Jury Brandolini

Video-assisted thoracoscopic surgery en bloc chest wall resection

In the latest two decades, the video-assisted thoracoscopic surgery (VATS) technique has gained recognition as an effective alternative to conventional open surgery, and the field of its application has gradually extended to more complex diseases, such as locally invasive non-small cell lung cancer (NSCLC) requiring combined lung and chest wall resection. The en bloc chest wall resection can be accomplished by using a typical VATS port placement, each time adjusted to allow a better thoracoscopic guidance and a correct resection of the tumour to achieve negative margins. Different approaches have been described by experienced surgeons, with a remarkable variability in the number and disposition of the ports, in the surgical tools used and in the strategy of sparing the covering tissues. The common denominator of these experiences is the aim of extending the criteria of functional and oncological operability to high-risk patients who are not suitable for a conventional thoracotomy. Indeed, the VATS approach has shown effectiveness in reaching unchanged oncological outcomes in comparison with the thoracotomic technique but involving significantly less postoperative pain, faster recovery, shorter hospitalisation and lower overall complications.

Materials and techniques in chest wall reconstruction: a review

Extensive chest wall resection and reconstruction are a challenging procedure that requires a multidisciplinary approach, including input from thoracic surgeon, plastic surgeon and oncologist. In particular chest wall neoplastic pathology is associated with high surgical morbidity and can result in full thickness defects hard to reconstruct. The goals of a successful chest wall reconstruction are to restore the chest wall rigidity, preserve pulmonary mechanic and protect the intrathoracic organs minimizing the thoracic deformity. In case of large full thickness defects synthetic, biologic or composite meshes can be used, with or without titanium plate to restore thoracic cage rigidity as like as more recently the use of allograft to reconstruct the sternum. After skeletal stability is established full tissue coverage can be achieved using direct suture, skin graft or local advancement flaps, pedicled myocutaneous flaps or free flaps. The aim of this article is to illustrate the indications, various materials and techniques for chest wall reconstruction with the goal to obtain the best chest wall rigidity and soft tissue coverage.

Four arms robotic-assisted pulmonary resection—left upper lobectomy: how to do it

Numerous published articles have shown the safety and efficacy of robotic anatomic pulmonary resection, including lobectomy for non-small cell lung cancer. Several techniques have been described to perform a lung lobectomy robotically. Since the beginning of our experience, we adopted a four-arm robotic approach with the da Vinci Si System. More recently we have used the newer Xi model, that offers a simplified and quicker set-up and docking time. This article emphases specifically on the technical aspects of how to complete the hilar dissection during four-arm robotic lobectomy.

Robotic internal mammary lymphadenectomy: another possible minimally invasive approach to sampling lymph nodes in breast cancer patients

Internal mammary lymphadenopathy may develop in breast cancer patients with silicone implants. Differential diagnosis includes malignant recurrence, infections, inflammations and granulomatous deposit. We report a case of internal mammary lymphadenopathy, in a patient with the previous history of breast cancer, requiring a tissue diagnosis. We performed a Robotic lymph nodes dissection of the left internal mammary. Final pathology diagnosis was positive for silicone granulomatous lymphadenitis secondary to silicone breast implants inserted after mastectomy for breast cancer.

Fat but fit for the improved survival in lung cancer surgery

“ Anger as soon as fed is dead, Tis starving makes it fat. ” nEmily Dickinson, Poems, Second Series, 1891.

Four arms robotic-assisted pulmonary resection—right lower/middle lobectomy: how to do it

In the last few years, robotic approach for anatomic lung resection has brought an innovative development in minimally invasive thoracic surgery. This study analyzes the technical aspects of performing the hilar dissection for a lobectomy via robotic approach. With a detailed step-by-step description and essential tips and videos, in this paper, we report the procedure to carry out a four-arm robotic middle and lower lobectomy.

