Talking about the roles of traditional VATS, single port surgery and robots in modern thoracic surgery.
The Ethicon (Johnson & Johnson) sponsored session was by far, the best of the conference – and an excellent overview of modern technologies in thoracic surgery.
starting with Dr. Ricardo Buitrago (purple tie), Dr. Diego Gonzalez Rivas (blue tie) and Dr. Mario Ghefter (pink tie) are changing the future of thoracic surgery
Dr. Diego Gonzalez Rivas
“Is uni-port surgery feasible for advanced cancers?” Short answer: Yes.
The first speaker, was Dr. Diego Gonzalez Rivas of Coruna, Spain. He is a world-renown thoracic surgeon and innovator of uni-port thoracoscopic surgery. He discussed the evolution of single port surgery as well as the most recent developments with this technique, including more advanced and technically challenging cases such as chest wall resections (2013), sleeve resections/ reconstructions (2013), pulmonary artery reconstructions (2013) and surgery on non-intubated, awake patients (2014).
Experience and Management of bleeding
The biggest challenges to surgeons learning this technique is management of bleeding. But as he explained in previous lectures, this can be overcome with a direct approach. (these lectures and YouTube videos, Dr. Gonzalez explains the best ways to manage intra-operative bleeding.) In the vast majority of cases – this did not require deviation or conversion from the uni-port technique.)
As surgeons gain proficiency with this technique which mirrors open surgery, the only contra-indications for surgical resection of cancerous tissue (by single port) are tumors of great size, and surgeon discomfort with the technique.
Dr. Mario Ghefter
My favorite lecture of the series was given by Dr. Mario Ghefter of Sao Paolo, Brazil. While his lecture was ostensibly about video-assisted thoracoscopy (VATS), it was more of a retrospective vision and discussion of the modern history of thoracic surgery as seen through the eyes of a 22 year veteran surgeon.
He talked about the beginnings of VATS surgery and the contributions from such legends as Cefolio and D’Amico, including the 2005 paper – and modern-day thoracic bible, “Troubleshooting video-assisted thoracoscopic lobectomy (Demmy, James, Swanson, McKenna and D’Amico).
Dr. Ghefter also talked about how improved imaging and diagnostic procedures such as PET-CT and EBUS have been able to provide additional diagnostic information pre-operatively that helps surgeons to plan their procedures and treatment strategies more effectively.
Dr. Mario Ghefter
As a counterpoint to both Dr. Gonzalez and Dr. Buitrago, Dr. Ghefter acquitted himself admirably. He reminded audience members that even the newer technologies have some drawbacks – both as procedures and for the surgeons themselves.
He also successfully argued (in my opinion) that while the popularity of procedures such as multiple port VATS and even open thoracotomies have dropped drastically as thoracic surgeons embrace newer technologies, there will always be a place and time for these more traditional procedures.
Dr. Mario Ghefter is the Director of Thoracic Surgery at Hospital do Servidor Público Estadual – Sāo Paulo and on staff at the Hospital Alemão Oswaldo Cruz.
Dr. Ricardo Buitrago
Native Colombian (and my former professor), Dr. Ricardo Buitrago is acknowledged as one of the foremost experts in robotic thoracic surgery in Latin America.
During his presentation, he discussed the principles and basics of use of robotic techniques in thoracic surgery. He reviewed the existing literature surrounding the use of robotic surgery, and comparisons of outcomes between thoracic surgery and traditional lobectomy.
He reviewed several recent robotic surgery cases and the use of robotics as a training tool for residents and fellows.
While he mentioned some of previously discussed limitations of robotic surgery (namely cost of equipment) he cited recent studies demonstrating significant cost savings due to decreased length of stay and a reduced incidence of surgical complications.
He also discussed recent studies (by pioneering surgeons such as Dr. Dylewski) demonstrated short operating times of around 90 minutes.
the Babe Ruth of thoracic surgery continues his winning streak; and Dr. Benny Weksler heads south to the University of Tennessee. Kudos to both of these fine surgeons!
It’s another home run for Dr. Gonzalez Rivas as he and his team perform a single port (uni-port) thoracoscopic lobectomy with under local anesthesia, as reported by a recent story, “Operan un tumor e pulmón con una sola incisión y anestesia local” by Raul Romar in La Voz de Galicia.
