uniportal VATS – Thoracic Surgery

Troubleshooting at the 6th Uniportal VATS course in Potsdam

Potsdam, Germany

Many of the modern masters of thoracic surgery were in Potsdam, Germany this June to discuss a myriad of topics in this year’s course until the heading of Troubleshooting. The lecturers included Dr. Diego Gonzalez Rivas, the inventor of the uniportal VATS technique, Dr. Alan Sihoe, a renown expert from Hong Kong, Dr. Timothy Yang from Shanghai Pulmonary Hospital, Dr. Marco Scarci, the creator of International VATS, and our host, Dr. Mahmoud Ismail. The course included both wet and dry labs so that surgeons unfamiliar with these techniques had an opportunity to apply what they learned during this and other sessions.

Standout presentations

Transcervical Uniportal VATS

Noted surgeon, and acknowledged expert in the area of transcervical VATS, Dr. Zielinski of Poland also gave a presentation on the transcervical uniportal approach, which is performed in the anterior cervical (neck) area. Using this collar incision, Dr. Zielinski is able to perform uniportal VATS for thymectomies and mediastinal operations as well as some lobectomies (generally upper lobes) and lung resections.

Dr. Zielinski talked about the challenges for this technique as well as the indications/ contraindications and potential complications while presenting data on his latest series of 32 patients. He gave surgical tips and tricks for using the transcervical approach, and how to avoid the most common complications.

There was a full session on setting up a uniportal VATS program with multiple speakers – along with troubleshooting the most common mistakes that surgeons (and their staff and administrators) make while starting a new uniportal VATS. They also talked about addressing the learning curve and ways to avoid common mistakes that occur during this period.

Common Complications after uVATS

Dr. Stefano Margaritora talked about how to prevent, detect and treat common complications after uniportal VATS. Drawing on his experience with over 1250 uniportal cases, Dr. Margaritora discussed the most common causes of bleeding such as dislodgement of vascular clips, bronchial artery bleeding, bleeding from lymph node harvesting sites and bleeding from the chest wall. He discussed the best ways to address this, such as use of newer anti-sliding clips, and the use of energy devices (like harmonic scalpels) for vessel sealing.

margaritora

The ways to anticipate and prevent prolonged airleaks was also reviewed. Using anatomic fissures often lessens the incidence of airleaks post-operatively. The prevention of subcuatneous emphysema, as well as the relatively rare complication of lung hernia was addressed. Both of these complications can be reduced by meticulous and tight closure of the fascia at the conclusion of this procedure.

Using a serratus/ intercostal nerve block during this procedure is recommended to help reduce post-operative pain.

Dr. Firas Abu Ar spoke at several sessions – on both the use of uniportal VATS in pediatric patients as well as a case presentation on hydatid cysts. (Thoracics.org is planning to present this case study at a later date).

There was a session on robotic VATs but with the exception of a discussion of preliminary trials of a robotic instrument that allows for uniportal VATS, most of the information has been presented on previous occasions.

The state of evidence for Uniportal VATS

Dr. Alan Sihoe gave an excellent presentation on the need more more randomized studies, and higher level evidence. “The time for case presentations on uniportal VATS is over.” As the leading academic researcher at this conference (as well as an active, practicing uniportal surgeon), and editor of multiple journals, Dr. Sihoe reminded attendees that as uniportal vats use continues to grow, and becomes a more common procedure, the types of articles surrounding the procedure need to advance as well. It’s no longer sufficient to submit papers like case reports where the purpose of the paper is to explain the procedure, and basically say, “look at this cool case I did.” Surgeons need to move beyond these sophomoric writings to produce high quality, high value papers that add to the body of scientific literature around uniportal VATS. He then gave the audience specific, helpful guidelines and advice on designing, writing and submitting articles for publication.

After the didactic portion was completed, there were two live cases streamed from the local hospital for surgeons to review along with the dry and wet labs.

ebus — a Mexican surgeon using one of the newest tumor located/ marking systems during one of the dry labs

Note to readers: This will be the last article on uniportal VATS training. This topic has been extensively covered thru this and other posts here at thoracics.org. For more information on the essentials of uniportal VATS training, please review our archives under meetings and conference coverage.

Additional references

Eckland K, Gonzalez-Rivas D. (2016). Teaching uniportal VATS in Coruña. J Vis Surg. 2016 Mar 11;2:42. doi: 10.21037/jovs.2016.02.25. eCollection 2016. PMID:29078470

Highlights from the 3rd VATS International

If you can only attend one thoracic surgery conference, shortlist VATS International.

