Uniportal complete video-assisted thoracoscopic lobectomy with systematic lymphadenectomy

Video-assisted thoracoscopic surgery (VATS) has permeated our thoracic surgical practice and now will develop in depth towards a next level of minimally invasive surgery (MIS). Irrespective of generation gaps and diversified perception within thoracic community, more and more surgical teams are adapting to the uniportal lobectomy. This video demonstrates a case undergoing uniportal VATS lobectomy with systematic lymphadenectomy for lung cancer. We here describe our technique for uniportal approach by using a combination of double-jointed and endoscopic instruments to combat the four major obstacles: (I) interference of the thoracoscope, stapler and the instrumentation in and out of the thoracic cavity? (II) whether the field of vision is enough or not without the other 1-3 ports to improve the exposure? (III) the optimal stapler introduction angle especially for upper and middle lobes resection? (IV) more importantly, the oncologic validity of uniportal procedures as well as the reduction of postoperative morbidity? We believe, uniportal VATS lobectomy with systematic lymphadenectomy is technically safe and feasible and alternative approach to conventional thoracoscopic lobectomy in lung cancer treatment. The issues of patient acceptability, the cosmetic and oncologic results, and cost-effectiveness remain to be determined in the future through multi-institution randomized controlled trials and long-term follow-up.     

Nonintubated thoracoscopic surgery: state of the art and future directions

Video-assisted thoracoscopic surgery (VATS) has become a common and globally accepted surgical approach for a variety of thoracic diseases. Conventionally, it is performed under tracheal intubation with double lumen tube or bronchial blocker to achieve single lung ventilation. Recently, VATS without tracheal intubation were reported to be feasible and safe in a series of VATS procedures, including management of pneumothorax, wedge resection of pulmonary tumors, excision of mediastinal tumors, lung volume reduction surgery, segmentectomy, and lobectomy. Patients undergoing nonintubated VATS are anesthetized using regional anesthesia in a spontaneously single lung breathing status after iatrogenic open pneumothorax. Conscious sedation is usually necessary for longer and intensively manipulating procedures and intraoperative cough reflex can be effectively inhibited with intrathoracic vagal blockade on the surgical side. The early outcomes of nonintubated VATS include a faster postoperative recovery and less complication rate comparing with its counterpart of intubated general anesthesia, by which may translate into a fast track VATS program. The future directions of nonintubated VATS should focus on its long-term outcomes, especially on oncological perspectives of survival in lung cancer patients. For now, it is still early to conclude the benefits of this technique, however, an educating and training program may be needed to enable both thoracic surgeons and anesthesiologists providing an alternative surgical option in their caring patients.     

Uniportal video assisted thoracic surgery: summary of experience,mini-review and perspectives

The uniportal-video assisted thoracic surgery (VATS) technique comprises operations which can be performed with skin incisions ranging from 2 to 8 cm and the manifest result of the introduction of the uniportal lobectomy had made possible to increase rapidly the number of published papers on this subject. Many of the large ensuing literature report incomplete historical information on uniportal VATS, and doubts exist about the indication of uniportal VATS for some thoracic oncologic pathologies. Known limitations have been overcome. On the other hand, the modern thoracic surgical team includes one surgeon, one assistant and a scrub nurse, and it is clear that the new generation of thoracic surgeons need to use the “less” used hand. The new technology which permitted the introduction of the uniportal VATS could influence the future need of thoracic surgeons worldwide.     

Emergent Repair of a Complex Dissecting Aneurysm in the Thoracic Aorta

Endovascular treatment of complex thoracic pathologic conditions involving the aortic arch can often be appropriate and safe; however, minimally invasive procedures are not always feasible, especially in emergent cases. We report the case of a 78-year-old woman who emergently presented in hemorrhagic shock with a ruptured chronic dissecting aneurysm that involved the aortic arch. Eight years earlier, she had undergone aortic valve replacement and plication of the ascending aorta, which was complicated a day later by Stanford type B dissection, malperfusion, and ischemia that required an axillobifemoral bypass. At the current admission, we successfully treated her surgically through a left thoracotomy, using moderate hypothermic extracorporeal circulation and advanced organ-protection methods. We discuss the surgical indications and our operative strategy in relation to open surgical repair versus endovascular treatment in patients with complex conditions.Key words: Aneurysm, dissecting/radiography/surgery; aortic aneurysm, thoracic/radiography/surgery; aortic diseases/surgery; aortic rupture/surgery; treatment outcome; vascular surgical proceduresPathologic involvement of the aortic arch and the presence of dissection are 2 major issues in descending thoracic aortic repair, particularly in emergent settings of aneurysmal rupture. A patient''s comorbidities and older age may contraindicate deep hypothermic circulatory arrest; however, a thoracoabdominal dissection could lead to malperfusion if left-side heart bypass is considered for organ protection. Endovascular or hybrid surgery is a less invasive approach in complex cases; however, a good aneurysmal neck and adequate vascular access for the device are mandatory for technical success. We present the case of an elderly woman with comorbidities who required emergent repair of a complex dissecting thoracic aneurysm.     

