Video-assisted Thoracoscopy Research Articles

Intrapericardial Ectopic Thyroid Arising From the Ascending Aorta

A 68-year-old woman with dyspnea, recurrent chest pain, and paroxysmal atrial fibrillation had, as indicated by chest computed tomography, a 42 × 44 × 53 mm mediastinal solid lesion with fluid cystic areas compressing the right atrium (Figure 1 [Ao, ascending aorta; At, right atrium; M, intrapericardial mass]), with a maximum standard uptake value of 1.5 at positron emission tomography scan. Considering the site of the mass and the radiologic and metabolic features, transthoracic computed tomography-guided needle biopsy was not performed, and surgical removal of the mass through right video-assisted thoracoscopy was scheduled instead.

Response to pembrolizumab in a patient with primary lung adenocarcinoma originated from indium lung

BackgroundIndium is a metal used as a compound called indium-tin oxide for liquid crystal display. Its inhalation causes lung toxicity, resulting in a new occupational lung disease called indium lung. Although the carcinogenicity of indium has been reported in an animal model, its carcinogenicity in humans is unknown.Case presentationThis is the first reported case of a primary lung cancer originating from indium lung. In this report, we describe a 46-year-old man with interstitial pneumonia-type indium lung diagnosed 16 years ago. The initial symptom was left chest pain, and computed tomography showed a mass adjacent to the aorta with left pleural effusion. Specimens collected using video-assisted thoracoscopy revealed an adenocarcinoma with a high expression of programmed cell death-ligand 1 (cT4N0M1a stage IVA). Although the lesions showed a remarkable aggressive nature, the patient benefited from pembrolizumab, a monoclonal antibody against programmed cell death 1, which was used as second-line therapy for 2 years.ConclusionsIt is important for clinicians to be aware of lung cancer development in indium-exposed workers or in patients with indium lung, as this could have an aggressive behavior. Treatment with immune checkpoint inhibitors is an option even in patients with interstitial pneumonia-type indium lung.

Feasibility and Advantages of a Modified Subxiphoidal Video-Assisted Thoracoscopy Procedure Compared to Established Traditional Video-Assisted Thoracoscopy Procedures in Intercostal Access

Minimally invasive thoracic surgical techniques are under continual development, especially the subxiphoidal approach, which until recently could only be done in a few centers across the world, due mainly to the many challenges associated with this method. There are ongoing discussions around minimally invasive methods including the instrument sizes and types, the incision position and expected outcomes. Robotic surgery using the subxiphoidal approach is still under discussion and is expected to be one of the methods of the future.

Enhanced Recovery Protocol for Boerhaave Syndrome: Our Experience

From its first description in 1724, the diagnosis and management of Boerhaave syndrome remain challenging till date. We share our management protocol for enhanced recovery in patients presenting more than 24 h following spontaneous esophageal rupture at a tertiary care center in India. A retrospective review of all patients diagnosed with Boerhaave syndrome and managed by the chief investigator in the Department of General Surgery at our institution in the last 3 years (2016–2019) was performed. After hemodynamic stabilization, an intercostal drainage (ICD) tube was inserted on the side of empyema to drain the collection. This was followed by an upper GI (UGI) endoscopy to confirm the site and size of perforation. No attempt at a therapeutic intervention was made during the procedure. A triple lumen tube was inserted under imaging at the same time for gastric decompression and advanced to the jejunum for enteric feeding. In patients with sepsis and persistent collection, a video-assisted thoracoscopic (VATS) drainage was performed. Twelve patients were admitted for Boerhaave syndrome. ICD was inserted for 9 patients and managed by us as per our enhanced recovery protocol. Three patients referred from other setup came with an ICD in situ showing signs of sepsis. Debridement and drainage by VATS was performed for these patients. No patient required prolonged ventilatory assistance, and there was no mortality. Gastric decompression, adequate and timely drainage of collection/s, and enteral nutrition form the pillars of enhanced recovery protocol for management of Boerhaave syndrome.