Attendees with Dr. Marco Scarci (2nd from the left)

VATS International

VATS International (previously known as Cambridge VATS) is the brainchild of Mr. (Dr.) Marco Scarci. The Italian surgeon recently made the switch from NHS Papsworth (Cambridge) to the historic Royal London Hospital. Each year, Dr. Scarci gathers the world’s specialists on minimally invasive surgery to meet here in the United Kingdom to share knowledge and practice techniques for traditional VATS, uniportal approaches (standard and subxyphoid) and robotic surgery.

This is the third year of the conference and it’s reputation for dynamic speakers and controversy continues. With over 100 attendees, and a wide range of global participation as well as live surgery sessions and a wet lab, Dr. Scarci has had runaway success despite some last-minute challenges posed by his recent defection from the Cambridge facility. (Having met several members of the rather staid and traditional thoracic surgery department at Cambridge, Dr. Scarci, with his emphasis on minimally invasive surgery, is undoubtedly better-suited to the London-based facility).

Excellent lecture content, dynamic speakers

There were several excellent speakers, making it difficult to narrow the selections for presentation here. The obvious standout was Dr. Lim, (as discussed in a previous post).

As one of the course directors, and the inventor of the uniportal approach, Dr. Diego Gonzalez Rivas gave several lectures on the technique aspects of uniportal VATS.

Dr. David Waller followed up with a lecture entitled “Intra-operative problems in VATS lobectomy: Avoidance and Management.” He discussed complicating patient factors such extensive adhesions, anthrocotic lymph nodes, anatomical variance and incomplete fissures that increase the complexity of uniportal cases. He also identified common surgical problems such as difficulty identifying the target lesion, development of large air leaks and inadvertent damage to hilum or bronchus with strategies to prevent & manage these issues. He reviewed surgical techniques on bleeding control/ major vascular injury as well as absolute indications for surgical conversion such as equipment failures, airway injuries and stapler jams. In closure, he also warned against using conversion rate as an outcome measure. It was a fairly dry lecture despite being an interesting and important topic.

Among the remaining speakers, the overwhelming theme of change, and evolution along with an underlying sense of defiance continued. These surgeons are here to discuss, learn and practice uniportal surgery even if more traditional surgeons don’t approve.

Some of the best presentations were:

Dr. Alan Sihoe, (Hong Kong) gave a modified lecture called “Reasons not to perform uniportal VATS lobectomy”. This lecture which was adapted from a previous lecture from last year’s conference also addressed criticism of uniportal VATS. He reviewed the existing literature on uniportal surgery which suggests that uniportal surgery is a safe alternative to other surgical approaches.

During the lecture, Dr. Sihoe encouraged surgeons to move past case reports to performing higher level research such as randomized control studies to create evidence in the area of uniportal surgery. He also encouraged participation in the European database, to gather prospective data on uniportal surgery. Until there is a larger body of literature utilizing higher levels of evidence, uniportal surgery will continue to face significant (and justifiable) criticism as a fad procedure. While it wasn’t a ground-breaking lecture by any means, it was also a reminder for thoracic surgeons to think like a researcher. It was a good follow-up on Dr. Lim’s opening lecture.

Dr. Gaetano Rocco (Italy).

Dr. Rocco, one of the pioneers of the uniportal approach, continued the discussion of the need for evolution and adaptation but with a different approach in a talk entitled, “VATS major pulmonary resection for (very) senior surgeons. He extended an olive branch to older, experienced thoracic surgeons with limited experience with VATS. His lecture discussed the ways to remediate older surgeons, and build their skills and comfort level in performing VATS procedures. His lecture offered a clear-cut and concrete , step-wise curriculum and self-assessment tool for surgeons looking to improve their VATS skills, starting with VATS lobectomy.

Dr. Ali Khan (India) delivered two lectures, the first on operating room technology, but it was the second on uniportal surgery for inflammatory and infectious diseases that really piqued my interest. Part of this is due to my interest in the surgical treatment of tuberculosis, and my great appreciation for empyema as a surgical disease. Most readers know that reducing the time from presentation/ diagnosis of empyema to surgical decortication is one of my goals in daily practice, so any reminder that the morbidity/ mortality of decortications have been greatly reduced by minimally invasive surgery is always welcome.

