Thoracics.org is here with registration information for two upcoming thoracic surgery conferences online.
With the continuing pandemic, and related infection control measures, the majority of thoracic surgery conferences have been postponed or cancelled. However, the are two upcoming online thoracic surgery conferences to take note of.
This webinar hosted by the Argentine Society of Thoracic Surgeons, and Dr. Hector Rivero. Interested readers may register for this webinar at this link: Register for Webinar 26 June 2020.
Duke Masters of Minimally Invasive Thoracic Surgery
While readers have just a few days to register for the conference above, there is considerably more time to register for the 13th Annual Masters of Minimally Invasive Thoracic Surgery – Virtual Conference. While the traditional conference has become the annual pilgrimage south – this year’s online offering offers opportunities for greater attendance and participation from surgeons outside North America.
This conference runs September 25th, 2020. Interested readers may click here to register. The full online schedule of speakers has not yet been published
Many of the modern masters of thoracic surgery were in Potsdam, Germany this June to discuss a myriad of topics in this year’s course until the heading of Troubleshooting. The lecturers included Dr. Diego Gonzalez Rivas, the inventor of the uniportal VATS technique, Dr. Alan Sihoe, a renown expert from Hong Kong, Dr. Timothy Yang from Shanghai Pulmonary Hospital, Dr. Marco Scarci, the creator of International VATS, and our host, Dr. Mahmoud Ismail. The course included both wet and dry labs so that surgeons unfamiliar with these techniques had an opportunity to apply what they learned during this and other sessions.
Standout presentations
Transcervical Uniportal VATS
Noted surgeon, and acknowledged expert in the area of transcervical VATS, Dr. Zielinski of Poland also gave a presentation on the transcervical uniportal approach, which is performed in the anterior cervical (neck) area. Using this collar incision, Dr. Zielinski is able to perform uniportal VATS for thymectomies and mediastinal operations as well as some lobectomies (generally upper lobes) and lung resections.
Dr. Zielinski talked about the challenges for this technique as well as the indications/ contraindications and potential complications while presenting data on his latest series of 32 patients. He gave surgical tips and tricks for using the transcervical approach, and how to avoid the most common complications.
There was a full session on setting up a uniportal VATS program with multiple speakers – along with troubleshooting the most common mistakes that surgeons (and their staff and administrators) make while starting a new uniportal VATS. They also talked about addressing the learning curve and ways to avoid common mistakes that occur during this period.
Common Complications after uVATS
Dr. Stefano Margaritora talked about how to prevent, detect and treat common complications after uniportal VATS. Drawing on his experience with over 1250 uniportal cases, Dr. Margaritora discussed the most common causes of bleeding such as dislodgement of vascular clips, bronchial artery bleeding, bleeding from lymph node harvesting sites and bleeding from the chest wall. He discussed the best ways to address this, such as use of newer anti-sliding clips, and the use of energy devices (like harmonic scalpels) for vessel sealing.
The ways to anticipate and prevent prolonged airleaks was also reviewed. Using anatomic fissures often lessens the incidence of airleaks post-operatively. The prevention of subcuatneous emphysema, as well as the relatively rare complication of lung hernia was addressed. Both of these complications can be reduced by meticulous and tight closure of the fascia at the conclusion of this procedure.
Using a serratus/ intercostal nerve block during this procedure is recommended to help reduce post-operative pain.
Dr. Firas Abu Ar spoke at several sessions – on both the use of uniportal VATS in pediatric patients as well as a case presentation on hydatid cysts. (Thoracics.org is planning to present this case study at a later date).
Hydatid cyst (photo provided by Dr. Firas Abu Akar)
There was a session on robotic VATs but with the exception of a discussion of preliminary trials of a robotic instrument that allows for uniportal VATS, most of the information has been presented on previous occasions.
The state of evidence for Uniportal VATS
Dr. Alan Sihoe gave an excellent presentation on the need more more randomized studies, and higher level evidence. “The time for case presentations on uniportal VATS is over.” As the leading academic researcher at this conference (as well as an active, practicing uniportal surgeon), and editor of multiple journals, Dr. Sihoe reminded attendees that as uniportal vats use continues to grow, and becomes a more common procedure, the types of articles surrounding the procedure need to advance as well. It’s no longer sufficient to submit papers like case reports where the purpose of the paper is to explain the procedure, and basically say, “look at this cool case I did.” Surgeons need to move beyond these sophomoric writings to produce high quality, high value papers that add to the body of scientific literature around uniportal VATS. He then gave the audience specific, helpful guidelines and advice on designing, writing and submitting articles for publication.
