Rainbow W.H. Lau

Uniportal and single-incision video-assisted thoracic surgery: the state of the art

Over the past decade, uniportal video-assisted thoracic surgery (VATS) has evolved dramatically into a sophisticated technique capable of performing some of the most complex thoracic procedures. The idea of operating through fewer surgical incisions and, therefore, with potentially better cosmesis, less postoperative pain and paraesthesia, has led to uniportal VATS increasing in popularity worldwide. The uniportal approach demands instrument design to be better suited for operating with multiple instruments through a single small incision. Furthermore, the drive by surgeons and industry to develop novel, smaller, more specialized procedure-specific instruments for uniportal VATS to further allow reduction in incision size is relentless. Refinement of uniportal VATS instruments, angulated and narrower endostaplers, and improvements in video-camera systems, including 3D systems, and 120° articulating lens will make uniportal VATS major lung resection easier to perform and learn. In the future, we could see the development of subcostal or e-NOTES access, endorobotic arms that open and operate within the chest cavity, and cross-discipline imaging assistance for uniportal VATS procedures.

Single port video-assisted thoracic surgery: advancing scope technology

We read with interest the article by Yang et al. [1] on the use of a flexible video endoscope for single-port video-assisted thoracic surgery (VATS) right upper lobectomy to improve space available for the operating surgeon and reduce fencing. The video endoscope their group described has great visual versatility, and can be utilized for multiple indications beyond those of thoracic surgery, for example as an aortic angioscope during aortic dissection surgery [2]. We have had the experience of using both the flexible video endoscope and another type of wide-angled rigid thoracoscope (Endocameleon, Karl Storz, Germany) for single-port VATS lung resections [3]. The wide-angled rigid thoracoscope allows vision between 0° and 120° through a rotating prism mechanism at the tip that provides variable views. One disadvantage of the flexible video-endoscope design is that the curved scope tip can occasionally interfere with the instruments in the operating field, which may inadvertently damage the soft scope tip. Furthermore, unlike conventional thoracoscopes, the handle design for angle adjustment is more akin to a bronchoscope, which may require a period of familiarization. The rigid 120° thoracoscope also has its shortcomings, being slightly wider than the flexible video endoscope for comparable visual resolution, hence occupying a larger proportion of the single incision. Although the choice of thoracoscope may play a role in facilitating single-port VATS lobectomy, to reduce instrument fencing and improve operating space during single-port VATS, the proper positioning of the instrument within the single incision and the maximal utilization of the 3D pleural cavity space with multiple angulated instruments may be more important [4]. Over the years, scopes have become narrower, and have more visual versatility and clarity to allow smaller surgical incisions and reduce interference with other instruments. The holy grail of scope design is a camera system that does not need to occupy the surgical incision, does not interfere with other instruments and provides multidirectional views. In the future, multiple small ‘remote’ wireless video cameras can be placed into the thoracic cavity, which are then held against the inner chest cavity by strong magnets, also known as magnetic anchoring and guidance systems (MAGS) camera, providing the ideal solution [5]. Although initially developed for single-incision laparoscopic surgery of the abdomen, ironically, MAGS may be more suited for surgery within the chest cavity because the rigidity of the chest wall provides more stability and less movement for magnetic anchorage when compared with the abdomen. We eagerly await further development and refinement of this technology.

Hybrid DynaCT-guided electromagnetic navigational bronchoscopic biopsy†.

Electromagnetic navigational bronchoscopy-guided biopsy of small pulmonary nodules can be challenging. Navigational error of the system and movement of the biopsy tool during its deployment adversely affect biopsy success. Furthermore, conventional methods to confirm navigational success such as fluoroscopy and radial endobronchial ultrasound become less useful for the biopsy of small lesions. A hybrid operating theatre can provide unparalleled real-time imaging through DynaCT scan to guide and confirm successful navigation and biopsy of difficult-to-reach or small lesions. We describe our technique for DynaCT image-guided electromagnetic navigational bronchoscopic biopsy of a small pulmonary nodule in the hybrid operating theatre. The advantages, disadvantages and special considerations in adopting this approach are discussed.

Comparison of Segmentectomy and Lobectomy in Stage IA Adenocarcinomas

Introduction: Recent studies have suggested that segmentectomy may be an acceptable alternative treatment to lobectomy for surgical management of smaller lung adenocarcinomas. The objective of this study was to compare survival after lobectomy and segmentectomy among patients with pathological stage IA adenocarcinoma categorized as stage T1b (>0 to ≤20 mm) according to the new eighth edition of the TNM system. Methods: In total, 7989 patients were identified from the Surveillance, Epidemiology, and End Results registry. Propensity scores generated from logistic regression on preoperative characteristics were used to balance the selection bias of undergoing segmentectomy. Overall and lung cancer–specific survival rates of patients undergoing segmentectomy and lobectomy were compared in propensity score–matched groups. Results: Overall, 564 patients (7.1%) underwent segmentectomy. Lobectomy led to better overall and lung cancer–specific survival than segmentectomy for the entire cohort (log‐rank p < 0.01). After 1:2 propensity score matching, segmentectomy (n = 552) was no longer associated with significantly worse overall survival (5‐year survival = 74.45% versus 76.67%, hazard ratio = 1.09, 95% confidence interval: 0.90–1.33) or lung cancer–specific survival (5‐year survival = 83.89% versus 86.11%, hazard ratio = 1.12, 95% confidence interval: 0.86–1.46) compared with lobectomy (n = 1085) after adjustment for age, sex, lymph node quantity, and histological subtype. Similar negative findings were identified when patients were stratified according to sex, age, histological subtype, and number of evaluated lymph nodes. Conclusions: Patients who underwent segmentectomy may have survival outcomes no different than those of some patients who received lobectomy for pathological stage IA adenocarcinomas at least 10 but no larger than 20 mm in size. These results should be further confirmed through prospective randomized trials.

