Maria Delgado

Uniportal video-assisted thoracoscopic lobectomy: two years of experience.

BACKGROUND A video-assisted thoracoscopic approach to lobectomy varies among surgeons. Typically, 3 to 4 incisions are made. Our approach has evolved from a 3-port to a 2-port approach to a single 4- to 5-cm incision with no rib spreading. We report results with single-incision video-assisted thoracic major pulmonary resections during our first 2 years of experience. METHODS In June 2010, we began performing video-assisted thoracoscopic lobectomies through a uniportal approach (no rib spreading). By July 12, 2012, 102 patients had undergone this single-incision approach. RESULTS Of 102 attempted major resections, 97 were successfully completed with a single incision (operations in 3 patients were converted to open surgery and 2 patients needed 1 additional incision). Five uniportal pneumonectomies were not included in the study. We have analyzed early outcomes of successful uniportal lobectomies (92 patients studied). Right upper lobectomy was the most frequent resection (28 cases). Mean surgical time was 154.1 ± 46 minutes (range, 60-310 minutes), mean number of lymph nodes was 14.5 ± 7 (range, 5-38 nodes), and mean number of explored nodal stations was 4.6 ± 1.2 (range, 3-8 stations). The mean tumor size was 2.8 ± 1.5 cm (0-6.5 cm). The median duration of time a chest tube was in place was 2 days and the median length of hospital stay was 3 days. There were complications in 14 patients; no postoperative 30-day mortality was reported. CONCLUSIONS Single-incision video-assisted thoracoscopic anatomic resection is a feasible and safe procedure with good perioperative results, especially when performed by surgeons experienced with the double-port technique and anterior thoracotomy.

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

OBJECTIVE To analyse the evolution of the video-assisted thoracoscopic (VATS) approach for lobectomy and results during the first 3 years of program. METHODS 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. RESULTS 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. CONCLUSIONS 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.

Is uniportal thoracoscopic surgery a feasible approach for advanced stages of non-small cell lung cancer?

OBJECTIVES Conventional video-assisted thoracoscopic (VATS) lobectomy for advanced lung cancer is a feasible and safe surgery in experienced centers. The aim of this study is to assess the feasibility of uniportal VATS approach in the treatment of advanced non-small cell lung cancer (NSCLC) and compare the perioperative outcomes and survival with those in early-stage tumors operated through the uniportal approach. METHODS From June 2010 to December 2012, we performed 163 uniportal VATS major pulmonary resections. Only NSCLC cases were included in this study (130 cases). Patients were divided into two groups: (A) early stage and (B) advanced cases (>5 cm, T3 or T4, or tumors requiring neoadjuvant treatment). A descriptive and retrospective study was performed, comparing perioperative outcomes and survival obtained in both groups. A survival analysis was performed with Kaplan-Meier curves and the log-rank test was used to compare survival between patients with early and advanced stages. RESULTS A total of 130 cases were included in the study: 87 (A) vs. 43 (B) patients (conversion rate 1.1 vs. 6.5%, P=0.119). Mean global age was 64.9 years and 73.8% were men. The patient demographic data was similar in both groups. Upper lobectomies (A, 52 vs. B, 21 patients) and anatomic segmentectomies (A, 4 vs. B, 0) were more frequent in group A while pneumonectomy was more frequent in B (A, 1 vs. B, 6 patients). Surgical time was longer (144.9±41.3 vs. 183.2±48.9, P<0.001), and median number of lymph nodes (14 vs. 16, P=0.004) were statistically higher in advanced cases. Median number of nodal stations (5 vs. 5, P=0.165), days of chest tube (2 vs. 2, P=0.098), HOS (3 vs. 3, P=0.072), and rate of complications (17.2% vs. 14%, P=0.075) were similar in both groups. One patient died on the 58th postoperative day. The 30-month survival rate was 90% for the early stage group and 74% for advanced cases. CONCLUSIONS Uniportal VATS lobectomy for advanced cases of NSCLC is a safe and reliable procedure that provides perioperative outcomes similar to those obtained in early stage tumours operated through this same technique. Further long term survival analyses are ongoing on a large number of patients.

Single-port video-assisted thoracoscopic lobectomy with pulmonary artery reconstruction

Despite the advances in video-assisted thoracoscopic surgery (VATS), vascular reconstruction of the pulmonary artery (PA) is still infrequently performed by thoracic surgeons because of the technical difficulties and the increased operative risk during thoracoscopy. The few published reports have been performed by using 3-4 incisions. We present the first report of a pulmonary artery reconstruction procedure performed by a single-incision VATS technique. A 73-year old male patient was operated on by the thoracoscopic approach through a single 4-cm incision with no rib spreading. The postoperative recovery was uneventful.

Non-intubated video-assisted thoracoscopic lung resections: the future of thoracic surgery?