Dr. Gonzalez Rivas demonstrates uniportal VATS
The answer is International collaboration and sharing of ideas
Dr. Gonzalez Rivas is used to sharing his ideas. After all, he spends a considerable amount of time traveling the world doing just that; sharing information about and teaching surgeons how to perform the single port thoracoscopic technique. But that doesn’t mean that he does find time to learn from his peers during his travels.
The article above highlights the importance of this international collaboration as it details how Dr. Gonzalez Rivas began to consider applying a local anesthesia approach to the single port surgical technique after talking (and visiting) surgeons in Taiwan and China.
Once he found the perfect candidate, he was ready to implement local anesthesia into his single port approach.. The rest, as they say – is now headed for the Annals of Thoracic Surgery.
Click here for English translation (note translation is not exact).
Dr. Benny Weksler, our own American (via Brazil) superstar surgeon recently made the move to the University of Tennessee. Dr. Weksler made the move in November of 2013 and is now settling in to his new position as Chief of Thoracic Surgery for the University of Tennessee (UT) Health Science Center and UT – Methodist.
Dr. Weksler, one of the United States most prominent thoracic surgeons, particularly in the area of esophageal surgery reports that he has big plans for the UT health system and the thoracic surgery department.
Big Plans for UT and the city of Memphis
These plans include a lung cancer screening program targeting vulnerable populations in Memphis including the uninsured/ underinsured, African-Americans (who are disproportionately affected) and smokers.
Related: Dr. Weksler talks about smoking cessation
Minimally invasive techniques for esophageal surgery
He has also started a new minimally invasive esophageal surgery program for esophageal cancer and reports “that there is almost an epidemics of squamous cell carcinoma of the esophagus” which is something tha was more rare in his previous practice in Pittsburgh, Pennsylvania.
Dr. Weksler and his colleagues are putting together a multi-disciplinary treatment plan to try to get these patients to a complete evaluation with a surgeon, an oncologist, and a radiation oncologist to provide patients with comprehensive, multi-faceted and coördinated care.
“The Surgeon Speaks” – Dr. Weksler talks about robotic surgery in this 2009 Jefferson University publication.
As a former Memphis resident, I want to say, “Welcome to the mid-south.. Hope you find time in your busy schedule to enjoy Beale Street, visit the Pink Palace and tour Graceland.. On behalf of all current Memphians, we are glad you are here.”
*This article was written by the author of this post.
writing about Dr. Diego Gonzalez Rivas and the other living legends in thoracic surgery and connecting people to the world of thoracic surgery
Readers at Cirugia de Torax have certainly noticed that there are numerous articles regarding the work of Dr. Diego Gonzalez Rivas. This week in particular, after a recent thoracic surgery conference and an afternoon in the operating room – there is a lot to say about the Spanish surgeon.
It’s also hard to escape that fact that I regard him in considerable awe and esteem for his numerous contributions to thoracic surgery and prolific publications. I imagine that this is similar to how many people felt about Drs. Cooley, Pearson or Debakey during their prime.
Making thoracic surgery accessible
But the difference is Dr. Diego Gonzalez Rivas himself. Despite the international fame and critical surgical acclaim, he remains friendly and approachable. He has also been extremely supportive of my work, at a time when not many people in thoracic surgery see the necessity or utility of a nurse-run website.
After all, the internet is filled with other options for readers; CTSnet.org, multiple societies like the Society of Thoracic Surgeons (STS), and massive compilations like journal-based sites (Annals of Thoracic Surgery, Journal of Thoracic Disease, Interactive Journal of Cardiothoracic Surgery).
But the difference between Cirugia de Torax and those sites is like the difference between Dr. Gonzalez Rivas and many of the original masters of surgery: Approach-ability and accessibility.
This site is specifically designed for a wider range of appeal, for both professionals in thoracic surgery, and for our consumers – the patients and their families. Research, innovation, news and development matters to all of us, not just the professionals in the hallowed halls of academia. But sometimes it doesn’t feel that way.
