Carmelina Cristina Zirafa

Transcollation® technique in the thoracoscopic treatment of primary spontaneous pneumothorax

OBJECTIVES The already low invasiveness of the thoracoscopic treatment of spontaneous pneumothorax may be further reduced by the transcollation® technique. Herein, we report our further experience with a new device, to coagulate blebs and bullae, compared with contrast to endostapler resection. METHODS Data of patients with recurrent or persistent spontaneous pneumothorax, who underwent thoracoscopic treatment, were prospectively collected and reviewed. Those with blebs or bullae (Stages III and IV in accordance with Vanderschuerens classification) were treated with a new device, based on coupling saline solution perfusion with radiofrequency energy. The combination of fluid with radiofrequency allows the sealing of tissue, avoiding charring or burning. Most operations were performed through two 1-cm incisions only. RESULTS From 2005 to 2010, 73 patients were treated. These were 59 males (80.8%) and 14 females (19.2%), with a mean age of 27.9 years [standard deviation (SD): 11.7]. Forty-three patients underwent general anaesthesia with selective intubation, 9 awake epidural anaesthesia and 21 spontaneous breathing anaesthesia with laryngeal mask. The mean operation time was 31 min (SD: 10.2). The median postoperative drainage period and hospital stay were 2 days (range of 1-11) and 3 days (range of 2-11), respectively. Prolonged air leak occurred in 1 patient (1.4%). Over a mean follow-up period of 60 months (SD: 22.5), two recurrences (2.7%) were reported. CONCLUSIONS The transcollation® technique by cold coagulation of blebs and bullae seems to be effective in the treatment of primary spontaneous pneumothorax. Owing to its potential advantages, it appears to be particularly suitable to be associated with awake epidural and LMA anaesthesia.

Surgery for malignant pleural mesothelioma : an international guidelines review

Currently there is no universally accepted surgical therapy for malignant pleural mesothelioma (MPM). The goal of surgery in this dismal disease is a macroscopic complete resection (MCR) and there are two types of intervention with a curative intent. At one side, there is the extrapleural pneumonectomy (EPP) which consists in an en-bloc resection of the lung, pleura, pericardium and diaphragm and at the other side, there is pleurectomy/decortication (P/D) a lung-sparing surgery. Initially, EPP was considered the only surgical option with a curative aim, but during the decades P/D have acquired a role of increasing importance in MPM therapy. Several randomized prospective trials are required to establish the best strategy in the treatment of pleural mesothelioma. Although which is the best surgical option remains unclear, the International Mesothelioma Interest Group (IMIG), recently have stated that the type of surgery depends on clinical factors and on individual surgical judgment and expertise. Moreover, according to the current evidence, the surgery should be performed in high-volume centres within multimodality protocols. The aim of this study is to examine the currently available international guidelines in the surgical diagnosis and treatment of MPM.

Nodal upstaging evaluation in NSCLC patients treated by robotic lobectomy

BackgroundOpen pulmonary resection is considered the gold standard treatment of early-stage non-small cell lung cancer (NSCLC). However, in the last decades, the use of minimal-invasive techniques has given promising results. Survival in lung cancer, after surgery, depends on the number of pathological nodes (pN), thus lymph nodal upstaging can be considered a surrogate for surgical quality of the procedure. Several studies have demonstrated a lower rate of upstaging in video-assisted thoracic surgery than in open surgery, suggesting an approach-related difference in lymphadenectomy. Features of robotic technique could consent a lymph nodal dissection similar to open surgery. The aim of the study is to compare nodal upstaging between thoracotomy and robotic approaches to evaluate the oncologic radicality.MethodsBetween January 2013 and December 2016, 212 consecutive cN0 NSCLC patients underwent lobectomy and lymphadenectomy (N1 + N2 stations) by either thoracotomy (Open Group) or robotic surgery (Robotic Group).ResultsLobectomy and lymphadenectomy were performed in 106 cN0–cN1 NSCLC patients by robotic surgery and in 106 cN0–cN1 NSCLC patients by open surgery. A mean of 14.42 ± 6.99 lymph nodes was removed in the Robotic Group (RG) and a mean of 14.32 ± 7.34 nodes in the Open Group (OG). Nodal upstaging was observed in 22 (20.75%) RG patients and in 19 OG (17.92%) patients.ConclusionsRobotic lobectomy for clinical N0–N1 NSCLC appears to be equivalent to thoracotomy in terms of efficacy of lymph node dissection and nodal upstaging. Given that the nodal upstaging is a surrogate of quality of surgery, we can consider robotic lobectomy an appropriate procedure which ensures similar result to the open approach.

From “open” to robotic assisted thoracic surgery: why RATS and not VATS?

Since 1990’s, when the first video-assisted thoracoscopic surgery (VATS) lobectomy was performed, the interest in minimally invasive surgery (MIS) to treat lung cancer has grown widely (1).

The application of robotic surgery on the anterior mediastinal tumors

Robotic surgery represents an excellent alternative approach for the treatment of anterior mediastinal lesions. Thanks to its advanced technological features, the robotic system allows to achieve a radical thymectomy, as suggested by National Comprehensive Cancer Network guidelines. Robotic thymectomy when performed by a skilled surgeon is an effective and safe procedure, also in challenging operations, guarantying better post-operative quality of life than the conventional approach.