Attending watching the first of two live cases
After the didactic portion was completed, there were two live cases streamed from the local hospital for surgeons to review along with the dry and wet labs.
a Mexican surgeon using one of the newest tumor located/ marking systems during one of the dry labs
Note to readers: This will be the last article on uniportal VATS training. This topic has been extensively covered thru this and other posts here at thoracics.org. For more information on the essentials of uniportal VATS training, please review our archives under meetings and conference coverage.
Additional references
Eckland K, Gonzalez-Rivas D. (2016). Teaching uniportal VATS in Coruña.J Vis Surg. 2016 Mar 11;2:42. doi: 10.21037/jovs.2016.02.25. eCollection 2016. PMID:29078470
Today’s recommended read is for all of the thoracic surgeons out there that are interested in establishing their own nonintubated uniportal programs. This is a interesting article if you’ve taken a masterclass on uniportal technique, reviewed the literature around nonintubated surgery, but haven’t yet taken the next step to start performing this procedure at your hospital.
Thoracics.org has reached out to the corresponding author, Sook Sung for more information about their experiences with nonintubated uniportal VATS including some updates, but let’s review the primary article while we await a reply.
In the article, Nonintubated uniportal video-assisted thoracoscopic surgery: a single center experience, Seha Ahn et al. discuss their experiences over a six month period after initiating this technique in January 2017.
During this period, 40 patients underwent this technique. Pre-operative patient selection was important with multiple exclusionary criteria.
Exclusionary criteria for initial cases: General
Obesity (BMI greater than 30
Anticipated/ expected difficult airway
Persistant cough/ or high amount of secretions
At increased risk of gastric reflux
Exclusionary criteria: Cardiopulmonary
Expected/ anticipated to have extensive adhesions
Prior pulmonary resection
N2 stage lung cancer
Severe cardiac dysfunction (exact definition not defined)
Photo by 서울성모병원
Anesthesia and Intra-operative Monitoring
Prior to the procedure, patients received dexmedtomidine. At the time of the procedure, patients were maintained with infusions of remifentanyl and propofol.
No patients were intubated. Patients did receive supplemental oxygen by mask at a rate of 6 to 9 liters/ min. Oxygenation was monitored with botha small single nostril end-tidal CO2 monitor and pulse oxymetry. Anesthesia monitoring including a BIS monitor. General hemodynamic monitoring consisted of continuous EKG/ telemetry and serial blood pressure cuff measurements.
Surgical technique
As part of the surgical technique, the authors administered an intercostal nerve block for additional analgesia. In the majority of patients (35 of 40), intrathoracic vagal nerve blocks were also performed to reduce / prevent coughing during the procedure.
The procedure was carried out using a single 3 to 4 cm incision. The main surgical instruments used were a 10mm 30 degree scope, a harmonic scalpel and a curved suction tip catheter.
Results
General demographics
There were 40 total patients in this study, which spanned a period of six months. More than half of these patients (57.5%) were women. The mean age was 60.
The vast majority of these patients (72.5%) had lung cancer. Seven patients (17.5%) had surgery for pulmonary metastasis. The remainder of patients had surgery for either benign lung disease or pleural disease.
Procedure types
Over half of the patients underwent lobectomies (57.5%). 10 patients (25%) had wedge resections, with six patients having segmentectomies (15%) and a solo patient undergoing a pleural biopsy.
Complications
There were several intra-operative conversions. The majority of these conversions were related to anesthesia, with 3 patients requiring conversion to standard intubation. The authors are a little unclear with the reasons for this – with one sentence saying it was not related to hypoxia (with all patient sats greater than 90%). The authors then attribute the conversions to excessive respiratory movements, but then report that all three of the patients’ hypoxemia resolved with intubation. This is better explained in a later portion of the paper, but it is still a bit confusing as to whether excessive respiratory movement was a contributing cause for the reason to intubate mid-procedure.
There was only one conversion for surgical technique, which occurred after the dread pulmonary artery injury, with the authors converting to multi-port VATS. There were no conversions to open thoracotomy.
Post-operative complications
Seven total post-operative complications (17.5%)
3 patients with prolonged air leaks
2 chylothorax
1 delayed pleural effusion
1 pneumonia
Interestingly enough, outcomes based on traditional criteria, (chest tube days, and overall length of stay) were not significantly different that results published for more traditional types of thoracic procedures.