Serving practicing surgeons
For practice-based clinicians, and international surgeons publication in an academia-based journal requires a significant effort. These surgeons usually don’t have research assistants, residents and government grants to support their efforts, collect their data and clean up their grammar. Often English is a second or third language. But that doesn’t mean that they don’t make valuable contributions to their patients and the practice of thoracic surgery. This is their platform, to bring their efforts to their peers and the world.
Heady aspirations
That may sound like a lofty goal, but we have readers from over a 110 countries, with hundreds of subscribers along with over 6,000 people with Cirugia de Torax directly on their smart phone. Each month, we attract more hits and more readers.
Every day, at least 200 people read “Blebs, Bullae and Spontanous Pneumothorax”. Why? Because it’s a concise article that explains what blebs are, how a pneumothorax occurs and how it’s treated. Another hundred people usually go on to read the accompanying case report about blebectomy, for similar reasons. There are links for more information, CT scans and intra-operative photos included, so that people can find exactly what they need with a minimum of effort.
Avoiding ‘Google overload’
With the massive volume of information available on the internet, high-quality, easily understood, applicable information has actually become even more difficult for patients to find than ever before. Patients spend hours upon hours browsing through academic jargon, commercial websites and biased materials while attempting to sift through the reams of information for pertinent and easily understandable information. There is also a lot of great material out there – so we provide links to reputable sites, recommend well-written articles and discuss related research.
Connecting patients to surgeons
We also provide patients with more information about the people they are entrusting their bodies, their hopes and their lives to. It’s important that they know about the Dr. Benny Wekslers, the Dr. Hanao Chens, and the Dr. Diego Gonzalez Rivas out there.
Update: June 2019
After multiple reader requests from this site, we have launched a service to assist readers in pursuiting minimally invasive thoracic surgery, uniportal surgery, HITHOC and other state-of-the-art thoracic surgery procedures with the modern masters of thoracic surgery. We won’t talk a lot about this on the site, but we do want readers to know that we are here to help you. If you are wondering what surgery costs like with one of the world’s experts – it’s often surprisingly affordable.
If you are interested in knowing more, please head to our sister site, www.americanphysiciansnetwork.org or send an email to kristin@americanphysiciansnetwork.org.
Keeping it ‘real’
Looking over the shoulder of Dr. Gonzalez Rivas in the operating room
As much as I may admire the work and the accomplishments of Dr. Gonzalez-Rivas – it’s important not to place him on a pedestal. He and his colleagues are real, practicing surgeons who operating on regular people, not just heads of state and celebrities. So when we interview these surgeons and head to the OR, it’s time to forget about the accolades, the published papers and the fancy titles. It’s time to focus on the operations, the techniques, the patients and the outcomes because ‘master of thoracic surgery’ or rural surgeon – the operation and patient are all that really matters.
For thoracic surgeons interested in becoming more familiar with uniport surgery, this is your chance to learn from the pioneers of the technique.
Several new dates for Uni-port thoracoscopy with Dr. Diego Gonzalez Rivas. These events span across the Americas and Europe, so if you are interested in uni-port thoracoscopic surgery, then there is something nearby.
The first date is coming up soon – in August 2013, in Bogotá, Colombia.
Dr. Diego Gonzalez Rivas in Bogotá, Colombia
I am excited about this one, and hope to be able to cover the event for readers of CdeT. While I am currently in Medellin, I became familiar with, (and have a great deal of respect for) many of Bogotá’s finest thoracic surgeons in the past so it’s a great opportunity not just to hear more about Dr. Diego Gonzalez Rivas and uni-port thoracoscopy but to check in local surgeons and hear about some of their more interesting cases.
Dr. Gonzalez will be joined by Dr. Paula Ugalde, a well-known thoracic surgeon from Brazil (now practicing in Quebec, Canada).
As soon as I get some more details on the Bogotá event – I’ll post them here..
Split, Crotia – September 12th – 15th – 23rd Congress of the World Society of Cardio-Thoracic Surgeons.
