Atlas of Uniportal Video Assisted Thoracic Surgery (eBook)

Editor Diego Gonzalez Rivas is Consultant Thoracic Surgeon, Coruna University Hospital, Spain. Editor Calvin Sze Hang Ng is an Associate Professor in The Chinese University of Hong Kong. Editor Gaetano Rocco is an Attending Thoracic Surgeon, Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, USA. Editor Thomas A. D’Amico is a Professor and Chief of Thoracic Surgery, Duke University Medical Centre, USA.

Contents 5
Part I: General Aspects & Background
The Evolution of Video Assisted Thoracic Surgery 9
Evolution: The Cornerstone of Surgical Progress 9
The Early History of VATS 9
The Evolution of VATS Outcomes Assessment 10
Birth: Defining the Technique 10
Infancy: Safety and Feasibility 10
Childhood: Crude Benefit 10
Adolescence: Objective, Quantifiable Benefit 11
Adulthood: Treatment Efficacy 11
The Evolution of VATS Technique 11
Early Three-Port VATS 11
Modified Three-Port VATS 12
Robot-Assisted Thoracic Surgery 12
Needlescopic VATS 13
Two-Port VATS 13
Uniportal VATS 13
Implications of Evolution on Technique 14
Step-wise Learning: Manual Skills, Then Visual 15
Instruments: Try Before You Buy 15
Coping Without the Posterior Port 16
Troubleshooting 16
Peri-operative Care 17
Implications of Evolution on the Future of VATS 17
Trial by Evidence 17
Training in VATS 18
Technology and Technique 18
Conclusion 19
References 19
The New Era of Uniportal VATS 22
Introduction 22
What Made Uniportal VATS Easier 22
Scope Technologies 22
Instrumental Design 22
Image-Guided VATS for Tiny Pulmonary Nodules 23
What Has Been Made Possible by Uniportal VATS? 24
Non-intubated VATS Lung Resection 24
Alternative Surgical Access 24
Robotic Uniportal VATS 24
Summary 25
References 25
Room Set Up and Instrumentation 27
Introduction 27
Perioperative Preparation 27
Patient Positioning and Incision Marking 27
Staff Positioning 28
Instrumentation 28
Intraoperative Tips and Tricks 29
Immediate Postoperative Care 30
Conclusion 30
References 30
Anaesthesia for Uniportal VATS 32
Introduction 32
Preoperative Evaluation 32
Monitoring 32
Airway Management 33
Pain Management 34
Conclusion 34
References 35
Geometric Considerations in Uniportal VATS 36
Introduction 36
A Bird Fly on Plane Geometry Concepts 36
Geometrical Characteristics of Uniportal VATS 38
Conclusions 40
References 40
Modified Uniportal Approach 42
Introduction 42
Surgical Technique 43
Discussion 44
Conclusion 45
References 45
Part II: Uniportal VATS in Pleural and Mediastinal Diseases 47
Uniportal Video-Assisted Thoracoscopic Surgery for the Management of Pleural Effusions, Empyema and Pleural Biopsy 48
Uniportal Video-Assisted Thoracoscopic Surgery (Vats) for Pleural Effusions and Pleural Biopsy 48
Uniportal Video-Assisted Thoracoscopic Surgery (Vats) for Empyema 49
References 50
Uniportal Approach to Pericardial Window and Sympathectomy 51
Pericardial Window 51
Introduction 51
Patient Selection and Preoperative Planning 51
Uniportal VATS Pericardial Window 52
Sympathectomy 53
Introduction 53
VATS Sympathectomy 54
Patient Selection 54
Technical Consideration of Sympathectomy 54
Uniportal Thoracic Endoscopic Sympathectomy 55
Nonintubated Uniportal Sympathectomy 56
Embryonic Natural Orificial Transumbilical Endoscopic Surgery (ENOTES) 56
Subxiphoid Uniport Technique 57
Conclusion 57
References 57
Uniport Anterior Mediastinal Surgery 59
Introduction 59
Operation Preparation (Fig. 1) 59
Creation of the Wound (Fig. 1) 60
Detaching the Anterior Mediastinal Tissue from the Pericardium (Fig. 2) 61