Honorable mention: Dr. Alex Brunelli, “Fast track enhanced recovery for MITS”. Basically a talk on care plans with specific markers for timely progression and discharge. While this is standard fare for nurses, the use of care plans for many surgeons is unfamiliar territory. It would have been nice if the care plans were available as a handout for surgeons who are still fine-tuning their own programs. It also would have been nice for a better breakdown of how specific items reduced the length of stay (how/ how much) or decreased the rate of complications. Nice to mention care plans but better to have measurable and specific examples.

After the extensive lecture series on the first day of the conference, the second day was devoted to live surgery cases and the practice lab.

Wet Lab

Since animal research of any kind is tightly controlled in the United Kingdom, 3D printed models were used for the wet lab portion of the course.

This is the first time that this type of model has been used. While the green plastic housing looks rudimentary, on closer inspection of the ’tissue’ inside, one gets a better appreciation for the models. The tissue is soft, and sponge-like. The lung doesn’t inflate but appears more lifelike than other models.

I don’t have the patience or temperament to shoot video footage, but I did record a couple of seconds so readers could have an idea what the wet lab portion of the course is like. In the video, Dr. Sihoe is instructing two trainees on the proper technique.

Despite its relative youth, VATS International remains one of the best conferences on minimally invasive surgery, inferior to none. This conference is highly recommended and considered superior to many of the traditional conferences on the topic (such as the annual Duke conference), due to lecture content on timely topics and controversial issues. The hands-on wet lab and participation by internationally recognized and globally diverse speakers makes this conference more valuable to attendees looking for exposure to newer surgical techniques.

Thoracics.org 2017 wish list

What would I like to see next year? As mentioned above, VATS International is one of the better courses available for surgeons interested in uniportal, subxyphoid and other minimally invasive techniques. But there is still more content I’d like to see – on nonintubated and awake surgery, for example.

However, with regards for this year’s speaker, an anesthesiologist from Papsworth Hospital, this topic would be better covered by one of the “masters” of the field; Dr. Eugene Pompeo of the Awake Surgical Group or Drs. Hung & Chen. The “Papsworth Experience” per se is limited to heavy sedation/ general anesthesia without mechanical ventilation. Patients still have LMAs and are heavily sedated. One of the main benefits of nonintubated anesthesia is the ability to operate on the medically fragile. It would be enlightening to hear more about operating on this population from more experienced clinicians. One of the topics that has been essentially ignored in the literature on this topic, is the implications for thoracic surgeons, anesthesiologists, operating room and recovery room staff on operating on this population of sicker patients. I think readers would like to hear about the new challenges in managing patients that were previously inoperable due to serious co-morbidities.

A discussion on developing or actualizing a formal certification process with examination for minimally invasive surgery with suggested curriculum, and case log requirements would be a nice addition. Blackmon et al. published a credentialing guideline but it’s a multi-part overly complex document full of “levels” of competency. I’d like to see a discussion on the development of an actual certification to be offered by a surgical licensing body or surgical society. Since the American agencies would probably take another 20 years to consider the idea, perhaps one of the guest speakers’ native society would be more willing to take on this project?

I’d also like to see at least a limited amount of content on esophageal surgery. I know, I know..While practice areas for thoracic surgeons vary around the globe, with the rapid rise in esophageal cancer, a lecture on the role of minimally invasive surgical techniques for esophageal surgery would be a great addition to the current roster of topics, particularly if it was given by one of the modern masters of esophageal surgery like Dr. Benny Weksler or Dr. Roy Chen.

Lastly, one of the most enjoyable aspects of this conference is the truly international flavor. Watching a surgeon from Israel demonstrate uniportal techniques from a practice site in Shanghai brings home the importance of global collaboration. Hearing surgeons from India, Brazil, France and Canada present data on their practices is critical to gain perspective, and exchange ideas. It also helps prevent attendees from falling into the trap of “we’ve always done it this way.” This concept could be expanded to include designated global snapshots, to highlight research or data in specific geographic areas, like Dr. Khan’s lecture on uniportal approaches for infectious and inflammatory disease.

A full lecture on cost containment techniques for surgeons practicing in hardship areas would be a great topic. Dr. Sihoe touched on the issue during one of his lectures, but since I’ve heard other surgeons talk about the limitations posed by having only one thoracoscope, I’d love to see an equipment representative give a lecture on maintaining thoracoscopes, where to donate old scopes or how to rehab these scopes for a second life. A talk about modifying existing surgical instruments for surgeons who can’t afford the Scanlan set would be helpful as well. One of the reasons these courses have been so successful it the fact that they are technically based, so adding a section like this might help spread the uniportal technique to a whole socio-economic and geographic segment of patients that it might not otherwise reach.