This conference is being jointly sponsered by the Society of Cardio-Thoracic Surgeons of South Africa (SCTSSA). Dr. Diego Gonzalez will be talking about “Uni-port VATS major pulmonary resections in advanced lung cancer” in an afternoon session on September 13, 2013. (Obviously they don’t know much about him – since it’s only a 20 minute session – but as a CTS conference, only about 10% is thoracic topics (he is one of just a handful of thoracic speakers.)
Then in mid -September 2013, he will part of a roster of the greats of thoracic surgery (Dr. Robert Cefolio, Dr. James Luketich and Dr. Thomas D’Amico) at the Duke Center for Surgical Innovation for a course entitled, “Masters of Minimally Invasive Thoracic Surgery”.
The second event, is a meeting/ conference/ training course in Dr. Gonzalez’s home hospital in Coruna, Spain. The event, “Live Thoracic” will feature ‘live-surgery’ demonstrations and will be streamed for real-time viewing from around the world.
In a side note – I want to thank the nearly 6,000 students, interns, nurses, residents and thoracic surgeons who have downloaded one of my thoracic surgery apps for Android devices.
Discussing Dr. Joseph Coselli and ‘the cowboys of cardiac surgery’ along with some of our own heros of thoracic surgery here at Cirugia de Torax.
There’s a great article in this month’s Annals of Thoracic Surgery, by Dr. Joseph Coselli, from Texas Heart Institute and the Michael DeBakey Department of Surgery at Baylor. His article, entitled,” My heros have always been cowboys” is more than just a title torn from the song sheets of Willie Nelson. It’s a look back at both the pioneers of cardiac surgery and his own experiences as a cardiac surgeon. He also discusses the role of surgeons, and medical practitioners in American society in general and the promises we make to both society at large and our patients.
Here at Cirugia de Torax, I’d like to take a moment to look back at the surgeons that inspired and encouraged me in this and all of my endeavors. Some of these surgeons knew me, and some of them didn’t – but their encouragement and kindnesses have spurred a career and life that have brought immense personal and professional satisfaction.
Like Dr. Coselli, I too, took inspiration from the likes of Dr. Denton Cooley. But our stories diverge greatly from there. I never met Dr. Cooley and I probably never will. But it was a related story, from my former boss (and cardiothoracic surgeon), Dr. Richard Embrey that led to an email to Dr. Cooley himself. My boss had too trained under Dr. Cooley, Dr. Debakey and the Texas Heart Institute, the citadel of American heart surgery. Then, somehow, along the way – Dr. Embrey stopped to work at our little rural Virginia hospital. We were the remnants of a larger Duke cardiothoracic program but we were a country hospital all the same.
While I learned the ins and outs of surgery from Dr. Embrey (and Dr. Geoffrey Graeber at West Virginia University) on a day-to-day basis, I was also weaned on the folklore of cardiothoracic surgery – stories of the giants of history, like the ones mentioned in Dr. Coselli’s article, as well as local Duke legends who occasionally roamed the halls of our tiny ICU and our two cardiothoracic OR suites; Dr. Duane Davis, Dr. Shu S. Lin and Dr. Peter Smith. While never working side-by-side, Dr. D’Amico’s name was almost as familiar as my own. As the sole nurse practitioner in this facility, without residents or fellows, there was no buffer, and little social divide in our daily practice. Certainly, this changed me – and my perceptions. I asked the ‘stupid’ questions but received intelligent and insightful answers. I asked even more questions, and learned even more..
These opportunities fed my mind, and nurtured my ambitions. Not to be a physician or a doctor, but to learn as much as possible about my specialty; to be the best nurse possible in my field. It also nurtured a desire to share these experiences, and this knowledge with my peers, my patients and everyone else who ever had an interest.
It was that tiny little email, a gracious three-line reply from Dr. Cooley himself that made me realize that I didn’t have to rely on folklore and second-hand stories to hear more. That’s critical; because as we’ve seen (here at Cirugia de Torax) there are a quite of few of “Masters of thoracic surgery” or perhaps future giants that haven’t had their stories told. Dr. Coselli and his fellow writers haven’t written about them yet.. So I will.
Sometimes I interview famous (or semi-famous) surgeons here, but other times, I interview lesser-known but equally talented/ innovative or promising surgeons. All of them share similar traits; dedication and love for the profession, immense surgical talent and proficiency and sincere belief in the future of technology of surgery.