Ligating the Thymic Vein, Retrieving the Bilateral Horns of Thymus (Fig. 3) 61
Extracting the Anterior Mediastinal Tumor (Fig. 4) 63
How to Deal with Visceral Pleural Adhesion and Bleeding Episode (Fig. 5) 63
Case Demonstration 65
Discussion 65
References 65
Uniportal Posterior Mediastinal Surgery 66
Anatomy 66
Incidence and Pathophysiology 66
Clinical Manifestation and Diagnosis 67
Surgical Technique 67
Patients Position 67
Incision Placement 67
Surgical Technique (Video 1) 67
Discussion 69
References 71
Subxiphoid Mediastinal Resections 72
Introduction 72
Operative Technique of Subxiphoid Single-Port Thymectomy 73
Instruments for Subxiphoid Single-Port Thymectomy 73
Patient Selection 74
Anesthesia Management 74
Operative Positioning 74
Surgical Technique (Video 1) 74
Tips for Surgery 76
Managing Hemorrhage 76
Subxiphoid Thymectomy (Dual-Port Thymectomy) 76
Postoperative Management 77
Results 77
Discussion 78
Conclusions 79
References 79
Part III: Parenchymal Lung Diseases 80
Uniportal Treatment for Spontaneous Pneumothorax 81
History 81
Principles 81
Anesthesia 81
Surgical Technique 82
Outcome 83
Conclusion 83
References 83
Uniportal Bullectomy for Emphysematous Bullous Lung Disease 84
Introduction and a Brief Historical Remark 84
Terminology and Basic Pathophysiology 84
Clinical Manifestations and Evolution 85
Surgical Indications and Preoperative Assessment 85
Surgical Treatment: Options Overview 87
Surgical Treatment: General Considerations About Giant Bullectomy 87
The Uniportal VATS Approach for Bullectomy 87
Results and Outcomes 89
Summary and Conclusion 89
References 89
Hookwire Localization of Pulmonary Nodules in Uniportal VATS 91
Introduction 91
Technique 91
Indication and Efficiency of Hookwire Localization 92
Complications 93
Technical Limitations 93
Ways to Improve the Technique 93
Trajectory Guidance System for Centesis 93
Decreasing the Rate of Dislodgement 94
Dual Localization 94
Simultaneous Localization and Resection 94
Initial Results of Hookwire Placement in a Hybrid OR 94
Conclusions 94
References 95
Intraoperative Ultrasound Guidance in Pulmonary Nodule Localization in Uniportal VATS 96
Technique (Videos) 96
References 97
Videoendoscopic Uniportal Resection of Solitary Peripheral Lung Nodule 98
Introduction 98
Indications 98
Contraindications 98
Anaesthetic Considerations 98
Positioning 98
Port Placement 99
Preference Card 100
Results and Discussion 100
References 100
Part IV: Uniportal Major Lung Resections 102
Right Lower Lobe 103
Introduction 103
General Aspects 103
Operative Techniques 103
Fissure Complete 103
Completion 106
References 107
Left Lower Lobe Resection 109
Introduction 109
Operative Technique 109
Results 113
Conclusions 113
References 113
Right Middle Lobe 114
Uniportal Video-Assisted Thoracoscopic Right Upper Lobectomy 116
General Aspects 116
Operative Technique 117
How to Select the Proper Angle for Stapler Insertion 120
Uniportal Right Upper Lobectomy 121
Introduction 121
VATS Evolution: From Multiportal to Uniportal 121
Indications for Uniportal Lobectomy 122
Contraindications for Uniportal Lobectomy 122
Preoperative Planning 122
Uniportal Right Upper Lobe Technique for Lung Cancer 122
Patient Positioning, Uniportal Access, and Lobectomy Overview 122
Ligation of the Pulmonary Artery Anterior Trunk 123
Dissection of the Right Upper Lobe Bronchus 123
Dissection of Right Upper Lobe Vein 124
Completion of the Fissure 124
Lymphadenectomy 124
Final Steps 124
Postoperative Care 125
References 125
Left Upper Lobectomy 127
Introduction 127
Indications and Preoperative Preparation 127
