Tag: single incision lobectomy

Block, Tuffier, Blalock & Gonzalez? Returning to single incision thoracoscopic surgery with Dr. Diego Gonzalez – Rivas

Checking in with Dr. Diego Gonzalez – Rivas and his team in Coruna, Spain – the innovators in single incision thoracic surgery, as Dr. Gonzalez publishes a new report on single incision pneumonectomy.

After speaking with Dr. Raimundo Santolaya last week – I contacted Dr. Diego Gonzalez over at UTCMI in Coruna, Spain  to see what he’s been doing since our last contact, and discuss a possible interview in the future.

The single-port thoracic surgery superstar and his colleagues are certainly keeping busy – and continue to push the edges of modern thoracic surgery firmly into more and more advanced minimally invasive techniques.

Last fall, he published another case report on single incision VATS – lobectomy, and since then he has continued to operate and publish reports on his successes.  Now he has an upcoming case report on a right-sided single-port pneumonectomy, which was largely held as one of the last frontiers in VATS procedures.   (Pneumonectomy by standard VATS, despite being reported in the literature several years ago, remains a relatively uncommon procedure.)

While a common criticism of his work is related to the fact that removing a portion of the lung as large as a lobe, or an entire lung requires a small additional incision at the conclusion of the case – but these criticisms are weak at best – and fail to see the true clinical importance of his continued innovation and investigation in advancing video-assisted thoracoscopic surgery for the benefits of our patients.  Ten years from now – single incision VATS will be a common procedure, and Drs. Gonzalez, Fernandez and De la Torre will be the ones responsible.


References: Single port pneumonectomy

Gonzalez-Rivas D, de la Torre M, Fernandez R, Garcia J. (2012). Single-incision video-assisted thoracoscopic right pneumonectomy.  Surg Endosc. 2012 Jan 11. [Epub ahead of print – abstract re-posted below]

Abstract

BACKGROUND: The most common approach for Video-assisted thoracoscopic (VATS) lobectomy is undertaken with three or four incisions, including a utility incision of about 3-5 cm. However, major pulmonary resections are amenable by using only a single utility incision. This video shows the technical procedure of a right pneumonectomy by single-incision approach with no rib spreading.

METHODS:  A 52-year-old woman was proposed for single-incision VATS resection of a 5-cm right lower lobe adenocarcinoma. A 4-cm incision was made in the fifth intercostal space. We placed a 30-degree, high-definition, 10-mm thoracoscope in the posterior anterior part of the incision. Digital palpation confirmed that the tumor involved the fissure and the posterior portion of the upper lobe, which indicated the need for right pneumonectomy. We inserted the instruments through the anterior part of the utility incision to start the detachment of the right upper lobe by using a harmonic scalpel. The first step was dissecting the inferior pulmonary vein. The hilar structures were exposed by using harmonic scalpel and a long dissector (Fig. 1A). The upper and middle-lobe pulmonary veins were dissected and transected, allowing visualization of truncus anterior, which was then stapled. The inferior pulmonary vein and the intermediate truncus artery were divided, allowing optimal exposure to the main bronchus, which was stapled. The lung was removed in a protective bag by adding 1 cm to the incision, and a systematic lymph node dissection was performed. A single chest tube was placed in the posterior part of the utility incision.

RESULTS: Total surgery time was 210 min. The chest tube was removed on postoperative day 2, and the patient was discharged home on day 4 with no complications.

CONCLUSIONS:  Single-port VATS pneumonectomy for selected cases is a feasible procedure, especially when performed from a center with previous experience in double-port VATS approach.

DISCUSSION: Recent advances in surgical and video-assisted techniques have allowed minimally invasive pneumonectomy to be undertaken safely. VATS pneumonectomy is not a new procedure and in fact was initially reported 15 years ago and was felt to result in less postoperative pain and a faster return to normal activities [1]. Despite this, there have been only a few case reports or series published of VATS pneumonectomies [2,3].

Additional References/ Resources

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.

Gonzalez-Rivas D, de la Torre M, Fernandez R, Mosquera VX. (2011).  Single-port video-assisted thoracoscopic left upper lobectomy.  Interact Cardiovasc Thorac Surg. 2011 Nov;13(5):539-41.

SITS lobectomy with Dr. Diego Gonzalez

Discussion of a case report by Gonzalez, Paradela, Garcia & Dela Torre (2011) of a lobectomy by single incision thoracoscopic surgery.

Since there’s been quite a bit of interest in single-port thoracoscopic surgery (SITS) here at Cirugia de Torax.org  – I’ve added information about SITS lobectomy.  British surgeons, Rocco et. al  had previously reported the outcomes of several wedge resections by uni-port (SITS) back in 2004 but this is the first case report that I’ve seen for lobectomies via this technique*.

Gonzalez et al. in Coruna, Spain published a case report of a lobectomy by SITS.  The authors note that they have performed three cases by this technique at the time of article submission (November 2010).

As expected, the authors reported decreased post-operative pain and parathesias when using this technique.   They also reported that while visibility is more limited with this approach, they feel that it is less problematic for surgeons already accustomed to, and familiar with double port lobectomies.  This approach, in their experience, is best used for lower lobe lesions due to difficulties accessing and maneuvering for bronchial resection for upper lobectomies.

* If you’ve seen other published reports – please send the citations to the site.

Update:  25 July 2011

I contacted Dr. Gonzalez to inquire about his surgical experiences since the publication of the article this past March.  Dr. Gonzalez reports that he and his colleagues (Dr. Mercedes De la Torre and Dr. Fernandez) have continued to practice SITS for lobectomies and other thoracic procedures, and that he is now using it for the majority of his cases.

Dr. Gonzalez states that many of his patients are discharged earlier (POD 2 or 3) and are experiencing less post-operative pain.  He is planning future studies to demonstrate this.

Dr. Gonzalez website

I expect we’ll be hearing more about Dr. Gonzalez and his partners in the future.

Note: Dr. Chu in Beijing, China has also published cases in the literature with single port lobectomies.

Reference

Gonzalez D., Paradela M., Garcia J. & De la Torre M. (2011). Single-port video-assisted thoracoscopic lobectomy. Interact Cardiovasc Thorac Surg. 2011 Mar;12(3):514-5. Epub  2010 Dec 5. (free full-text article with photographs).

Rocco,  G.,  Martin-Ucar, A. & Passera, E. (2004).  Uniportal VATS wedge pulmonary resections. Ann Thorac Surg 2004;77:726-728. (free full text aricle with color photographs).