Tag: SITS

Courses / Classes and meetings on Uni-port thoracoscopic techniques with Dr. Diego Gonzalez Rivas

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.)

Information about this event is available here.

Orlando, Florida – September 19th – 21st 2013

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”.  

Complete details for this course are available here..  Sign up before 7/19 for a small discount in registration fees.

Live Thoracic  – February 2014

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.

1st Asian Single Port Symposium & Live Surgery

Interested in learning more about single port thoracoscopy, or talking to the inventors of this technique? This March – head to the 1st Asian single port surgery conference in Hong Kong.

It doesn’t look like Cirugia de Torax will be in attendance for this conference, but it’s another opportunity for practicing thoracic surgeons and thoracic surgery fellows to learn more about single port thoracoscopic surgery.

This March (7th – 8th), the Chinese University of Hong Kong, along with the Minimally Invasive Thoracic Surgery Unit (Coruna, Spain), and Duke University are presenting the 1st Asian Single Port Symposium and Live Surgery conference in Hong Kong.

This is your chance to meet the experts – and the inventors of this technique (such as Dr. Diego Gonzalez – Rivas, one of the new masters frequently featured here at Cirugia de Torax.)

conference

In the operating room with Dr. Mauricio Velaquez: Single port thoracoscopy

a day in the operating room with one of Colombia’s New Masters of Thoracic Surgery

Cali, Colombia

Dr. Mauricio Velasquez is probably one of the most famous thoracic surgeons that you’ve never heard of.  His thoracic surgery program at the internationally ranked Fundacion Valle del Lili in Cali, Colombia is one of just a handful of programs in the world to offer single port thoracic surgery.  Dr. Velasquez has also single-handedly created a surgical registry for thoracic surgeons all over Colombia and recently gave a presentation on the registry at a national conference.  This registry allows surgeons to track their surgical data and outcomes, in order to create specifically targeted programs for continued innovation and improvement in surgery (similar to the STS database for American surgeons).

Dr. Mauricio Velasquez after another successful case

Dr. Velasquez is also part of a team at Fundacion Valle del Lili which aims to add lung transplant to the repertoire of services available to the citizens of Cali and surrounding communities.

He is friendly, and enthusiastic about his work but humble and apparently unaware of his growing reputation as one of Colombia’s finest surgeons.

Education and training

After completing medical school at Universidad Pontificia Bolivariana in Medellin in 1997, he completed his general surgery residency at the Universidad del Valle in 2006, followed by his thoracic surgery fellowship at El Bosque in Bogotá.

The Colombia native has also trained with thoracic surgery greats such as Dr. Thomas D’Amico at Duke University in Durham, North Carolina, and single port surgery pioneer, Dr. Diego Gonzalez Rivas in Coruna, Spain.  He is also planning to receive additional training in lung transplantation at the Cleveland Clinic, in Cleveland, Ohio this summer.

Single port surgery

Presently, Dr. Velasquez is just one of a very small handful of surgeons performing single port surgery.  This surgery is an adaptation of a type of minimally invasive surgery called video-assisted thoracoscopy.  This technique allows Dr. Velasquez to perform complex thoracic surgery techniques such as lobectomies and lung resections for lung cancer through a small 2 – 3 cm incision.  Previously, surgeons performed these operations using either three small incisions or one large (10 to 20cm) incision called a thoracotomy.

By using a tiny single incision, much of the trauma, pain and lengthy hospitalization of a major lung surgery are avoided.  Patients are able to recovery and return to their lives much sooner.  The small incision size, and lack of rib spreading means less pain, less dependence on narcotics and a reduced incidence of post-operative pneumonia and other complications caused by prolonged immobilization and poor inspiratory effort.

However, this procedure is not just limited to the treatment of lung cancer, but can also be used to treat lung infections such as empyema, and large mediastinal masses or tumors like thymomas and thyroid cancers.

Dr. Velasquez in the operating room with Lina Caicedo Quintero (nurse)

Team approach

Part of his success in due in no small part to Dr. Velasquez’s surgical skill, another important asset to his surgical practice is his wife, Dr. Indira Cujiño, an anesthesiologist specializing in thoracic anesthesia.  She trained for an additional year in Spain, in order to be able to provide specialized anesthesia for her husband’s patients, including in special circumstances, conscious sedation.  This allows her husband to operate on critically ill patients who cannot tolerate general anesthesia.  While Dr. Cujiño does not perform anesthesia for all of Dr. Velasquez’s cases, she is always available for the more complex cases or more critically ill patients.

