I was a little intimidated to actually interview Dr. Diego Gonzalez Rivas after reading his articles and pestering him with emails for the last few years. But he was just as nice and patient with my questions as he’s always been.
Since publishing the last few articles on his single port technique, Dr. Gonzalez has been in high demand from thoracic surgeons wanting to learn more, and to train in single port techniques. In addition to traveling the world to teach – he continues to offer training at the Minimally Invasive Thoracic Surgery Unit at the Complexo Hospitalario Universitario de A Coruna, in Coruna, Spain.
Dr. Gonzalez reports that single port thoracoscopy doesn’t just provide patients with the least invasive surgery possible, but that single port thoracoscopy is superior to traditional VATS in the vast majority of cases. Single port thoracoscopy is defined by the creation of one 2cm to 4cm incision – with no rib spreading and utilization of video-assisted thoracoscopy.
He states that using a single port approach gives much better visibility than traditional VATS. This visibility is equal to that of open surgery – versus the 3 or 4 port approach, which is constrained by the 30 degree movement / rotation of the thoracoscope. This visibility concept; called ‘Forward Motion,’ along with the ease of using instrumentation through the same port makes single port surgery amendable to most thoracic surgery procedures.
Learning curve? What learning curve?
He reports that members of the “Playstation Generation” as he terms the newest young surgeons, adapt more readily to the use of both traditional and single port thoracoscopy. In fact, he reports that the residents (in his program) are able to learn and use this approach with minimal assistance.
With the exception of lung transplantation (requiring the traditional clamshell incision), Dr. Gonzalez reports that he is able to successfully perform a wide range of surgeries from wedge resections and lobectomies to more complicated procedures such as pneumonectomies and sleeve resections.
In today’s lecture he debunks some of the myths regarding the ‘classic contraindications’ to video-assisted thoracoscopy (VATS) such as broncheoplasty, the presence of dense adhesions or the need for complete lymph node dissection. While he reports that dense adhesions may make the procedure more painstaking and difficult – it is still possible.
Lymph Node Dissection
In cases of lymph node dissection – he reports that lymphadenectomy is actually superior by single port and other VATS methods, with the average surgeon actually harvesting more nodes, more easily.
While he initially believed that right upper lobe resections would be impossible with this method – his recent experiences (included in an upcoming paper on 102 cases) show that any anatomic complexities are readily overcome by an experienced VATS surgeon. Not only that, but he has been able to successfully remove very large (8cm or greater) lung tumors using this method – by slightly enlarging the port at the time of specimen removal. He has also successfully removed Pancoast tumors and performed chest wall resections with this procedure, as well as single port thoracoscopy after previous VATS or previous thoracotomy including completion pnuemonectomies and completion sleeve lobectomies.
One of the biggest obstacles for surgeons implementing the single port method is the dreaded complication of catastrophic bleeding. This often causes inexperienced single port surgeons to hasten to convert to open surgery without attempting to control the bleeding. Dr. Gonzalez presented several cases today to demonstrate the difference between controlled bleeding that can be managed with the speedy application of surgical staples, clips or sutures versus heavy uncontrolled bleeding, which requires quick recognition and prompt conversion to open thoracotomy.
He reports that in the over 500 cases he has performed by VATS (3 port, dual port and single port), conversion to open thoracotomy remains a very rare occurence. (He presented data on his outcomes today.)
In his own practice, he reports that prior to 2007 the majority of cases were by traditional thoracotomy. He began using 3 port VATS more heavily in 2007 – 2009. After training with Dr. D’Amico at Duke University in Durham, NC – he moved to dual port thoracoscopy in 2009. Since 2010, his practice is almost exclusively single port thoracoscopy.
The future of single port thoracoscopy
Dr. Gonzalez believes the future of single port thoracoscopy will be a hybridization of current robotic thoracic surgery (which now uses three and four port techniques) to using less invasive, smaller robotic arms that will allow surgeons to enjoy the micro-precision of robotic technology through a single port.
Not just a ‘single port surgeon’
While he is famous internationally for his innovations in the field of minimally invasive surgery, he is also a transplant surgeon. In fact, along with his partners, he performed an average of 35 – 40 lung transplants a year.* This makes the transplant program in Coruna the second largest in Spain, despite the relatively small size of Coruna compared to other cities such as Barcelona or Madrid.
