VATS Lobectomy Tecnica triportale Prof. Giuseppe Marulli UOC Chirurgia Toracica Policlinico Universitario di Padova
VATS LOBECTOMY: FIRST EXPERIENCES CLINICAL MAIN CONCERNS Morbidity/mortality rates comparable with open approach Not significant trend in reduction of postoperative pain Oncological safety Lack of long-term follow-up NON CLINICAL No standardized techniques and definition Difficult technique No easy to teach Long learning curve Quality of operation (lymph-nodes dissection) Lack of dedicated devices High cost
VATS LOBECTOMY TODAY CLINICAL PERSPECTIVES VATS LOBECTOMY HAS BEEN ASSOCIATED WITH : LESS PAIN LESS COMPLICATIONS SHORTER LENGHT OF STAY BETTER QoL IMPROVED DELIVERY AND TOLERANCE TO ADJUVANT CHEMOTHERAPY SIMILAR (BETTER??) LONG TERM SURVIVAL
Postoperative pain Karmakar MK, Ho AM. Postthoracotomy pain syndrome. Thorac Surg Clin. 2004 OPEN APPROACH PROBLEM Acute Chronic: post-thoracotomy pain syndrome - 25-60% of cases Post-operative related complications Kim Wildgaard, Jesper Ravn, Henrik Kehlet. Chronic post-thoracotomy pain a critical review of pathogenic mechanisms and strategies for prevention. European Journal of Cardio-thoracic Surgery. 2009 - Present still 4-5 yrs after surgery Jun-Gol Song, Jin Woo Shin, Eun Ho Lee, Dae Kee Choi, Ji Youn Bang, Ji Hyun Chin and In Cheol Choi. Incidence of post-thoracotomy pain: a comparison between total intravenous anaesthesia and inhalation anaesthesia Eur J CardioThorac Surg. 2012 M.L. Rogers, et al. Preliminary findings in the neurophysiological assessment of intercostal nerve injury during thoracotomy. European Journal of Cardio-thoracic Surgery. 2002 Fabrizio Benedetti, MD, et al. Postoperative Pain and Superficial Abdominal Reflexes After Posterolateral Thoracotomy. Ann Thorac Surg. 1997 RIBS SPREADER
2106 (VATS) vs 2661 (Thor)
VATS LOBECTOMY: FIRST EXPERIENCES CLINICAL MAIN CONCERNS Morbidity/mortality rates comparable with open approach Not significant trend in reduction of postoperative pain Oncological safety Lack of long-term follow-up NON CLINICAL No standardized techniques and definition Difficult technique No easy to teach Long learning curve Quality of operation (lymph-nodes dissection) Lack of dedicated devices High cost
VATS LOBECTOMY TODAY NON CLINICAL PERSPECTIVES Standardized techniques and definition Reproducible technique Easy to teach and to learn Acceptable learning curve High quality standard of operation Dedicated devices Cost lower than open approach
VATS LOBECTOMY TODAY STANDARDIZATION OF SURGICAL APPROACH POSTERIOR EDINBURGH APPROACH ACCORDING WALKER: Richards JMJ, Dunning J, Oparka J, Carnochan FM, Walker WS. Video-assisted thoracoscopic lobectomy: The Edinburgh posterior approach. Ann Cardiothorac Surg 2012;1(1):61-69. LATERAL APPROACH ACCORDING McKENNA Robert J. Mckenna, Jr. M.D., Ali Mahtabifard, M.D., Scott J. Swanson, M.D. Atlas of Minimally Thoracic Surgery (VATS). Elsevier Science Health Science Division, 2010. Invasive ANTERIOR APPROACH ACCORDING COPENAGHEN Hansen HJ, Petersen RH. Video-assisted thoracoscopic lobectomy using a standardized three-port anterior approach - The Copenhagen experience. Ann Cardiothorac Surg 2012;1(1):70-76. TOTALLY ENDOSCOPIC APPROACH ACCORDING GOSSOT Dominique Gossot. Atlas of endoscopic major pulmonary resections Springer, 2011 ANTERIOR APPROACH ACCORDING D'AMICO: William R. Burfeind and Thomas A. D Amico. thoracoscopic Lobectomy - Operative Techniques in Thoracic and Cardiovascular Surgery, Vol 9, No 2 (Summer), 2004: pp 98-114 UNIPORTAL APPROACH ACCORDING GONZALES RIVAS Gonzalez-Rivas D, Paradela M, Fernandez R, Delgado M, Fieira E, Mendez L, Velasco C, de la Torre M. Uniportal video-assisted thoracoscopic lobectomy: two years of experience. Ann Thorac Surg. 2013 Feb;95(2):426-32.
- POSTERIOR EDINBURGH APPROACH ACCORDING WALKER: Richards JMJ, Dunning J, Oparka J, Carnochan FM, Walker WS. Video-assisted thoracoscopic lobectomy: The Edinburgh posterior approach. Ann Cardiothorac Surg 2012;1(1):61-69.
- ANTERIOR APPROACH ACCORDING COPENAGHEN Hansen HJ, Petersen RH. Video-assisted thoracoscopic lobectomy using a standardized threeport anterior approach - The Copenhagen experience. Ann Cardiothorac Surg 2012;1(1):70-76.
