The best of VATS International 2017: Joel Dunning

In a day crammed full of lectures from internationally recognized experts – as part of a series of articles,  here are our picks



Best Orator:  Dr. Joel Dunning – for overall style, presentation as well as his lecture content.  In particular, his lecture on microlobectomy is excellent for being both informative and entertaining in delivery.  He promotes this 3 port technique, which utilizes a subxiphoid port as the utility incision, stating that the subxiphoid area is more flexible (no ribs) which results in less post-operative pain even when very large tumors or sections of lung5 are removed via the subxiphoid port.   He uses CO2 insufflation, and two 5mm accessory ports.  Insufflation decreases the amount of instrumentation needed, and he can perform most cases easily with the standard laparoscopic general surgery instruments, which fit easily in the 5mm posts.  The most impressive part of this technique is his pot-operative statistics, with 22% of his patients being discharged on post-operative day #1.

Essential of Microlobectomy

His second lecture: Robotic surgery is better than VATS: Against was a more-tongue-in cheek poke at Dr. Robert Cerfolio.  While entertaining, Dr.  Dunning answered the debate challenge in a less progressive fashion than I would have anticipated.  (While stating that RATS wouldn’t be needed if surgeons would follow all of the best practices for general thoracic surgery because of the excellent outcomes in areas of pain, mortality, length of stay, infection etc. with standard (open) thoracotomy using data researched and published by Dr. Cerfolio was a clever presentation, it doesn’t really address the fact that this very expensive procedure is being touted as “state-of-the-art”  and “cutting edge treatment” despite the lack of scientific evidence to document any real surgical advantages for patients.

Dr. Joel Dunning


At VATS Peru 2016

Cusco, Peru


Day One of the VATS Peru 2016 Conference was a primer for surgeons interested in learned and performing uniportal VATS.  Dr. Gonzalez Rivas’ lectures formed the basis of theory and principles of uniportal thoracoscopic surgery, with additional lectures by Dr. William Guido, Dr. Timothy Young and Dr. Deping Zhao.

Surprisingly, many of the surgeons at the event informed me that they already use some uniportal techniques in their practice.  But they came here to Cusco, Peru to learn more from the Master of Uniportal surgery himself, Dr. Diego Gonzalez Rivas before attempting more complicated and complex surgical cases like sleeve resections.  Others came to learn more about nonintubated surgery in their uniportal patients.  The remainders were the core group of surgeons who came to get their first taste of uniportal surgery.

Some came from the local areas; from Lima, from Chile, and Ecuador.  Others came from other parts of Latin America; from Mexico and Costa Rico.  There was even a practicing surgeon from the United States, who realized that if he wanted to pursue the most advanced surgical techniques and minimally invasive surgery in thoracic surgery, that he couldn’t do it at home.  That’s a big paradigm shift for a surgeon from a nation that tends to think if it wasn’t invented in the United States, that it doesn’t exist, or has no merit.   It is also, from my perspective, a welcome change.

With Dr. Tim Young, Dr. Diego Gonzalez Rivas and Dr. William Guido

In the five years that I have been travelling the globe, writing about surgical innovation, I am usually alone in my quest, in seeking innovation outside of  American medicine.  That’s not to say we(Americans)  don’t have our own great surgeons – I can easily rattle off quite a few – but it’s an acknowledgment that surgical innovation (or any innovation in general) is not the exclusive domain of the United States.   That sounds like a fairly basic principle, but one that is rarely seen in practice. American doctors and nurses just don’t attend international events to learn.  They only attend to teach – and often leave as soon as their lecture is complete, ensuring that an accidental opportunity to be exposed to new ideas is minimized.

So it was a pleasure to meet the surgeon from California, who took time off from a perfectly successful practice performing routine thoracotomies, to learn more about uniportal surgery at this and another upcoming master course.


Case Study: Thymectomy by Uniportal subxyphoid approach

Dr. Giuseppe Aresu of the University Hospital of Udine, Italy presents a case of thymectomy by subxyphoid approach

Article originally published October 31, 2015

We report the case of a thymectomy performed through a subxyphoid vertical single incision port carried out in a 51 years old female myasthenic patient presenting a Masaoka stage I thymoma.

The subxhyphoid approach permits an excellent view of the mediastinal anterior region and of the two pleural spaces giving the surgeon the possibility to perform a very radical and safe dissection of the thymic and peri-thymic fatty tissues.

Considering the position and the 3.5 cm length of the port, it is esthetically excellent. Without a sternal incision, or VATS – associated intercostal nerve injury, the recovery can be faster and less painful than the sternotomy approach or other vats approaches carried out through the intercostal spaces.


We performed extended thymectomy through a uniportal subxiphoid approach in a 51 years old female presenting a thymoma of 2.5 cm and myasthenia gravis.

The patient was informed about the risks and the benefits of the procedure and the consent to carry on with the operation was obtained.

Under general anesthesia, the patient was intubated with a double-lumen endotracheal tube and artificial ventilation was applied.

The patient was placed in a supine position with a silicon roll positioned below the lower part of the chest in order to lift the subxiphoid region.

The operating surgeon stood on the right side of the patient, the assistant stood on the patient’s left side and operated the endoscope. The  monitor was positioned at the right side of the patient toward the cranial side of the bed.

A 3.5-cm longitudinal muscle sparring incision was made below the xiphoid process between through the linea alba.

the incision
the incision

The xiphoid process was exposed,  the inferior part of the sternum was lifted up with a retractor and a blunt dissection was carried out in order to find the pericardial plane.

A SILS port (Covidien, Mansfield, MA) was then inserted into the port, and CO2 was insufflated at a maximal pressure of 8 mm Hg. The CO2 insufflation within the mediastinum generates a very useful  amount of extra working space within the anterior-superior mediastinum allowing an easier dissection and a better visualization of the mediastinal structures especially toward the cranial part of the mediastinum cephalad to the left innominate vein including the upper poles of the thymus.


Under visual guidance provided through a 10-mm EndoCAMeleon® Telescope, the operator utilized grasping forceps designed for single-incision surgery with his left (SILS Hand Instruments Endo Clinch™ II (Covidien) and performed dissection, coagulation, and division of tissue mainly using  the Sonicision™ cordless ultrasonic dissection device (Covidien, Mansfield, MA) and occasionally using a normal straight hook cautery.

The bilateral phrenic nerves and the bilateral mammary arteries and veins were always under optimal control as well as the cranial part of the mediastinum permitting a safe dissection en bloc of the  thymus, thymic tumor, and surrounding fatty tissue anterior to the phrenic nerves.


The operation time was about 2 hours and 30 minutes, and blood loss was minimal.


No complications occurred during or after the operation, the drain was taken out after one day and the patient was discharged home 2 days after surgery.

closed incision
closed incision

Postoperative pain was very low requiring just 1 g  X 3 daily of paracetamol during the hospital stay, and no analgesic administration after the discharge.

 Case study submitted by:

Dr. Giuseppe Aresu

University Hospital of Udine

Udine, Italy

Dr. Guiseppe Arescu
Dr. Giuseppe Aresu

This case was later published (Dec 14, 2015) at CTSnet.  Congratulations Dr. Aresu!

Additional Reading

Suda, T. (2016). Single-port thymectomy using a subxiphoid approach-surgical technique. Ann Cardiothorac Surg. 2016 Jan;5(1):56-8. doi: 10.3978/j.issn.2225-319X.2015.08.02. Review. Free fulll text discussion of a similar case by Japanese surgeon.  This article includes a video presentation and a in-depth discussion of technical aspects of the case such as surgeon position and camera access.