This last item might be a tall order for Dr. Scarci and his group but he’s done pretty well thus far.

Why you should have attended VATS Peru 2016

Why you should have attended VATS Peru 2016

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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.

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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.

Dr. William Guido and the state of thoracic surgery in Costa Rica

Cusco, Peru

One of the guest lecturers at the 2^nd VATS Peru Uniportal Master course is Dr. William Guido Gerrero from Costa Rica. Dr. Guido talked about the challenges of implementing a minimally invasive thoracic surgery program in the small central american nation that boasts a total population of less than 5 million.

Despite the small population and the low surgical volumes that accompany it; Dr. Guido is one of ten thoracic surgeons in Costa Rica, who are affiliated with two thoracic surgery departments within the nation.

Dr. Guido initially performed his first two uniportal cases with some trepidation. The first cases were simple biopsies and drainage of pleural effusions. He then performed his first lobectomy but it was a slow tedious process. After that experience, he traveled to Shanghai, and the Shanghai Pulmonary Hospital to attend and train with Dr, Diego Gonzalez Rivas in the wet lab, practicing cases on live animals.

At Hospital Rafael Angel Calderon Guardia

Dr. Guido primarily operates in a 350 bed hospital in the capital city of 1.4 million habitants. The thoracic surgery unit consists of eight beds, and cases are performed three days a week with an annual case volume of around 350 cases.

Majority of cases by Uniportal VATS

The majority of surgical cases (67%, includes all types of cases) are performed using the uniportal approach. 31% of the remainder are performed via a traditional ‘open’ approach with only 2% of cases performed using traditional (multiport) VATS. This discrepancy is explaned by Dr. Guido in that there is currently only one thoracoscope in the hospital, and it is not always available. He predicts that the rate of uniportal VATS cases will soon increase, as the second thoracoscope is scheduled to arrive in just a few weeks, followed by a third thoracoscope next year. These equipment limitations are not the only challenges for Dr. Guido and his fellow thoracic surgeons.

Low volumes, suboptimal equipment and a lack of institutional support

The low volume of surgical cases and a lack of institutional support are also problems. Unfortunately, it’s harder to convince the medical community of the value of uniportal VATS (and thus boost surgical volume) than it is to order new equipment. Despite these limitations, Costa Rica also manages to maintain a struggling lung transplantation program, that performs approximately two transplants per year, with five patients with pulmonary fibrosis and pulmonary hypertension currently on the waiting list.

Excellent care, at home

Dr. Guido hopes that many of these problems can be resolved in the future. He wants Costa Rican patients to feel that they can stay in Costa Rica for their thoracic surgery without making any sacrifices in care. He’s already lost one patient to Dr. Gonzalez Rivas himself (when the patient traveled to Spain for surgery) and another to the United States (where the patient ended up getting an open thoracotomy). Losing a patient to the Master of Uniportal Surgery himself is inevitable, but losing a patient to a country where the patient received an inferior procedure at an exorbitant cost is a bit harder to swallow.

Best of luck to Dr. Guido and his colleagues.

Thoracic surgery conference – VATS Peru this September..

Dr. Diego Gonzalez Rivas headlines the ALAT sponsored event this September.

Cardiothoracic surgeon and the coordinator and director of VATS Peru, Dr. Carlos Fernandez Crisosto cordially extends an invitation for all interested thoracic surgeons to attend VATS Peru. This event is co-sponsored by ALAT being held at the Hospital Essalud Tacna in Tacna, Peru on the 21st and 22 of September. The 2 day course includes a wet-lab for a hands on approach at teaching uniportal VATS with Dr Gonzalez Rivas.

Thoracics.org has written for additional information – so I will update this post as information arrives. To register – click here.

Corrections: as many readers know, I do much of my writing on the fly, in airports, waiting rooms etc. The sometimes results in spelling and grammatical errors. As always my sincere apologies.

Live surgery sessions – Naples minimally invasive surgery course

Dr. Henrik Hansen on how to streamline your surgery, and Dr. Diego Gonzalez Rivas at the Live surgery sessions of the Minimally invasive surgery conference in Naples, Italy.

Monaldi Hospital – If these walls could talk

It’s the second day of the conference at Monaldi Hospital which is located in Zona Ospedale, in the hills of Naples. The corridors of the 800 bed, 135 year-old former tuberculosis sanitarium give away few hints of the rich and interesting history of this institution. Commandeered by the Allies during the second world war, and containing a small but extensive pathology museum hidden in a back office, showcasing lung disease and many of the disseminated tuberculosis cases that were cared for here, one can only be intrigued by the stories contained within such as the first specimen in the collection, a five month’s gestational fetus (in utero) of a deceased tuberculosis patient.