Energy devices safety and impact on video-assisted thoracoscopic lung lobectomy postoperative course: monopolar electrocautery versus ultrasonic dissector

BackgroundThis study aims to compare safety and impact of monopolar electrocautery and ultrasonic dissector (Harmonic ACE Plus®) on postoperative short-term outcomes after video-assisted thoracoscopic (VATS) lobectomy and lymphadenectomy for lung cancer.MethodsWe analyzed the prospectively collected data of 140 consecutive patients [59% male; median age: 71(IQR:62–76) years] undergoing VATS lobectomy and lymphadenectomy in our institution between October 2016 and November 2019. Patients were divided in two groups based on device used: monopolar electric hook in 79 cases (Group A); ultrasonic dissector in 61(Group B). Energy instrument-related intraoperative accidents, hemothorax/chylothorax incidence, total pleural effusion volume at 48 postoperative hours and chest tube duration were compared between groups. Multivariable analysis was performed to test energy device as possible independent risk factor either for increased pleural effusion volume or for prolonged chest tube duration.ResultsNo intraoperative accidents due to energy device occurred. No hemothorax was recorded. Postoperative chylothorax incidence was slightly higher in Group A (2.5% vs 0%; p-value = 0.21). Total pleural effusion volume at 48 h was significantly higher in Group B: 400 (285–500) vs 255 (150–459) ml (p-value = 0.005). Chest tube duration was similar in the two groups: 5 (3–9) vs 5 (3–8) days (p-value = 0.77). At multivariable analysis the energy device used was not associated with increased pleural effusion volume (p-value = 0.43) nor with prolonged chest tube duration (p-value = 0.28).ConclusionsMonopolar electrocautery and Harmonic ACE Plus® were safe and had a similar impact on short-term outcomes after VATS lobectomy and lymphadenectomy, suggesting that energy devices choice could be left to surgeon’s preference.

Feasibility investigation of near-infrared fluorescence imaging with intravenous indocyanine green method in uniport video-assisted thoracoscopic anatomical segmentectomy for identifying the intersegmental boundary line.

ObjectivesTo investigate the perioperative outcomes of patients who underwent uniport video‐assisted thoracoscopic (VATS) segmentectomy for identifying the intersegmental boundary line (IBL) by the near‐infrared fluorescence imaging with the intravenous indocyanine green (ICG) method or the modified inflation‐deflation (MID) method and assess the feasibility and effectiveness of the ICG fluorescence (ICGF)‐based method.MethodsWe retrospectively analyzed the perioperative data in total 198 consecutive patients who underwent uniport VATS segmentectomy between February 2018 and August 2020. With the guidance of a preoperative imaging interpretation and analysis system (IQQA‐3D), the targeted segment structures could be precisely identified and dissected, and then the IBL was confirmed by the ICGF‐based method or the MID method. The clinical effectiveness and postoperative complications of the two methods were evaluated.ResultsAn IBL was visible in 98% of patients in the ICGF‐based group, even with low doses of ICG. The ICGF‐based group was significantly associated with a shorter IBL clear presentation time (23.6 ± 4.4 vs. 23.6 ± 4.4 s) (p < 0.01) and operative time (89.3 ± 31.6 vs. 112.9 ± 33.3 min) (p < 0.01) compared to the MID group. The incidence of postoperative prolonged air leaks was higher in the MID group than in the ICGF‐based group (8/100, 8% vs. 26/98, 26.5%, p = 0.025). There were no significant differences in bleeding volume, chest tube duration, postoperative hospital stays, surgical margin width, and other postoperative complications.ConclusionThe ICGF‐based method could highly accurately identify the IBL and make anatomical segmentectomy easier and faster, and therefore has the potential to be a feasible and effective technique to facilitate the quality of uniport VATS segmentectomy.

Outcomes of surgical resection after neoadjuvant chemoimmunotherapy in locally advanced stage IIIA non-small-cell lung cancer.

