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A.D.L. Sihoe
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SC20 - Small is Beautiful: Impact of Surgical Approach (ID 344)
- Event: WCLC 2016
- Type: Science Session
- Track: Surgery
- Presentations: 4
- Moderators:A.D.L. Sihoe, A. Toker
- Coordinates: 12/06/2016, 16:00 - 17:30, Strauss 1
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SC20.01 - Muscle-Sparing Thoracotomy: Can It Still Be Considered a Standard? (ID 6681)
16:00 - 17:30 | Author(s): C. Aigner
- Abstract
- Presentation
Abstract:
Muscle sparing thoracotomy has been a standard approach in thoracic surgery for a long time. Minimal invasive approaches have gained a widespread acceptance recently and were included in the treatment guidelines for early stage NSCLC by several societies. Prospective randomized trials comparing minimal invasive approaches versus muscle sparing thoracotomy in stage I NSCLC have already been performed more than twenty years ago and demonstrated equal morbidity and mortality. Nevertheless it took until 2013 that the American College of Chest Physician guidelines recommended a VATS approach for clinical stage I NSCLC over a thoracotomy in experienced centers (1). No recommendation is made for more advanced stages. When analyzing national registry data still a high percentage of procedures in performed in an open way. This means that in current practice thoracotomy is still used as a standard approach by many surgeons. Minimal invasive approaches – both videothoracoscopic and robotic – are not different operations but different approaches towards performing an operation. It has been proven in several studies that in early stage lung cancer minimal invasive approaches in its various form lead at least to equivalent or even better oncologic outcome compared to an open approach. Nevertheless in more advanced stages this proof is lacking. Experienced centers reported individual series of minimal invasive approaches towards advanced procedures such as sleeve resection, pneumonectomy, chest wall resection and Pancoast tumor resection. While this is technically feasible no data on long-term outcome of larger patient cohorts are available and an open approach is considered standard in these cases. Thus for tumors with invasion of hilar structures or sleeve resection a muscle sparing thoracotomy currently remains a standard approach. Perceived advantages of minimal invasive approaches – VATS as well as RATS – include less pain, fewer complications, shorter length of stay, faster return to normal activity and higher rate of adjuvant chemotherapy compliance. There are a few single center studies challenging these assumptions (2,3) as well as a recent analysis of Danish national data (4), however the majority of studies are in favor of minimal invasive approaches. In summary muscle sparing thoracotomy remains a standard approach for advanced stage tumors, whereas early stage lung cancer should be treated minimally invasive in experienced centers. References 1) Detterbeck FC1, Lewis SZ, Diekemper R, Addrizzo-Harris D, Alberts WM. Executive Summary: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013 May;143(5 Suppl):7S-37S. 2) Rizk NP, Ghanie A, Hsu M, Bains MS, Downey RJ, Sarkaria IS, Finley DJ, Adusumilli PS, Huang J, Sima CS, Burkhalter JE, Park BJ, Rusch VW. A prospective trial comparing pain and quality of life measures after anatomic lung resection using thoracoscopy or thoracotomy. Ann Thorac Surg. 2014 Oct;98(4):1160-6. 3) Kuritzky AM, Aswad BI, Jones RN, Ng T. Lobectomy by Video-Assisted Thoracic Surgery vs Muscle-Sparing Thoracotomy for Stage I Lung Cancer: A Critical Evaluation of Short- and Long-Term Outcomes. J Am Coll Surg. 2015 Jun;220(6):1044-53 4) Licht PB, Schytte T, Jakobsen E. Adjuvant chemotherapy compliance is not superior after thoracoscopic lobectomy. Ann Thorac Surg. 2014 Aug;98(2):411-5
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SC20.02 - What Have We Achieved? Should It Be Performed for Stages Higher Than Stage I Disease? (ID 6682)
16:00 - 17:30 | Author(s): T. Grodzki
- Abstract
- Presentation
Abstract:
Since the introduction of the videothoracoscopic anatomical lung resections in the early 90-ties both indications and contraidications for this type of approach have changed dramatically (1,2). There is common agreement that the oncological principles during surgery for lung cancer have to be the same regardless the type of approach: standard, minimally invasive (MIS – VATS multiportal or uniportal, intubated or non-intubated) or robotic. It regards predominantly requirements such like careful and atraumatic dissection, sufficient free-of-neoplasm margins and proper lymphadenectomy (standard or extended). Keeping it in mind we have to admit that stage I NSCLC seems „ideal” indication for MIS, particularly for less experienced surgeons. This type of surgery (MIS for stage I) is widely accepted and performed worldwide in thousands of cases. However, many experienced centers and surgeons