Video-assisted Thoracoscopic Approach Research Articles

Video-assisted thoracoscopic transdiaphragmatic liver resection for hepatocellular carcinoma

Because of technical complexity, concern for vascular control, and uncertainty in regard to oncologic outcome, the application of minimally invasive techniques to liver surgery has been slower than in most other abdominal procedures. This is despite well-known advantages with respect to postoperative pain, length of hospitalization, and recovery time. Although laparoscopic liver surgery has recently become more common, the majority of laparoscopic liver resections comprise anterolateral wedge resections and left lateral sectorectomies. Laparoscopic resections of the posterosuperior segments are more difficult and few reports are available in the literature. Compared to laparoscopy, gaining access to tumors in the dome of the liver may be more easily obtained via thoracoscopy, thereby preserving the benefits of minimally invasive surgery. This technical report describes two cases of hepatocellular carcinoma in segments VII and VIII resected via a video-assisted thoracoscopic transdiaphragmatic approach.

Thoracoscopic management of spontaneous pneumothorax due to azygos lobe bullae

A 22-year-old man presented with recurrent right-sided spontaneous pneumothorax caused by rupture of azygos lobe bullae. Surgical management was successfully completed using a video-assisted thoracoscopic approach. Resection of the bullae harboring azygos lobe and subsequent pleurodesis were performed, sparing the meso-azygos and azygos vein.

A Novel Retrograde Laser Extraction Technique Using a Transatrial Approach

Background— The use of percutaneous lead extraction techniques in a patient with extracardiac or protruding atrial leads could have disastrous consequences. Traditionally, the management of these patients has included a median sternotomy. We describe a minimally invasive technique that involves a transatrial, retrograde laser lead extraction using a video-assisted thoracoscopic approach. Methods and Results— Between January 2004 and June 2009, 14 patients with severed leads at the clavicle and extracardiac leads or lead-caused erosions of the atrial wall were identified through chest radiograph and CT scan. There were 9 men and 5 women aged 19 to 91 years (mean age, 69.71±20.67 years). Ten devices were pacemakers, and 4 were defibrillators. Indications for extraction were 12 infections and 2 malfunctions. Mean ejection fraction was 42±17.67% (range, 10% to 65%). Time of implanted leads was 93.69±51.88 months (range, 33 to 213 months). Laser sheaths size were 12 F (7.1%), 14 F (85.7%), and 16 F (7.1%). A right-side thoracoscopy was performed under general anesthesia. A retrograde laser sheath maneuver was performed, freeing the lead from any adhesions. The lead was removed and the incision closed. One patient experienced a pleural effusion. There was no mortality, and all patients were alive and well at 1-month follow-up. Conclusions— Transatrial, retrograde laser lead extraction is a safe and effective procedure. This procedure may provide an excellent alternative to open sternotomy.

Minimally invasive approaches for lung lobectomy – from VATS to robotic and back!

BACKGROUND: Recently, minimally invasive approaches for pulmonary lobectomy have gained increasing interest and acceptance. Besides, the "conventional" video-assisted thoracoscopic (VATS) approach, the robotic technique with the da Vinci™ surgical system has been evaluated by different groups. METHODS: An appraisal of both approaches is given based on profound personal experiences and with reflexion of the current literature. RESULTS: Both techniques have been proven to be feasible and safe. Operating times and costs are higher with the robotic approach, without proven advantages over conventional VATS. Long-term follow-up data support the oncologic accuracy of the VATS approach but are still lacking for the robotic approach. CONCLUSIONS: The robotic approach provides no proven benefits over the conventional thoracoscopic approach and is thus not recommended for pulmonary lobectomy.

Video-Assisted Thoracoscopic Repair of a Lung Hernia in a Child

Pulmonary intercostal hernias are extremely rare. They have been reported to occur in children after blunt trauma to the chest wall as a result of disruption of intercostal muscle fibers. We present a case of a left anterior chest lung hernia caused by blunt handlebar chest trauma in a 13-year-old boy treated with placement of a mesh using a video-assisted thoracoscopic approach.

