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Future of Thoracic Surgery, New Masters, Single port thoracic surgery

Single-port thoracoscopy as a first-line approach & the “Chen esophagectomy”

Single-port thoracoscopic surgery (SITS) as a first-line approach
With the advent of minimally invasive surgical techniques such as VATS, surgeons now have the ability to perform multiple surgical procedures such as lobectomy, decortication and even esophagectomy through 1 – 2 cm port incisions instead of traditional open surgery. However, as mentioned during an interview with Dr. Mark Dylewski, few American* surgeons have fully embraced this technology. Even fewer surgeons internationally have embraced the emerging single port techniques that have developed from VATS. One of these surgeons is Dr. Chih-Hao Chen at Mackay Memorial Hospital in Taiwan. We previously discussed one of his studies here at Cirugia de Torax, so it was with great delight when we had an opportunity to discuss his continuing research and development in this area in a series of emails.
Dr. Chen is currently in the forefront of the movement to make SITS a first-line approach for majority of thoracic surgery procedures that can currently be approached with traditional VATS. The biggest risk to this “less is more” approach to port placement is needing to add additional ports during the case (thus converting to traditional VATS 3-4 port approach).

As Dr. Chen explains, “In contrast to creating 3 small wounds, I always try single-port first. If it is technically unavoidable, I would make the second port incision. If it is still difficult, a third port incision would be made. The conversion rate (to 2-port or three port methods not open) is very low in most conditions.
“I believe the role of SITS as a first-line endoscopic approach is possible in nearly all patients. So far, I have performed roughly, SITS in more than 150 patients with various thoracic diseases, including esophagectomy in 5 cases using 2.5 cm single incision”.
However, the contraindications for the SITS approach are mainly those with “unstable hemodynamics in trauma”, “highly complicated cancer resection(such as sleeve lobectomy, etc)” and “thick and dense peel in chronic empyema”.

Dr. Chen was kind of the provide this clip of him performing single port thoracoscopy.

Over 150 cases, so far.

“According to my experience, patients with spontaneous pneumothorax and acute stage empyema as well as solitary pulmonary nodules are the best candidates for such procedure. The time required for the same operation is much shorter in single-port approach. For simple spontaneous pneumothorax, the time may be as short as 20-25 minutes. ( from skin incision to suture )”.
As I mentioned in my report (see publications linked below), the conversion rate of such condition is pretty low and worthy to try. In my experience, SITS w/o trocar greatly decrease incisional pain and have pleasant cosmetic results, as the wound can be extremely small”.

A recent case: Wedge resection by SITS

Procedure: single-port approach for a case of lung cancer in a 77 year-old woman.

Multiple wedge resections, pleural biopsy and LN smapling were performed.

single incision (now with chest tube) and specimen removed (photo courtesy of Dr. Chen)

The wound was 1.5 cm in length and the specimen is 7cm X 4cm ( solid part :2.5 cm ).  The specimen was removed within an endo-bag. (From previous experience, I knew that a specimen of this size can be safely removed through a tiny incision w/o destruction of the specimen.

Her chest tube was removed within 24 hrs and patient reports minimal discomfort. ( I injected Marcaine in ICS to prevent neuralgia in all cases.)

Sometimes innovation is hard
As we’ve seen frequently in the history of medicine / surgery, early innovators and adopters of new technology are often face significant resistance from their colleagues despite utilizing ‘best-evidence’ to support their ideas. People, many people, including surgeons – don’t like change and are sometimes hesitant to learn and practice techniques that develop in the years following fellowship.
One of the reasons Dr. Chen contacted Cirugia de Torax is to share his experiences and this technique with other interested thoracic surgeons. ‘Unfortunately, only a small portion of thoracic surgeons would like to try such procedure in Taiwan. Actually, most of them considered the procedure not valuable. Therefore, I would like to publish more experiences in the journals, which is one way to tell them “to try”.

Wait.. Did you say single-port thoracoscopy for esophagectomy?

“Esophagectomy in my team was performed by single-port thoracoscopic approach (in the chest). However, the abdominal portion was performed with four-port or 5-port laparoscopic approach, because the abdominal part was done by another doctor who is not familiar with single-incision laparoscopy (SILS). However, I have to admit that esophagectomy through single-port approach is much more difficult than other procedures. The main reason for this is that the esophagus is located in posterior mediastinum.”

While I usually utilize a more anterior ICS as my port incision for other single-incision procedures because the anterior ICS is very easy, with low conversion ( to 2- or 3-port ) rate. However, the same port is not appropriate for esophagectomy because of poor visualization.

New Approach, the “Chen esophagectomy” but ergonomic considerations
“For the reason, I tried a more lateral port incision (usually 5 ICS along the mid-axillary line. ) This is a BIG problem for me due to ergonomic issues. Manipulation of endoscopic instruments and the endoscope through the port is uncomfortable. At times, I have to rest for a while in order to alleviate soreness in my arm”.
“The time-determining step is to loop the esophagus. Proximal and distal dissection as well as lymph node dissection would be done with a harmonic scalpel. (We resected the esophagus, the anastomosis is in the neck ). For uncomplicated case, the procedure in the chest takes aroud 1-2.5 hours”.

*American research data suggests that VATS is used for less than 30% of all thoracic surgery procedures. However, anecdotal evidence suggests that internationally, VATS is utilized with much higher frequency outside of the United States.

Articles about single-incision thoracoscopic surgery (SITS) by Dr. Chih-Hao Chen

Chih-Hao Chen, Shih-Yi Lee, Ho Chang, Hung-Chang Liu, Chao-Hung Chen (2012). The adequacy of single-incisional thoracoscopic surgery as a first-line endoscopic approach for the management of recurrent primary spontaneous pneumothorax: a retrospective study. Journal of Cardiothoracic Surgery 2012, 7:99  [abstract only, full article pending publication.]

Chih-Hao Chen, Shih-Yi Lee, Ho Chang, Hung-Chang Liu, Chao-Hung Chen (2012). Technical Aspects of Single-Port Thoracoscopic Surgery for Lobectomy. Journal of Cardiothoracic Surgery 2012, 7:50.

Chih-Hao Chen, Ho Chang, Tzu-Ti Hung, Hung-Chang Liu (2012). Single Port Thoracoscopic Surgery can be a First-line Approach for Elective Thoracoscopic Surgery. Revista Portuguesa de Pneumologia, Portuguese Journal of Pulmonology, 2012, Sept 22.

About K Eckland

World of Thoracic Surgery is a blog about the work, research, and practices of thoracic surgeons around the world. It includes case studies, [sometimes] dry research, interviews with thoracic surgeons along with patient perspectives, and feedback.

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