have moved the borders forward treating more advanced cases by MIS with acceptable results regarding complications, mortlity, conversion rate or quality of lymphadenectomy. Gonzalez-Rivas presented the series of 43 advanced patients (tumors bigger > 5cm, T3 or T4, treated by neoadjuvant chemo- or radiotherapy) who were treated by uniportal VATS with good results comparable with earlier stages (3). Authors stated that „Skilled VATS surgeons can perform 90% or more of their lobctomies thoracoscopically, reserving thoracotomy only for huge tumors or complex bronchovascular reconstructions”. Large multicenter series of more than 400 advanced cases treated by VATS approach compared with propensity score matched open thoracotomy group with no differences in overall survival was published by Cao et al. (4). According to the VATS Consensus Statement (among 50 international experts to establish a standardized practice of VATS lobectomy after 20 years of clinical experience) eligibility for VATS lobectomy should include tumors <7cm and N0 or N1 status. Chest wall involvement was considered contraindication while centrality of tumour was considered a relative contraindication when invading hilar structures (5). This important statement is widely accepted however some surgeons consider it too restrictive regarding chest wall invasion. Currently there is a relatively small (but growing) group of thoracic surgeons who are performing double-sleeve (pulmonary vessels and bronchi) and carinal resections by MIS – extremely complex procedures even in open surgery (6). It requires modern instruments, sutures and definitely is not a procedure for beginners. Published series are small and overall experience is limited but this initial efforts are good example of the continuos drive of thoracic surgeons community to move indications for MIS further and further. Advanced NSCLC cases started to be treated by MIS just few years ago and there are no prospective randomised studies available in medical literature therefore we cannot definitively compare and assess the long term results but keeping in mind that the main oncological principles should be preserved and remain the same in every type of surgical approach we can expect comparable and similar results as it was reported in currently published papers. We all know that generally speaking the future is unpredictable but inevitable from the other side. Considering MIS in advanced NSCLC cases we can state with just minimal exagerration that the future is now. Selected references: 1. Roviaro G, Varoli F, Vergani C et al.: Long term survival after videothoracoscopic lobectomy for stage I lung cancer. Chest 2004;126:725-732 2. Hanna JM, Berry MF, D`Amico TA: Contraindications of videoassisted thracoscopic surgical lobectomy and determinants of conversion to open. J Thorac Dis 2013;5:182-189 3. Gonzalez-Rivas D, Fieira E, Delgado M et al.: Is uniportal thoracoscopic surgery a feasible approach for advanced stages of NSCLC? J Thorac Dis 2014;6:641-648 4. Cao C, Zhu ZH, Yan TD et al.: Videoassisted thoracic surgery versus open thoracotomy for NSCLC: a propensity score analysis based on a multi-institutional registry. Eur J Cardiothorac Surg 2013;44:849-54 5. Yan TD, Cao C, D`Amico TA et al.: Videoassisted thoracoscopic surgery lobectomy at 20 years: a consensus statement. Eur J Cardiothorac Surg 2014;45:633-639 6. Lyscov A, Obukhova T, Ryabova V et al.: Double-sleeve and carinal resections using the uniportal VATS technique: a single centre experience. J Thorac Dis 2016;8 (suppl 3):235-241
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SC20.03 - Robotic Surgery: What Can Be Done? (ID 6683)
16:00 - 17:30 | Author(s): F. Melfi
- Abstract
- Presentation
Abstract not provided
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SC20.04 - Uniportal VATS (ID 6684)
16:00 - 17:30 | Author(s): D. Gonzalez Rivas
- Abstract
- Presentation
Abstract:
Introduction Uniportal video-assisted thoracic surgery (VATS) has been established as an alternative surgical approach for the treatment of most intrathoracic conditions. The potential benefits of a better view, anatomic instrumentation, better cosmesis and potential less postoperative pain and paraesthesia have led this approach to become of increasing interest worldwide. Performing surgery through a single incision approach represents an evolution of VATS to a less invasive approach. The early period of uniportal VATS development was focused on minor procedures until the second phase uniportal VATS started in 2010 with the development of the technique for major pulmonary resections. The creation of specific uniportal VATS programs in high volume centers like the Shanghai pulmonary hospital (the biggest thoracic program in the world with more than 8000 major resections per year) has contributed to spread out the technique to a large number of surgeons from all over the world in a short period of time. Surgical technique Uniportal VATS represents a radical change in the approach to lung resection