Hybrid Video-Assisted Thoracic Surgery-Robotic Minimally Invasive Right Upper Lobe Sleeve Lobectomy

Video-assisted thoracoscopic (VATS) lobectomy has been demonstrated to be safe and feasible. However, only a few reports exist on minimally invasive sleeve lobectomy. In most of these, bronchial anastomoses were accomplished in an open surgical technique through a minithoracotomy. We report on a combined robotic and VATS approach for a true minimally invasive right upper sleeve lobectomy. To our knowledge it is the first report of this kind. A 30-year-old female patient presented with a low grade neuroendocrine tumor occluding the orifice of the right upper lobe bronchus. A complete minimally invasive right upper sleeve lobectomy was performed. Dissection and individual control of the right upper lobe pulmonary vessels was performed through three 1.5 to 2 cm incisions by means of conventional VATS. The specimen was retrieved through the upper thoracocentesis, which was enlarged to 4.5 cm. For airway reconstruction, a bronchial anastomosis between the right intermediate and the right main bronchus was performed with the da Vinci robot through the same incisions. Intraoperative blood loss was minimal and total operative time was 364 minutes. The postoperative course was uneventful. Chest X-rays showed no sign of atelectasis. The chest tube was removed on postoperative day 9 due to prolonged pleural effusion. Bronchoscopy on postoperative day 14 showed a patent right airway and a well healing anastomosis. The patient was discharged on postoperative day 15. The da Vinci robot provides a benefit in more complex thoracic procedures like pulmonary sleeve resections. It is an ideal tool to perform delicate surgical maneuvers in vulnerable and difficult to reach anatomic areas. The study of the literature shows that VATS sleeve lobectomy is being performed in dedicated centers only with a low morbidity.

Video-assisted thoracic surgery lobectomy: 3-year initial experience with 200 cases

To analyse the evolution of the video-assisted thoracoscopic (VATS) approach for lobectomy and results during the first 3 years of program. From 1(st) July-2007 to 31(th) July-2010 we carried out 200 lobectomies by VATS. In February 2009 we started performing VATS lobectomies with only 2 incisions .We have analyzed both annual and overall outcomes regarding type of approach, conversion rate, surgical time, lymphadenectomy and overall survival. Distribution of the cases per year were as follows: first-year 32, second-year 65, third-year 103. Overall conversion rate was 14,5% (first-year 25%, second-year 20%, third-year 7.8%; p = 0.017). Surgical approach was: 4 ports (1 case), 3 ports (99 cases, 100% in first-year), 2 ports (99 cases, 80% in third-year), single-port (1 case, third-year) Mean surgical time in successful VATS was 193.8 min (210.8 first-year, 207.9 second-year, 181.1 third-year; p = 0.011), mean number of lymph nodes were 11.9 (9.3 first-year, 10.1 second-year, 13.9 third-year; p = 0.003) and mean explored stations was 4.2 (3.6 first-year, 3.8 second-year, 4.5 third-year; p < 0.001). Globally median chest tube duration was 3 days. Median length of stay was 4 days. The disease-free survival at 30 months was 85% for Stage I patients and 62% for non-stage I patients. As we gain more experience over time, with more cases performed each year and less invasive approaches, results improve in terms of less surgical time and more extended lymphadenectomies. Furthermore, we have observed a clear evolution in our surgical approach to a less invasive 2-port approach. In selected cases we have implemented the single-port lobectomy.

Unique Extralobar Sequestration With Atypical Location and Aberrant Vessels

We report a unique extralobar pulmonary sequestration in the upper thoracic region with 3 aberrant vessels connecting to the right subclavian artery, right superior pulmonary vein, and right pulmonary artery in a 20-year-old man. The sequestered lung was completely excised using a video-assisted thoracoscopic approach.

A novel ytterbium-169 brachytherapy source and delivery system for use in conjunction with minimally invasive wedge resection of early-stage lung cancer