Dr. Majorino, thoracic surgeon (who has worked at Monaldi Hospital for over 30 years and the head of the pathology department - in the museum of pathology — Dr. Majorino, thoracic surgeon (who has worked at Monaldi Hospital for over 30 years and the head of the pathology department – in the museum of pathology

But we digress. As intriguing as all the tales of thoracic disease past are, we are gathered here today to advance the present and change the future of thoracic surgery here at Monaldi Hospital. As mentioned in a previous post, the surgeons here in the department of thoracic surgery have only recently adopted VATS surgery. Now after four years of practice, it is time to perfect it. For that reason, the first guest surgeon to perform the live demonstration today is Dr. Henrik Hansen.

Live Surgery with Drs. Hansen & Gonzalez Rivas

Dr. Henrik Hansen

Dr. Hansen is a Denmark native who currently operates in one of Europe’s busiest VATS programs, located in Copenhagen. 80% of all the thoracic surgeries performed at his institution, Rigshospitalet. (In comparison, in most of Europe, VATS comprises of 52% of thoracic procedures, according to data presented by Dr. Hansen).

As the head of the minimally invasive surgery department at Righospitalet, he has mastered and streamlined the ‘traditional’ or three-port VATS approach, so there are no wasted efforts to maximize efficiency.

During a short lecture prior to surgery, Dr. Hansen discussed the literature, including a paper by WS Walker et al. in 2003, which compared cancer survival outcomes in patients undergoing VATS and standard open procedures. In the paper, the authors unequivocally recommended VATS as the operation of choice. It was this paper that led Dr. Hansen to aggressively pursue VATS for the majority of his patients. This position was not echoed in the official guidelines until 2013.

slide from Dr. Hansen's presentation — slide from Dr. Hansen’s presentation

Dr. Hansen allows that not all cases should be VATS cases; he prefers to perform sleeve resections via thoracotomies instead of VATS pneumonectomies, to prevent excess tissue loss in these cases).

Interestingly enough, residents in Dr. Hansen’s program learn VATS techniques without knowing the equivalent open surgical technique. He cites one of his thoracic surgery fellows as performing over 80 VATS procedures but only two thoracotomies. As a surgery purist, this disturbs me in some way, but then again – by much of Dr. Hansen’s criteria, I would be labeled a traditionalist.

For the morning’s case, he is performing a left upper lobectomy. (There are no other case details available to spectators in the auditorium)*.

He places the first port along the transverse line where the standard thoracotomy incision would normally be placed. He then triangulates the second and third ports, though only one actual trocar port is used, a 12 mm port for the camera insertion.

The “working” incision is the uppermost incision, which appears to be quite large, (but this may be a distortion due to my perspective – from a camera placed above the operating room table). At times he uses more than one instrument in this incision – and watching him, he seems that he could easily convert to single port surgery with equal efficiency. He almost forgets about his second port at times, and uses the remainder (3rd port) solely for the camera access.

He is precise and exacting in his movements, which is what makes his reliance on traditional VATS a little puzzling. Habit, mainly, I suspect because the surgery proceeds as if by rote. He really is the master of efficiency – and the case progresses quickly.

He uses ligasure for greater precision during dissection and isolation of tissue and minimizes the external torsion and retraction placed on the lung during hilar dissection, isolation and ligation of the pulmonary vasculature. He completes the procedure by performing an extensive lymph node dissection.

*Since I was outside of the operating room for this case, there are not very many operative photos, and none of Dr. Hansen operating.

Dr. Diego Gonzalez Rivas

As part of his pre-surgical lecture, “Recent advances in uniportal VATs,” Dr. Gonzalez reviewed the recent history of uniportal VATS as well as surgical tips for surgeons learning the technique. He also reviewed some of his more recent forays into surgery including complete uniportal resections using only the harmonic scalpel, and surgery on non-intubated (and awake) patients on nasal cannula. He discussed that the non-intubated project was a anesthesia counterpart to minimally invasive surgery. Since the risks and complications related to thoracotomies and other large incisions have been eliminated, it’s a normal progress to advance towards less invasive anesthetic techniques (since general anesthesia is associated with serious risks such as severe hypotension, peri-operative myocardial infarction and cardiovascular collapse). While rare, eliminating general anesthesia in many cases, greatly reduces the risk of adverse anesthesia-related events.

