Sep 17, 2016 - J Thorac Dis 2014;6(S6):S623-S630. Masters .... 9/17/2016. 6. Masters MITS '2016. V-loc Device. Masters MITS '2016 .... STS VATS vs. Open.
9/17/2016
Thoracoscopic Lobectomy for Locally Advanced Lung Cancer
No Disclosures Todd L. Demmy Masters MITS '2016
5/13/15
What is Locally Advanced? Anatomic Definition
Procedural Definition • Pneumonectomy • Sleeve Lobectomy • Chest Wall Resection • Advanced exposure
Duke Series After Preoperative Chemo
• Lesion size >5 cm • Strong pleural adhesions • Adjacent structure involvement (parietal/mediastinal pleura, diaphragm, rib) • N1 or N2 • Centrally located tumors (endo- or peribronchial extension to lobar bronchus orifice) • Previous chemo- or chemoradiotherapy, or previous surgery
J Thorac Dis 2014;6(S6):S623-S630
Masters MITS '2016
MSK Series Preoperative Chemo
Propensity Matched
Yang, European Journal of Cardio-Thoracic Surgery (2015) 1–9
Masters MITS '2016
RPCI Local Advanced – UPDATE
Park, J Thorac Dis 2016;8(Suppl 4):S406-S413
Masters MITS '2016
Masters MITS '2016
1
9/17/2016
RPCI Local Advanced – UPDATE EBL (ml) OR time (min) Time to start adjuvant (days) Size of tumor (cm) Total LNs Positive LNs Recurrence Overall survival (mon) Disease-free survival (mon) Path Stage > 1
VATS (n=224) 290.0341.6 312.4126.7 50.520.7
Conversion (n=55) 671.0619.3 373.0134.5 53.413.4
Open (n=37) 419.6314.1 307.3125.3 61.418.4
4.152.10 15.412.4 0.71.8 63 (28.1%) 41.227.8 36.128.4
4.402.33 14.411.3 1.52.5 22 (40.0%) 32.627.2 25.721.9
4.732.39 15.79.5 1.53.4 15 (40.5%) 36.234.8 31.434.7
62%
92%
54%
Visualization Tools 5 mm Optimal For Sharing ports p value < 0.001 < 0.01 0.07
0.29 0.86 < 0.01 < 0.05 0.10 < 0.001
Masters MITS '2016
Masters MITS '2016
Common 3D Systems today
Importance of Low Profile and Angles
Olympus ENDOEYE Flex 3D Laparoscopy
Viking ConMed.com bbraun.com
Masters MITS '2016
Masters MITS '2016
Lymph Node Grasping
Multiple retractors
No Grasp - Metal Endoscopic Sucker -- Liu et al. BMC Surgery (2015) 15:38
00:26
Masters MITS '2016
Masters MITS '2016
2
9/17/2016
PA control - Loops
PA control - Bulldogs
• #1 Silk
A. Watanabe et al. / European Journal of Cardio-thoracic Surgery 31 (2007) 129—131 Masters MITS '2016
Masters MITS '2016
PA control - Bulldogs
PA control - Bulldogs
Dong, J Thorac Dis 2014;6(12):1855-1860
Masters MITS '2016
PA control - Bulldogs
Dong, J Thorac Dis 2014;6(12):1855-1860
Masters MITS '2016
Follow the “Fs” when you are stuck- 1 • Free All Adhesions, All Lobes • Find Somewhere else to work or view – Pleurae and lymphatic tissue – Divide more distally • Fissure Division (also opens camera angles) – Partially (outside in) – Completely (blunt clamp technique)
Dong, J Thorac Dis 2014;6(12):1855-1860
Masters MITS '2016
Masters MITS '2016
3
9/17/2016
Follow the “Fs” when you are stuck - 2
Exposure Problems Vessel Access
• Flip order of anatomical divisions (eg. Change to Fissure Last Technique) • Fill the port/access incisions (“fers”) – Traction – Countertraction to define anatomy (eg. “Two-fer” and vessel loops) • Fresh planes (eg. Open pericardium) • Flatten the diaphragm
00:20
Masters MITS '2016
Masters MITS '2016
Left Lower Lobe
Left Lower Lobe Access Work Camera 00:11
Masters MITS '2016
07:13
Masters MITS '2016
VATS Sleeve N=118 He Team - GuangzhouUniversity
VATS Sleeve Resection
3.0 Prolene, running memb, inter cart
Lobe
Number
RUL
59
RML
7
RLL
8
LUL
34
LLL
10
Huang (He), J Thorac Dis 2016;8(3):553-574 Masters MITS '2016
Nakanishi, 2007, Ann Thorac Surg 84(1): 191-195.