Surgical and non-surgical management of thoracic and cervical paraganglioma

Thoracic and cervical paragangliomas (PGLs) are rare neuroendocrine tumors arising from chromaffin cells of the neural crest progenitors located outside the adrenal gland. We describe our current protocol as a multidisciplinary team for the management of cervical and thoracic PGLs. Surgery is generally considered the treatment of choice as it offers the best chance for cure. For resection of thoracic PGLs, video-assisted thoracoscopic surgery (VATS) is the main surgical approach, while open thoracotomy is preferred in case of tumors > 6 cm, lacking confirmation of a plane of separation with adjacent structures, or with technical difficulties during VATS. In cervical PGLs, the surgical approach should be individualized according to location, mainly based on the Glasscock-Jackson and the Fisch-Mattox classifications. Surgery is the treatment of choice for most cervical and thoracic PGLs, but radiotherapy or observation could be more suitable options in unresectable cervical and thoracic PGLs or when resection has been incomplete.     

Single-port video-assisted thoracoscopic surgery for lung cancer

In 2004, novel results using pulmonary wedge resection executed through single-port video-assisted thoracoscopic surgery (VATS) was first described. Since that time, single-port VATS has been advocated for the treatment of a spectrum of thoracic diseases, especially lung cancer. Lung cancer remains one of the top three cancer-related deaths in Taiwan, and surgical resection remains the “gold standard” for early-stage lung cancer. Anatomical resections (including pneumonectomy, lobectomy, and segmentectomy) remain the primary types of lung cancer surgery, regardless of whether conventional open thoracotomy, or 4/3/2-ports VATS are used. In the past three years, several pioneers have reported their early experiences with single-port VATS lobectomy, segmentectomy, and pneumonectomy for lung cancer. Our goal was to appraise their findings and review the role of single-port VATS in the treatment of lung cancer. In addition, the current concept of mini-invasive surgery involves not only smaller resections (requiring only a few incisions), but also sub-lobar resection as segmentectomy. Therefore, our review will also address these issues.     

Subxiphoid uniportal video-assisted thoracoscopic middle lobectomy and anterior anatomic segmentectomy (S3)

The video-assisted thoracoscopic surgery (VATS) approach for combined lobectomy and segmentectomy in the same lung is an infrequent procedure, rarely reported in the literature. Currently, Most of the surgeons still use 2–3 thoracic incisions for thoracoscopic anatomic resections. However, the uniportal approach is gaining worldwide acceptance in the recent years. The main advances of uniportal VATS during the last years are related to improvements in surgical technique by implementing new technology. The experience acquired with the uniportal technique allows expert uniportal VATS surgeons to explore new approaches in order to minimize even more the surgical invasiveness. Recently the aim to avoid the intercostal nerve damage created by the transthoracic incision has led to the creation of a novel procedure entitled uniportal VATS subxiphoid approach. Here we report the first case of a lobectomy combined with anatomic segmentectomy performed through a uniportal subxiphoid approach.     

Malignant pleural effusion treatment outcomes: pleurodesis via video-assisted thoracic surgery (VATS) versus tube thoracostomy

STUDY OBJECTIVES: Video-assisted thoracic surgery (VATS) has been widely used in the diagnosis and management of various thoracic diseases. The objective of this retrospective study was to compare the effectiveness of patients undergoing pleurodesis through VATS versus tube thoracostomy for malignant pleural effusion (MPE). Study design was a retrospective review of patients treated in medical centers and hospitals in Taiwan. PATIENTS: One hundred and forty-eight patients with MPE resistant to systemic therapy resulting from various types of carcinomas were retrospectively reviewed. VATS pleurodesis was carried out in 82 and tube thoracostomy with pleurodesis in 66 patients. RESULTS: There were no intraoperative deaths and 4 (2.7 %) in-hospital deaths. One hundred and eighteen (79.7 %) patients were available for follow-up. There were no statistically significant differences in the preoperative characteristics of the two treatment groups, except that the amount of effusion and the percentage of patients with dyspnea were both higher in the VATS treatment group. The duration of chest tube drainage was significantly longer ( P < 0.01) in the tube thoracostomy treatment group (9.1 +/- 3.3 vs. 6.2 +/- 2.3 days). There were no significant differences between the treatment groups with regard to the incidence of surgical complications and perioperative mortality. Median survival was similar in both treatment groups; however, the VATS treatment group had a significantly longer median recurrence-free survival than the tube thoracostomy treatment group. CONCLUSIONS: VATS treatment for MPE appears to be superior to tube thoracostomy for diagnostic accuracy and effectiveness in preventing effusion recurrence; however, the role of these treatments for MPE is palliative, and does not significantly prolong survival time.     