Anesthesia and Analgesia 127
Positioning 128
Incision and Instrumentation 128
Thoracic Exploration 128
Left Upper Lobectomy 128
“Single Direction” Left Upper Lobectomy 128
Management of the Truncus Apicoanterior Branch 129
Management of the Superior Pulmonary Vein 129
Management of the Posterior Arterial Branches 130
Management of the Left Upper Bronchus 130
Management of the Fissure and the Lingular Arterial Branch 130
Hybrid Approach Left Upper Lobectomy 130
Other Procedure 130
Conclusions 131
References 131
Left VATS Upper Lobectomy 132
Patient Positioning 132
Port Position 132
Procedural Steps 133
Further Reading 134
Uniportal Video-Assisted Thoracoscopic Segmentectomy 135
Introduction 135
Indication and Preoperative Evaluation 135
Operative Technique 135
Lingula-Sparing Left Upper Lobectomy 136
Lingulectomy 137
Superior Segmentectomy (Video 2) 137
Basilar Segmentectomy 137
Upper Lobe Posterior Segmentectomy (LUL-RUL) 137
Left Posterior Segmentectomy (It Is Uncommon, Usually in the Left Side the S1+2 Are Removed Together) 139
Right Posterior Segmentectomy 139
Right Upper Lobe Apical-Posterior Segmentectomy 139
Right Upper Lobe Apical Segmentectomy 140
References 140
Segmental Resection 141
Introduction 141
Localization Technique 142
Localization Techniques for Small Pulmonary Nodules 142
Percutaneous Localization 142
Intraoperative Localization 144
Identification of the Intersegmental Plane 145
Operative Techniques 145
Right and Left Upper Lobe Apical and Posterior Segments (Fig. 4) 145
Right and Left Lower Lobe Superior Segments (Fig. 5) 147
Right and Left Lower Lobe Basilar Segments (Fig. 6) 147
Left Upper Divisional Segment (Tri-segment) (Fig. 7) 147
Left Lingular Segment (Fig. 8) 147
Results 150
Conclusions 151
References 152
Left Uniportal VATS Pneumonectomy 154
Pre-operative Considerations 154
Operative Strategy 154
Postoperative Care 156
References 156
Right Pneumonectomy 158
Indications 158
Contraindications 158
Historical Review 158
Patient Selection 159
Surgical Technique 159
Discussion 161
References 162
Uniportal Lymphadenectomy 163
Introduction 163
Operative Techniques 163
The Material 163
The Technical Aspects in Mediastinal Lymph Node Dissection 164
Right Paratracheal Space 164
Left Paratracheal Space 164
Right Subcarinal Lymphadenectomy 164
Left Subcarinal Lymphadenectomy 164
Aortopulmonary Window Space 165
Para-oesophageal and Pulmonary Ligament Lymph Nodes 166
Hiliar and Interlobar Lymph Nodes 166
Comments 166
References 166
Part V: Advanced Uniportal Techniques 168
Uniportal Video-Assisted Thoracoscopic Sleeve Resections 169
Introduction 169
Preoperative Planning 169
Surgical Thoracoscopic Technique 170
Sleeve Bronchoplasty 171
Vascular Reconstruction 171
RUL Sleeve Lobectomy (Videos 1, 2) 172
Right Lower Lobe Sleeve Resection (Middle Lobe Bronchus to Intermediate Bronchus Sleeve) (Video 4) 172
Right Upper Sleeve Bilobectomy (Video 5) 173
Left Upper Lobe (LUL) Sleeve Resection (Video 6) 173
Left Lower Sleeve Resection (Video 7) 175
Bronchial Sleeve Resection (Lung Sparing) 175
Sleeve Segmental Procedures (Video 8) 177
Tracheal and Carinal Resection Reconstruction (Video 9) 177
Literature Review and Discussion 179
Conclusions 181
References 182
Sleeve Resection 184
Introduction 184
Operative Technique 184
Results 185
Conclusions 185
References 187
Tracheal and Carina Resection/Reconstruction 189
Introduction 189
Preoperative Preparation 189
Induction of Anesthesia 190
Position and Incision Selection 190
Surgical Technique 190
Post-operative Care 195
Conclusion 195
References 196
