MY JOURNEY TO UNIPORTAL VATS

Transcription

1 MY JOURNEY TO UNIPORTAL VATS Diego Gonzalez-Rivas, MD, FECTS Thoracic Surgery and Lung Transplantation Department Minimally Invasive Thoracic Surgery Unit (UCTMI),Coruña, Spain Shanghai Pulmonary Hospital, Tongi University, Shanghai, China

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3 The story begins here Coruña University Hospital

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5 El viaje de los pioneros TED talk-diego Gonzalez Rivas

6 Searching for adrenaline.. Surfing big waves..

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8 Good friends in this story!

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13 Learning VATS?

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15 Begining (2007) Visit other hospitals Meetings Literature, articles Wetlab Videos

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17 VATS INCISIONS: DOUBLE PORT X

18 Double port technique

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20 First Uniportal VATS lobectomy 29 th June 2010

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22 In our experience, this technique is possible for lower lobes. For upper lobes, the hilar dissection is possible via one incision but there are difficulties stapling the upper vein, mediastinal trunk and the bronchus. Probably, the development of new technologies (angled optics, angled and curved staplers) will lead to single-port upper lobectomies becoming possible in experienced VATS groups

23 Think Uniportal!

24 First upper lobe resection (after 6 lower lobes) Completion pneumonectomy (Nov 2010)

25 Learning curve-fighting

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27 Single-incision VATS lobectomy

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29 Advanced cases

30 Unisurgeon surgery 2016 No limits Carinal resections 2015 Subxiphoid resections 2015 Non intubated surgery 2014 Double sleeve

31 You just need a little help at the beginning to fly and enjoy the way..

32 Con Gasol

33 What is the best approach? THE MOST COMFORTABLE APPROACH FOR THE SURGEON THE LEAST INVASIVE APPROACH

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36 Evolution in technique

37 Incision: fifth intercostal space

38 POSITION OF INSTRUMENTS

39 Upper lobe vein management Gonzalez-rivas et al. Advances in Uniportal video-assisted thoracoscopic surgery: pushing the envelope. Thorac Surg Clinics 2015.Review

40 Small vessels- Click av-grena-45 degree

41 Correct Training!! Symposia Workshops Visiting (Observer) Attachments Videos Training courses (2 weeks) Train the Team!!!

42 Mathematics Absence of dihedral or torsion angle More anatomic instrumentation, ergonomy Image plane x z a b c y 0, l p 0 Camera center C Vanishing point v Line on ground plane

43 DIRECT VIEW!

44 Reduced compression to the nerve 2-3 ports -More confortable for assistant -Camera lean on trocar Single port -More uncomfortable for assistant -Camera is suspended,no trocar

45 Anatomic instrumentation

46 Oncologic technique Paratracheal Subcarinal

47 Published in journals, atlas, textbook, etc Data and survival

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49 Advanced cases Gonzalez-Rivas D et al. Is uniportal thoracoscopic surgery a feasible approach for advanced stages of non-small cell lung cancer? J Thorac Dis 2014 May 22. doi: /j.issn

50 Stage IA-Disease-free survival

51 Stage IA-Overall survival

52 Study McElnay et al (2015) [50] Chung et al (2015) [51] Liu et al (2015) [52] Zhu et al (2015) [53] Liu et al (2105) [54] Hirai et al (2015) [55] Shen et al (2015) [56] Mu et al (2015) [57] Uniportal patients Multiportal patients Study design Operation Pain & Morbidity Recovery Retrospective - Pain score ND Chest drain duration ND Observational Analgesic use ND Length of stay ND Complications ND Retrospective Operative time ND Complications ND Chest drain duration ND Observational Nodes dissected ND Length of stay ND Propensity Operative time Uniportal Complications ND Length of stay ND matched faster Blood loss Uniportal less Nodes dissected Uniportal higher yield Retrospective Operative time Pain score Uniportal lower Chest drain duration ND Observational Multiportal portal faster Complications ND Length of stay ND Blood loss ND Nodes dissected ND Retrospective Operative time Uniportal Complications ND Length of stay Uniportal Observational faster shorter Blood loss Uniportal less Nodes dissected Uniportal higher yield Retrospective Operative time ND Pain score Uniportal lower Chest drain duration ND Observational Blood loss ND Analgesic use Uniportal Length of stay ND less CPKmax ND Paresthesia Uniportal less CRPmax ND frequent Complications ND Propensity Operative time ND Complications ND Length of stay ND matched Blood loss ND Nodes dissected ND Propensity Operative time ND Complications ND Chest drain duration ND matched Blood loss ND Length of stay Multiportal Nodes dissected ND shorter Abbreviations used: ND = no difference; CPK max = maximum postop level of creatine phosphokinase; CRP max = maximum postop level of C-reactive protein