Thanks to the experience gained through the improvement of video-assisted thoracoscopic surgery (VATS) technique, and the enhancement of surgical instruments and high-definition cameras, most pulmonary resections can now be performed by minimally invasive surgery. The future of the thoracic surgery should be associated with a combination of surgical and anaesthetic evolution and improvements to reduce the trauma to the patient. Traditionally, intubated general anaesthesia with one-lung ventilation was considered necessary for thoracoscopic major pulmonary resections. However, thanks to the advances in minimally invasive techniques, the non-intubated thoracoscopic approach has been adapted even for use with major lung resections. An adequate analgesia obtained from regional anaesthesia techniques allows VATS to be performed in sedated patients and the potential adverse effects related to general anaesthesia and selective ventilation can be avoided. The non-intubated procedures try to minimize the adverse effects of tracheal intubation and general anaesthesia, such as intubation-related airway trauma, ventilation-induced lung injury, residual neuromuscular blockade, and postoperative nausea and vomiting. Anaesthesiologists should be acquainted with the procedure to be performed. Furthermore, patients may also benefit from the efficient contraction of the dependent hemidiaphragm and preserved hypoxic pulmonary vasoconstriction during surgically induced pneumothorax in spontaneous ventilation. However, the surgical team must be aware of the potential problems and have the judgement to convert regional anaesthesia to intubated general anaesthesia in enforced circumstances. The non-intubated anaesthesia combined with the uniportal approach represents another step forward in the minimally invasive strategies of treatment, and can be reliably offered in the near future to an increasing number of patients. Therefore, educating and training programmes in VATS with non-intubated patients may be needed. Surgical techniques and various regional anaesthesia techniques as well as indications, contraindications, criteria to conversion of sedation to general anaesthesia in non-intubated patients are reviewed and discussed.

Uniportal video-assisted thoracoscopic sleeve lobectomy and other complex resections.

Thanks to the recent improvements in thoracoscopy, a great deal of complex lung resections can be performed without performing thoracotomies. During the last years, experience gained through video-assisted thoracoscopic techniques, enhancement of the surgical instruments and improvement of high definition cameras have been the greatest advances. The huge number of surgical videos posting on specialized websites, live surgery events and experimental courses has contributed to the rapid learning of minimally invasive surgery during the last years. Nowadays, complex resections, such as post chemo-radiotherapy resections, lobectomies with chest wall resection, bronchial and vascular sleeves are being performed by thoracoscopic approach in experienced centers. Additionally, surgery has evolved regarding the thoracoscopic surgical approach, allowing us to perform these difficult procedures by means of a small single incision, with excellent postoperative results.

Double sleeve uniportal video-assisted thoracoscopic lobectomy for non-small cell lung cancer

Double sleeve (vascular and bronchial) lobectomy is a reasonable alternative to pneumonectomy in patients with centrally located tumors involving the pulmonary artery and bronchus. However, it is a challenging and complex procedure even when performed through thoracotomy.

Left lower sleeve lobectomy by uniportal video-assisted thoracoscopic approach

Endobronchial tumours requiring sleeve resection have been usually considered a contraindication for video-assisted thoracoscopic surgery (VATS). However, with new technical advances and the experience gained in VATS, sleeve lobectomy has been performed by thoracoscopy in experienced VATS centres. Right-sided sleeve anastomoses are easier to perform by VATS than left-sided ones because of the presence of the pulmonary artery and aortic arch on the left side. Most surgeons use a 3 to 4 incision VATS technique for sleeve anastomosis but the surgery can be performed by using only one incision. This is the first report of a left-sided sleeve lobectomy by uniportal approach.

Uniportal video-assisted thoracoscopic lobectomy

Over the past two decades, video-assisted thoracic surgery (VATS) has revolutionized the way thoracic surgeons diagnose and treat lung diseases. The major advance in VATS procedures is related to the major pulmonary resections. The best VATS technique for lobectomy has not been well defined yet. Most of the authors describe the VATS approach to lobectomy via 3 to 4 incisions but the surgery can be performed by only one incision with similar outcomes. This single incision is the same as we normally use for VATS lobectomies performed by double or triple port technique with no rib spreading. As our experience with VATS lobectomy has grown, we have gradually improved the technique for a less invasive approach. Consequently the greater the experience we gained, the more complex the cases we performed were, hence expanding the indications for single-incision thoracoscopic lobectomy.

Bronchovascular right upper lobe reconstruction by uniportal video-assisted thoracoscopic surgery

Lung cancer requiring double bronchial and vascular reconstruction of the pulmonary artery is a challenging procedure usually performed by thoracotomy. However, recent development of video-assisted thoracoscopic techniques allows experienced and skilled surgeons to perform these cases through a minimally invasive approach. Most of these complex thoracoscopic resections are performed by using 3 to 4 incisions. We present the first report of a right side combined vascular reconstruction and bronchoplasty performed through a single-incision video-assisted thoracoscopic surgery (VATS) technique.