So, let’s hope that it won’t take forty more years for these surgeons to be recognized for their contributions to thoracic surgery in the way that Cooley, DeBakey and Crawford are heralded in cardiac surgery.
The Spanish-language lecture entitled, “El viaje de los pioneros: Dr. Diego Gonzalez Rivas” should be just as inspiring to readers/ and viewers as it is to Cirugia de Torax.
If you don’t speak Spanish – don’t despair! Dr. Gonzalez’ TED talk is now available with captions in multiple languages. (Click on the closed captioning icon for translation options.)
Sometimes, it’s lonely out front – and being innovative is difficult. It’s one thing to be Ivor Lewis, Pearson or McKeown but it’s another to be the first or sole surgeon to challenge edicts and procedures laid down by the giants of the specialty. But without the modern-day Dylewskis, Gonzalez Rivas, Chen, (and others) – technology within the specialty would remain static.
Changing the future of thoracic surgery
These surgeons take big risks with their careers and reputations by attempting to deviate from long-standing surgical traditions. But sometimes, it pays off – and when it does, it is wonderful to see these daring and forward thinkers receive the admiration and appreciation they deserve for their contributions to the field and to their patients.
Dr. Santolaya, Dr. Sales dos Santos, Dr.Berrios and Dr. Diego Gonzalez Rivas
Congratulations, Dr. Diego Gonzalez Rivas! Here’s to your continued success..
This article is one of several articles and content from Cirugia de Torax that has been used commercially without consent, permission or attribution/ proper citation.
an Interview with Dr. Diego Gonzalez Rivas – and coverage of ‘Videotoracoscopia y cirugia robotica en torax: Avances y perspectivas’ in Santiago, Chile
Santiago, Chile
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.
Dr. Santolaya, Dr. Sales dos Santos, Dr.Berrios and Dr. Diego Gonzalez Rivas
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.
“Forward Motion”
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.
LymphNode 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
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.
Dr. Chih-Hao Chen at Mackay Memorial Hospital in Taiwan talks about his experiences with single port/ single incision thoracic surgery (SITS) as well as the “Chen esophagectomy”; a new single port approach to esophagectomies.
Single-port thoracoscopic surgery (SITS) as a first-line approach
With the advent of minimally invasive surgical techniques such as VATS, surgeons now have the ability to perform multiple surgical procedures such as lobectomy, decortication and even esophagectomy through 1 – 2 cm port incisions instead of traditional open surgery. However, as mentioned during an interview with Dr. Mark Dylewski, few American* surgeons have fully embraced this technology. Even fewer surgeons internationally have embraced the emerging single port techniques that have developed from VATS. One of these surgeons is Dr. Chih-Hao Chen at Mackay Memorial Hospital in Taiwan. We previously discussed one of his studies here at Cirugia de Torax, so it was with great delight when we had an opportunity to discuss his continuing research and development in this area in a series of emails.
Dr. Chen is currently in the forefront of the movement to make SITS a first-line approach for majority of thoracic surgery procedures that can currently be approached with traditional VATS. The biggest risk to this “less is more” approach to port placement is needing to add additional ports during the case (thus converting to traditional VATS 3-4 port approach).
As Dr. Chen explains, “In contrast to creating 3 small wounds, I always try single-port first. If it is technically unavoidable, I would make the second port incision. If it is still difficult, a third port incision would be made. The conversion rate (to 2-port or three port methods not open) is very low in most conditions.
“I believe the role of SITS as a first-line endoscopic approach is possible in nearly all patients. So far, I have performed roughly, SITS in more than 150 patients with various thoracic diseases, including esophagectomy in 5 cases using 2.5 cm single incision”.
However, the contraindications for the SITS approach are mainly those with “unstable hemodynamics in trauma”, “highly complicated cancer resection(such as sleeve lobectomy, etc)” and “thick and dense peel in chronic empyema”.
Dr. Chen was kind of the provide this clip of him performing single port thoracoscopy.
Over 150 cases, so far.