Image-guided localization of small lung nodules in video-assisted thoracic surgery

The advancement of imaging technology has recently facilitated single port minimally-invasive thoracic surgery techniques. Cone-beam computed tomography (CBCT) shows promising results in visualizing the target lesion and its surrounding critical anatomy, with an error of less than 2 mm. The integration of CBCT with the operating room (OR) to form the hybrid OR, provides unparalleled real-time imaging of the patient, which can be used with electromagnetic navigation bronchoscopy to confirm successful navigation and increase procedural accuracy particularly for small peripheral pulmonary targets. Furthermore, implantation of hookwires or microcoils that are widely used to localize the lesion can take place in the hybrid suite, eliminating the common complications and discomfort associated with the conventional workflow carried out in the radiology suite. Displacement leading to localization failure can be also reduced, and sublobar resection will be performed without resecting a larger area of parenchyma than desired. This one-stop, paradigm-shifting concept for simultaneously diagnosing and managing small pulmonary lesions in the hybrid OR can lead to reduced invasiveness and improved patient care.

Penetrating thoracic injury with retained foreign body: can video-assisted thoracic surgery take up the leading role in acute management?

Video-assisted thoracic surgery (VATS) is widely adopted in acute management of patient with thoracic trauma, but its use in penetrating thoracic injuries with retained foreign bodies were rarely reported. We described three of such cases using VATS as the first line approach. Identification of injuries, control of bleeders, clot evacuation, resection of damaged lung parenchyma and safe retrieval of foreign bodies were all performed via complete VATS within short operative time. Patient were uneventfully discharged during early post-operative period. We suggest that, for haemodynamically stable patients, VATS offers a safe and minimally-invasive alternative to conventional thoracotomy for penetrating thoracic injury with retained foreign bodies.

Delayed Stent Deformity and Fracture of Djumbodis Dissection System

In recent years, a novel approach using the Djumbodis dissection system aortic stent has been introduced as an alternative to aortic arch replacement in acute type A aortic dissection involving the arch. From 2010 to 2013, we treated 7 patients with acute type A aortic dissection using the technique of replacing the ascending aorta with interposition graft and stenting of the aortic arch with the Djumbodis dissection system. We followed up the patients with serial imaging and in 3 consecutive patients who had been followed up for more than 10 months, we noted significant deformity and fracture of the Djumbodis stent.

Chest wall reconstruction with MatrixRib system: avoiding pitfalls

Reconstructions of the chest wall using commercially available artificial metallic rib systems are gaining in popularity. The MatrixRib system involves use of plates and screws to bridge any defect and provide support for the chest wall following resection. So far, there has been no publication focusing on describing the use of this new technology in a step-by-step approach. We describe our technique and discuss potential pitfalls and difficulties of using the system.

Hybrid Theater and Uniportal Video-Assisted Thoracic Surgery: The Perfect Match for Lung Nodule Localization

Cone-beam computed tomography provides unparalleled real-time imaging of the patient within the hybrid theater, which can be used for simultaneously diagnosing and localizing small pulmonary lesions for resection. Hybrid theater can guide more precise placement of electromagnetic navigation bronchoscopy tools, thereby increasing the diagnostic yield in biopsy procedures while reducing diffusion artifact in dye marking for nodule localization. Furthermore, hook-wires implantation that is widely used to assist in lesion localization for uniportal thoracoscopic surgery can take place in the hybrid suite, eliminating the common complications and discomfort associated with the conventional workflow carried out in the radiology suite.

Mitral valve repair using a semirigid ring: patient selection and early outcomes

Background Commonly used complete mitral annuloplastic rings include saddle-shaped and semirigid rings, with no clear indication for either type. A semirigid ring may be preferred in patients whose native mitral saddle shape is well maintained. We present our experience of using semirigid rings for mitral valve repair. Methods We routinely measured the annular height-to-commissural width ratio by 3-dimensional transesophageal echocardiography prior to mitral repair. We generally chose a semirigid (Memo 3D) ring in patients whose annular height-to-commissural width ratio was normal (≥ 15%). The same semirigid ring with an additional chordal guiding system (Memo 3D ReChord) was selected for patients with anterior leaflet or bileaflet pathology. Over an 18-month period, 66 patients with severe degenerative (n = 60) or functional (n = 6) mitral regurgitation had Memo 3D (n = 32) or Memo 3D ReChord (n = 34) rings implanted. Results Postoperative 3-dimensional transesophageal echocardiography was completed in all patients (mean follow-up 7 ± 5 months). The majority of patients had no or mild residual mitral regurgitation; only two had moderate (2+) mitral regurgitation. There was no mortality at 30-days or on midterm follow-up. Conclusions Our series represents the first Asian clinical experience using the Memo 3D ReChord ring. Although the long-term durability of mitral repair with this type of semirigid annuloplastic ring warrants further validation, our current clinical data are encouraging.