Video-assisted Thoracoscopic Surgery Surgeons Research Articles

A Diaphragmic Traction Suture Increases Pleural Cavity Volume and Surgical Field Overview During Video-Assisted Thoracoscopic Surgery.

An elevated hemidiaphragm may impair surgical field overview during video assisted thoracoscopic surgery (VATS) and may consequently jeopardize a safe surgical procedure or prolong the duration of surgery. The aim of this study was to evaluate if tension applied to a diaphragmatic suture improves the surgical field overview. Following informed consent and at the surgeon's discretion during elective VATS procedures, a single stitch was placed at the posterior tendinous border of the diaphragm and retracted through the camera port. The surgical field overview was evaluated using a numeric rating scale (1-10) by the surgeon before and after applying tension during the procedure, and later by 9 VATS surgeons (> 10years' experience) using video recordings. During a 4-month period, 43 patients scheduled for elective VATS by two surgeons gave informed consent to participate. The hemidiaphragm was elevated to such an extent in 27 patients that the surgeon placed a diaphragmatic stitch suture. When tension was applied to the suture, surgical field overview improved significantly (p < 0.001). A diaphragmatic traction suture improves surgical field overview in selected patients with elevation of the hemidiaphragm. This simple procedure may facilitate VATS in patients with impaired surgical field overview and consequently improve safety during VATS. CLINICAL TRIAL NUMBER: http://ClinicalTrials.gov (No. NCT04837950).

Switching from Thoracoscopic to Robotic Platform for Lobectomy: Report of Learning Curve and Outcome.

The optimal minimally invasive surgical management for patients with non-small-cell lung cancer (NSCLC) is unclear. For experienced video-assisted thoracoscopic surgery (VATS) surgeons, the increased costs and learning curve are strong barriers for adoption of robotics. We examined the learning curve and outcome of an experienced VATS lobectomy surgeon switching to a robotic platform. We conducted a retrospective review to identify patients who underwent a robotic or VATS lobectomy for NSCLC from 2016 to 2018. Analysis of patient demographics, perioperative data, pathological upstaging rates, and robotic approach (RA) learning curve was performed. This study evaluated 167 lobectomies in total, 118 by RA and 49 by VATS. Patient and tumor characteristics were similar. RA had significantly more lymph node harvested (14 versus 10; P = 0.004), more nodal stations sampled (5 versus 4; P < 0.001), and more N1 nodes (8 versus 6; P = 0.010) and N2 nodes (6 versus 4; P = 0.017) resected. With RA, 22 patients were upstaged (18.6%) compared to 5 patients (10.2%) with VATS (P = 0.26). No differences were found in perioperative outcome. Operative time decreased significantly with a learning curve of 20 cases, along with a steady increase in lymph node yield. RA can be adopted safely by experienced VATS surgeons. Learning curve is 20 cases, with RA resulting in superior lymph node clearance compared to VATS. The potential improvement in upstaging and oncologic resection for NSCLC may justify the associated investments of robotics even for experienced VATS surgeons.

Video-assisted thoracoscopic surgery (VATS) for central airway tumors: VATS carinal resection and reconstruction

This review article focuses attention on the feasibility of airway management and technical strategies for complex anastomosis during carinal reconstruction under the video-assisted thoracoscopic surgery (VATS) approach. Between April 1992 and March 2017, English studies published worldwide were retrieved from a listing of bibliographic references obtained from the National Institutes of Health using the specific keywords “vats”, “thoracoscopic”, “carinal”, and “reconstruction”. Technical issues specific to the VATS approach, including airway management, port strategy, reduction of anastomotic tension, extent of resection, modes of reconstruction, suturing techniques, types of suture thread, and prophylactic wrapping are discussed in this review. VATS carinal resection and reconstruction remain challenging due to the limited modes of carinal reconstruction as well as problems specific to the VATS approach, such as airway management, reduction of anastomotic tension, and suturing techniques. However, VATS carinal surgery with or without anatomic pulmonary resection may be feasible using certain devices, such as high-frequency jet ventilation (HFJV) using a blocker tube, effective traction using endoscopic devices, and continuous suture techniques, and should be performed either by or with skilled and experienced VATS surgeons. In addition, non-intubated anesthesia and a uniportal strategy for VATS carinal surgery may be feasible at centers with a great deal of experience. The current indications for VATS carinal surgery are quite narrow and include the second diameter of the lesion ≤5 cm, minimal invasion to the surrounding organ, and extent of resection ≤4 cm between the lower trachea and contralateral main bronchus.