Uniportal VATS Chest Wall and Diaphragm Resection and Reconstruction 197
Introduction 197
Discussion 197
Incidence 197
Staging and Prognosis 197
The Role of VATS 198
Surgery 199
Anesthesia 199
Positioning 199
Technique 200
Lobectomy with Chest Wall Resection 200
Lobectomy with Diaphragm Resection and Reconstruction 203
References 205
Troubleshooting: Management of Bleeding 207
Introduction 207
Bleeding During VATS Lobectomies 208
References 210
Uniportal Minimally Invasive Esophagectomy 211
Introduction 211
Patient Selection 211
Surgical Anatomy for Esophagus and Regional Lymph Nodes 211
Operative Methods 212
Incision and Access 212
Surgical Exposure Under Uniportal Thoracoscopy 212
Mobilization and Dissection of Esophagus 213
Mediastinal Lymphadenectomy 213
Gastric Mobilization Under Uniportal Laparoscopy 214
Completion of Procedure 216
Tri-incision 216
Ivor-Lewis 216
Discussion 218
References 218
Part VI: The Future of Uniportal VATS 219
Non-intubated Uniportal VATS Major Pulmonary Resections 220
Introduction 220
Alternative or Recommendation: Advantages of Thoracic Surgery Without Intubation 220
Anesthesia Management for Non-intubated Thoracic Surgery: From Theory to Practice 221
Monitoring 222
Ventilation 222
Sedation 222
Regional Anesthesia Techniques 223
Local Anesthesia and Intercostal Blockade 223
Paravertebral Blockade 223
Epidural Anesthesia 223
Vagus Nerve 224
Conversion to General Anesthesia 225
Conclusions 225
References 225
Subxiphoid Uniportal Video-Assisted Thoracoscopic Surgery 227
Introduction 227
General Principles 227
Patients Selection and Preoperative Assessment 227
Operative Technique 228
Anesthesia Considerations 228
Positioning 228
Creating the Wound and the Working Channel 229
Basics of Instrumentation 231
Subxiphoid Technique for Lobectomy 231
Right Upper Lobectomy (Video 2) 231
Right Middle Lobectomy (Video 3) 233
Right Lower Lobectomy (Video 4) 234
Left Upper Lobectomy (Video 5) 235
Left Lower Lobectomy (Video 6) 235
Thymectomy and Anterior Mediastinal Mass Resection (Video 7) 236
Specimen Removal 237
Mediastinal and Hilar Lymph Nodes Dissection 237
Closure of the Wound 239
References 239
Natural-Orifice Uniport VATS for Lung Resection 240
Introduction 240
Historical Background 240
Transvesical Approach 240
Transgastric Approach 240
Transesophageal Approach 240
Transtracheal Approach 241
Transoral Approach 241
Transumbilical Approach 241
Potential Future Direction 241
References 242
Natural Orifice Transluminal Endoscopic Surgery (NOTES) Uniportal VATS for Sympathectomy 243
Inclusion and Exclusion Criteria 243
Inclusion Criteria 243
Exclusion Criteria 243
Special Instruments and Equipments/Materials 243
Surgical Procedures 244
Postoperative Treatment and Care 244
Surgical Experience and Recommendation 244
Umbilical Incision 245
Diaphragm Incision 245
Intrathoracic Operation 246
Advantages and Disadvantages of This Surgery 246
Prospect 246
References 247
Image-Guided Uniportal VATS in the Hybrid Operating Room 248
Hybrid Theater and Its Preclinical Data 248
Structure of Hybrid Theater 248
Image-Guided ENB Diagnostic/Marking Procedure 249
Image-Guided Metallic Implantation 254
Conclusions 256
References 256
Development of 3D VATS 258
Introduction and Development 258
Current Status 258
Surgery 258
Teaching 259
Issues and Concerns 259
One Step Ahead Glasses-Free 3D VATS 259
Future 259
References 261
Future Development and Technologies 262
Introduction 262
Thoracoscopes 262
Uniportal Platforms 264
Advanced Multimodality Image-Guided Operating Room 267
Conclusion 267
References 268