In the operating room with Dr. Velasquez

I spent the day in the operating room with Dr. Velasquez for several cases and was immediate struck by the ease and adeptness of the single port approach.  (While I’ve written quite a bit about the literature and surgeons using this technique, prior to this, I’ve had only limited exposure to the technique intra-operatively.)  Visibility and maneuverability of surgical instruments was vastly superior to multi-port approaches.  The technique also had the advantage that it added no time, or complexity to the procedure (unlike robotic surgery).

Dr. Velasquez performing single port thoracoscopy

Cases proceeded rapidly; with no complications.

close up view

Note to readers – some of the content, and information obtained during interviews, conversations etc. with Dr. Velasquez may be used on additional websites aimed at Colombia-based readers.

Recent Publications

Zarama V, Velásquez M. (2012). Mainstem Bronchus Transection after Blunt Chest Trauma.  J Emerg Med. 2012 Feb 3.

Single port thoracoscopy for wedge resection – does size matter?

Dr. Chen discusses single port thoracoscopy – and specimen size.

Single port thoracoscopy for wedge resection – does size matter?
Dr. Chih-Hao Chen, Thoracic Surgeon, Mackay Memorial Hospital, Taiwan
Correspondence: musclenet2003@yahoo.com.tw

Case presentation and discussion

A 77 y/o woman was found to have a neoplasm in RML during routine health exam. (Full case presentation here.)
The incision was 2.5 cm. The specimen was removed successfully; patient experienced no complications and was discharged from the hospital without incident. However, when discussing this case with surgeon colleagues a specific question arose.

preparing to remove the specimen through the port

Does size matter? How big is too big to remove through a port incision?
An important issue is the theoretically smallest (and effective) incision size.  The issue is very challenging for most surgeons. In the past, other surgeons have questioned me :
“The specimen to be removed is more than 12-15 cm. How can you remove the specimen from a 3.5 cm incision?”

BUT, the fact is “the smallest size depends mostly on the solid part of the neoplasm “.

The lung is soft in nature. In my experience, a 3.5 cm port is usually enough for any lobe.  The only problem is that if the solid part is huge, pull-out of the specimen may be difficult.
Therefore, the solid part size is probably the smallest incision size we have to make, usually in the last step when dissection completed , if needed.

successful removal of lung specimen thru small port
Port with chest tube in place

Using endo-bags to avoid larger incisions
There is an exception. I have never do this but I think it may be possible.  We usually avoid opening the tumor (or cutting tumor tissue into half ) within the pleural space in order to prevent metastasis from spillage of cancerous tissue.

What if we can protect the tumor from metastasis while we cut it into smaller pieces? For example, into much smaller portions that will easily pass through the small port incisions?
My idea is to use double-layer or even triple layers of endo-bag to contain the specimen. If it is huge, with perfect protection, we cut it into smaller parts within the bag. Then the huge specimen  can be removed through a very tiny incision. This is possible.

We still have to avoid “fragmentations” since this might interfere or confuse the pathologist for accurate cancer staging. Therefore, in theory, we can cut it into smaller parts but not into fragments. However this idea is worthy of consideration, and I welcome debate from my fellow surgeons and medical colleagues.

Thank you to Dr. Chen.

Single Incision Thoracoscopic Surgery (SITS) for spontaneous pneumothorax

Chen et. al discuss their experience with single incision thoracoscopic surgery (SITS) in the treatment of spontaneous pneumothorax in this Taiwanese study.

A study from Taiwan (April 2011) highlights the surgeons’ experience using single incision thoracoscopic surgery (SITS) for the treatment of spontaneous pneumothorax.  While the study is small – involving 30 patients, with just ten patients receiving treatment via single incision thoracoscopy, it’s a useful study in demonstrating that SITS is not only possible but feasible for uncomplicated thoracic procedures.

The major advantage of using this procedure in the spontaneous pneumothorax population is the low level of underlying thoracic disease, or co-morbidities necessitating conversion to VATS or open surgery.  In general, true spontaneous pneumothoraces occur in younger patients (teens and twenties) in the absence of other conditions such as infection, emphysema or effusion.  The benefits of using this procedure in such a young, mobile population is reduced pain, and a speedier recovery – and returning these patients to work/ life faster, with less post-operative limitations.

As the authors noted, a consistent obstacle to widespread adoption of this surgical technique is the lack of specialized surgical instruments.   This has also plagued single incision laparoscopy to some extent, with several minor modifications being made by practicing surgeons to overcome these problems, primarily of positioning several instruments thru a single port*.  This is more problematic in thoracic surgery than general surgery due to patient positioning.  (In general surgery the patient is usually laying supine, allowing for a flat surface).