Treatment of pulmonary nodule: from VATS to RATS

Background The incidental detection of solitary pulmonary nodule (SPN) is currently increasing due to the widespread use of computed tomography (CT) during the follow up in oncological patients or in screening trials. A quick and definitive histological diagnosis of these nodes is mandatory as, in case of primitive lung cancer, an early detection could improve both surgical results and prognosis. The minimally invasive pulmonary resection (MIPR) is the gold standard procedure for diagnosis and treatment of small lung nodules, but it can be difficult to localize deep nonpalpable nodes that lie in the lung parenchyma. Hence, throughout the years several techniques have been developed to better localize deep or sub solid nodes. We describe our experience with radio-guided technique. Methods Patients with SPN smaller than 10 mm and/or with a distance from the visceral pleura equal or larger than 10 mm underwent MIPR after CT injection of a solution containing 0.2 mL 99Tc-labelled human serum albumin microspheres and 0.1 mL of non-ionic contrast. During surgical procedures, a collimated probe, connected to a gamma-ray detector, was used to scan the lung and detect the target area. The area of major radioactivity was then resected. Results Between 2010 and 2015, 175 patients (M/F: 97/78) underwent minimally invasive resection (thoracoscopic or robotic) with radio-guided technique. The mean node diameter was 13 mm (range, 5-20 mm), and the mean distance from the visceral pleura was 15 mm (range, 6-39 mm). No significant CT-guided-injection-related complications occurred, except for 13 patients (7.4%) who developed a pneumothorax (PNX) not requiring chest tube insertion. This technique guaranteed a successfully intra-operative node localization in 100% of cases. The mean duration of the surgical procedure was 44 min (range, 25-130 min). The mean length of pleural drainage and mean hospital stay was 2.6 days (range, 1-5 days) and 3.9 days (range, 1-7 days) respectively. No mortality or perioperative complications occurred. Pathology reports showed 105 metastases, 55 primitive lung cancers and 15 benign lesions. In case of suspicion of primitive lung tumour an intraoperative frozen exam was conducted, and all patients underwent lobectomy or segmentectomy with lymphadenectomy [41 patients with thoracotomy, 11 with robotic surgery and 3 with video-assisted thoracoscopic surgery (VATS)]. Conclusions Our experience confirms that radio-guided thoracoscopic surgery (RGTS) is a feasible and safe procedure, thanks to its high success rate the radio-guided technique is helpful to overcome the lack of tactile feedback during MIPR [VATS and robotic-assisted thoracoscopic surgery (RATS)] and to limit conversion to open surgery.

How to get the best from robotic thoracic surgery

The application of Robotic technology in thoracic surgery has become widespread in the last decades. Thanks to its advanced features, the robotic system allows to perform a broad range of complex operations safely and in a comfortable way, with valuable advantages related to low invasiveness. Regarding lung tumours, several studies have shown the benefits of robotic surgery including lower blood loss and improved lymph node removal when compared with other minimally invasive techniques. Moreover, the robotic instruments allow to reach deep and narrow spaces permitting safe and precise removal of tumours located in remote areas, such as retrosternal and posterior mediastinal spaces with outstanding postoperative and oncological results. One controversial finding about the application of robotic system is its high capital and running costs. For this reason, a limited number of centres worldwide are able to employ this groundbreaking technology and there are limited possibilities for the trainees to acquire the necessary skills in robotic surgery. Therefore, a training programme based on three steps of learning, associated with a solid surgical background and a consistent operating activity, are required to obtain effective results. Putting this highest technological innovation in the hand of expert surgeons we can assure safe and effective procedures getting the best from robotic thoracic surgery.

Robotic-assisted thoracic surgery versus uniportal video-assisted thoracic surgery: is it a draw?

In the last two decades the role of minimally invasive surgery (MIS) for non-small cell lung cancer (NSCLC) treatment has grown considerably and numerous studies comparing the surgical results of MIS with open surgery, have confirmed that the MIS constitutes an excellent approach for the treatment of lung cancer, especially in early stages.

Robotic lobectomies: when and why?

During the last decade, an abundance of papers has supported minimally invasive pulmonary resections (MIPR) vs. traditional open approach. Both video assisted thoracic surgery (VATS) and robotic thoracic surgery have shown better perioperative outcomes and equivalent oncologic results compared with thoracotomy, confirming the effectiveness of the MIPR. Despite the profound changes and improvements that have taken place throughout the years and the increasing use of robotic system worldwide, the controversy about the application of robotic surgery for lung resections is still open. Some authors wonder about the advantages of using a more expensive and more complex platform for thoracic surgery instead of the more established VATS technique. Robotic thoracic surgery represents, although the cumulative experience worldwide is still limited and evolving, a significant evolution over VATS, nonetheless several authors criticize the longer operative time and the high costs of robotic procedures. The aim of this paper is to answer two relevant questions: why and when the application of robotic technology in thoracic surgery is appropriate?

Robot-assisted surgery for posterior mediastinal mass

In the last decade, robotic surgery is increasingly becoming an essential instrument in the hands of thoracic surgeons. Indeed, the Robotic Surgical Systems (da Vinci, Intuitive Surgical, Inc., Sunnyvale, CA, USA), particularly the latest models, the SI system and the latest XI system, are used to perform lung resection and exeresis of mediastinal lesions (1-3). Thanks to their features it is possible to work in a comfortable and secure manner in narrow spaces, such as the anterior mediastinum, or in remote areas, such as the posterior mediastinum or the costal-phrenic areas. Robotic surgery allows a mini-invasive approach overcoming the limits that characterize video-assisted thoracic surgery (e.g., complex manoeuverability of the instruments in close or deep spaces, 2-dimensional and limited vision). As a matter of fact, surgical procedures are easier thanks to the 3D magnified vision, the surgeon’s direct control of the camera, the possibility to have instruments with a large range of articulation and movements, the filtration of the physiological tremor of the hands (4,5).