Purpose To describe a novel source–delivery system for intraoperative brachytherapy in patients with early-stage lung cancer that is readily adaptable to a video-assisted thoracoscopic surgery approach and can be precisely delivered to achieve optimal dose distribution. Methods and Materials Radioactive ytterbium-169 ( 169Yb) was sealed within a titanium tube 0.28 mm in diameter and then capped and resealed by titanium wires laser welded to the tube to serve as the legs of a tissue-fastening system. Dose simulations were performed using Monte Carlo computer code (Los Alamos National Laboratory, Los Alamos, NM) to mimic the geometric and elemental compositions of the source, fastening apparatus, and surroundings. Results Five test source capsules were subjected to a tensile load to failure. Failure in each capsule occurred in the wire of the fastener leg; there were no weld failures. Monte Carlo simulations and subsequent dose measurement showed the perturbation by the source legs in the deployed (bent over) position to be small (4–5%) for 169Yb and much less than that for iodine-125 (32%). Conclusion We have developed a 169Yb brachytherapy source–delivery system that can be used in conjunction with commercially available surgical stapling instruments, facilitates the precise placement of brachytherapy sources relative to the surgical margin, assures the seeds remain fixed in their precise position for the duration of the treatment, overcomes the technical difficulties of manipulating the seeds through the narrow surgical incision associated with video-assisted thoracoscopic surgery, and reduces the radiation dose to the clinicians.

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.

Is Video-Assisted Thoracic Surgery Lobectomy Better? Quality of Life Considerations

Video-assisted thoracic surgery lobectomy has controversial advantages over traditional open surgical approaches. Subjective concerns such as pain, dyspnea, physical functioning, and overall satisfaction generally favor VATS but vary depending on survey timing. Independence, a major quality of life component, favors video-assisted thoracic surgery because fewer objective hospital and discharge resources are needed because pulmonary function, activity level, muscle strength, and walking capacity are better. Video-assisted thoracic surgery often hastens return to work and facilitates adjuvant chemotherapy or subsequent urgent surgical procedures. Video-assisted thoracic surgery-related quality of life benefits are amplified by advanced age (or other frailties) and reduced by advanced cancer stage or comorbid illness.

Video-Assisted Thoracoscopic Surgery versus Robotic-Assisted Thoracoscopic Surgery Thymectomy

Video-Assisted Thoracoscopic Surgery versus Robotic-Assisted Thoracoscopic Surgery Thymectomy

Management of constrictive pericarditic in the 21st century

Definitive treatment for constrictive pericarditis is surgical pericardiectomy. Because constriction may be transient in a small proportion of patients, particularly those with exudative effusions, the initial treatment for constrictive pericarditis should be conservative, with loop diuretic therapy to manage volume expansion and edema and the use of colchicine, nonsteroidal anti-inflammatory agents, or, if necessary, glucocorticoid therapy for active inflammation. For subjects with persisting evidence of constriction, symptomatic management is advised for those with only minimal symptoms. Surgical pericardiectomy is advised for subjects with New York Heart Association class II or III symptoms and persisting evidence of constriction at echocardiography and cardiac catheterization and with associated pericardial abnormality on CT or MRI. Complete resection of the pericardium and, where possible, the diseased epicardium via a midline sternotomy is the favored approach, although a video-assisted thoracoscopic approach may be suitable in some subjects. Lateral thoracotomy should be used for suppurative pericarditis to avoid sternal infection. Because of higher mortality, increased complication rates, and suboptimal clinical outcomes, pericardiectomy should be avoided in older patients or those with radiation-induced disease, very advanced symptoms, or evidence of myocardial fibrosis.

Evidence of Lower Alteration of Expiratory Volume in Patients With Airflow Limitation in the Immediate Period After Lobectomy

Recently published papers have shown that lobectomy improves lung function in selected patients with chronic obstructive pulmonary disease (COPD) months after surgery, but little information can be found discussing the effect of lobectomy on pulmonary function in the immediate period after surgery in these cases. The aim of this multicenter prospective study is to evaluate whether preoperative COPD influences the decrease of forced expiratory volume in 1 second the day after surgery. One hundred eighty-five patients undergoing nonextensive lobectomy were included. Selection criteria and perioperative management were homogeneous; all procedures were performed by muscle-sparing or video-assisted thoracoscopic surgical approach. Multivariate regression analysis was performed to identify whether COPD index (calculated by adding the percent preoperative forced expiratory volume in 1 second to the preoperative ratio of forced expiratory volume in 1 second to forced vital capacity, both values taken in decimal form) had an independent and reliable association with the decrease in forced expiratory volume in 1 second observed on the first postoperative day corrected for the effect of other preoperative and operative factors. The regression analysis was then validated by bootstrap analysis. Thirty-day mortality of the series was 1.1% (2 patients) and cardio-respiratory morbidity 20% (37 patients). Patients with lower preoperative pulmonary volumes had lower postoperative decrease of the pulmonary function (Pearson correlation coefficient, 0.28; p < 0.001). At linear regression, COPD index (p = 0.008), modality of analgesia (p < 0.0001), pain score (p = 0.01), the percentage of functioning parenchyma removed during operation (p = 0.006), and the presence of coronary artery disease (p = 0.03) had independent and reliable influence on the dependent variable (p < 0.001 and 0.003, respectively). Preoperative COPD degree (measured as COPD index) has a direct independent correlation with the decrease in postoperative forced expiratory volume in 1 second the day after surgery.

