H. Volkan Kara

Modified Uniportal Video-Assisted Thoracoscopic Lobectomy: Duke Approach

Traditional thoracoscopic strategies using two to four ports has been demonstrated to be oncologically successful for patients with resectable lung cancer, with numerous advantageous over thoracotomy. A single-incision approach has been described, but it is associated with potential disadvantages. The modified uniportal approach described may address those disadvantageous, with retention of the potential advantages of using a single incision.

Challenging cases: thoracoscopic lobectomy with chest wall resection and sleeve lobectomy—Duke experience

Video-assisted thoracoscopic surgery (VATS) had recent advances in both equipment and technique so has been applied to more complex conditions in some thoracic surgery centers. We have adopted our VATS lobectomy experience for patients with chest wall invasion and endobronchial localized tumor requiring bronchial sleeve resection. We are describing our decision-making and surgical methods for these patients which we believe will be decreasing the number of contraindications for VATS and offering this surgical method for more patients.

Editorial on Totally endoscopic (VATS) first rib resection for thoracic outlet syndrome

Thoracic outlet syndrome (TOS) is defined as compression of neural and vascular structures passing through the superior aperture of the chest ‘Thoracic Outlet’. The involved anatomical structures are brachial plexus, subclavian artery and vein, and they are at risk of compression on their course between neck and axilla.

A prospective randomized trial comparing homologous and autologous fibrin sealants for the control of alveolar air leak

Background Postoperative air leak is a common complication seen after pulmonary resection. It is a significant reason of morbidity and also leads to greater hospital cost owing to prolonged length of stay. The purpose of this study is to compare homologous sealant with autologous one to prevent air leak following pulmonary resection. Methods A total of 57 patients aged between 20 and 79 (mean age: 54.36) who underwent pulmonary resection other than pneumonectomy (lobar or sublobar resections) were analyzed. There were 47 males (83%) and 10 females (17%). Patients who intraoperatively had air leaks were randomized to receive homologous (Tisseel; n=28) or autologous (Vivostat; n=29) fibrin sealant. Differences among groups in terms of air leak, prolonged air leak, hospital stay, amount of air leak were analyzed. Results Indications for surgery were primary lung cancer in 42 patients (71.9%), secondary malignancy in 5 patients (8.8%), and benign disease in 10 patients (17.5%). Lobectomy was performed in 40 patients (70.2%), whereas 17 patients (29.8%) had wedge resection. Thirteen (46.4%) patients developed complications in patients receiving homologous sealant while 11 (38.0%) patients had complication in autologous sealant group (P=0.711). Median duration of air leak was 3 days in two groups. Time to intercostal drain removal was 3.39 and 3.38 days in homologous and autologous sealant group respectively (P=0.978). Mean hospital stay was 5.5 days in patients receiving homologous sealant whereas it was 5.0 days in patients who had autologous agent (P=0.140). There were no significant differences between groups in terms of measured maximum air leak (P=0.823) and mean air leak (P=0.186). There was no significant difference in the incidence of complications between two groups (P=0.711). Conclusions Autologous and heterologous fibrin sealants are safe and acts similarly in terms of air leak and hospital stay in patients who had resectional surgery.

Modified uniportal video-assisted thoracoscopic surgery (VATS).

Video-assisted thoracoscopic surgery (VATS) for resectable lung cancer patients has been frequently used in the past decades. The potential beneficial advantages and safety of VATS has been shown in large patient series and meta-analyses. The strategy of limiting access to one incision in one intercostal space (uniportal VATS) has been adopted by some thoracic surgeons in recent years. We have described a modified uniportal VATS technique with its potential advantages. Modified uniportal VATS potentially offers better exposure, beneficial opportunities for education and improved comfort for the thoracic surgery team in clinical usage.