Example of single incision laparoscopy for cholecystectomy

In thoracic surgery, the patient’s side lying positioning puts the operator at  greater disadvantage, with gravity working against the surgeon.  As mentioned in a previous post – there is a commercial port of multiple instruments available, however it is costly, unwieldly and requires larger incisions (making SITS more of a mini-thoracotomy).  The other mechanical problem is the instruments themselves – when placed in a single incision, care has to be taken to prevent the instruments from obstructing the movements of each other.  The authors were able to overcome this obstacle thru practice, but suggest needed modifications to existing instruments.

Despite frequently cited concerns about visibility with this technique, in the article (and confirmed by my own observations in the operating room), properly done single incision thoracoscopy offers the same visibility as multi-port (VATS) thoracoscopy. (See the original article full text for photos of procedure illustrating visibility.)

More recently, (June 2011) Berlanga & Gigirey in Caceres, Spain reported the use of SITS for spontaneous pneumothorax in 13 patients. They reported similar findings, and came to the same conclusions as Chen et. al.  However, these researchers used the commercially available port and reported satisfactory results.

There is a place for single incision thoracoscopy within thoracic surgery.  However, it will take continued research to further delineate its role, and surgical innovation to adapt the current instrumentation for more effective and surgeon friendly use.

Berlanga, L. A. & Gigirey, O. (2011).   Uniportal video-assisted thoracic surgery for primary spontaneous pneumothorax using a single–incision laparoscopic surgery port: a feasible and safe procedure.  Surg Endosc. 2011 Jun;25(6):2044-7. Epub  2010 Dec 7. Full text article not available for link (paid article).

SITS: That’s Single Incision Thoracoscopic Surgery

the development and application of single-port thoracoscopic surgery, (or the lack there of.)

Right now, single incision scopic surgery (laparoscopic, generally*) is in all the literature. This is a minimally invasinve technique using only one port (or incision) for access to the surgical area (usually the abdomen).

I’ve seen it performed by several general surgeons as part of my travels for BogotaSurgery.org and read the literature surrounding it, but hadn’t heard much about it’s close kin, single port thoracoscopic surgery, though I’d seen it performed during a trip to Cartagena early last year. At the time, I immediately noticed the difference in technique in the operating room (it’s not something you miss) but the surgeon performing the procedure just sort of shrugged, and went back to work, a “Yeah, well.. I do this all the time sort of thing.”

Since that trip, I’ve talked to several thoracic surgeons about this technique, and they all agreed; that due to limited visibility and maneverability, it was a procedure with “limited applications”. But it didn’t sound like any of them had attempted it, or knew much on the subject.
Since ‘limited applications’ describes many surgical techniques, I decided to go to the literature, and see what has been published on the topic.

Hmm.. Not much.

An article from two Spanish surgeons dating to 2009. It’s a well written article with a decent amount of subjects (24) for the treatment of spontaneous pneumothorax. They mention one of the adaptations required is use of the Coviden multi-station system to hold instruments – this is a silly piece of equipment that costs about a thousand dollars. I know that in general surgery, several surgeons have adapted a sterile surgical glove for the same purpose. Since use of this costly but specialized piece of rubber also requires an even bigger incision – I hope these surgeons have since moved on to the sterile glove technique. In this study, length of stay and amount of post-operative pain were not greatly reduced, which was a little surprising.

Jutley, Khalil and Rocco published a paper in 2005 in the European Journaol of Cardiothoracic Surgery on the same technique for spontaneous pneumothorax with 16 patients having uniport surgery (versus 19 in the standard three port group) with positive findings of reduced pain, and less residual neuralgias.

An Italian group reported similar positive findings (compared to Jutley, et. al) in 2008 on a similar sized group/ population (28 patients uniport versus 23 ‘traditional’ 3 port). They also reported a minimum of problems with the uniport technique.

So, three published studies (there are probably more, but this is what I could find over at Pubmed) with minimum of fuss or problems… So, why isn’t there more single incision thoracoscopic surgery? Where are the surgeons performing this technique? Maybe I’m just not talking to enough thoracic surgeons, or the right thoracic surgeons..

I’ll get back to you on this.

* This laparoscopic technique goes by the anacronym: SILS for single-incision laparoscopic surgery. It is also called uni-port (uniportal) laparoscopy and it has both it’s champions and detractors.