The average post-operative chest tube time was 3.2 days (range: 1-13 days)
The average hospital stay was 4.4 days (range 1 – 18 days).
There was one notable outlier listed, a patient with a prolonged airleak that resulted in a 20 day hospital stay.
Discussion
This article is note worthy of several reasons, in that the authors both describe their techniques and the initial results of the initiation of a new surgical approach (nonintubated and uniportal) in their facility. The authors are to be commended for reporting research results that show a (17.5 %) high rate of complications, which is presumably related to the learning curve of adopting a new surgical protocol.
However, this article would have been much more informative if there had been more of an in-depth discussion of the challenges involved in initiating and managing a nonintubated uniportal program, instead of a general review of the literature. While the article notes that there was a solo surgeon involved in these 40 procedures, there is little discussion of the prior experience of that surgeon or the anesthesia team(s) involved. What the surgeon previously experienced in uniportal VATS? If so, what was the level of experience?
The same goes for the anesthesiologists involved in this study, since a large portion of the procedure (ie. the nonintubated portion) as well as the highest level of conversions (to standard intubation) occurred under their guidance. A short discussion about intra-operative intubation would have been a helpful addition for readers as well, such as a discussion of the difficulties (or lack thereof) of intubating a patient after they have been secured into a lateral decubitus position.
While the traditional outcomes measures appear fairly unchanged in comparison to standard VATS with general anesthesia and intubation, what was the difference in related outcomes?
Was there a difference in/ would they anticipate a difference in (with larger numbers of patients):
Post-operative intubation? How man patients required urgent/ emergent intubation during the post-operative period?
Post-operative pneumonias and other respiratory complications? While the authors cite one post-operative pneumonia, there appear to be few other respiratory complications cited in this study.
Post-operative anesthetic complications such as hemodynamic compromise (requiring prolonged use of pressors, for example). What about post-operative nausea/ vomiting or gastric ileus?
Since nonintubated and uniportal techniques have been proposed as a alterative to standard surgery for high risk patients (patients with poor respiratory reserve/ cardiovascular disease), the presence or lack of these complications in patients (even specially selected patients) is important.
When reviewing the lack of clear-cut advantages such as shorter length of stay, were there other reasons for it, such as post-operative nursing care? Are there changes that need to be implemented/ have been implemented since this study was published that have resulted in fewer chest tube days, or a shorter overall length of stay?
In the time since this study was concluded, what have been this group’s continued experience? Have there been any unexpected outcomes or observations? What changes continue to need to be addressed?
Are there any other observations that the authors would like to share? While traditional journals have size and article length limitations, we don’t here at thoracics.org.
Dr. Eric Lim challenges thoracic surgeons to remain relevant with a call to action at the 3rd VATS International conference in London, England
“Act different or watch thoracic surgery die”
With that dramatic shot across the bow, the dynamic and forthright Mr. (Dr.) Eric Lim of Royal Brompton Hospital opened the third VATS International conference. In a lecture entitled, “The Why of advancing minimally invasive surgery,” Dr. Lim put out a call to action to thoracic surgeons around the world, in an effort to remain relevant.
In an increasingly competitive world of thoracic oncology, nonsurgical options like stereotactic radiotherapy, and the developing MRI proton beam therapy are gaining traction for the treatment of early stage lung cancers. These nonsurgical treatments are gaining publicity and popularity due to the efforts of radiation oncologists.
The PCI of Lung Cancer Treatment
Reminding thoracic surgeons of the plight of their cardiac counterparts, Dr. Lim taunted the audience that having superior long-term outcomes does not guarantee success in a consumer-driven market. Public and medical perception is shaped not only by clinical research findings, but by the inherent bias introduced by the authors of these publications. As he explained, this bias, along with a public desire for simplicity, has driven the overwhelming success of percutaneous angioplasty (PCI) and declining rates of cardiac surgery despite well-documented research studies and clear evidence demonstrating the overwhelming superiorityof coronary artery bypass grafting (CABG) for long term survival. Thoracic surgeons must not fall into the trap of complacency and arrogant belief in surgical superiority that has plagued cardiac surgery if we want the specialty to survive.