Video-assisted thoracoscopic sleeve lobectomy

Although minimally invasive video-assisted thoracic surgery (VATS) lobectomy has proved to be equal and in some aspects superior to open lobectomy in T1 and T2 lung cancers, video-assisted thoracic sleeve lobectomy is not widely practiced. Reconstruction is one of the most problematic techniques in thoracic surgery. We present a case of a patient who underwent VATS right-sided sleeve lobectomy due to right lung cancer. Based on the preoperative examinations, our VATS technique consisted of four incisions: three ports and a 3-4 cm long utility incision without any kind of rib spreading. Total surgery time was 180 min and blood loss was 100 mL. The chest tube was removed on the 5th post-operative day and the patient was discharged home on the 10th postoperative day. The final histopathological examination confirmed squamous cell lung cancer (T2aN0M0 stage IB). In the authors’ opinion VATS right-sided sleeve lobectomy should be performed by a surgeon with adequate experience with this approach. Despite limited indications for VATS right-sided sleeve lobectomy, if the patients fulfill the sleeve lobectomy inclusion criteria in general, they may gain from all the advantages of minimally invasive techniques.     

Cervical thoracic duct cyst

Thoracic duct cysts are rare lesions presenting as mediastinal or supraclavicular masses. We report a case of a 77-year-old female who presented with a left supraclavicular mass. A cervical thoracic duct cyst was suspected after contrast-enhanced computed tomography (CT) of the neck and chest. Diagnosis was confirmed by ultrasound-guided cyst aspiration and lymphangiography. Therapeutic embolization of the thoracic duct was unsuccessful. Definitive treatment was achieved with thoracic duct ligation using video-assisted thoracoscopic surgery (VATS) followed by surgical excision of the cyst. This is believed to be the first report of using minimally invasive surgery for thoracic duct ligation in the treatment of a thoracic duct cyst.     

Decreased invasiveness via two methods of thoracoscopic lobectomy for lung cancer, compared with open thoracotomy

BACKGROUND AND OBJECTIVE: Video-assisted thoracic surgery (VATS) lobectomy for primary lung cancer is considered minimally invasive. However, different procedures may be used for the VATS lobectomy, from complete videoscopic (CV) surgery to a technique similar to the muscle-sparing thoracotomy. We divided patients into two groups based on the surgical approach and analysed the outcomes. METHODS: Two hundred and thirty-one patients were treated using one of two VATS procedures: the video-supported method (VS, n = 63) and the CV method (n = 168). Patients treated by posterolateral thoracotomy (PL, n = 61) were also evaluated for certain postoperative parameters and pulmonary function. The CV method is the standard VATS lobectomy procedure in our institution, but the VS method is used when the CV method becomes difficult because of severe adhesion around the pulmonary artery, or for other reasons. RESULTS: Creatinine phosphokinase and CRP levels, and blood loss were lower in the VS and CV groups than in the PL group. Blood loss during CV was lower than that during VS. Postoperative VC after CV was higher than that after PL. Analgesic requirements in both VATS groups were lower than that in the PL group. The visual analogue scale pain score was lower in both VATS groups than in the PL group. CONCLUSIONS: Two methods of VATS cause less surgical damage than PL. CV, in particular, causes less damage to pulmonary function than PL, and achieves good postoperative quality of life.     

Potentially disseminated solitary fibrous tumor of the pleura: a case report

We report a case involving a female patient with frequent relapse, pleural dissemination, and port site recurrence (PSR) of a pleural solitary fibrous tumor (SFT). At the age of 55 years, she underwent tumor resection via video-assisted thoracoscopic surgery (VATS). The tumor arose from the mediastinal pleura; it was 7 cm in diameter and well demarcated. Histological examination showed neither hemorrhage nor necrosis, but moderate cellularity was present, and the Ki-67 labeling index was 15%. Despite complete resection, the tumor relapsed in the ipsilateral thoracic cavity 3 years postoperatively, and thoracoscopic complete tumor resection was performed; however, pleural lavage cytology (PLC) showed the presence of tumor cells. Multiple pleural dissemination and PSR developed 7 years after the initial surgery. The port site recurrent tumor was resected with the intercostal muscle via VATS. This case illustrates that a SFT may disseminate despite the fact that histological examination shows no evidence of malignancy.     