Surgical procedure**: Left upper lobectomy with radial lymph node dissection for a left upper lobe peripheral nodule in a 65 year patient.

Surgeon: D. Gonzalez Rivas. Assistant Surgeon: D. Amore Scrub nurse: Guiseppe

Initial post-intubation vital signs: HR 83, NSR B/P 90/60 Saturation 99%

1445: Initiation of patient prep (betadine). Patient is in a side-lying position.

1510 First incision (only incision)

1515: camera inserted, initial chest cavity inspection, lung deflated. No significant adhesions or unexpected findings. Hilar dissection commences, with attention being given first to the pulmonary artery. By 1605, the left upper lobe branch of the pulmonary artery has been divided.

Dr. Gonzalez Rivas operating with Dr. Amore assisting. Dr. Casazza looks on.

1608: Bronchus stapled (resected). Patient noted to have an incomplete fissure of the upper lobe.

By 1612: The lobe is out. Dr. Gonzalez proceeds with radical lymph node dissection – including the nodes of the paratracheal area/ aortapulmonary window. The surgical field is essentially dry, with small amount of liquified fat from electrocautery dissection with just minor oozing from the aortopulmonary window. He places a small amount of surgicell in the subcarinal space, after harvesting several nodes to show the best angle of approach (posterior).

Dr. Gonzalez Rivas examines the ung specimen after removal — Dr. Gonzalez Rivas examines the lung specimen after removal

During surgery, he spends a few minutes demonstrating alternative techniques to hold and manipulate several instruments in one hand so that surgeons can minimize wasted movements.

After final inspection, Dr. Dario Amore assumes the role of primary surgeon – to place the chest tube (1653). Lung is re-inflated, and the ventilator/ respiratory loop is used to determine that there is no air leak. Camera out of the chest at 1655.

Vital signs: HR 76, NSR B/P 121/62 Sats 100% No hemodynamic instability or hypotension during the case. EBL for the case is around 90ml (+/- 10 ml due to lack of graduations on the suction canister).

Skin incision closed: 1710

By 1715: Patient is awake, extubated and able to verbal respond to commands/ questions.

**Since I was present in the operating room, I was privy to a great deal more information than audience members in the auditorium such as the pre-surgical patient review, monitor readings, etc.

Welcome to Shanghai Pulmonary Hospital

Shanghai Pulmonary Hospital – Shanghai, China

Shanghai Pulmonary Hospital is a dream come true for a thoracic surgery aficionado like myself. Twelve operating rooms, a 30 ICU beds, 30 to 40 operations per day and over 40 staff surgeons means that there is always something interesting going on down the hall.

Am case presentations is like a review of Robbins’ pathology. Bilateral nodules, ground glass opacity nodules, giant-sized tumors, mediastinal masses of all types and atypical presentations abound. By tradition, all tuberculosis cases must come to the medical complex at Shanghai Pulmonary Hospital because they have a designated tuberculosis hospital on site. Even with other facilities competing for some of the pathology, there is plenty to go around, and I am able to see a couple of lung abscesses as well as several varieties of cavitary lesions. I am sure that there is still a wealth of untapped pathology for me to explore, but I suspect that more interesting infectious cases and occupational diseases are probably confined to the more distant provinces.

I briefly talk to one of the surgeons here, who is from Kashdar region, on the far western side of China. Kashdar is located in one of the more mountainous regions of China, which was part of the famous Silk Road trade route explored by the likes of Marco Polo more than half a millennia ago. We discuss the region and compare it to its American counterpart of West Virginia. It’s not a perfect analogy but there are enough similarities to help me for a picture of life, and industry there. That is where the mines are concentrated, and that is where I might find the black lung disease, the silicosis and similar type diseases, though the surgeon I speak with reports that the rates of occupational disease for this occupation to be quite low. Given the dangerousness of underground mining, I wonder if many of the miners worry about living long enough to see a chronic disease like black lung. I don’t know enough about China to ask a lot of the other interesting questions that are swarming in my mind, but I wonder about mesotheliomas and other diseases related to all the heavy industry that forms the backbone of the booming Chinese economy. I wonder about the prevalence of empyemas given the pollution levels and the closeness in which many people are forced to live. It seems like it would be a daily surgical feast, but I don’t know a polite way to ask directions to the hospital with the pus-filled buffet.