Dr. Lim has identified three behaviors of thoracic surgeons that are harming the specialty:
Refusal to look at the evidence – thoracic surgeons must be willing to continuously review, understand and accept new clinical evidence and publications. Evolving and emerging treatments have changed many of the cornerstones of thoracic surgery, and core concepts of 1980’s thoracic oncology management need to give way to the increasingly body of knowledge favoring VATS resections, neo-adjuvant treatments, and improved outcomes.
An important caveat to this – is the need for Surgeon led research, and clinical trials to help eliminate the medical bias that has crept into much of the existing literature. Surgeons need to stop allowing other specialties to control the narrative. This is what allowed cardiologists to introduce concepts such as “non-inferiority” when research studies failed to show the benefit of cardiology interventions.
These research trials need to compare surgical interventions with non-surgical treatments. Our inter-specialty debates over which surgical technique need to take a backseat to studies designed to compare relevant outcomes like long-term survival and cancer recurrence if we want to demonstrate surgical superiority over medical treatments. “We need to stop arguing about which surgical technique and favor surgery over other therapies,” Dr. Lim explains.
Refusal to engage with industry – industry drives and funds innovation. If we want to continue to develop wireless technologies, robotics and other innovations for use in minimally invasive surgery, thoracic surgeons must be willing to engage and participate with industry.
3. Refusal to evolve – this is a fundamental problem plaguing thoracic surgery and addressing this issue is the underlying theme of many of the presentations at this year’s course. Dr. Lim has also addressed this refusal to evolve previously. Surgeons need to evolve, and be willing and able to change their surgical practices based on evidence and clinical guidelines. The failure to adopt VATS as the primary surgical approach in thoracic surgery in North America, and Europe despite decades of evidence and clear clinical guidelines favoring this approach is a symptom of this failure to evolve.
The future of thoracic surgical oncology
How will thoracic surgery survive? We already know that surgical excision offers the best long-term outcomes for our patients. But as we have seen, having ‘right’ on your side isn’t enough.
Make surgery the most attractive option
For surgery to succeed, thoracic surgeons need to focus on making surgery safer and more acceptable to our patients. Many patients prefer surgical removal on a philosophical level, but this preference is being eroded by promises of “easy” with SABER and newer chemotherapy regimens.
One of the benefits of surgery versus many of the newer treatments is that surgery is a single treatment versus multiple episodes of care. If we can make that single encounter better for our patients, with shorter hospital stays, less pain/ less trauma and less risk, then surgery will remain the first and preferred treatment option for lung cancer.
the second annual Cambridge VATS : uniportal VATS, nonintubated thoracic surgery and the masters
Cambridge, UK
Cambridge center for continuing education
It may only be the second annual Cambridge VATS conference but Dr. Marco Scarci has managed to assemble one of the finest assortments of speakers in one short course since the days of the original giants. This included a roster of the biggest names, publishers of innovative research and the Masters of Minimally Invasive Surgery including Gaetano Rocco, Alan Sihoe, Joel Dunning, Thomas D’Amico, Henrik Hanson and Diego Gonzalez Rivas.
Dr. Ismail (Berlin), Dr. Hansen (Copenhagen) and Dr. Alan Sihoe (Hong Kong)
However, one of the standout presentations was given by none other than Dr. Guillermo Martinez, an Argentine anesthesiologist from Cambridge’s own Papworth hospital. He immediately leapt into one of thoracic surgery’s more controversial topics, nonintubated thoracic surgery. While Dr. Martinez primarily focused on the nonintubated but heavily sedated (or generally anesthetized patient with LMA for airway support) he gave an excellent presentation on the anesthetic considerations for nonintubated surgery. As he explained, it’s a natural progression for nonintubated surgery and VATS go hand in hand, as surgeries become less traumatic to patients, the anesthesia should be less invasive as well. He discussed the rationale for nonintubated surgery from an anesthesiologist’s perspective and outlined the practices at Papworth Hospital where he is part of the thoracic surgery team.
He also discussed the many challenges posed by this method of patient management including the fact that anesthetic techniques for nonintubated surgery need to be reproducible, safe and feasible for eligible patients. Anesthesiologists and thoracic surgeons also need to pre-establish criteria for conversion (such as heavy bleeding, patient hemodynamic instability or conversion to open surgery) to general anesthesia prior to cases, and to be fully prepared to perform urgent intubation as needed.
He also touched on the methods of analgesia used during these cases such as adjuvant like local anesthesia (chest wall infiltration), regional blocks and thoracic epidurals as well as cough suppressant mechanisms.