Video-assisted thoracoscopic surgery (VATS) for central airway tumors: VATS carinal resection and reconstruction

This review article focuses attention on the feasibility of airway management and technical strategies for complex anastomosis during carinal reconstruction under the video-assisted thoracoscopic surgery (VATS) approach. Between April 1992 and March 2017, English studies published worldwide were retrieved from a listing of bibliographic references obtained from the National Institutes of Health using the specific keywords “vats”, “thoracoscopic”, “carinal”, and “reconstruction”. Technical issues specific to the VATS approach, including airway management, port strategy, reduction of anastomotic tension, extent of resection, modes of reconstruction, suturing techniques, types of suture thread, and prophylactic wrapping are discussed in this review. VATS carinal resection and reconstruction remain challenging due to the limited modes of carinal reconstruction as well as problems specific to the VATS approach, such as airway management, reduction of anastomotic tension, and suturing techniques. However, VATS carinal surgery with or without anatomic pulmonary resection may be feasible using certain devices, such as high-frequency jet ventilation (HFJV) using a blocker tube, effective traction using endoscopic devices, and continuous suture techniques, and should be performed either by or with skilled and experienced VATS surgeons. In addition, non-intubated anesthesia and a uniportal strategy for VATS carinal surgery may be feasible at centers with a great deal of experience. The current indications for VATS carinal surgery are quite narrow and include the second diameter of the lesion ≤5 cm, minimal invasion to the surrounding organ, and extent of resection ≤4 cm between the lower trachea and contralateral main bronchus.

Lymphadenectomy during thoracoscopy: techniques and efficacy.

Nowadays several studies have shown that, in the management of patients with early-stage lung cancer, video-assisted thoracoscopic surgery (VATS) lobectomy compared to open surgery is associated with many clinical short-term benefits, such as less post-operative pain and shorter hospital stay. Despite the advantages described earlier, some authors have expressed concern about the effectiveness of the procedure arguing that the lymph node harvest performed during VATS lobectomy is inferior to that performed through thoracotomy access. Experience from a multicentre database, with a more balanced number of VATS versus open patients, actually has shown that there is no difference in the efficacy of mediastinal lymph node dissection during lobectomy for lung cancer by thoracoscopy and thoracotomy. In expert hands the technique of VATS lymphadenectomy is the same as that performed by thoracotomy: instrumentation and tricks can change but not the oncologic principles. We believe that is necessary to follow a learning curve not only for VATS lobectomy but also for thoracoscopic lymph node dissection. However even experienced VATS surgeons should keep in mind that the metastatic lymphadenopathy with extracapsular lymph node spread requires great caution during dissection and that a preoperative plan for conversion to thoracotomy can be useful in this case.

Subxiphoid mediastinal lymphadenectomy.

Video-assisted thoracoscopic surgery (VATS) has experience an exponential growth in lung anatomic resections. Since its beginnings in early 90s with the conventional multiport VATS to the more recent uniportal approach, a continuous search for a less invasive procedure has fueled the development of minimally invasive thoracic surgery. In this sense, subxiphoid uniportal VATS has surge as a uniportal option that avoids damage to the intercostal nerve created in a transthoracic approach. In order for this technique to become as an acceptable choice for lung cancer, oncologic principles must be respected, including a feasible and safe mediastinal lymphadenectomy. Although technically more difficult than other VATS approaches, a complete lymphadenectomy is possible in the hands of expert VATS surgeons through a subxiphoid approach.

Subxiphoid uniportal video-assisted thoracoscopic middle lobectomy and anterior anatomic segmentectomy (S3).

