uniportal subxiphoid – Thoracic Surgery

Why you should have attended VATS Peru 2016

Why you should have attended VATS Peru 2016

There were plenty of reasons for surgeons from all over Latin America to converge on Cuscu, Peru for the 2^nd annual VATS PERU Uniportal Master Class, which covered the basics of the uniportal approach as well as nonintubated and awake uniportal surgery. There were subxiphoid and uniportal cases streamed live from Shanghai Pulmonary Hospital. But beyond the usual reasons of networking, discussing and sharing case knowledge, and the presentation of research findings and evidenced-based practice, there were several reasons why VATS Peru was more than just your average regional thoracic surgery conference.

Why attend VATS Peru? The three best reasons:

1. The wet lab – which allowed surgeons and their surgical assistants to apply the theoretical knowledge they learned during the first two days of lecture in operating room scenario en vivo. The “en vivo” is critical, fancy simulators aside, there is no better challenge to ‘book knowledge’, and application of practical skills than in the scenario of an operating room, with real models and active bleeding.

img_1281_fotor — A surgeon in the master course receives instruction from Dr. Diego Gonzalez Rivas

2. Lectures from the master surgeon himself; Dr. Diego Gonzalez Rivas: That’s where the second critical component comes in, in the form of the candid, direct and straight-forward lecture by Dr. Diego Gonzalez Rivas on Control of Inter-operative Bleeding. If you weren’t paying attention during this lecture, it’s obvious in the lab. This isn’t a computer course where you can dial in your answers, fast-forward thru lectures and print off a shiny new certificate. This isn’t a computer app, or a simulation that you can reset and re-start as soon as the surgery heads off course, to try again.. It’s real surgery.

3. Dr. Carlos Fernandez Crisosto

Lastly, if you didn’t attend VATS Peru, then you missed an opportunity to know and to talk to Dr. Carlos Fernandez Crisosto. VATS Peru is his brainchild, and the organization was created specifically to advance minimally invasive surgery in Peru. VATS Peru is separate from ALAT (the Latin American Society of Thoracic Surgeons), of which Dr. Fernandez is the current president. VATS Peru is also separate from the Peruvian Society of Thoracic Surgeons which has its own focus in the thoracic surgery specialty.

Dr. Carlos Fernandez Crisost0, Cardiothoracic and Vascular surgeon

Dr. Fernandez, a Tacna native, works at Daniel Alcides Carrion Essalud facility in the southernmost region of Peru. He is the sole cardiovascular and thoracic surgeon for the city of Tacna, and performs cardiac, vascular, and endovascular surgeries in addition to general thoracic surgery. While he is a trained cardiovascular surgeon, (in addition to general thoracic) thoracic surgery is what he enjoys most.

He trained in Argentina, and practiced in Cordoba, Argentina for 23 years before returning to Tacna in the last few years.

His average case volume is around 380 surgeries a year, and he reports that all of his thoracic surgeries are generally performed using the uniportal thoracoscopic approach. He also does transplant, which requires him to travel to Lima specifically to perform the procedure. The transplant program is small and performs 4 to 5 transplants per year.

In his practice he sees the usual oncology cases, and empyemas but he also sees a large number of patients with tuberculosis, as well as an assortment of hydatid cysts, and pectus cases. Trauma from accidents, as well as injuries from guns, and knives also comprises a large part of his practice.

Dr. Fernandez is pleased with the success of his course, since this is only the second time the course has been available here in Peru. It was a complex logistical arrangement to hold the course in Cusco this year, but with the help of his wife, a professional events planner, they were able to pull of the event with very few hiccups. Next year, they plan to hold the event in Lima, the capitol of Peru and a city famed for its gastronomic offerings.

If you missed this year’s VATS Peru, look for VATS Peru 2017 here at Thoracics.org next fall.

VATS Peru 2016

VATS Peru 2016 – learn uniportal and subxiphoid techniques in the wet lab, at the hands of the inventors of these techniques at this year’s conference in Cusco, Peru.

Cusco, Peru – September 2016

The 2016 VATS Peru conference and wet lab is scheduled for September 7th – 9th and this year’s agenda looks to be interesting and exciting.

Dr. Carlos Fernandez Cristoso is this year’s director of the course, and he has all the essentials of uniportal (single port thoracic surgery) VATS including special sections on : Management of intraoperative bleeding, difficult / advanced uniportal cases, and uniportal VATS on awake and nonintubated patients in addition to much of the standard uniportal fare.

Dr. Diego Gonzalez Rivas is honorary president of the course.