This analysis aimed to evaluate perioperative outcomes of surgical resection following neoadjuvant treatment with chemotherapy plus nivolumab in resectable stage IIIA non-small-cell lung cancer. Eligible patients received neoadjuvant chemotherapy (paclitaxel + carboplatin) plus nivolumab for 3 cycles. Reassessment of the tumour was carried out after treatment and patients with at least stable disease as best response underwent pulmonary resection. After surgery, patients received adjuvant treatment with nivolumab for 1 year. Surgical data were collected from the NADIM database and patient charts were reviewed for additional surgical details. Among 46 patients who received neoadjuvant treatment, 41 (89.1%) underwent surgery. Two patients rejected surgery and 3 did not fulfil resectability criteria. There were 35 lobectomies (85.3%), 3 of which were sleeve lobectomies (9.4%), 3 bilobectomies (7.3%) and 3 pneumonectomies (7.3%). Video-assisted thoracoscopy was the initial approach in 51.2% of cases, with a conversion rate of 19% (n = 4). There was no operative mortality at either 30 or 90 days. The most common complications were prolonged air leak (n = 8), pneumonia (n = 5) and arrhythmia (n = 4). Complete resection (R0) was achieved in all patients who underwent surgery, downstaging was observed in 37 patients (90.2%) and major pathological response in 34 patients (82.9%). Surgical resection following induction therapy with chemotherapy plus nivolumab appears to be safe and offers appropriate oncological outcomes. Perioperative morbidity and mortality rates in our study were no higher than previously reported in this setting. A minimally invasive approach is, therefore, feasible.

Bronchoalveolar Lavage Fluid Reflects a TH1-CD21low B-Cell Interaction in CVID-Related Interstitial Lung Disease.

BackgroundAbout 20% of patients with common variable immunodeficiency (CVID) suffer from interstitial lung disease (ILD) as part of a systemic immune dysregulation. Current understanding suggests a role of B cells in the pathogenesis based on histology and increased levels of BAFF and IgM associated with active disease corroborated by several reports which demonstrate the successful use of rituximab in CVID-ILD. It is debated whether histological confirmation by biopsy or even video-assisted thoracoscopy is required and currently not investigated whether less invasive methods like a bronchoalveolar lavage (BAL) might provide an informative diagnostic tool.ObjectiveTo gain insight into potential immune mechanisms underlying granulomatous and lymphocytic interstitial lung disease (GLILD) and to define biomarkers for progressive ILD by characterizing the phenotype of B- and T-cell populations and cytokine profiles in BAL fluid (BALF) of CVID-ILD compared to sarcoidosis patients and healthy donors (HD).MethodsSixty-four CVID, six sarcoidosis, and 25 HD BALF samples were analyzed by flow cytometric profiling of B- and T-cells and for cytokines by ELISA and Multiplexing LASER Bead technology.ResultsBoth sarcoidosis and CVID-ILD are characterized by a predominantly T-cell mediated lymphocytosis in the BALF. There is an increase in T follicular helper (TFH)-like memory and decrease of regulatory T cells in CVID-ILD BALF. This TFH-like cell subset is clearly skewed toward TH1 cells in CVID-ILD. In contrast to sarcoidosis, CVID-ILD BALF contains a higher percentage of B cells comprising mostly CD21low B cells, but less class-switched memory B cells. BALF analysis showed increased levels of APRIL, CXCL10, and IL-17.ConclusionUnlike in sarcoidosis, B cells are expanded in BALF of CVID-ILD patients. This is associated with an expansion of TFH- and TPH-like cells and an increase in APRIL potentially supporting B-cell survival and differentiation and proinflammatory cytokines reflecting not only the previously described TH1 profile seen in CVID patients with secondary immune dysregulation. Thus, the analysis of BALF might be of diagnostic value not only in the diagnosis of CVID-ILD, but also in the evaluation of the activity of the disease and in determining potential treatment targets confirming the prominent role of B-cell targeted strategies.

Video Assisted Thoracoscopy as a therapeutic modality in evacuating retained or clotted haemothoraces.

To determine the role of video-assisted thoracoscopy for evacuating retained / clotted haemothoraces to minimise the duration of chest tube drainage and length of hospital stay. The prospective cohort study was conducted from July 2019 to February 2020 at the Department of Thoracic Surgery, Jinnah Postgraduate Medical Centre, Karachi, and comprised consecutive patients who underwent video-assisted thoracoscopy for retained or clotted haemothoraces. Outcome was measured as evacuation of retained haemothoraces resulting in partial or complete lung expansion and length of hospital stay. Data was analysed using SPSS 22. Of the 160 patients, 128(80%) were males and 32(20%) were females. The overall mean age was 36.08±11.91 years. Overall, 103(64.37%) patients underwent the procedure in within 4-7 days, and 57(35.63%) within 8-14 days. Complete lung expansion was achieved in 95(71.9%) patients when the procedure was performed in the first week, and in 37(28.1%) when performed in the second week (p=0.01). Within the first week, 87(84.4%) patients had shorter duration of stay compared to patients having undergone the procedure in the second week (p=0.001). Relapse of collection was found in 21(13.7%) patients. Video-assisted thoracoscopy was found to be a safe, reliable and effective technique for the evacuation of retained haemothorax in haemodynamically stable patients. Early intervention resulted in better outcome.