Thoracic surgery in Estonia

Estonia, a small Northern European country with the population of 1.3 million, has two centres of thoracic surgery, both established in 1960s. One is in the capital Tallinn, and another in the university town Tartu. Both departments cover the full spectrum of thoracic surgery, apart from oesophageal cancer surgery, yet including paediatric operations and chest trauma management. However, the focus is on lung cancer surgery. Currently, the proportion of lung cancer cases treated surgically is 20% in Estonia. Between 2000 and 2015 the proportion of lobectomies increased from 53% to 76%, while pneumonectomies decreased from 28% to 8%. Although the absolute number of lung cancer operations in Estonia is small, upon need complex and extended resections are performed. In the last decades a considerable survival gain of lung cancer patients has been observed. Minimally invasive surgery is widely used since its implementation in 1995, with the list of indications constantly evolving. In 2005, first video-assisted thoracoscopic (VATS) thymectomy and lobectomy were performed. VATS as surgical access in lung cancer operations exceeded thoracotomy in 2015 and is currently considered in all cases. In 2018, the first uniportal VATS sleeve-lobectomy was performed. The lung transplant program is functioning together with other solid organ transplant programs only at the Tartu University Hospital. Up to now, 33 lung transplantations have been performed, including lobar transplantations, a paediatric case, a few urgent cases for patients on extracorporeal membrane oxygenation (ECMO), and two re-transplantations. General thoracic surgery is a separate monospeciality in Estonia with an independent 5-year residency program, which is arranged by the Medical Faculty of University of Tartu. In last years, thoracic surgery related research in Estonia has mainly focused on lung cancer detection and management. Currently, a national lung cancer screening program feasibility study is being led by thoracic surgeons.     

New trainer for video-assisted thoracic surgery lobectomy

BACKGROUND: Only a few simulators are available which offer training in video-assisted thoracic surgery (VATS). We have developed a VATS training model for surgeons. METHODS: The simulator consists of a training module housing three disposable components: the lung (made of polyurethane), the bronchus, and the artificial circulatory pulmonary vessels (made of polyvinyl chloride), connected to a pump. VATS procedures were videotaped and evaluated using a checklist assessment method. RESULTS: This unique module has been tested at several VATS seminars in Japan. In the questionnaire, training participants strongly agreed that the trainer was helpful and prepared them well for VATS lobectomy prior to performing actual surgery. Evaluation of the dexterity score for thoracoscopic surgery with our simulator correlated with the surgeons' experience with actual surgery. Technical factors were well taught using this model. CONCLUSIONS: Our unique trainer may enhance the skill of VATS surgeons at a national level.     

Robotic assisted thoracic surgery for resection of an esophageal cyst

Many centers around the world are now developing robotic surgical programs. The benefit of robotics, particularly in those centers where there is already expertise with minimally invasive surgical techniques, is unclear. We present the case of a 58-year-old man presenting with an esophageal cyst. This was removed using a robotic assisted, VATS (video assisted thoracic surgery) approach. The technical details of the procedure are described. Additionally, a discussion of the relative merits of using a robotic rather than a standard minimally invasive approach is discussed. In a procedure such as the case described, the critical parts of the procedure are focused within a small operative field. We believe that the articulating instrumentation and the 3-dimensional magnified view provided by the robot offers significant advantages over a standard VATS approach.     

Video-assisted thoracoscopic surgery for catamenial hemoptysis

Catamenial hemoptysis is a rare condition, and only 36 cases have been reported since the first published case. We describe a woman with catamenial hemoptysis recurring over 8 years. The lesion was diagnosed using chest CT scan during menses and was also visualized clearly via thoracoscopy. The patient was treated successfully with a partial resection of the lung using video-assisted thoracic surgery (VATS) and has been asymptomatic for 14 months since the operation. We suggest that VATS for catamenial hemoptysis is a more effective treatment than medical therapy.     