Reigniting controversey
This along with Dr. Diego Gonzalez Rivas’ subsequent presentation on uniportal surgery combined with nonintubated and awake thoracic surgery reignited much of the firestorm that we first saw at the Duke conference.
Dr. Diego Gonzalez Rivas
Commentary by Dr. Eric Lim perfectly captured some of the sentiments of younger members of the audience, when he took the stage as part of a separate debate on the merits of VATS versus SART when he stated, “I am tired of surgeons calling [new techniques/ technologies / treatments] crap when they’ve read the papers and seen the videos [demonstrating the procedure]. It’s not crap – if you just watched it.” He continued to address the resistance to change in surgery, and the attitudes of surgeons unwilling to adapt. It was a refreshing moment of forthrightness and candor that has been sorely missing from many events. It was also a 180 degree perspective from many of the more critical and conservative attitudes that liken techniques like nonintubated, awake anesthesia or uniportal surgery as being a type of showmanship rather than real innovation, or critics who question the relevancy of pursing research in this area with the “just because we can do it, should we?” mantra that has pervaded many of the recent surgical discussions.
Representatives from Shanghai Pulmonary Hospital (SPH) also gave several presentations. Dr. Haifeng Wang discussed high volume surgical training while Dr. Lei Jiang discussed uniportal surgery using a subxyphoid approach.
Dr. Wang explained how the research and lessons learned from the Shanghai Pulmonary Hospital has authenticated the uniportal VATS technique to many surgeons in China. He presented original data from his facility on over 1500 uniportal cases.
While he and his colleagues initially debated the safety of this procedure, after learning this technique, it has been adopted throughout Shanghai Pulmonary Hospital. He and the 39 other surgeons on staff use this technique every single day. In fact, the sheer volume of cases at Shanghai Pulmonary Hospital has made these surgeons some of the most experienced uniportal surgeons in the world. After the first uniportal VATS case was performed at SPH in 2013, the technique has rapidly gained popularity. Last year (2014), surgeons at SPH performed 6855 cases, with uniportal cases comprising 50% of all cases. That percentage will only grow, as this year, the hospital is on target for over 8000 cases.
Cambridge 2016?
Now, with such a great entree, what will be the encore for 2016? It would be great to see more “micro-invasive surgery” like a serious sit-down debate among the Awake Thoracic Surgical Group, Gonzalez Rivas, Hung et. al and the traditionalists on the merits of nonintubated surgery along with presentation of more original research, on-going projects and a meta-analysis of the work to date in this area.
It would be interesting to hear more from Dr. Scarci himself, who has been responsible for bringing these surgical innovations to the NHS specialty hospital in Cambridge. Like Dr. Alan Sihoe, who spoke during this session on how to start a uniportal program, Dr. Scarci himself undoubtedly has some excellent experience and insights to share.
More subxyphoid, including bilateral surgical case presentation or a live surgical case also top the wish list here at Thoracics.org.
That doesn’t mean that all of the old standards should be phased out – Henrik Hanson’s standardized approach to 3 port VATS is a classic, for good reason. As Dr. Hansen said himself, “The Gold Standard should not be what Diego [Gonzalez Rivas] or I can do, but a safe, standardized approach.” Not every surgeon is ready to embrace subxyphoid or uniportal approaches, and particularly for surgeons in the twilight of their careers, maybe they shouldn’t. But there is certainly no excuse for any thoracic surgeon on the planet not to excel at traditional VATS.
Topics that should be retired include debates on whether VATS of any approach respects oncological principles, and many of the topics in Robotic surgery. If it’s anyone but Dr. Robert Cerfolio or Dr. Mark Dylewski, then there’s probably not much that they can add to the topic. For everyone else, robotic surgery remains more of an expensive surgical toy than a legitimate area of research. In that vein, less presentations on developing toys and more guidance to the younger audience on transitioning from case reports to more academic research would make for a nice change. If we are going to continue to promote minimally invasive surgery, that we should encourage more advanced research; like the development of more randomized or multi-site trials on topics in this area.
Minimally invasive surgery course in Naples at Hospital Monaldi (April 23 – 24th, 2015)
Munich airport, Germany
I am on the last leg of a long journey to the beautiful southern Italian coastal city of Naples. Best known for its claim as the home of pizza and the nearby ruins of Pompeii, for the next few days, the department of thoracic surgery at Hospital Monaldi will be hosting surgeons (and one wee writer) from around the world for a two day course on minimally invasive and robotic surgery.
