Modified Uniportal Video-Assisted Thoracoscopic Lobectomy: Duke Approach H. Volkan Kara, MD, MS, Stafford S. Balderson, PA-C, and Thomas A. D’Amico, MD Department of Surgery, Division of Thoracic Surgery, Duke University Medical Center, Durham, North Carolina
Traditional thoracoscopic strategies using two to four ports has been demonstrated to be oncologically successful for patients with resectable lung cancer, with numerous advantageous over thoracotomy. A singleincision approach has been described, but it is associated with potential disadvantages. The modified
uniportal approach described may address those disadvantageous, with retention of the potential advantages of using a single incision.
V
ventilation (either dual-lumen endotracheal tubes or bronchial blocker) and is positioned in a full lateral decubitus position with slight flexion of the table at the level of the middle of the chest, which allows slight splaying of the ribs to improve exposure in the absence of rib spreading [1, 3]. We prefer using the fifth intercostal space, which is known to be wider, thus allowing for both better exposure and easier retrieval of specimens. A 4-cm “access incision” is made anteriorly, and the fifth intercostal space is opened, approximately 1 cm more anterior and posterior than the extent of the skin incision (Fig 1). Adjacent and posterior to the incision, a 5-mm “camera port incision” is made (Fig 2). A 5-mm 30 thoracoscope is placed within a trocar. The camera is operated by a team member standing at the back side of the patient, and the surgeon stands at the patient’s anterior side (Fig 3).
Technique The reoperative setup for the modified uniportal VATS technique is the same as our classic VATS procedure [1]. The patient is under general anesthesia with single-lung Accepted for publication June 11, 2014. Address correspondence to Dr Kara, Department of Surgery, Division of Thoracic Surgery, Duke University Medical Center, Box 3496, Durham, NC 27710; e-mail: [email protected].
Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier
Fig 1. Fifth intercostal space (ICS) is opened, approximately 1 cm more anterior and posterior than the extent of the skin incision so the 5-mm camera port uses the same intercostal space. 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.06.086
FEATURE ARTICLES
ideo-assisted thoracoscopic surgery (VATS) describes resection for pulmonary pathologic conditions by use of a minimally invasive method wherein visualization is dependent on video monitors and rib spreading is avoided [1–4]. There has been much experience with this technique, with the proven benefits of VATS lung resection responsible for the increase in its clinical use [1–5]. VATS lobectomy has traditionally been performed by the use of two to four incisions [1–5]. Uniportal access for VATS was first described in 2004 by Rocco and colleagues [6], and this strategy has been used for numerous indications, including lobectomy [7]. We have been using a two-incision VATS for anatomic pulmonary resection since 1999 [1, 3–5]. Although the potential advantages of a one-incision (uniportal) approach have not been demonstrated to date, it does seem reasonable to consider that the use of only one incision and only one interspace may result in less pain. However, the uniportal approach has two important disadvantages: the camera competes for the same space with the multiple operating instruments needed for lobectomy, and the single incision must be closed around a chest tube. We have recently developed a modified uniportal approach, using a small 5-mm counterincision in the same interspace adjacent to the operating incision, which keeps the camera separate from the operating instruments and gives the chest tube its own incision.
(Ann Thorac Surg 2014;98:2239–41) Ó 2014 by The Society of Thoracic Surgeons
2240
HOW TO DO IT KARA ET AL MODIFIED UNIPORTAL VATS LOBECTOMY
Ann Thorac Surg 2014;98:2239–41
Comment
Fig 2. A 4-cm “access incision” located anteriorly and a 5-mm “camera port insicion” posteriorly.
FEATURE ARTICLES
Hilar dissection is carried out through the anterior incision, as with the standard two-incision VATS resection. Dissection of the pulmonary vessels and bronchi is performed begining anteriorly and continuing posteriorly. Endoscopic linear staplers are used for individual vessel and bronchial ligation. Once the lobe is completely resected, it is placed in a specimen bag for retrieval to avoid implantation of tumor cells into the incision. We also perform systematic mediastinal lymph node dissection. A single 24F chest tube for drainage is inserted in the camera incision with a single stitch to be tied as the the tube is removed. The anterior incision is sutured subcutaneously with absorbable material.
Fig 3. (A) Layout of the VATS team members. Camera holder and operating room (OR) nurse stands at the back, the surgeon and resident or fellow stands at the patient’s anterior side. (B) The 5-mm 30 thoracoscope is placed within a trocar from the posterior side (black arrow). The instruments are used through the access insicion anteriorly (white arrow).