TRIPORTAL VS UNIPORTAL APPROACH OPEN QUESTIONS DOES TRIPORTAL APPROACH MUST BE CONSIDERED THE STANDARD? IS UNIPORTAL APPROACH SUPERIOR (OR EQUAL) TO TRIPORTAL? IN TERMS OF: - TECHNICAL FEASIBILITY - POSTOPERATIVE PAIN - OUTCOME - LEARNING CURVE - OTHER (i.e. COSMETICS, PATIENT S ACCEPTABILITY, SURGICAL IMPACT) IS UNIPORTAL APPROACH A NATURAL AND UNAVOIDABLE EVOLUTION OF TRIPORTAL?
TRIPORTAL VS UNIPORTAL APPROACH OPEN QUESTIONS DOES TRIPORTAL APPROACH MUST BE CONSIDERED THE STANDARD? IS UNIPORTAL APPROACH SUPERIOR (OR EQUAL) TO TRIPORTAL? IN TERMS OF: - TECHNICAL FEASIBILITY - POSTOPERATIVE PAIN - OUTCOME - LEARNING CURVE - OTHER (i.e. COSMETICS, PATIENT S ACCEPTABILITY, SURGICAL IMPACT) IS UNIPORTAL APPROACH A NATURAL AND UNAVOIDABLE EVOLUTION OF TRIPORTAL?
VATS LOBECTOMY TODAY THE FACTS TRIPORTAL APPROACHES ARE THE MOST COMMON USED MOST OF LITERATURE STUDIES ARE ON TRIPORTAL LOBECTOMY MOST OF MODERN DEVICES FOR VATS LOBECTOMY ARE DESIGNED AND PROJECTED FOR MULTIPORTAL APPROACH MOST OF THE TRAINING PROGRAMS AND STUDIES ON LEARNING CURVE ARE ON TRIPORTAL APPROACH
TRAINING PROGRAM LEARNING CURVE: ~ 50 CASES: - Shorter operative time - Lower complications - Less intraoperative blood loss
VATS LOBECTOMY TODAY EVOLUTION OF DEVICES (NEW DEDICATED INSTRUMENTS)
VATS LOBECTOMY TODAY EVOLUTION OF DEVICES (STAPLERS)
TRIPORTAL VS UNIPORTAL APPROACH OPEN QUESTIONS DOES TRIPORTAL APPROACH MUST BE CONSIDERED THE STANDARD? IS UNIPORTAL APPROACH SUPERIOR (OR EQUAL) TO TRIPORTAL? IN TERMS OF: - TECHNICAL FEASIBILITY - POSTOPERATIVE PAIN - OUTCOME - LEARNING CURVE - OTHER (i.e. COSMETICS, PATIENT S ACCEPTABILITY, SURGICAL IMPACT) IS UNIPORTAL APPROACH A NATURAL AND UNAVOIDABLE EVOLUTION OF TRIPORTAL?
Troubleshooting VATS Lobectomy Demmy TL, Ann Thorac Surg 2005; 79: 1744-1752 Technical Considerations Instrumentation Retraction Exposure Fissures Management of Bleeding Specimen Removal
MAIN TECHNICAL LIMITATIONS OF UNIPORTAL APPROACH CROWDING OF INSTRUMENTS DIFFICULT MANIPULATION OF THE LUNG LACK OF DEDICATED DEVICES (STAPLERS WITH WIDE ANGULATION) UPPER LOBECTOMY MORE DIFFICULT ASSISTANT WITH CAMERA IN AN UNCOMFORTABLE POSITION MORE DIFFICULT TO LEARN
THORACOSCOPIC UPPER LOBECTOMY Represents clear majority of VATS lobectomy Greatest degree of anatomic variation Higher likelihood of conversion to thoracotomy Higher likelihood of becoming pneumonectomy Mastery of VATS Upper Lobectomy is essential to success
ROLE OF POSTERIOR ACCESS IN UPPER LOBECTOMY
TRIPORTAL VS UNIPORTAL APPROACH OPEN QUESTIONS DOES TRIPORTAL APPROACH MUST BE CONSIDERED THE STANDARD? IS UNIPORTAL APPROACH SUPERIOR (OR EQUAL) TO TRIPORTAL? IN TERMS OF: - TECHNICAL FEASIBILITY - POSTOPERATIVE PAIN - OUTCOME - LEARNING CURVE - OTHER (i.e. COSMETICS, PATIENT S ACCEPTABILITY, SURGICAL IMPACT) IS UNIPORTAL APPROACH A NATURAL AND UNAVOIDABLE EVOLUTION OF TRIPORTAL?
Padua experience (220 cases)
SUMMARY THE TRIPORTAL APPROACH FOR VATS LOBECTOMY IS THE MOST COMMON USED APPROACH. IT HAS SEVERAL RECOGNIZED ADVANTAGES: EASY AND SAFE TO DO, LEARN AND TEACH, MORE ANATOMICAL AND MORE ADAPTABLE TO THE CURRENT INSTRUMENTATION, EASIER THAN UNIPORTAL FOR UPPER LOBECTOMY. DATA ARE STILL LACKING ON THE EFFECTIVE COMPARISON BETWEEN TRIPORTAL AND BI- OR UNIPORTAL APPROACHES. THE ANTERIOR TRIPORTAL COPENAGHEN APPROACH SEEMS THE BEST FOR ALL SITUATIONS.
Padua - Italy Thank you