The course also includes lectures on the uniportal subxiphoid approach, as well as how to teach uniportal approaches to residents and fellows. The surgeons of Shanghai Pulmonary Hospital as well as Dr. Diego Gonzalez Rivas , the inventors of subxiphoid and uniportal approaches (respectively) will be there. The surgeons of Shanghai Pulmonary Hospital will be sharing their experiences of performing over 8000 uniportal resections a year, as well as presenting a live case direct from Shanghai during the conference.

Also – this conference is unique in offering an opportunity for surgical assistants, and scrub nurses to gain insight and share experiences in uniportal techniques with concurrent courses scheduled for operating room nurses. Both sections spend the last day of the conference in the wet lab applying newly learned techniques.

To register for this course – click here or e-mail : consultas@vatsperu.org

Case Study: Thymectomy by Uniportal subxyphoid approach

Dr. Giuseppe Aresu of the University Hospital of Udine, Italy presents a case of thymectomy by subxyphoid approach

Article originally published October 31, 2015

We report the case of a thymectomy performed through a subxyphoid vertical single incision port carried out in a 51 years old female myasthenic patient presenting a Masaoka stage I thymoma.

The subxhyphoid approach permits an excellent view of the mediastinal anterior region and of the two pleural spaces giving the surgeon the possibility to perform a very radical and safe dissection of the thymic and peri-thymic fatty tissues.

Considering the position and the 3.5 cm length of the port, it is esthetically excellent. Without a sternal incision, or VATS – associated intercostal nerve injury, the recovery can be faster and less painful than the sternotomy approach or other vats approaches carried out through the intercostal spaces.

Technique

We performed extended thymectomy through a uniportal subxiphoid approach in a 51 years old female presenting a thymoma of 2.5 cm and myasthenia gravis.

The patient was informed about the risks and the benefits of the procedure and the consent to carry on with the operation was obtained.

Under general anesthesia, the patient was intubated with a double-lumen endotracheal tube and artificial ventilation was applied.

The patient was placed in a supine position with a silicon roll positioned below the lower part of the chest in order to lift the subxiphoid region.

The operating surgeon stood on the right side of the patient, the assistant stood on the patient’s left side and operated the endoscope. The monitor was positioned at the right side of the patient toward the cranial side of the bed.

A 3.5-cm longitudinal muscle sparring incision was made below the xiphoid process between through the linea alba.

The xiphoid process was exposed, the inferior part of the sternum was lifted up with a retractor and a blunt dissection was carried out in order to find the pericardial plane.

A SILS port (Covidien, Mansfield, MA) was then inserted into the port, and CO2 was insufflated at a maximal pressure of 8 mm Hg. The CO2 insufflation within the mediastinum generates a very useful amount of extra working space within the anterior-superior mediastinum allowing an easier dissection and a better visualization of the mediastinal structures especially toward the cranial part of the mediastinum cephalad to the left innominate vein including the upper poles of the thymus.

Under visual guidance provided through a 10-mm EndoCAMeleon® Telescope, the operator utilized grasping forceps designed for single-incision surgery with his left (SILS Hand Instruments Endo Clinch™ II (Covidien) and performed dissection, coagulation, and division of tissue mainly using the Sonicision™ cordless ultrasonic dissection device (Covidien, Mansfield, MA) and occasionally using a normal straight hook cautery.

The bilateral phrenic nerves and the bilateral mammary arteries and veins were always under optimal control as well as the cranial part of the mediastinum permitting a safe dissection en bloc of the thymus, thymic tumor, and surrounding fatty tissue anterior to the phrenic nerves.

The operation time was about 2 hours and 30 minutes, and blood loss was minimal.

No complications occurred during or after the operation, the drain was taken out after one day and the patient was discharged home 2 days after surgery.

Postoperative pain was very low requiring just 1 g X 3 daily of paracetamol during the hospital stay, and no analgesic administration after the discharge.

Case study submitted by:

Dr. Giuseppe Aresu

University Hospital of Udine

Udine, Italy

Dr. Guiseppe Arescu — Dr. Giuseppe Aresu

This case was later published (Dec 14, 2015) at CTSnet. Congratulations Dr. Aresu!

Additional Reading

Suda, T. (2016). Single-port thymectomy using a subxiphoid approach-surgical technique. Ann Cardiothorac Surg. 2016 Jan;5(1):56-8. doi: 10.3978/j.issn.2225-319X.2015.08.02. Review. Free fulll text discussion of a similar case by Japanese surgeon. This article includes a video presentation and a in-depth discussion of technical aspects of the case such as surgeon position and camera access.