53 Operation Uniportal VATS Operation times (mins) Blood loss (ml) Nodes dissected Conventional VATS

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55 Pain

56 Pain

57 Recovery

58 Recovery Chin Med J 2015;128:2731-5

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61 RECENT ADVANCES IN UNIPORTAL VATS Complex hilum (lymph nodes or fibrosis) Use of energy devices for vessel dissection and division, new instruments Complex segmentectomies and lobectomies Sleeve broncho-vascular procedures, carinal Bleeding control Non intubated lobectomy Unisurgeon assisted with robotic arm

62 Uniportal LUL and chest wall resection Gonzalez-Rivas D, Xie B, Yang Y, Jiang G. Uniportal video-assisted thoracoscopic lobectomy with en bloc chest wall resection. J Vis Surg 2015;1:7.

63 Bronchial sleeve Vascular reconstruction Direct suture Patch Sleeve anastomosis 63

64 Uniportal bronchial sleeve Gonzalez-Rivas D et al. Uniportal video-assisted thoracoscopic bronchovascular, tracheal and carinal sleeve resections. Eur J Cardiothorac Surg 2015; doi: /ejcts/ezv410

65 Uniportal vascular sleeve Gonzalez-Rivas D et al. Uniportal video-assisted thoracoscopic bronchovascular, tracheal and carinal sleeve resections. Eur J Cardiothorac Surg 2015; doi: /ejcts/ezv410

66 RUL and carinal resection High frequency ventilation jet Gonzalez-Rivas D et al. Advances in Uniportal video-assisted thoracoscopic surgery: pushing the envelope.thoracic Surgery Clinics DOI:

67 Even less invasive.. Non intubated surgery

68 Non intubated Uniportal VATS lobectomy Gonzalez-Rivas D, Bonome C, Fieira E, Aymerich H, Fernandez R, Delgado M et al. Non-intubated video-assisted thoracoscopic lung resections: the future of thoracic surgery? Eur J Cardiothorac Surg 2015; doi: /ejcts/ezv136.

69 Subxiphoid single incision VATS Hernandez L, Lin L, Yang Y, Liu M, Guido W, Gonzalez-Rivas D, Jiang G, Liang L. Initial experience in subxiphoid uniportal video-assisted thoracoscopy major pulmonary resections. Eur J Cardiothorac Surg Jul 11. pii: ezw189. [Epub ahead of print]

70 Single port is the best approach to stimulate industry to develope new technology

71 Open gate to the future Uniportal Unisurgeon VATS lobectomy

72 Uniportal UNISURGEON VATS lobectomy Uniportal VATS left hand double finger technique

73 Wireless Steerable Endoscope

74 Magnetic graspers

75 UNIPORTAL VATS IN 2017

76 Uniportal VATS in the future Improved staplers (electric, more angulated, 5mm) Energy devices for vessels and fissure Wireless cameras and graspers, remote control Robotic instruments (paralel instrumentation) 3D technology (naked eye) Non intubated surgery Portable drainage systems Subxiphoid approach, NOTES?

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78 Shanghai Pulmonary Hospital Lung resections

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80 Keep calm and think uniportal even in the end of the world Antarctica, South Pole