For patients who are interested in Dr. Gonzalez-Rivas and his program, please contact him at Info@videocirugiatoracica.com
I published an article based on this interview over at Examiner.com
Publications/ References – Dr. Gonzalez Rivas
1. Single-port video-assisted thoracoscopic anatomic segmentectomy and right upper lobectomy. Gonzalez-Rivas D, Fieira E, Mendez L, Garcia J. Eur J Cardiothorac Surg. 2012 Aug 24
2 / Single-incision video-assisted thoracoscopic lobectomy: Initial results. Gonzalez-Rivas D, Paradela M, Fieira E, Velasco C.J Thorac Cardiovasc Surg. 2012;143(3):745-7
3 / Single-incision video-assisted thoracoscopic right pneumonectomy. Gonzalez Rivas D, De la Torre M, Fernandez R, Garcia J. Surgical Endoscopy. Jan 11. 2012 (Epub ahead of print)
4 / Single-port video-assisted thoracoscopic left upper lobectomy. Gonzalez-Rivas D, de la Torre M, Fernandez R, Mosquera VX. Interact Cardiovasc Thorac Surg. 2011 Nov;13(5):539-41
5 / Video-assisted thoracic surgery lobectomy: 3-year initial experience with 200 cases. Gonzalez D, De la Torre M, Paradela M, Fernandez R, Delgado M, Garcia J,Fieira E, Mendez L. Eur J Cardiothorac Surg. 2011 40(1):e21-8.
6 / Single-port Video-Assisted Thoracoscopic Anatomical Resection: Initial Experience. Diego Gonzalez , Ricardo Fernandez, Mercedes De La Torre, Maria Delgado, Marina Paradela, Lucia Mendez. Innovations.Vol 6.Number 3. May/jun 2011. Page 165.
Books/ Book Chapters
1 / Thoracoscopic lobectomy through a single incision. Diego Gonzalez-Rivas, Ricardo Fernandez, Mercedes de la Torre, and Antonio E. Martin-Ucar. Multimedia Manual of Cardio-Thoracic Surgery. MMCTS (2012) Vol. 2012 doi:10.1093/mmcts/mms007. Includes multiple videos demonstrating single port techniques.
2 / Tumores del diafragma. M. de la Torre Bravos, D. González Rivas, R. Fernández Prado, JM Borro Maté. Tratado de Cirugía Torácica. Editores L. Fernandez Fau, J. Freixinet Gilart. SEPAR Editores médicos SA. Madrid 2010. Vol 2, Sec VIII, Capitulo 87: 1269-78.
3 / Trasplante Pulmonar. C. Damas, M. De la Torre, W. Hespanhol, J.M. Borro. Atlas de Pneumología. Editores A. Segorbe Luís y R. Sotto-Mayor 2010. Vol 2, Capítulo 54 651-8.
4 / Doble utilidad hemostática y sellante de fuga aérea de tachosil en un caso de cirugía compleja por bronquiectasias. M. De la Torre, J.M. Borro, D. González, R. Fernández, M. Delgado, M. Paradela. Anuario 2009. Casos clínicos en cirugía. Accesit en la 3ª edición de los Premios Nycomed 2008.
5 / Cirugía Torácica videoasistida avanzada. D. González Rivas. Videomed 2008. Certamen internacional de cine médico y científico.
6 / Traumatismo Torácico. M. de la Torre, M. Córdoba. En « Manual de Urgencias en Neumología». Editado por Luis M Domínguez Juncal, 1999 165-78.
7 / Neumotórax. M. Córdoba, M. de la Torre. En « Manual de Urgencias en Neumología». Editado por Luis M Domínguez Juncal, 1999 139-56.
8 / Cirugía del enfisema. P. Gámez, J.J. Rivas, M . de la Torre. En « Neumología Práctica al Día». Boehringer Ingelheim 1998 77-102.
9 / Neumotórax. J.J. Rivas, J. Torres, M. de la Torre, E. Toubes. En « Manual de Neumología y Cirugía Torácica». Editores Médicos S.A. 1998 1721-37.