Predictors of general complications after video-assisted thoracoscopic surgical procedures

The video-assisted thoracoscopic approach has become the preferred method for many procedures due to the reduced trauma, complication rate and morbidity. The aim of this study was a risk evaluation of patients undergoing video-assisted thoracoscopic surgery (VATS) procedures. Between 1991 and 2004, 1,008 patients were included in this single-center retrospective analysis. Risk assessment was performed using univariate and multivariate analysis. Multivariate analysis revealed that patient age (p = 0.003), the duration of the VATS procedure (p = 0.008), redo-VATS (p < 0.001) and conversion to open thoracotomy (p < 0.001) correlated significantly with the incidence of complications. Patients with immune deficiency following organ transplantation had the highest complication rate at 31.7%, which was significantly higher than for patients with either benign disease (p = 0.010) or malignant disease (p = 0.019). VATS is a safe procedure, but extra caution is recommended for patients with a higher risk profile (age, redo-VATS, immune deficiency).

Mediastinal hyperfunctioning parathyroids: incidence, evolving treatment, and outcome

Background The evaluation and treatment of hyperfunctioning mediastinal parathyroid gland(s) (MPG) is evolving. This study reports our overall experience with MPG in a tertiary referral center. Methods A prospective database of 922 patients undergoing parathyroidectomy by 2 surgeons from 1982 to 2005 was reviewed. Results Thirty-two of 922 (3.5%) patients had MPG. Nine (28%) patients had a prior failed parathyroidectomy. Sestamibi and computed tomography scans were correctly positive in 24/28 (86%) and 6/7 (86%) patients, respectively. MPGs were removed via cervical approach in 22 (69%). Eleven of 22 patients had a focused cervical approach. Nine MPGs required a limited sternotomy (n = 3) or a successful radioguided video-assisted thoracoscopic approach (VATS, n = 4) for removal. Two VATS were converted to a full sternotomy. One patient refused surgery. All patients who required sternotomy/VATS had MPGs caudal to the innominate vein. Twenty-nine of 31(94%) patients were cured. Two are stable on calcimimetics. One patient has permanent hypoparathyroidism. Conclusions Most MPGs can be removed through a cervical approach. Preoperative Sestamibi and computed tomography scans can help the surgeon plan the best initial surgical approach. Those below the innominate vein require a thoracic procedure, preferably a radioguided probe-assisted thoracoscopic resection with intraoperative parathyroid hormone (ioPTH). An alternative to surgical removal is medical treatment.

An experimental sheep model used to develop an ablation procedure for chronic atrial fibrillation

Atrial fibrillation is the most common form of serious arrhythmia in humans. The therapeutic options offered are medical, surgical, and interventional. The surgical approach is justified in cases of atrial fibrillation already subjected to cardiac surgery for an associated organic heart disease such as a valvular or ischemic disease. A minimally invasive surgical approach is needed to extend the possibility of surgical treatment to patients with lone atrial fibrillation and those who cannot be treated by interventional procedures. This study aimed to use sheep as an experimental model in developing a minimally invasive surgical procedure for chronic atrial fibrillation therapy in humans. The investigation was conducted with 20 animals using a video-assisted thoracoscopic approach, in which a flexible microwave energy ablating probe was positioned on the epicardial surface encircling the pulmonary veins. In 10 of the 20 animals, it was possible to encircle the pulmonary veins using the thoracoscopic approach in less than 3 h without major complications. The epicardial ablation procedure using the thoracoscopic approach is feasible, safe, and reproducible.