Video assisted transaxillary first rib resection in treatment of thoracic outlet syndrome (TOS)

A 24-year-old woman presented with a history of swelling and heaviness in her right upper extremity following swimming or any prolonged physical activity involving overhead arm abduction. She noted occasional numbness and paresthesia. Electromyography (EMG) and nerve conduction velocity (NCV) results were normal. Venogram demonstrated high-grade narrowing of the subclavian vein at the thoracic outlet with provocative maneuvers (hyperabduction and rotation) of right upper extremity. She was referred for surgical treatment of thoracic outlet syndrome (TOS).

Spontaneous Herniation of the Lung and Diaphragm Treated With Surgical Repair

Lung herniation is rare and is usually caused by blunt trauma, congenital abnormalities of the ribs, or previous thoracic operations. We report a rare case of spontaneous lung herniation in a 72-year-old woman and describe the operative repair.

Thoracoscopic diaphragm plication

The diaphragm is grasped, and as much of the anterior diaphragm as possible is pulled into a retaining clamp. This maneuver is easier to perform for the right diaphragm than the left diaphragm, owing to the risk of incorporating viscera on the left. Upon initial placement of the clamp, it is evident that all of the diaphragm that would optimally be resected cannot occur in one application. This is precluded by three factors: the dome of the diaphragm, the length of the staple line, and the amount of diaphragm that would optimally be resected. Rather, the clamp is progressively advanced on the redundant diaphragm after each firing of the stapler resection is progressively regrasped after each staple load. A linear endostapling device (Covidien Endo GIATM and 45-mm Purple Reload with Tri-StapleTM) is placed under the clamp, and the diaphragm resection is begun at the most anterior aspect, with the intention to resect as much of the central portion of the diaphragm as possible. The diaphragm is then resected with subsequent staple loads, serially proceeding from anterior and medial on the diaphragm, diagonally in posterior and lateral direction.

Minimally invasive injection laryngoplasty in the management of unilateral vocal cord paralysis after video-assisted mediastinal lymph adenectomy

Introduction Video-assisted mediastinal lymphadenectomy (VAMLA) is a valuable tool for invasive staging of the mediastinum. Unilateral vocal cord paralysis (UVCP) may occur in patients following VAMLA and may result in secretion retention within the lungs, atelectasis and associated infectious situations such as pneumonia. Minimally invasive injection laryngoplasty (ILP) is the treatment of choice in UVCP. Aim To evaluate the efficacy and success of acute minimally invasive injection laryngoplasty for patients with UVCP following VAMLA. Material and methods Patients with the symptom of dysphonia following VAMLA were reviewed. All of the patients had UVCP according to the video laryngoscopy examination and had symptoms of aspiration and ineffective coughing. The Voice Handicap Index (VHI) questionnaire and maximum phonation time (MPT) were measured. Minimally invasive ILP was performed under general anesthesia with 1 cm of hyaluronic acid. Results There were 525 consecutive non-small cell lung cancer (NSCLC) patients who underwent VAMLA. Five (0.95%) of the patients had UVCP and were suffering from aspiration during oral intake and ineffective coughing reflex. Maximum phonation time (MFT) was measured before and after ILP, and the results were 7.1 ±1.6 and 11.1 ±2.3 s, respectively (p < 001). The Voice Handicap Index-10 (VHI-10) score was 30.4 ±4.7 and 13.4 ±3.5 (p < 0.01), respectively. Patients underwent surgical lung resection. There was no morbidity or mortality. Conclusions Unilateral vocal cord paralysis may occur as a complication of VAMLA. ILP may be an active tool for treating UVCP before anatomical lung resection to avoid potential morbidities. Successful management of this complication with multidisciplinary team work may encourage the use of VAMLA more frequently.

Multidisciplinary approach to treatment of radiation-induced chest wall sarcoma

Radiation-induced sarcoma (RIS) is a rare complication following therapeutic external irradiation for lung cancer patients. Patients with RIS may develop recurrence or metastasis of the previous disease and also at high risk for early chest wall complications following operation, which requires close follow-up and multidisciplinary approach. We present a challenging case of RIS with a multidisciplinary teamwork in the decision-making and successful management.