Surgical approaches in patients with oligometastatic non-small cell lung cancer

In recent years, retrospective analyses have suggested that an oligometastatic state could exist, but the best evidence to date that a temporary oligometastatic disease exists for lung cancer mainly derives from the survival data on retrospective patients underwent surgical resection of a single M1 site and all intrathoracic disease. The critical determinates of long-term survival include definitive treatment of the primary non-small cell lung cancer (NSCLC), a single organ site of synchronous or metachronous disease, a long disease-free interval between treatment of the primary NSCLC and development of metastases, and the absence of intrathoracic lymph node (N0) disease. The ongoing development of innovative approaches to local therapy and treatment directed to the oligometastatic sites should be defined in future studies.

Diaphragmatic and pericardial reconstruction after surgery for malignant pleural mesothelioma

Extrapleural pneumonectomy (EPP) and pleurectomy-decortication (P/D) are both recognised surgical procedures for selected cases affected by malignant pleural mesothelioma (MPM). Surgical techniques have ameliorated over the last years, remaining the complete macroscopic resection of the disease the main surgical principle. EPP is defined as an en-bloc resection of the visceral pleura, parietal pleura, pericardium and diaphragm alongside the pneumonectomy. The thoracic domain of the International Association for Study of Lung Cancer (IASLC) recently clarified the, previously confused, surgical terminology. Extended P/D is considered as parietal and visceral pleurectomy, diaphragmatic and pericardial resection with the purpose to remove all macroscopic disease. The term radical was replaced by extended to underline that this procedure does not have oncologic radicality aims. Both operations above are technically challenging and associated with a significant rate of peri-operative morbidity and non-negligible mortality. The diaphragmatic and pericardial reconstruction technique is mandatory to avoid respiratory impairment and to reduce post-operative complications like gastric and cardiac herniation. The technical aspects of resection and reconstruction are described and the choice of different prosthetic materials, considering the most recent innovations in the field, are discussed.

Uniportal video-assisted thoracoscopic surgery in hemothorax

The management of hemothorax (spontaneous or, more often, due to thoracic trauma lesions), follows basic tenets well-respected by cardiothoracic surgeons. In most, a non-operative approach is adequate and safe, with a defined group of patients requiring only tube thoracostomy. Only a minority of patients need a surgical intervention due to retained hemothorax, persistent bleeding or incoming complications, as pleural empyema or entrapped lung. In the early 1990s, the rapid technological developments determined an increase of diagnostic and therapeutical indications for multiport video-assisted thoracoscopic surgery (VATS) as the gold standard therapy for retained and persistent hemothorax, allowing an earlier diagnosis, total clots removal and better tubes placement with less morbidity, reduced post-operative pain and shorter hospital stay. There is no consensus in the literature regarding the timing for draining hemothorax, but best results are obtained when the drainage is performed within the first 5 days after the onset. The traditional multi-port approach has evolved in the last years into an uniportal approach that mimics open surgical vantage points utilizing a non-rib-spreading single small incision. Currently, in experienced hands, this technique is used for diagnostic and therapeutic interventions as hemothorax evacuation as like as the more complex procedures, such as lobectomies or bronchial sleeve and vascular reconstructions.

Uniportal video-assisted thoracic surgery for pneumothorax and blebs/bullae

The last British Society of Thoracic Surgeons guidelines of 2010 for the management of primary spontaneous pneumothorax (PSP) stated that, after the first recurrence, the treatment of PSP should be a surgical operation, like a bullectomy accompanying with a procedure for inducing pleural adhesions. Therefore, the surgical approach is considered the best treatment to minimise the risk of recurrence in patients who experienced a PSP. There is substantial evidence in the literature demonstrating that the minimally invasive approach should be preferred to the thoracotomic procedure since it can reduce the postoperative pain and it is associated with a faster recovery of the physical and working activity. The video-assisted thoracic surgery (VATS) approach has been shown to offer greater advantages about patient pain and respiratory function when compared to thoracotomic incisions. A single port or single incision or uniportal approach was developed as an alternative to the standard multi-port VATS. Uniportal technique has shown to be safe and efficient not only for pulmonary resections and biopsies but also for lobectomy. When used for PSP, the bullectomy/blebectomy and pleural abrasion/pleurectomy is performed through the single incision through which the chest drain is then inserted. In this perspective, evidence showed that the minimally invasive approach should be preferred, confirming the advantages in comparison with traditional techniques.