duration was 2.7 days with a prolonged air leak of >7 days in five patients. Mean hospital length of stay after surgery was 5.0 days. The mean postoperative chest tube duration was 5.1 days. Blebs, mostly upper lobe, were identified during 95% of VATS procedures. Among the different surgical techniques, patients treated with thoracoscopic blebectomy and mechanical pleurodesis (n=31) had the shortest length of stay (mean of 4.3 days). Seven of the 32 patients (22%) subsequently developed contralateral PSP requiring VATS. Two patients developed recurrent ipsilateral PSP requiring VATS within one year of the original procedure; both were found to have blebs not originally seen and in the lower lobes. The failure rate of VATS cases in preventing future pneumothorax was 5% (2/39). Blebectomy plus mechanical pleurodesis led to five minor recurrences which did not require repeat VATS and were successfully treated non-operatively. No major or minor recurrences were seen in the group treated with blebectomy and chemical pleurodesis (n=6). The authors conclude that both chemical and mechanical pleurodesis with blebectomy are associated with acceptable patient outcomes. Dr. Cavett has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device. PSP usually occurs in healthy adolescents without other lung disease.1 Recent studies have shown that rapid adolescent linear growth of the thorax compared with horizontal growth is likely to cause increase in negative pressure at the apex of the lung, which may lead to subpleural bleb formation and subsequent PSP upon rupture.1 Nonoperative treatment with observation as an inpatient includes needle aspiration and/or tube thoracostomy. This conservative therapy has been associated with a recurrence... You do not currently have access to this content.