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Case Reports

Uniportal VATS with chest wall resection

Uniportal VATS with chest wall resection at Shanghai Pulmonary Hospital

Shanghai, China

Authors: Gonzalez – Rivas, D. & Eckland, K.

Surgeons: Dr. Diego Gonzalez Rivas with Dr. Boxiong Xie assisting.

Case:  66-year-old patient with large left upper lobe mass extending into chest wall, biopsy proven carcinoma.

Pulmonary function tests – within acceptable margins

Imaging:

CT scan – showing a large left-sided lung upper lobe mass with chest wall invasion and rib involvement at the level just beneath the scapula.

Chest wall resection  chest mass

Procedure: Uniportal (single incision) VATS with rib resection

Description: at a glance

Determining port placement

Determining port placement

Due to tumor location, port placement had to be carefully considered and adjusted.

Vital signs at initiation of operation: HR 78, NSR   B/P 95/56  Oxygen saturations: 100% (intubated with double lumen ETT)

First incision: 14:17

Making the initial incision

Making the initial incision

The tumor was adherent to the chest wall, requiring chest wall resection with rib resection.

performing uniportal VATS for tumor with chest wall invasion

performing uniportal VATS for tumor with chest wall invasion

The tumor was palpated thru the 2 cm incision allowing the surgeon the benefit of open surgery despite using a minimally invasive technique.

Palpating the tumor

Palpating the tumor

 

Ribs were resected using a guillotine designed for minimally invasive use.

Rib resection

Rib resection

Lung resection complete at 17:42.   The tumor was removed enblock using a bag system to prevent tumor spillage.

Tumor enblock after removal

Tumor enblock after removal

Lymph node dissection completed at 17:56

There was a brief run of PVCs lasting about 30 seconds (B/P 83/54) with no desaturations.   Patient was otherwise hemodynamically stable for the duration of the case.

Frozen section: clear pleural margins

EBL: 200ml

Discussion:

As noted by Pischik and others, many of the traditional contraindications for VATS procedures are no longer applicable, particularly for surgeons well versed in minimally invasive techniques like uniportal thoracoscopic surgery. In the case above, several of these contraindications were successfully addressed, including multiple adhesions, an incomplete interlobar fissure and a tumor with chest wall involvement.

That being said, this case was technically challenging from start to finish, due to the position of the chest wall tumor that required adjustment of port placement, a lengthy dissection of dense adhesions in addition to a sizeable chest wall mass.  Hilar dissection was complicated by anatomical position, and the bronchus was difficult to access.  This in addition to an incomplete fissure significantly lengthened the procedure.

VATS resection using a single port approach can be challenging even for experienced surgeons.  However, it is a viable alternative for more complicated cases including those requiring a degree of chest wall resection.

References

Gonzalez-Rivas D, Fieira E, Delgado M, de la Torre M, Mendez L, Fernandez R.  (2014). Uniportal video-assisted thoracoscopic sleeve lobectomy and other complex resections.  J Thorac Dis. 2014 Oct;6(Suppl 6):S674-81.

Huang CL, Cheng CY, Lin CH, Wang BY. (2014). Single-port thoracoscopic rib resection: a case report. J Cardiothorac Surg. 2014 Mar 15;9:49.

Kara HV, Balderson SS, D’Amico TA. (2014). Challenging cases: thoracoscopic lobectomy with chest wall resection and sleeve lobectomy-Duke experience.  J Thorac Dis. 2014 Oct;6(Suppl 6):S637-40

Pischik VG. (2014).  Technical difficulties and extending the indications for VATS lobectomyJ Thorac Dis. 2014 Oct;6(Suppl 6):S623-30

 About this and other uniportal surgeries

This case was just one of numerous cases performed by Dr. Diego Gonzalez Rivas as part of the Uniportal VATS training course at Shanghai Pulmonary Hospital.  Dr. Diego Gonzalez Rivas is the inventor of the uniportal technique and Director of Uniportal VATS training program at Shanghai Pulmonary Hospital.  He has partnered with the Chinese facility to offer training courses for interested surgeons three times a year, in addition to his ‘wet-lab’ surgical training offerings in his home facility at La Coruna, Spain.

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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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