UNIPORTAL VATS COMPLEX ANATOMIC SEGMENTECTOMY

Transcription

1 UNIPORTAL VATS COMPLEX ANATOMIC SEGMENTECTOMY Diego Gonzalez Rivas, MD, FETCS Shanghai Pulmonary Hospital, Tongji University, China Coruña University Hospital and Minimally Invasive Thoracic surgery Unit (UCTMI) Coruña, Spain

2 Anatomy 1. Bronchial anatomy is consistent 2. Arterial anatomy sometimes follows the bronchus but not always! 3. Venous anatomy can drain multiple segments. Travels in intersegmental planes, not essential to define and isolate.

3 Uniportal VATS Segmentectomy Indications Small tumors. <2cm? GGO (ground glass opacity) COPD-Impaired lung function test Previous resections Central metastasis,benign lesions Ager > 75

4 20% Decrease in Lung Cancer mortality with CT Screening

5 Preoperative marking Vital Dyes (methylene blue) Hook-wire Radiolabeled aggregates Electromagnetic navigation Blue dye Barium sulfate Coils Lipiodol injection Hybrid OR

6 Novel Techniques Intraoperative Near-Infrared Imaging Activatable cell-penetrating peptides Okusanya, O, et al.ann Thorac Surg 2014;98: Nguyen, Q.T. et al. PNAS,2010, 107(9), pp

7 Anatomic variations by 3D-CT reconstruction image

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9 Uniportal Technique Previous double-port experience Utility incision: 2-4 cm 4 th or 5 th intercostal space No rib spreading, no trocar Lung exposure Direct visualization target tissue One screen, 30 degree 5-10mm HD thoracoscope Camera: posterior part of incision Bimanual instrumentation, coordination Vascular clips, ligasure, curved tip staplers

10 Instruments Adapted VATS instruments (Scanlan, Shanghai pulmonary) Long Curved suction Long cautery, hook Harmonic, Ligasure, thunderbeat Vascular clips: Click a V (Grena),hemolocks Staplers: Tri-staple, PVS, Cardica HD 30ºcamera (Olympus)

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12 Challenging segmentectomies Variations of anatomy Non intubated Unisurgeon, no assistant Bilateral segmentectomies Situs inversus Combined segments Inflamatory disease Single segments lower lobes

13 Complex anatomic segmentectomy S1+S2 (Tuberculosis) Abnormal anatomy

14 Complex anatomic segmentectomy S1+S2 (Tuberculosis)- Abnormal anatomy

15 Left Apical segmentectomy S1

16 Uniportal S1+S2 (abnormal A1+A3 trunk)

17 RUL apical segmentectomy S1 (Non intubated)

18 Open gate to the future Uniportal Unisurgeon VATS

19 Uniportal UNISURGEON VATS instrumentation Uniportal VATS left hand double finger technique

20 Posterior RUL segmentectomy (S2) Uniportal Unisurgeon

21 Uniportal Unisurgeon VATS Right apical segmentectomy S1 Magnetic grasper

22 Unisurgeon Anterior Right upper segmentectomy (S3)

23 Uniportal Bilateral anatomic S3 Argueta AJ, Cañas SR, Zhu Y, Gonzalez- Rivas D. Bilateral uniportal video-assisted thoracic surgery segmentectomy S3: an unusual case. J Vis Surg 2017

24 Subxiphoid uniportal VATS segmentectomy S3 Gonzalez-Rivas D, Yang Y, Lei J, Hernandez L, Jiang G. Subxiphoid uniportal video-assisted thoracoscopic middle lobectomy and anterior anatomic segmentectomy (S3). J Thorac Dis doi: / j.issn

25 Situs inversus right S6 and S1-S2

26 En bloc antero-posterior S3+S2 Gonzalez-Rivas D, Lirio F, Sesma J. Uniportal anatomic combined unusual segmentectomies. J Vis Surg 2017;3:91.

27 ML Lateral segmentectomy (S4)

28 En bloc segmentectomy S10a+S6+S2 Gonzalez-Rivas D, Lirio F, Sesma J. Uniportal anatomic combined unusual segmentectomies. J Vis Surg 2017;3:91.

29 Uniportal VATS left S3+S4+S5

30 Uniportal VATS anatomic S7+S4-5

31 Complex CCAM lower lobe S6 Segmentectomy

32 Anatomic S3 after Thoracotomy and middle lobectomy (8 year old)

33 Ultra advanced instrumentation

34 Anatomic segmentectomy (S10)

35 Unisurgeon Uniportal S9-S10

36 Right Anatomic segmentectomy (S9-10)

37 Left Anatomic segmentectomy (S9-10)

38 Conclusions Uniportal VATS complex Segmentectomy is feasible and safe When in doubt follow the bronchus to the lesion Anatomic variations by 3D-CT reconstruction image frozen section for LN10, remove LN 11, 12 in order to skeletonize the bronchovascular structure Identify inster-segmental vein and intra-segmental vein Inflation/ deflation test for inter-segmental plane if in doubt

39 KEEP CALM AND ENJOY UNIPORTALSEGMENTS!!