The event features live surgery demonstrations by Dr. Henrik Hansen and Dr. Diego Gonzalez Rivas, with a host of other speakers. For more details on the V corso VATS Monaldi Napoli dr Curcio dr Amore dr Casazza click the highlighted link for the full program.
Meanwhile, I will bring readers photos and highlights from the event.
This case study was prepared with assistance from Dr. Carlos Ochoa. Since we have been discussing the relevance of case reports and providing tips on case report writing for new academic writers – we have written the following case report in the style advocated by McCarthy & Reilley (2000) using their case report worksheet to demonstrate the ease of doing so in this style.
Since the previous presentation of dual-port thoracoscopy for decortication was missing essential materials, we are presenting a second case report.
Authors: K. Eckland, ACNP-BC, MSN, RN & Carlos Ochoa, MD
Case Report: Dual port thoracoscopy for decortication of a parapneumonic effusion
Abstract: The use of increasingly minimally invasive techniques for the treatment of thoracic disease is becoming more widespread. Dual and even single port thoracoscopy is becoming more frequent in the treatment of parapneumonic effusions and empyema.
Clinical question/problem: the effectiveness and utility of dual port thoracoscopy for parapneumonic effusions.
Analysis of literature review: Despite the increasing frequency of dual and single port thoracoscopic techniques, there remains a dearth of literature or case reports on this topic. Pubmed and related searches reveal only a scattering of reports.
Summary: As the case report suggests, dual port thoracoscopy is a feasible and reasonable option for the treatment of parapneumonic effusion.
Case history: 50-year-old patient with a three-week history of pneumonia, with complaints of right-sided chest pain, cough and increased phlegm production. Additional past medical history is significant for poorly controlled diabetes, hypertension, and obesity with central adiposity. Medications included glyburide and lisinopril.
After being seen and evaluated by an internal medicine physician, the patient was started on oral antibiotics. After three weeks, when his symptoms failed to improve, he was referred by internal medicine to thoracic surgery for out-patient evaluation.
On exam: middle-aged obese diabetic gentleman in no immediate distress, resting comfortable in the exam room. Face appeared moderately flushed, but skin cool and dry to the touch, no evidence of fever.
On auscultation, he had diminished breath sounds over the right lower lobe with egophony over the same area. The remainder of the exam was essentially normal.
Lab studies showed a mildly elevated WBC of 11.6, decreased Hgb of 10.4 / HCT 32.5. Hemoglobin A1c 10.6, Fasting glucose 228, HDL mildly low at 40.
EKG showed slight axis deviation, with slightly prolonged QRS complex (.16) with no evidence of loss of R, St elevation or other abnormalities. He was cleared by internal medicine for surgery.
After risks, benefits and alternatives to VATS decortication were explained to the patient – the patient consented to proceed with surgical decortication. After scheduling surgery, the patient was seen by anesthesia in preparation for the procedure.
Surgical procedure: Dual-port thoracoscopy with decortication of parapneumonic effusion.
Dual port thoracoscopy
After being prepped and drapped in sterile fashion and confirmation of dual lumen endotracheal tube placement, a small 2 cm incision was made for insertion of a 10mm port. Following entry into the chest with the thoracoscope, the right lung was deflated for optimal inspection and decortication of loculations. After completing the majority of the procedure, a second access port was created for better visualization and to ensure that a thorough decortication was completed. The lung and pleural were separated from the chest wall, and diaphragm, and demonstrated good re-expansion with lung re-inflation prior to completion of the procedure.
chest tubes at conclusion of case
At the conclusion of the procedure, two 28 french chest tubes were placed in the existing incisions. These were sutured into place, and connected to a pleurovac drainage system before applying a sterile gauze dressing. The patient remained hemodynamically stable throughout the case, with no episodes of hypoxia or desaturation. Following surgery, the patient was transferred to the PACU in stable condition.
Post-operative course was uncomplicated. Chest tubes were water-sealed on POD#3 and chest tubes were removed POD#4, with the patient being subsequently discharged after chest x-ray.
close up view of dual port thoracoscopy
Literature Review
A literature review was performed on PubMed using “dual port thoracoscopy”, “dual port VATS”, “2 port” as well as minimally invasive thoracoscopic surgery “
Results of search: A limited number of case studies (3) described thoracoscopic surgery with a single port. There was one case found describing cases conducted with two ports, and the majority of reports involved three or more access ports.