compared to the conventional three-port VATS. Since the placement of all the surgical instruments and the camera is done through the same incision, Uniportal VATS can pose a challenge for both the surgeon and the assistant. The surgeon and the assistant should be positioned in front of the patient in order to have the same thoracoscopic vision during all steps of the procedure and experience more coordinated movements. Even though the field of vision is only obtained through the anterior access site, the combined movements of the thoracoscope along the incision will create different angles of vision (in this context, a 30 degree thoracoscope is recommended to achieve a panoramic view). The advantage of using the thoracoscope in coordination with the instruments is that the vision is directed to the target tissue, bringing the instruments to address the target lesion from a direct, sagittal perspective. Instruments must preferably be long and curved to allow the insertion of 3 or 4 instruments simultaneously.Optimal exposure of the lung is vital in order to facilitate the dissection of the structures and to avoid instrument interference. The rule of thumb is that for any lobectomy, the Uniport is best sited between the mid- and anterior axillary lines in the 5[th] intercostal space. This slightly anterior position takes advantage of the naturally wider intercostal spaces at the front of the human body. If the wound is sited too high – in the 4[th] space for an upper lobectomy – the dissection of the hilar vessels may be easier, but the instruments enter directly towards the hilum so that there is a smaller angle for the stapler to pass without impinging on the structures behind. If the wound is too low, there may be a good angle for the stapler to pass, but the distance to the hilum becomes too great and the arc in which instruments can be placed towards the hilum becomes too narrow – leading to more chance of ‘fencing’ between the instruments and camera. The incision itself is typically 3-4cm long, although longer incisions can be used (e.g. for an inexperienced surgeon, large tumor, thicker chest wall, etc) without any obvious disadvantage to the patient. It is helpful to rotate the surgical table away from surgeons during the hilar dissection and division of structures, and towards the surgeons for the lymph node dissection. For most of the surgical steps the thoracoscope is usually placed at the posterior part of the utility incision working with the instruments in the anterior part. For lower lobectomies the normal sequence of dissection is as follows: inferior pulmonary ligament, inferior pulmonary vein, pulmonary artery, bronchus and finally completion of the fissure. In case of upper lobectomies, the pulmonary artery is normally divided first, followed by vein, bronchus and fissure. When the lobectomy is completed, the lobe is removed in a protective bag and a systematic lymph node dissection is accomplished. The intercostal spaces are infiltrated with bupivacaine at the end of the surgery under thoracoscopic view. A single-chest tube is placed in the posterior part of the incision. We do not routinely employ epidural or paravertebral catheters. Future Recent industry improvements such as the specifically designed surgical instrumentation with double articulation, improvements in high definition video-camera systems, new energy devices and more narrower and angulated curved tip staplers have made single-port VATS, for major lung resections, easier to adopt and learn than conventional VATS. The demonstrated benefits of geometrical characteristics of the technique enables expert surgeons to perform complex cases and reconstructive techniques, such as broncho-vascular procedures or even carinal resections. The future of the thoracic surgery is based on the evolution of minimally invasive procedures and innovations directed towards reducing even more the surgical and anaesthetic trauma. We can expect more developments of subcostal or embryonic natural orifice translumenal endoscopic surgery access, evolution in anaesthesia strategies, and cross-discipline imaging-assisted lesion localization for single-port VATS procedures. Improvements in anaesthetic techniques such as non-intubated or awake uniportal VATS,may further quicken postoperative recovery allowing the tumor resection to be performed in an ambulatory setting. Furthermore, the need to reduce the risk of intercostal nerve damage associated with the transthoracic incision has led to the recent development of uniportal subxiphoid VATS technique for major pulmomary resections. We truly believe in the use of the uniportal approach, combined with yet-to-come 3D image systems (adapted on the screen, no glasses) and single port robotic technology and wireless cameras in awake patients. We understand that the future goes in the direction of digital technology which will facilitate the adoption of single-port technique worldwide in the next coming years.
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