Masters MITS '2016
4
9/17/2016
Uniportal Sleeve Review
Diego-Rivas, European Journal of Cardio-Thoracic Surgery 49 (2016) i6–i16
Masters MITS '2016
Uniportal Sleeve Review
Diego-Rivas, European Journal of Cardio-Thoracic Surgery 49 (2016) i6–i16
Masters MITS '2016
Uniportal Sleeve Review Diego-Rivas, European Journal of CardioThoracic Surgery 49 (2016) i6–i16
Diego-Rivas, European Journal of Cardio-Thoracic Surgery 49 (2016) i6–i16
Masters MITS '2016
Masters MITS '2016
TiKnot Device Diego-Rivas, European Journal of CardioThoracic Surgery 49 (2016) i6–i16
Masters MITS '2016
Masters MITS '2016
5
9/17/2016
V-loc Device
LUL Sleeve Lobectomy
0:23 Masters MITS '2016
Masters MITS '2016
LUL Sleeve Lobectomy
Traction Sutures
Xu, J Thorac Dis 2013;5(S3):S298-S300.
0:25 Masters MITS '2016
Masters MITS '2016
Gigli/Rib Cutter/High Speed Burr
***Scanlon***
Midas Rex™ Masters MITS '2016
Methods-Retraction
• Wylie or similar • Self-retaining systems, Bookwalter • Fan-retraction
Black Max™ Masters MITS '2016
6
9/17/2016
Case Presentation LUL Chest Wall Invasion
Results – NSCLC Groups
0:26 0:26
Masters MITS '2016
Open (n=16)
p-value
2
6
0.028
7
13
0.002
6.7%
56.3%
0.001
66.7%
62.5%
0.594
53.3%
87.5%
0.036
In Hospital (days) Reconstruction with Patch Neoadjuvant Chemo or ChemoRT 90-Day Mortality/Major Morbidity
Open (n=16)
p-value
Age (years)
76
56
0.003
Operative Time (min)
500
410
0.167
EBL (mL)
450
525
0.441
Ribs Resected
3 (range 1-5)
3 (range 1-5)
0.105
Hennon, Ann Thorac Surg. 2015 Jun;99(6):1929-34
Less Variation for VATS Despite Older Patients
VATS (n=15)
ICU (days)
VATS (n=15)
Masters MITS '2016
Results Variable (median)
Variable (median)
Pneumonectomy
Neuro ? Other
Emergency
Hennon, Ann Thorac Surg. 2015 Jun;99(6):1929-34 Masters MITS '2016
Summary • Highly selected cases of primary or T3 lung cancer may be appropriate VATS resection candidates. • ? short-term recovery benefits • Not for all frail patients • Cooperative study is needed Masters MITS '2016
Colon ischemia
Hennon, Ann Thorac Surg. 2015 Jun;99(6):1929-34 Masters MITS '2016
Conclusions • Thoracoscopic chest wall resection is technically feasible – expanded our case selection – reduced prosthetic reconstruction • It did not, however, reliably protect all frail, elderly patients.
Masters MITS '2016
7
9/17/2016
VATS Brachytherapy
VATS Brachytherapy Video
Pract Radiat Oncol. 2016 May 7. pii: S1879-8500(16)30048-0. doi: 10.1016/j.prro.2016.04.006.
Masters MITS '2016
Masters MITS '2016
VATS Brachytherapy Video Access Work Camera
13:36
Masters MITS '2016
Troubleshooting Guide
Troubleshooting Guide
• Ann Thorac Surg 2005;79:1744 –53 Masters MITS '2016
Masters MITS '2016
8
9/17/2016
RPCI Local Advanced
STS Database: % Thoracoscopic Lobectomy 4000
* 5/2010
42.8%
45% 44.7
Number of Pulmonary Resections
3500
Thoracoscopy Series 2 Thoracotomy
3000
2500
39.7%
33.3%
2000
26.2%
1500
1000
Ann Surg Oncol (2011) 18:3732–3736 0
986
617 790
15.6%
500
1541
11.6%