Discussion/ Conclusion
While convention medical wisdom dictates a trial and error treatment approach with initial trial of antibiotic therapy followed by chest tube placement (Light, 1995), surgeons have long argued that this delay in definitive treatment places the patient at increased risk of significant morbidity and mortality (Richardson, 1891). Multiple recent reviews of the literature and research comparisons continue to demonstrate optimal outcomes with surgery based approaches versus antibiotics alone, TPA and tube thoracostomy. The ability to perform these procedures in the least invasive fashion (VATS versus thoracotomy approaches) defies the arguments against surgical intervention as advanced by interventionalists (radiologists and pulmonologists.) Successful decortication with the use of dual port thoracoscopy is another example of how technology is advancing to better serve the patient and provide optimal outcomes, and offers a minimally invasive option when single port surgery may not be feasible.
During the case above, visibility and access to the thoracic cavity was excellent. However, in cases requiring additional access, reversion to the standard VATS configuration can be done easily enough with significant delays or additional risks to the patient.
References/ Resources
Foroulis CN, Anastasiadis K, Charokopos N, Antonitsis P, Halvatzoulis HV, Karapanagiotidis GT, Grosomanidis V, Papakonstantinou C. (2012). A modified two-port thoracoscopic technique versus axillary minithoracotomy for the treatment of recurrent spontaneous pneumothorax: a prospective randomized study. Surg Endosc. 2012 Mar;26(3):607-14. [free full text not available.]
Gonzalez – Rivas, D., Fernandez, R., De la Torre, M., & Martin – Ucar, A. E. (2012). Thoracoscopic lobectomy through a single incision.Multimedia manual cardio-thoracic surgery, Volume 2012. This is an excellent article which gives a detailed description, and overview of the techniques used in single incision surgery. Contains illustrations, full color photos and videos of the procedure.
Gonzalez-Rivas D, Paradela M, Fieira E, Velasco C. (2012). Single-incision video-assisted thoracoscopic lobectomy: initial results. J Thorac Cardiovasc Surg. 2012 Mar;143(3):745-7.
Interview with Dr. Juan Carlos Garzon Ramirez in Bogota, Colombia
During a recent trip to Colombia, I stopped in to re-visit* renown Bogotá thoracic surgeon, Dr. Juan Carlos Garzon Ramirez. He’s tired from a long night with three back to back urgent cases – ending at 3 am but as always, he is charming, well-spoken and engaged in our discussions on thoracic surgery, and Bogotá, his home.
Dr. Juan Carlos Garzon during a VATS procedure
Dr. Juan Carlos Garzon is a dynamic, innovative young surgeon and was recently named one of Bogotá’s Hottest Young Surgeons by Adriaan Alsema of Colombia Reports for his efforts (April 2011**). (This article highlights several young surgeons contributing to the advancement of the Colombian medical community.) He currently works at several facilities including Fundacion Cardioinfantil, Clinica del Country, Clinica Colombia (and other Colsanitas facilities).
After completing his thoracic surgery training at the El Bosque in Bogotá, he went to Hong Kong for additional thoracoscopy training. He now trains other surgeons in these surgical techniques
During my visit, we talked about what he sees as the future of thoracic surgery (more minimally invasive surgery) the role of thoracic surgery in the medical tourism phenomenon and the potential role of Bogotá surgeons in this growing trend.
We also discussed his reaction to The Bogotá Surgeons which examines the interplay and dynamics among the twenty practicing thoracic surgeons in Bogotá, as well as the upcoming Thoracic Surgery conference this October (which Dr. Garzon chairs.) This year’s featured speaker, is Dr. Shu S. Lin, noted lung transplant surgeon (previously interviewed here.)
Dr. Juan Carlos Garzon
*Dr. Juan Carlos Garzon, is thoracic surgeon practicing in Bogotá, Colombia. He specializes in minimally invasive procedures such as VATS (video-assisted thoracoscopic surgery.) He was gracious enough during a recent visit to Bogotá to agree to several interviews as part of a separate project and is featured in both Bogotá! A Hidden Gem Guide to Surgical Tourism and The Thoracic Surgeons: Bogotá.*
More information about Dr. Garzon, and his surgical practice is available at his website, www.toracoscopica.com/
He also has several YouTube films, discussing surgical procedures (in Spanish)
**this report was based in part by information provided during an interview with Adriaan Alsema in April 2011, Medellin, Colombia.
Thoracic Surgery 