Justifying video-assisted thoracic surgery for spontaneous hemopneumothorax

STUDY OBJECTIVES: Video-assisted thoracic surgery (VATS) has gained a prominent role in routine thoracic surgery practice. This study discusses the clinical aspects and utility of VATS in spontaneous hemopneumothorax (SHP). PATIENTS: Of 363 spontaneous pneumothorax (SP) cases, 24 patients presented with SHP (6.6%). The clinical features, surgical indications, emergency VATS technique, and patient outcomes are discussed. RESULTS: All 24 patients were male (mean age, 25.3 years). Eleven patients were in hypovolemic shock, and their hemoglobin levels ranged from 6.7 to 12.7 g/dL; therefore, they received fluid resuscitation and blood transfusion. The amount of blood drained through the chest tube varied from 200 to 3,500 mL. Emergency VATS revealed that 5 cases were simple hemothoraces and 19 cases were associated with pneumothorax. The cause of bleeding was identified by thoracoscopy, as from an aberrant vessel (n = 11), torn parietal pleura (n = 4), ruptured vascularized bullae (n = 2), and lung parenchyma (n = 1). Six patients had no evidence of an obvious bleeding site. Bullous lesions were at the apex of the upper lobe in 14 patients, and multiple lobar involvement was seen in 2 patients. All the bullae were resected with endoscopic stapler in eight patients and ligated with a homemade endoloop in eight patients. The mean operation time was 42 min. The mean chest tube removal time was 3.5 days after insertion, and mean postoperative stay was 4.5 days. There is no recurrence of SHP or SP during the follow-up period. CONCLUSION: SHP complicated by severe bleeding presents a potentially grave emergency. VATS may be considered as feasible treatment for patients with SHP.     

Thoracic surgery in Slovenia

Slovenia is a small country in the Southeastern part of Europe with a Gross Domestic Product slightly below the European average. There are eleven board-certified thoracic surgeons and four residents, dealing with roughly 2,500 thoracic cases per year. Thoracic Surgery in Slovenia is a challenging surgical specialty covering a wide range of problems such as lung cancer and other thoracic cancers, diseases of the esophagus, airway surgery, interventional endoscopy, pediatric thoracic surgery, lung transplantation, and even some nonthoracic problems such as surgery of the thyroid and parathyroid. Slovenian patients certainly enjoy the privilege of having free access to almost everything contemporary thoracic surgery can offer, including the most complex and least invasive procedures. In 2008 Slovenia was the first country in South-eastern Europe to adopt video-assisted thoracoscopic surgery (VATS) to treat lung cancer and other malignant diseases. It has also played an essential role in spreading the technique to neighboring countries. Slovenia also has a very successful lung transplantation program. On the other hand, most of the infrastructure is outdated, with both university hospitals built in the 1970s unable to provide a very comfortable hospital stay or increase their operating room capacities to meet the increased demand, thus waiting times for procedures of lesser priority, such as laparoscopic fundoplication and thyroidectomy became unacceptably long.     

History and current status of mini-invasive thoracic surgery

Mini-invasive thoracic technique mainly refers to a technique involving the significant reduction of the chest wall access-related trauma. Notably, thoracoscope is the chief representative. The development of thoracoscope technique is characterized by: developing from direct peep to artificial lighting, then combination with image and video technique in equipments; technically developing from diagnostic to therapeutic approaches; developing from simpleness to complexity in application scope; and usually developing together with other techniques. At present, the widely used mini-invasive thoracic surgery refers to the mini-open thoracic surgery performed mainly by using some instruments to control target tissues and organs based on the vision associated with multi-limb coordination, which may be hand-assisted if necessary. The mini-invasive thoracic surgery consists of three approaches including video-assisted thoracic surgery (VATS), video-assisted Hybrid and hand-assisted VATS. So far the mini-invasive thoracic technique has achieved great advances due to the development in instruments of mini-invasive thoracic surgery which has the following features: instruments of mini-invasive thoracic surgery appear to be safe and practical, and have successive improvement and diversification in function; the specific instruments of open surgeries has been successively developed into dedicated instruments of endoscopic surgery; the application of endoscopic mechanical suture device generates faster fragmentation and reconstruction of organ tissues; the specific delicated instruments of endoscopic surgery have rapid development and application; and the simple instruments structurally similar to the conventional instruments are designed according to the mini-incison. In addition, the mini-invasive thoracic technique is widely used in five aspects including diseases of pleura membrane and chest wall, lung diseases, esophageal diseases, mediastinal diseases and heart diseases. However, there remain many problems in specifications and trainings, economic cost, conservation and innovation. Therefore, particular attention should be paid to these problems. Nevertheless, the promotion of thoracic surgery appears promising in the future.     

Video-assisted thoracic surgery: A renaissance in surgical therapy

Within a few years, video-assisted thoracic surgery (VATS) has become the accepted or preferred approach over a wide range of thoracic procedures. The authors review the development of this technique, the basic operative strategies and the current surgical indications. Technical pitfalls and future developments are also discussed.