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D. Gonzalez Rivas

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    SC20 - Small is Beautiful: Impact of Surgical Approach (ID 344)

    • Event: WCLC 2016
    • Type: Science Session
    • Track: Surgery
    • Presentations: 1
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      SC20.04 - Uniportal VATS (ID 6684)

      16:00 - 17:30  |  Author(s): D. Gonzalez Rivas

      • Abstract
      • Presentation
      • Slides

      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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