My hosts also tell me regretfully that they also only see a limited amount of esophageal cancer because many people are misled by the name of the facility, and are unaware that esophagectomies are performed here. One of the surgeons looks so woe-begotten as he tells me this that I know he has the same love of that surgery as I do – that feeling of joy when surgical planning, pre-operative optimization, surgical skill and aggressive post-operative care come together flawlessly for an uncomplicated post-operative course in a complex case. It’s not just satisfaction with a job well-done but pure joy at seeing our patients walk out of the hospital and back to the regular lives.

I am here at part of the Uniportal VATS conference with Dr. Diego Gonzalez, but it’s also an opportunity to literally wander the operating rooms at will, listen to case discussions and interview surgeons as I encounter them. I always joke about feeling like a kid in a candy store, now I really am. If I hear a particularly interesting case during am rounds, I am welcome to come into the operating room, watch the case, listen to the discussions and talk to the surgeons.

As one of the largest general thoracic surgery departments in the world*, it would be impossible for me to know and present all staff surgeons in the few days that we are here for the Uni-portal Surgery conference. Instead I would like to highlight a just a few of the interesting and talented surgeons at this busy facility.

Dr. Jiang Gening – Chief of Thoracic Surgery

Dr. Jiang is the head of one of the world’s largest thoracic surgery services, but it doesn’t seem to faze him. Then again, he’s been here at Shanghai Pulmonary Hospital (SPH) since he came here to train in 1982. At that time, the thoracic surgery department was just a fraction of the size it is today.

As resident, staff surgeon, and then now Chief for the last ten years, Dr. Jiang has seen numerous changes, many of which have occurred in just the last few years. Volumes have dramatically increased, resulting in annual hospital construction to expand the operating rooms. A 16 bed thoracic surgery department has grown to over 250 beds.

Dr. Jiang has a strong vision of where his hospital ranks in the world, and where he would like it to be. He sees a strong future for this facility as an international leader in thoracic surgery and clinical research, and he has been working aggressively towards these aims.

Dr. Jiang has trained with Dr. Patterson (Bowman Grey, St. Louis) and other leaders in thoracic surgery in Boston and Los Angeles, and he encourages his surgeons to do the same. He strongly supports surgical development among his staff such as bringing leading surgeons like Dr. Diego Gonzalez Rivas to train staff in the most up-to-date procedures.

As a surgeon himself, he enjoys the more complex cases, the larger surgeries for the challenges they bring. When I mention, ‘chest wall resection,’ he smiles and nods before Dr. Wang can translate.

He is also very interested in expanding the lung transplant program but acknowledges that his facility has difficulties in obtaining donors now that China has discontinued the policy of using incarcerated people for organ donation. Organ procurement has been complicated by the traditionally low rates of voluntary donation in Chinese societies. As Dr. Jiang explains, Chinese culture and many Chinese families has a hard time recognizing and reconciling with the concept “brain death” in the absence of physical death. This means that Dr. Jiang and his program are focusing on donation after cardiac death and ex-vivo implantation. But this too is problematic – the scarcity of organs means that despite being in a metropolitan area of almost 30 million, surgeons may have to travel to Beijing or other locations for available organs. Often on arrival, these organs are not in suitable condition for transplantation. Another problem is the reluctance of Chinese insurance companies and third-party payers to cover the cost of ex-vivo support. Dr. Jiang acknowledges that his facility has several large hurdles to overcome if Shanghai Pulmonary Hospital is to become the transplant center for Singapore, Korea and the rest of Asia, as he envisions.

I am hoping to find my way into Dr. Jiang’s operating room. I have been advised by the Taiwanese surgeons that Dr. Jiang is widely-known and admired for his ‘nimble fingers’ so I want a chance to see him in action.

Dr. HaiFeng Wang

Dr. HaiFeng Wang is a very nice 41 year old surgeon who assisted in translating during the interview with Dr. Jiang. It was strange, as soon as I started talking to Dr. Wang, it was like we recognized each other. I immediately knew that we would see eye to eye. And so it was, as he presented his daily cases, and we discussed the findings, the planned surgeons and related research. So it seemed natural for me to spend the day with Dr. Wang in the operating room.

Like Dr. Jiang, Dr. Wang is from Shanghai. After completing a combined medical school and internship program, (with training in urology), Dr. Wang decided to switch to thoracic surgery (a decision that cirugia de torax wholeheartedly supports).

After receiving the World Health Organization fellowship, he traveled to Australia to train with Dr. Peter Clarke at Austin Hospital in Victoria. He focused his studies on the surgical control of cancer. More recently, in 2013, he received the Graham fellowship (from AATS) to study with Dr. Mathisen in Boston, Massachusetts. He also spent one month with Dr. McKenna in Los Angeles and another month with Dr. Patterson in St. Louis.

