Out of all of the topics covered here at Thoracics.org – one of the most popular topics among surgeons and surgical residents is minimally invasive surgery – uniportal, in particular. There is a steady stream of inquiring readers wanting to know more – about the data, the current evidence, and state of uniportal surgery. There is also a flood of inquiries on where to obtain training in these minimally invasive techniques. With the annual VATS International conference, attendees can have it all – access to the leaders in the field, while listening and participating in (sometimes) heated discussions on evidence based data, surgical outcomes and relevant research. This year, the conference moves out of merry ole England, and over to Italy. This year, the conference is being held in Monza, outside of Milan on September 28 – 29th.
It continues to be the best of all of the available surgical conferences for thoracic surgeons, with the opportunities to learn from the masters themselves, in the surgical lab that accompanies live surgery, panel discussions and formal presentations.
in the operating room with Dr. Diego Gonzalez Rivas for single port thoracoscopic (uniportal) surgery.
Hilar mass resection using single port thoracoscopy with Dr. Diego Gonzalez – Rivas
K. Eckland & Andres M. Neira, MD
Instituto Nacional de Cancerlogia
Surgeon(s): Dr. Diego Gonzalez Rivas and Dr. Ricardo Buitrago
59-year-old female with past medical history significant for recurrent mediastinal mass previously resectioned via right VATS. Additional past medical history included prior right-sided nephrectomy.
CBC: WBC 7230 Neu 73% Hgb:14.1 Hct 37 platelets 365000
Pt 12.1 / INR1.1 PTT: 28.3
Pre-operative CT scan: chest
Procedure: Single port thoracoscopy with resection of mediastinal mass and lymph node sampling
After review of relevant patient history including radiographs, patient was positioned for a right-sided procedure. After being prepped, and draped, surgery procedure in sterile fashion. A linear incision was made in the anterior chest – mid clavicular line at approximately the fifth intercostal space. A 10mm port was briefly inserted and the chest cavity inspected. The port was then removed, and the incision was expanded by an additional centimeter to allow for the passage of multiple instruments; including camera, grasper and suction catheter.
The chest cavity, pleura and lung were inspected. The medial mediastinal mass was then identified.
As previously indicated on pre-operative CT scan, the mass was located adjacent and adherent to the vessels of the hilum. This area was carefully dissected free, in a painstaking fashion. After freeing the mediastinal mass from the hilum, the remaining surfaces of the mass were resected. The mass was fixed to the artery pulmonary and infiltrating it) . The mass was removed en-bloc. Care was then taken to identify, and sample the adjacent lymph nodes which were located at stations (4, 7 and 10).
Following removal of the tumor and lymph nodes, the area was re-inspected, and the lung was re-inflated. A 28 french chest tube was inserted in the original incision, with suturing of the fascia, subcutaneous and skin layers.
Hemostasis was maintained during the procedure with minimal blood loss.
Patient was hemodynamically stable throughout the case, and maintained appropriate oxygen saturations. Following surgery, the patient was awakened, extubated and transferred to the surgical intensive care unit.
Post-operative: Post-operative chest x-ray confirmed appropriate chest tube placement and no significant bleeding or pneumothorax.
Patient did well post-operatively. Chest tube was discontinued on POD#2 and discharged home.
Discussion: Since the initial published reports of single-port thoracoscopy, this procedure has been applied to an increasing range of cases. Dr. Gonzalez and his team have published reports demonstrating the safety and utility of the single-port technique for multiple procedures including lobectomies, sleeve resections, segmentectomies, pneumonectomies and mediastinal mass resections. Dr. Hanao Chen (Taiwan) has reported several successful esophagectomies using this technical, as well as bilateral pleural drainage using a unilateral single-port approach.
Contrary to popular perception, the use of a single-port versus traditional VATS procedures (three or more) is actually associated with better visibility and accessibility for surgeons. Surgeons using this technical have also reported better ergonomics with less operating fatigue related to awkward body positioning while operating.
The learn curve for this surgical approach is less than anticipated due to the reasons cited above, and has been cited at 5 to 20 cases by Dr. Gonzalez, the creator of this approach.
The main limitations for surgeons using this technique is often related to anticipated (but potentially unrealized) fears regarding the need for urgent conversion to open thoracotomy. In reality, many of the complications that may lead to urgent conversion, such as major bleeding, are manageable thoracoscopically once surgeons are experienced and comfortable with this approach.
Dr. Gonzalez and his colleagues have reported a conversion rate of less than 1% in their practice. Subsequent reports by Dr. Gonzalez and his colleagues have documented these findings.
Other barriers to adoption of this technique are surgeon-based, and may be related to the individual surgeon’s willingness or reluctance to adopt new techniques and technology. Many of these surgeons would be surprised by how this technique mimics open surgery.
The successful adoption of this technique by numerous thoracic surgery fellows shows the feasibility and ease of learning single-port thoracoscopy by surgeons interested in adopting and advancing their surgical proficiency in minimally invasive surgery.
The benefits for utilizing this technique include decreased length of stay, decreased patient discomfort and greater patient satisfaction.
References/ Additional Readings
Bertolaccini, L., Rocco, G., Viti, A. & Terzi, A. (2013). Surgical technique: Geometrical characteristics of uniportal VATS. J. Thorac Dis. 2013, Apr 07. Article from thoracic surgeons at the National Cancer Institute in Naples, Italy explains how the geometric advantages of uniportal VATS improves visibility and spatial perception over traditional VATS, and mimics open surgery.
Calvin, S. H. Ng (2013). Uniportal VATS in Asia. J Thorac Dis 2013 Jun 20. Article discussing the spread of uniportal techniques in Taiwan, China and other parts of Asia.
Chen, Chin-Hao, Lin, Wei-Sha, Chang, Ho, Lee, Shih-Yi, Tzu-Ti, Hung & Tai, Chih-Yin (2013). Treatment of bilateral empyema thoracis using unilateral single-port thoracoscopic approach. Ann Thorac Cardiovasc Surg 2013.
Gonzalez Rivas, D., Fieira, E., Delgado, M., Mendez, L., Fernandez, R. & De la Torre, M. (2013). Surgical technique: Uniportal video-assisted thoracoscopic lobectomy. J. Thorac Dis. 2013 July 4.
Gonzalez Rivas, D., Delgado, M., Fieira, E., Mendez, L. Fernandez, R. & De la Torre, M. (2013). Surgical technique: Uniportal video-assisted thoracoscopic pneumonectomy. J. Thorac Dis. 2013 July 4.
Rocco, G. (2013). VATS and uniportal VATS: a glimpse into the future. J. Thorac Dis. 2013 July 04. After coming across several articles by Dr. Gaetano Rocco, and actively pursuing several other publications by this Italian thoracic surgeon, I have become increasingly convinced that Gaetano Rocco, along with Dr. Gonzalez Rivas is one of the world’s leading innovators in thoracic surgery. Hopefully, cirugia de torax will be able to catch up to Dr. Rocco at some point for an in-depth discussion.
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.