VATS for mediastinal masses

Transcription

1 VATS for mediastinal masses Diego Gonzalez-Rivas, MD, FECTS Minimally Invasive Thoracic Surgery Unit (UCTMI) Coruña Hospital, Spain Masters of Minimally Invasive Thoracic Surgery Waldorf Astoria, Orlando, September , 2013

2 Learning curve

3 Carefully, step by step!

4 MEDIASTINAL MASS Lesiones benignas: Miastenia Gravis Quiste tímico VATS Timoma: I II = No invasión capsular = Invasión capsular III = Invasión de órganos adyacentes IVa = Diseminación pleural o pericárdica I y II- VATS III - Sternotomy? IVb = Diseminación linfática o hematógena IV Sternotomy + RT Indication and procedure of video-assisted thoracoscopic surgery to thymic disease. Kyobu Geka Jul;59(8 Suppl):742-8 The role of surgery in the management of thymoma: A sistematic Review. Eric Davenport. Ann Thorac Surg 2008;86:673-84

5 Side of approach Selective intubation Gas? Ports? Minithoracotomy? Optic? Drain? LEFT: DERECHO: La Identificación grasa mediastínica de la cava se localiza superior mayoritariamente y disección de la en el vena lado innominada izquierdo desde la confluencia entre ambas Menor riesgo de lesionar el Mejor Nervio visión Frénico del área cervical Mejor Disección acceso más para ergonómica la disección tímica para los del cirujanos área contralateral diestros Thoracoscopic Thymectomy Mid-Term Results. Tomulescu et al. Ann Thorac Surg 2006;82: Thymectomy for myastenia gravis by video-assisted thoracoscopic surgery through right anterior-lateral aproach. Tan Qy et al. Zhonghua Wai Ke Za Zhi 2008;46(6):

6 THYMECTOMY Side of approach Selective intubation Gas? Ports? Doble luz B T B B BI Minithoracotomy? Optic? Drain? BD Thoracoscopic Thymectomy Mid-Term Results. Tomulescu et al. Ann Thorac Surg 2006;82: Thymectomy for myastenia gravis by video-assisted thoracoscopic surgery through right anterior-lateral aproach. Tan Qy et al. Zhonghua Wai Ke Za Zhi 2008;46(6):

7 THYMECTOMY Side of approach? Selective intubation? Gas? Ports? Minithoracotomy? Optic? Drain? GAS CO2: 6-10 mmhg Camera trocar Better view Thoracoscopic Thymectomy Mid-Term Results. Tomulescu et al. Ann Thorac Surg 2006;82: Thymectomy for myastenia gravis by video-assisted thoracoscopic surgery through right anterior-lateral aproach. Tan Qy et al. Zhonghua Wai Ke Za Zhi 2008;46(6):

8 THYMECTOMY Lado de abordaje? Ventilación selectiva? Neumomediastino? Ports? Minithoracotomy? Optic? Drain? GAS CO2: 6-10 mmhg Camera port Bettter view Thoracoscopic Thymectomy Mid-Term Results. Tomulescu et al. Ann Thorac Surg 2006;82: Thymectomy for myastenia gravis by video-assisted thoracoscopic surgery through right anterior-lateral aproach. Tan Qy et al. Zhonghua Wai Ke Za Zhi 2008;46(6):

9 GA Partial lateral position Selective intubation 1-3 entry ports Gas CO 2 Óptic 30º Drain Nº20

10 AG IOT selectiva Semidecúbito lateral Hemitórax izdo 3 puertas de entrada Gas CO 2 Óptica 30º Drain Nº20

11 AG IOT selectiva Semidecúbito lateral Hemitórax izdo 3 puertas de entrada Gas CO 2 Óptica 30º Drain N 20

12 Triangulation

13 VATS thymectomy

14 Single port thymectomy

15 SILS fot thymectomy?

16 Supine position. Anti-trendelenburg Double lumen intubation Left approach CO2 Video-assisted thoracoscopic extended thymectomy and extended transsternal thymectomy in non thymomatous myastenia gravis patients: Remission after 6 years follow up. Mantegazza et al. Neurol Sci Aug 15;217 Video-assisted thoracoscopic extendedthymectomy for myastenia gravis. Yu L et al. Zhonghua Wai Ke Za Zhi 2008 Nov 15;46(22):

17 Bleeding, what to do? COMPRESSION Enlarge the incision (avoid inflation if suction) Suction Clips, coagulation,ligasure,harmonic If no control: Open surgery (thoracotomy vs sternotomy)

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20 Extended Resection

21 Remove tumor-enlarge incison

22 Teratoma

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24 Cyst

25 Single-port Cystic mass

26 Thymoma-Single-port

27 Neurogenic tumor (single-port)

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29 Huge Final mass diagnosis: resection Neurogenic (preop: fibrous tumor tumor)

30 16 cm Mediastinal mass (single port)

31 VATS limits? Huge tumors: open surgery

32 Videothoracoscopy is the less invasive approach for mediastinal lesions with excellent postoperative results The most important aspect is to achieve a radical resection and preserve the oncologic principles in case of mediastinal tumors

33 There is only one thing that makes a dream impossible to achieve: the fear of failure. Paulo Coelho CORUÑA UNIVERSITY HOSPI MINIMALLY INVASIVE THORACIC SURGER