Our classic approach to thoracoscopic lobectomy has been through two insicions, placing a 10-mm 30 thoracoscope in the seventh or eighth intercostal space in the midaxillary line, and a 4- to 5-cm anterior utility incision is placed in the fifth intercostal space [1, 3]. With increasing knowledge and experience with this method, we have been performing the most advanced cases sucessfully, including pneumonectomy, hybrid thoracocopic lobectomy with chest wall resection [8], and bronchoplastic resection. Several authors have described a single-incision approach for thoracoscopic lobectomy [6, 7], but there have been no reported advantages over a two-incision approach to date. In additon, the standard uniportal approaches are associated with these potential disadvantages: (1) the camera competes with the operative instruments, and (2) the chest tube needs to be incorporated within the 4- to 6-cm access incision. The modified uniportal VATS technique described herein addresses both of these potential disadvantages by creating a small incision adjacent to the access incision, using the same (fifth) intercostal space. Although it is acknowledged that a single intercostal space approach has not been proved to be advantageous in terms of pain and recovery, it does seem reasonable to limit the procedure to one intercostal space in selected procedures. We have operated on approximately 40 to 50 patients with this technique and have the impression that the lower lobes are easier to complete because there is less need to direct the stapler from a more medial port. As advances in camera and instrumentation develop, the modified uniportal technique will become even more efficient. Outcome studies should be performed, however, to confirm the advantages of the uniportal approach
over more traditional and established thoracoscopic approaches.
References 1. Burfeind WR, D’Amico TA. Thoracoscopic lobectomy. Oper Tech Thorac Cardiovasc Surg 2004;9:98–114. 2. Onaitis MW, Petersen RP, Balderson SS, et al. Thoracoscopic lobectomy is a safe and versatile procedure: experience with 500 consecutive patients. Ann Surg 2006;244:420–5. 3. Paul S, Altorki NK, Sheng S, et al. Thoracoscopic lobectomy is associated with lower morbidity than open lobectomy: a propensity-matched analysis from the STS Database. J Thorac Cardiovasc Surg 2010;139:366–78.
HOW TO DO IT KARA ET AL MODIFIED UNIPORTAL VATS LOBECTOMY
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4. McKenna RJ Jr, Houck W, Fuller CB. Video-assisted thoracic surgery lobectomy: experience with 1,100 cases. Ann Thorac Surg 2006;81:421–5. 5. Ceppa DP, Kosinski AS, Berry MF, et al. Thoracoscopic lobectomy has increasing benefit in patients with poor pulmonary function: a Society of Thoracic Surgeons database analysis. Ann Surg 2012;256:487–93. 6. Rocco G, Martin-Ucar A, Passera E. Uniportal VATS wedge pulmonary resections. Ann Thorac Surg 2004;77:726–8. 7. Gonzalez-Rivas D, Paradela M, Fernandez R, et al. Uniportal video-assisted thoracoscopic lobectomy: two years of experience. Ann Thorac Surg 2013;95:426–32. 8. Berry MF, Onaitis MW, Tong BC, Balderson SS, Harpole DH, D’Amico TA. Feasibility of hybrid thoracoscopic lobectomy and en-bloc chest wall resection. Eur J Cardiothorac Surg 2012;41:888–92.
FEATURE ARTICLES
Ann Thorac Surg 2014;98:2239–41
Traditional thoracoscopic strategies using two to four ports has been demonstrated to be oncologically successful for patients with resectable lung cancer, with numerous advantageous over thoracotomy. A singleincision approach has been described, but it is associated with potential disadvantages. The modified
uniportal approach described may address those disadvantageous, with retention of the potential advantages of using a single incision.
V
ventilation (either dual-lumen endotracheal tubes or bronchial blocker) and is positioned in a full lateral decubitus position with slight flexion of the table at the level of the middle of the chest, which allows slight splaying of the ribs to improve exposure in the absence of rib spreading [1, 3]. We prefer using the fifth intercostal space, which is known to be wider, thus allowing for both better exposure and easier retrieval of specimens. A 4-cm “access incision” is made anteriorly, and the fifth intercostal space is opened, approximately 1 cm more anterior and posterior than the extent of the skin incision (Fig 1). Adjacent and posterior to the incision, a 5-mm “camera port incision” is made (Fig 2). A 5-mm 30 thoracoscope is placed within a trocar. The camera is operated by a team member standing at the back side of the patient, and the surgeon stands at the patient’s anterior side (Fig 3).
Technique The reoperative setup for the modified uniportal VATS technique is the same as our classic VATS procedure [1]. The patient is under general anesthesia with single-lung Accepted for publication June 11, 2014. Address correspondence to Dr Kara, Department of Surgery, Division of Thoracic Surgery, Duke University Medical Center, Box 3496, Durham, NC 27710; e-mail: [email protected].
Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier
Fig 1. Fifth intercostal space (ICS) is opened, approximately 1 cm more anterior and posterior than the extent of the skin incision so the 5-mm camera port uses the same intercostal space. 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.06.086
FEATURE ARTICLES
ideo-assisted thoracoscopic surgery (VATS) describes resection for pulmonary pathologic conditions by use of a minimally invasive method wherein visualization is dependent on video monitors and rib spreading is avoided [1–4]. There has been much experience with this technique, with the proven benefits of VATS lung resection responsible for the increase in its clinical use [1–5]. VATS lobectomy has traditionally been performed by the use of two to four incisions [1–5]. Uniportal access for VATS was first described in 2004 by Rocco and colleagues [6], and this strategy has been used for numerous indications, including lobectomy [7]. We have been using a two-incision VATS for anatomic pulmonary resection since 1999 [1, 3–5]. Although the potential advantages of a one-incision (uniportal) approach have not been demonstrated to date, it does seem reasonable to consider that the use of only one incision and only one interspace may result in less pain. However, the uniportal approach has two important disadvantages: the camera competes for the same space with the multiple operating instruments needed for lobectomy, and the single incision must be closed around a chest tube. We have recently developed a modified uniportal approach, using a small 5-mm counterincision in the same interspace adjacent to the operating incision, which keeps the camera separate from the operating instruments and gives the chest tube its own incision.