Video‐assisted Thoracoscopic Resection of a Small Pulmonary Nodule after Computed Tomography–guided Localization with a Hook‐wire System

This study is a single-institution validation of video-assisted thoracoscopic (VATS) resection of a small solitary pulmonary nodule (SPN) previously localized by a CT-guided hook-wire system in a consecutive series of 45 patients. The records of all patients undergoing VATS resection for SPN preoperatively localized by CT-guided a hook-wire system from January 2002 to December 2004 were assessed with respect to failure to localize the lesion by the hook-wire system, conversion thoracotomy rate, duration of operation, postoperative complications, and histology of SPN. Forty-five patients underwent 49 VATS resections, with simultaneous bilateral SPN resection performed in 4. Preoperative CT-guided hook-wire localization failed in two patients (4%). Conversion thoracotomy was necessary in two patients (4%) because it was not possible to resect the lesion by a VATS approach. The average operative time was 50 min. Postoperative complications occurred in 3 patients (6%), one hemothorax and two pneumonia. The mean hospital stay was 5 days (range: 2-18 days). Histological assessment revealed inflammatory disease in 17 patients (38%), metastasis in 17 (38%), non-small-cell lung cancer (NSCLC) in 4 (9%), lymphoma in 3 (6%), interstitial fibrosis in 2 (4%), histiocytoma in one (2%), and hamartoma in one (2%). Histological analysis of resected SPN revealed unexpected malignant disease in more than 50% of the patients indicating that histological clarification of SPN seems warranted. Video-assisted thoracoscopic resection of SPN previously localized by a CT-guided hook-wire system is related to a low conversion thoracotomy rate, a short operation time, and few postoperative complications, and it is well suited for the clarification of SPN.

Treatment of Thoracolumbar Fractures by Video-Assisted Mini-invasive Thoracotomy: Report of 20 Cases

Purpose: This study reports the clinical and radiological results of the use of thoracoscopy in the treatment of 20 patients following a thoracolumbar spine injury. Method: An intraoperative reduction system was used to reduce the spinal deformity at the time of thoracoscopy. Results: Mean immediate postoperative improvement in vertebral kyphosis (VK) was 12.18° and 11.71° at final follow-up. Mean immediate postoperative improvement in corrected regional angle (CRA) was 13.24° and was identical at the latest follow-up. Gains in VK and CRA were 2-fold greater with use of an endodistractor than with external maneuvers. Conclusion: Provided the learning curve is respected, the mini-invasive video-assisted thoracoscopic approach to the treatment of a thoracolumbar injury leads to less intraoperative blood loss or late complications compared to an open classical thoracotomy or combined surgical approach. The correction obtained is satisfactory and is lasting as per the latest follow-up. An endodistractor shoul...

Long-term outcomes after a variety of video-assisted thoracoscopic lobectomy approaches for clinical stage IA lung cancer: A multi-institutional study

Although video-assisted thoracic surgery (VATS) has been in use for more than a decade, its application to major lung resection for lung cancer is still not widely practiced. The success of a cancer operation is judged by the long-term survival of the treated patients. Therefore, the goal of the present study was to evaluate long-term outcomes associated with various video-assisted lobectomy techniques and conventional surgery in patients with peripheral non-small cell lung cancer less than or equal to 2 cm in diameter (stage IA). A multi-institutional, retrospective review was performed in 145 consecutive patients. Patients with clinical stage IA disease, with tumor size less than or equal to 2 cm in diameter, from three institutions underwent a complete VATS (c-VATS, n = 56), an assisted VATS (a-VATS, n = 34), or a conventional open (open, n = 55) approach for pulmonary lobectomy and lymph node dissection. Patients undergoing lobectomy and lymph node dissection with c-VATS had less blood loss, faster recovery, shorter hospitalization, and longer operating times than did patients undergoing the lobectomy with the a-VATS and open approaches. At a mean follow-up of 38.8 months, Kaplan-Meier probabilities of survival at 5 years were as follows: c-VATS, 96.7%; a-VATS, 95.2%; open, 97.2%. There was no significant difference in the rate of recurrence among the 3 different procedures. VATS lobectomy, a safe procedure with earlier return to normal activities, can be regarded as an acceptable cancer operation for the patients with peripheral non-small cell lung cancer less than or equal to 2 cm in diameter (clinical stage IA) with the same long-term survivals as open surgery.