The video-assisted thoracoscopic surgery (VATS) approach for combined lobectomy and segmentectomy in the same lung is an infrequent procedure, rarely reported in the literature. Currently, Most of the surgeons still use 2-3 thoracic incisions for thoracoscopic anatomic resections. However, the uniportal approach is gaining worldwide acceptance in the recent years. The main advances of uniportal VATS during the last years are related to improvements in surgical technique by implementing new technology. The experience acquired with the uniportal technique allows expert uniportal VATS surgeons to explore new approaches in order to minimize even more the surgical invasiveness. Recently the aim to avoid the intercostal nerve damage created by the transthoracic incision has led to the creation of a novel procedure entitled uniportal VATS subxiphoid approach. Here we report the first case of a lobectomy combined with anatomic segmentectomy performed through a uniportal subxiphoid approach.

Uniportal video-assisted thoracoscopic bronchoplastic and carinal sleeve procedures.

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

Techniques and difficulties dealing with hilar and interlobar benign lymphadenopathy in uniportal VATS.

Surgical treatment of lung cancer has evolved to a minimally invasive approach and currently is recognized as an acceptable treatment for resectable non-small cell lung cancer (NSCLC). As the volume and complexity of cases has increased technical difficulties had arisen. Hilar and sublobar lymph nodes can represent a challenge for video-assisted thoracoscopic surgery (VATS) surgeons in order to complete a safe dissection of vascular and bronchial structures without complications or conversion. It is not unusual the patients with smoking history or benign infections in the past present with enlarged calcified nodes that are fused to the hilum, fissure and specially the bronchus which can lead to an accident during the procedure if the surgeon has no experience handling this issue. As the amount of surgeons carrying out VATS lobectomies grows it is very important for them to know what to do in this specific case so the completion of the procedure can be achieved safely. The coordination between the surgeon and the assistant is very important in order to carry out the procedure without discomfort positions and good visualization, the use of energy devices in expert hands can help considerably during the dissection of lymph nodes in the hilum and fissure reducing the bleeding, which provides a clean operative field. It is a necessary maneuver during the dissection to find the correct adventitial plane between the lymph node and the structure before passing it. The videos in this article show the different maneuvers a VATS surgeon can implement when facing enlarged fussed lymph nodes in the hilum, fissure or mediastinum. Improving exposure, opening the fissure, using energy and carrying out the dissection through the correct plane are keys to complete the procedure successfully. With growing experience in uniportal VATS and advances in surgical technology, enlarged or fussed lymph nodes are no longer a contraindication to complete a VATS lobectomy, experience VATS surgeons have a repertory of options in order to perform a safe and effective dissection.

Video-Assisted Thoracic Surgery Major Lung Resection Can Be Safely Taught to Trainees

Video-assisted thoracoscopic surgery (VATS) major lung resection for lung cancer has been an important part of thoracic surgical training program in our institution. In this study, we compared the results of VATS major lung resection performed by surgical trainees with those performed by experienced thoracic surgeons with specialist interest in VATS. From January 2002 to October 2006, the clinical data of 111 consecutive patients scheduled for VATS major lung resection were prospectively entered into the computerized clinical management system of the local health authority; these include patient demographics, comorbidity, operating time, postoperative complications, and outcome. We retrospectively compared the data of patients who were operated on by trainees with those who were operated on by experienced VATS surgeons. One hundred and eleven patients with clinical stage I and II lung cancer underwent VATS major lung resection. Fifty-one (46%) of the procedures were performed by consultant surgeons and 60 VATS lung resections (54%) were performed by supervised trainees. Patients' demography and risk factors were comparable between the two groups. Trainees spent more time in performing the operation as compared with experienced VATS surgeons (mean operating time 162 minutes, p = 0.01). There was no significant difference in intraoperative or postoperative complications and outcomes between the two groups. Video-assisted thoracic surgery major lung resection for early stage nonsmall-cell lung cancer can be taught to residents who work under the supervision of experienced VATS surgeons. Video-assisted thoracic surgery major lung resection for lung cancer should be an integral part of thoracic surgical training program.