Chronic chest pain and paresthesia after video-assisted thoracoscopy for primary pneumothorax.

BackgroundThis study aims to identify clinical and surgical risk factors for chronic chest pain and paresthesia after video thoracoscopic surgery for primary spontaneous pneumothorax.MethodsWe retrospectively collected the data of 1,178 consecutive patients <40-years-old undergoing video thoracoscopic surgery for primary spontaneous pneumothorax in 9 Italian centers in 2007–2017. Cases with <2-month follow-up were excluded, leaving 920 patients [80% male; median age: 21 (IQR, 18–27) years] for statistical analysis. The following risk factors for chronic chest pain and chronic paresthesia were assessed by univariable and multivariable Cox regression model: age, gender, cannabis smoking, video thoracoscopy ports number, pleurodesis technique (partial pleurectomy/pleural electrocauterization/pleural abrasion/talc poudrage), chest tube size (24/28 F), postoperative chest tube stay.ResultsBlebs/bullae resection with pleurodesis was performed in 732 (80%) cases; pleurodesis alone in 188 (20%). During a median follow-up of 68 (IQR: 42–95) months, chronic chest pain developed in 8% of patients, chronic chest paresthesia in 22%; 0.5% of patients regularly assumed painkillers. Chronic chest pain was independently associated with partial pleurectomy/pleura abrasion (P<0.001) and postoperative chest tube stay (P=0.019). Chronic chest paresthesia was independently associated with pleurodesis by partial pleurectomy (P<0.001), chest tube stay (P=0.035) and 28 F chest tube (P<0.001).ConclusionsAfter video thoracoscopic surgery for primary spontaneous pneumothorax, the incidence of chronic chest pain and paresthesia was significantly lower when pleurodesis was performed by pleural electrocauterization or talc poudrage, and chest tube was removed early. A 24 F chest tube was associated with lower risk of chronic chest paresthesia.

Multiple traumas with coagulation abnormality treated by video-assisted thoracoscopy

Multiple traumas with coagulation abnormality treated by video-assisted thoracoscopy

Morbidity after thoracoscopic resection of congenital pulmonary airway malformations (CPAM): single center experience over a decade.

Video-assisted thoracoscopic (VATS) resection of CPAM in children is an established, albeit controversial strategy for its management. We report a 10-year single center experience. All children underwent VATS (2008-2017) and their current status was reviewed. Patients were grouped: 'symptomatic-P' (if parents reported recurrent lower respiratory tract infections etc.) or 'symptomatic-S' (neonates presenting with respiratory distress/difficulty) or 'asymptomatic'. 73 children, aged 10m (4d-14yrs) underwent VATS; a neonate as an emergency ('symptomatic-S') and all others electively. The lesion was unilateral in all but one case. Histologically none were malignant. Of the elective 72 cases, 7 (10%) required conversion to open thoracotomy. Twenty (27.7%) were 'symptomatic-P' and the duration of surgery when compared to 'asymptomatic' children was longer 269 (range 129-689) versus 178 (range 69-575) minutes (P = 0.01). Post operatively, 8 children (11%) had a grade III/IV (Clavien-Dindo) complication; persistent air leak/pneumothorax (n = 5), chylothorax (n = 1), pleural effusion (n = 1) and seizure/middle cerebral artery thrombosis (n = 1). There was no mortality. Twenty-four children (33.3%) were reported 'symptomatic-P' post-surgery after a median follow up of 2.18years. The surgical intervention had no impact on 'symptomatic-P' status (P = 0.46). The risks of surgery may outweigh benefit in asymptomatic children. CLINICALTRIALS. NCT04449614.