(Ann Thorac Surg 2014;98:2239–41) Ó 2014 by The Society of Thoracic Surgeons
2240
HOW TO DO IT KARA ET AL MODIFIED UNIPORTAL VATS LOBECTOMY
Ann Thorac Surg 2014;98:2239–41
Comment
Fig 2. A 4-cm “access incision” located anteriorly and a 5-mm “camera port insicion” posteriorly.
FEATURE ARTICLES
Hilar dissection is carried out through the anterior incision, as with the standard two-incision VATS resection. Dissection of the pulmonary vessels and bronchi is performed begining anteriorly and continuing posteriorly. Endoscopic linear staplers are used for individual vessel and bronchial ligation. Once the lobe is completely resected, it is placed in a specimen bag for retrieval to avoid implantation of tumor cells into the incision. We also perform systematic mediastinal lymph node dissection. A single 24F chest tube for drainage is inserted in the camera incision with a single stitch to be tied as the the tube is removed. The anterior incision is sutured subcutaneously with absorbable material.
Fig 3. (A) Layout of the VATS team members. Camera holder and operating room (OR) nurse stands at the back, the surgeon and resident or fellow stands at the patient’s anterior side. (B) The 5-mm 30 thoracoscope is placed within a trocar from the posterior side (black arrow). The instruments are used through the access insicion anteriorly (white arrow).
Our classic approach to thoracoscopic lobectomy has been through two insicions, placing a 10-mm 30 thoracoscope in the seventh or eighth intercostal space in the midaxillary line, and a 4- to 5-cm anterior utility incision is placed in the fifth intercostal space [1, 3]. With increasing knowledge and experience with this method, we have been performing the most advanced cases sucessfully, including pneumonectomy, hybrid thoracocopic lobectomy with chest wall resection [8], and bronchoplastic resection. Several authors have described a single-incision approach for thoracoscopic lobectomy [6, 7], but there have been no reported advantages over a two-incision approach to date. In additon, the standard uniportal approaches are associated with these potential disadvantages: (1) the camera competes with the operative instruments, and (2) the chest tube needs to be incorporated within the 4- to 6-cm access incision. The modified uniportal VATS technique described herein addresses both of these potential disadvantages by creating a small incision adjacent to the access incision, using the same (fifth) intercostal space. Although it is acknowledged that a single intercostal space approach has not been proved to be advantageous in terms of pain and recovery, it does seem reasonable to limit the procedure to one intercostal space in selected procedures. We have operated on approximately 40 to 50 patients with this technique and have the impression that the lower lobes are easier to complete because there is less need to direct the stapler from a more medial port. As advances in camera and instrumentation develop, the modified uniportal technique will become even more efficient. Outcome studies should be performed, however, to confirm the advantages of the uniportal approach
over more traditional and established thoracoscopic approaches.
References 1. Burfeind WR, D’Amico TA. Thoracoscopic lobectomy. Oper Tech Thorac Cardiovasc Surg 2004;9:98–114. 2. Onaitis MW, Petersen RP, Balderson SS, et al. Thoracoscopic lobectomy is a safe and versatile procedure: experience with 500 consecutive patients. Ann Surg 2006;244:420–5. 3. Paul S, Altorki NK, Sheng S, et al. Thoracoscopic lobectomy is associated with lower morbidity than open lobectomy: a propensity-matched analysis from the STS Database. J Thorac Cardiovasc Surg 2010;139:366–78.
HOW TO DO IT KARA ET AL MODIFIED UNIPORTAL VATS LOBECTOMY
2241
4. McKenna RJ Jr, Houck W, Fuller CB. Video-assisted thoracic surgery lobectomy: experience with 1,100 cases. Ann Thorac Surg 2006;81:421–5. 5. Ceppa DP, Kosinski AS, Berry MF, et al. Thoracoscopic lobectomy has increasing benefit in patients with poor pulmonary function: a Society of Thoracic Surgeons database analysis. Ann Surg 2012;256:487–93. 6. Rocco G, Martin-Ucar A, Passera E. Uniportal VATS wedge pulmonary resections. Ann Thorac Surg 2004;77:726–8. 7. Gonzalez-Rivas D, Paradela M, Fernandez R, et al. Uniportal video-assisted thoracoscopic lobectomy: two years of experience. Ann Thorac Surg 2013;95:426–32. 8. Berry MF, Onaitis MW, Tong BC, Balderson SS, Harpole DH, D’Amico TA. Feasibility of hybrid thoracoscopic lobectomy and en-bloc chest wall resection. Eur J Cardiothorac Surg 2012;41:888–92.
FEATURE ARTICLES
Ann Thorac Surg 2014;98:2239–41
