The dynamic young Spaniard has been making headlines over the last decade as he introduced and then refined the single port surgical technique. He and his colleagues, Dr. Maria Mercedes
de la Torre Bravos and Dr. Ricardo Fernandez Prado at the Minimally Invasive Thoracic Surgery Unit (UCTMI) in Coruna, Spain have successfully used this technique on thousands of patients, for a wide variety of procedures including sleeve lobectomies, pneumonectomies, bilobectomies and other complex procedures.
Despite this widespread fame, Dr. Gonzalez Rivas remains unaffected and approachable. He spends much of his time in operating rooms around the world, teaching his technique to his peers. Next week, he heads to Guangzhou, China.
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: email@example.com
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.
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.
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.