Long-term outcomes of thoracoscopic thymectomy for thymoma stage i-ii

To compare long-term outcomes of video-assisted thoracoscopic (VATS) and conventional open surgery in patients with early-stage (Masaoka stage I-II) thymic malignancies. Retrospective study included patients after VATS and open thymectomy for the period 2000-2019. Long-term outcomes were analyzed. VATS thymectomy was performed in 53 (54.1%) patients, open thymectomy - in 45 (45.9%) cases. Median follow-up period was 66.9 months. Overall 5-year survival was 89.8% and 97% in the Open and VATS groups, respectively (p=0.076). Disease-free survival rates were 79.6% and 86.6% (p=0.279), respectively. There was no significant difference in cumulative incidence of recurrence (13.3% vs 7.5%, p=0.505). Age <50 years and tumor size >5 cm were the independent risk factors of recurrence. VATS thymectomy is an effective approach ensuring similar long-term outcomes in patients with early stages of thymic malignancies.

Video-Assisted Thoracoscopy For Penetrating Cardiac Box Injury in Stable Patients.

IntroductionIn high-volume trauma centers, especially in developing countries, penetrating cardiac box injuries are frequent. Although many aspects of penetrating chest injuries have been well established, video-assisted thoracoscopy is still finding its place in cardiac box trauma and algorithmic approaches are still lacking. The purpose of this manuscript is to provide a streamlined recommendation for penetrating cardiac box injury in stable patients.MethodsLiterature review was carried out using PubMed/MEDLINE and Google Scholar databases to identify articles describing the characteristics and concepts of penetrating cardiac box trauma, including the characteristics of tamponade, cardiac ultrasound, indications and techniques of pericardial windows and, especially, the role of video-assisted thoracoscopy in stable patients.ResultsPenetrating cardiac box injuries, whether by stab or gunshot wounds, require rapid surgical consultation. Unstable patients require immediate open surgery, however, determining which stable patients should be taken to thoracoscopic surgery is still controversial. Here, the classification of penetrating cardiac box injury used in Colombia is detailed, as well as the algorithmic approach to these types of trauma.ConclusionAlthough open surgery is mandatory in unstable patients with penetrating cardiac box injuries, a more conservative and minimally invasive approach may be undertaken in stable patients. As rapid decision-making is critical in the trauma bay, surgeons working in high-volume trauma centers should expose themselves to thoracoscopy and always consider this possibility in the setting of penetrating cardiac box injuries in stable patients, always in the context of an experienced trauma team.

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Pulmonary tuberculosis surgery is characterized by a number of aspects associated with adhesions in the pleural cavity, fibrosis of the lung root, destruction of the parenchyma, which contribute to the development of intra- and postoperative complications such as residual pleural cavity and reactivation of tuberculosis in operated lung due to compensatory tissue distortion. Aim: to improve video-assisted lung resection (VATS) in tuberculosis patients with the presence of pleural cavity obliteration. Materials and methods. The developed method of VATS for tuberculosis patients with pleural cavity obliteration is based on separate intubation of right and left main bronchi for mechanical ventilation of one lung, placement of thoracic port, performing revision of pleural cavity using video-assisted thoracoscopy, performing mini-thoracotomy and resection of lung with separate treatment of anatomical structures in required volume by means of disposable stapler or regular open thoracotomy instruments, pleural cavity draining and layered wound closure. Computed tomography of chest is performed during the operation in order to assess the extent and severity of pleural adhesions and to locate safe position of thoracic ports. Hydraulic needle preparation of parietal pleura is performed in severe adhesions area. Hemorrhage is treated using hemostatic plate Surgicel Fibrillar made of restored cellulose. Phrenicotripsy, pleural cavity drainage and, finally, artificial pneumoperitoneum are performed. The proposed method of video-assisted lung resection was used in 41 patients, 25 patients underwent video-assisted resection according to the prototype method. Results. The proposed method reduced duration of the surgical intervention by 52.7 minutes; the frequency of intraoperative complications by 14.4%; the incidence of postoperative complications by 14.2; the duration of patient�s stay at the hospital by 5.8 days and increased of overall treatment efficiency by 14.5%. The proposed method of VATS for patients with pulmonary tuberculosis and pleural cavity obliteration is safe, effective, simple to implement and can be performed at thoracic surgery departments of various pulmonary hospitals of city and regional level. Key words: pulmo

Gamma-Glutamyl Transpeptidase to Platelet Ratio Is a Novel and Independent Prognostic Marker for Resectable Lung Cancer: A Propensity Score Matching Study.