His areas of interest include minimally invasive surgery, tracheal surgery, lung transplantation and the diagnosis and treatment of ground glass opacities.

HIs first surgery of the day is an asymptomatic middle-aged patient with an incidental finding[1] of a large bronchiogenic cyst in the right middle lobe.

On the CT scan, it looks like an egg-yolk with solid material within a fluid-based cyst. The initial suspicion is a possible aspergilloma but this presumptive diagnosis is eliminated during surgery based on tumor appearance.

Frozen section is requested intra-operatively but the results of that only deepen the mystery when a diagnosis of a possible sarcoma is suggested by the pathologist. The resection is completed quickly, but the mysterious aspect of the case has me intrigued as we wait for the final pathology.

Update: Final pathology completed 3/17/2015. The report says pulmonary lymphangioma, a rare disease in the lung, and the pathologist says that the cyst itself is actually the lymphangioma, not only the small nodules we see inside the cyst wall.

The second case is a young patient with a GGO (ground glass opacity) in the right upper lobe. A needle biopsy confirms that the mass is a malignancy, an adenocarcinoma. This surgery is also smooth and uneventful.

There is a third case still scheduled, (and interesting too!) but unfortunately, it’s time for me to race back to the hotel, do some writing before I go to sleep to get ready to do this all over again.

I’ll be here in China for three weeks, so this isn’t the last you will hear about Thoracic surgery in China or Shanghai Pulmonary Hospital.

[1] In China, a CT scan is a fairly affordable diagnostic tool ($40) for most middle class Chinese citizens. Healthcare among certain classes, is also consumerized to a degree that the United States is only beginning to approach. This means that many Chinese residents have CT scans with the same gravitas that a many of us may approach a new hairstyle, or similar type purchase.

* noncardiac. There may be larger combined CTS departments.

Note: this article has been edited for corrections due to translational and other inaccuracies.

I’m with the band

on location with Dr. Diego Gonzalez Rivas as he embarks on his latest project: teaching uniportal VATS to surgeons in China

Right now, I am on a Air China flight heading to Beijing after finishing up the first date on Dr. Diego Gonzalez Rivas, “7 Days, 7 Cities” Uniportal VATS instructional tour. I am here at the invitation of Dr. Gonzalez to chronicle the making of his second documentary film.

with Dr. Gonzalez Rivas and Spanish filmmaker, Danilo Lopez

Our first stop was Wenzhou, China where Dr. Gonzalez Rivas gave a lecture and performed a right middle lobectomy on a patient with a large lung lesion.

Dr. Gonzalez Rivas reviews patient films in consultation with local surgeons

It’s a different kind of experience for me, and it takes getting used to – knowing where NOT to stand, or walk so Danilo can get his shots. The whole live camera thing is a little bit off-putting. Everything is a production, nothing is left to chance. It can’t be – like the title of the film – it’s a fast trip, in and out. But it’s also an amazing experience. Danilo is amazingly talented (and very nice), and it’s hard to reconcile what looks like every day, run of the mill stuff with the footage he manages to capture. It’s strange and wonderful to see surgery thru his eyes. It’s also nice to have some camaraderie in the operating room as ‘media’.

The case went beautifully – another uniportal success story!

Dr. Gonzalez Rivas performing a surgical demonstration in Wenzhou, China

Goodbye Wenzhou – now off to Beijing!

**”I’m with the band” is my own lame joke because it says everything about my personality that I liken spending time in the operating room with a thoracic surgeon akin to traveling on the road with Mick Jagger back in his heyday.

Live streaming single-port surgery: International Symposium

the latest from Dr. Diego Gonzalez Rivas and the masters of thoracic surgery.

Dr. Gonzalez Rivas and the Thoracic Surgery Unit in Coruna, Spain are hosting the “International Symposium on Uniportal VATS” this week (February 26th to 28th, 2014).

Dr. Gonzalez Rivas demonstrates uniportal VATS

While the in-person, on-site event is limited to just 100 attendees, the event will be offering real-time live streaming surgery for viewers worldwide.

With registrations from around the world, Dr. Gonzalez Rivas estimates that thousands of pairs of eyes will be watching; from Australia to Saudi Arabia, Hong Kong to Colombia, Brazil to Russia, and the United States.

If you’ve ever wanted to learn more about single port VATS, this is the time to find out.

For more information:

Livethoracic.com – link to the event and on-line registration. Registration is 500 Euros.

Article at Examiner.com with more details on this event.