“According to my experience, patients with spontaneous pneumothorax and acute stage empyema as well as solitary pulmonary nodules are the best candidates for such procedure. The time required for the same operation is much shorter in single-port approach. For simple spontaneous pneumothorax, the time may be as short as 20-25 minutes. ( from skin incision to suture )”.
As I mentioned in my report (see publications linked below), the conversion rate of such condition is pretty low and worthy to try. In my experience, SITS w/o trocar greatly decrease incisional pain and have pleasant cosmetic results, as the wound can be extremely small”.
A recent case: Wedge resection by SITS
Procedure: single-port approach for a case of lung cancer in a 77 year-old woman.
Multiple wedge resections, pleural biopsy and LN smapling were performed.
single incision (now with chest tube) and specimen removed (photo courtesy of Dr. Chen)
The wound was 1.5 cm in length and the specimen is 7cm X 4cm ( solid part :2.5 cm ). The specimen was removed within an endo-bag. (From previous experience, I knew that a specimen of this size can be safely removed through a tiny incision w/o destruction of the specimen.
Her chest tube was removed within 24 hrs and patient reports minimal discomfort. ( I injected Marcaine in ICS to prevent neuralgia in all cases.)
Sometimes innovation is hard
As we’ve seen frequently in the history of medicine / surgery, early innovators and adopters of new technology are often face significant resistance from their colleagues despite utilizing ‘best-evidence’ to support their ideas. People, many people, including surgeons – don’t like change and are sometimes hesitant to learn and practice techniques that develop in the years following fellowship.
One of the reasons Dr. Chen contacted Cirugia de Torax is to share his experiences and this technique with other interested thoracic surgeons. ‘Unfortunately, only a small portion of thoracic surgeons would like to try such procedure in Taiwan. Actually, most of them considered the procedure not valuable. Therefore, I would like to publish more experiences in the journals, which is one way to tell them “to try”.
Wait.. Did you say single-port thoracoscopy for esophagectomy?
“Esophagectomy in my team was performed by single-port thoracoscopic approach (in the chest). However, the abdominal portion was performed with four-port or 5-port laparoscopic approach, because the abdominal part was done by another doctor who is not familiar with single-incision laparoscopy (SILS). However, I have to admit that esophagectomy through single-port approach is much more difficult than other procedures. The main reason for this is that the esophagus is located in posterior mediastinum.”
While I usually utilize a more anterior ICS as my port incision for other single-incision procedures because the anterior ICS is very easy, with low conversion ( to 2- or 3-port ) rate. However, the same port is not appropriate for esophagectomy because of poor visualization.
New Approach, the “Chen esophagectomy” but ergonomic considerations
“For the reason, I tried a more lateral port incision (usually 5 ICS along the mid-axillary line. ) This is a BIG problem for me due to ergonomic issues. Manipulation of endoscopic instruments and the endoscope through the port is uncomfortable. At times, I have to rest for a while in order to alleviate soreness in my arm”.
“The time-determining step is to loop the esophagus. Proximal and distal dissection as well as lymph node dissection would be done with a harmonic scalpel. (We resected the esophagus, the anastomosis is in the neck ). For uncomplicated case, the procedure in the chest takes aroud 1-2.5 hours”.
*American research data suggests that VATS is used for less than 30% of all thoracic surgery procedures. However, anecdotal evidence suggests that internationally, VATS is utilized with much higher frequency outside of the United States.
Articles about single-incision thoracoscopic surgery (SITS) by Dr. Chih-Hao Chen
The innovative and dynamic ‘New Masters’ of thoracic surgery
Most of us never had the opportunity to meet or talk to some of the ‘masters’ of thoracic surgery like Dr. Hermes Grillo (1923 -2006), the ‘Father of Tracheal Surgery’ or Dr. Joel Cooper, the “Father of Lung Transplant” or legends in esophageal surgery such as Dr. Griffith Pearson or Dr. Henry Heimlich.
However, as we have discussed before, thoracic surgery is not static. New technologies and new techniques are emerging all the time, and with these developments – new masters of thoracic surgery. These include innovative and dynamic young surgeons such as Dr. Diego Gonzalez, and Dr. Mark Dylewski. We hope to bring you more New Masters here at Cirugia de Torax.
Thoracic Surgery 