Background: We report this propensity score matching (PSM) analysis to assess prognostic roles of preoperative gamma-glutamyl transpeptidase to platelet ratio (GPR) in video-assisted thoracoscopic (VATS) lobectomy for stage I-II non-small-cell lung cancer (NSCLC).Methods: The PSM-based study conducted on our single-center prospectively collected database from January 2014 to August 2015 provided Kaplan–Meier survival analyses using the log-rank test to discriminate differences in overall survival (OS) and disease-free survival (DFS) between patients stratified by preoperative GPR.Results: Our study includes 379 patients diagnosed with operable primary stage I-II NSCLC. A GPR value at 0.16 was recognized as the optimal cutoff point for prognostic prediction. Both OS and DFS of patients with GPR ≥0.16 were significantly shortened when compared to those of patients with GPR <0.16. Patients with GPR ≥0.16 had significantly lower 5-year rates of OS and DFS than those of patients with GPR <0.16 (P <0.001). Significant associations between GPR and unfavorable survival still are validated in the PSM analysis. Multivariable Cox regression models on both the entire cohort and the PSM cohort consistently demonstrated that an elevated preoperative GPR could be an independent prognostic marker for both OS and DFS of resectable NSCLC.Conclusions: GPR may be an effective and noninvasive prognostic biomarker in VATS lobectomy for surgically resectable NSCLC.

Study on the Correlation between Syndrome Differentiation of Malignant Pleural Effusion Treated by External Treatment of Traditional Chinese Medicine and Immunohistochemistry of Biopsy Tissue Based on Medical Video-assisted Thoracoscope

Study on the Correlation between Syndrome Differentiation of Malignant Pleural Effusion Treated by External Treatment of Traditional Chinese Medicine and Immunohistochemistry of Biopsy Tissue Based on Medical Video-assisted Thoracoscope

Erratum to: Contra: thoracic epidural anesthesia for video-assisted thoracoscopy

Ein Erratum zu dieser Publikation wurde veröffentlicht: https://doi.org/10.1007/s00101-020-00840-4

Minimizing postoperative pulmonary complications in thoracic surgery patients.

Quantification and optimization of perioperative risk factors focusing on anesthesia-related strategies to reduce postoperative pulmonary complications (PPCs) after lung and esophageal surgery. There is an increasing amount of multimorbid patients undergoing thoracic surgery due to the demographic development and medical progress in perioperative medicine. Nevertheless, the rate of PPCs after thoracic surgery is still up to 30-50% with a significant influence on patients' outcome. PPCs are ranked first among the leading causes of early mortality after thoracic surgery. Although patients' risk factors are usually barely modifiable, current research focuses on procedural risk factors. From the surgical position, the minimal-invasive approach using video-assisted thoracoscopy and laparoscopy leads to a decreased rate of PPCs. The anesthesiological strategy to reduce the incidence of PPCs after thoracic surgery includes neuroaxial anesthesia, lung-protective ventilation, and goal-directed hemodynamic therapy. The main anesthesiological strategies to reduce PPCs after thoracic surgery include the use of epidural anesthesia, lung-protective ventilation: PEEP (positive end-expiratory pressure) of 5-8 mbar, tidal volume of 5 ml/kg BW (body weight) and goal-directed hemodynamics: CI (cardiac index) ≥ 2.5 l/min per m2, MAD (Mean arterial pressure) ≥ 70 mmHg, SVV (stroke volume variation) < 10% with a total amount of perioperative crystalloid fluids ≤ 6 ml/kg BW (body weight) per hour.

Uniportal VATS Lobectomy and Decortication: Not an Everyday Occurrence.

Management of trapped lung with an underlying lung lesion and hydropneumothorax remains controversial. Furthermore, Aspergillus empyema and aspergilloma are rare pathologies for which uniportal video-assisted thoracoscopic (VATS) surgical management remains controversial. We present a young patient referred to our service after recent hospitalization for pneumonia. The patient was found to have a chronic effusion with a right lower lobe cystic parenchymal lesion and was taken to the operating room. The patient underwent right uniportal VATS surgery with evacuation of empyema, total pulmonary decortication, and right lower lobectomy. His postoperative course was unremarkable, and he was discharged home. Postoperative workup demonstrated lymphocyte variant hypereosinophilia. He continues to follow with thoracic surgery at the time of this report and remains asymptomatic. We conclude that uniportal VATS is a most minimally invasive, safe, and efficient approach for management of complex intrathoracic pathology including total pulmonary decortication and lobectomy.