recent advances in uniportal vats -...
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RECENT ADVANCES IN UNIPORTAL VATS
Diego Gonzalez-Rivas, MD, FECTS Thoracic Surgery and Lung Transplantation DepartmentMinimally Invasive Thoracic Surgery Unit(UCTMI),Coruña, SpainShanghai Pulmonary Hospital, Tongi University, Shanghai, China Yunan cancer hospital, Kunming, China
www.diegogonzalezrivas.com
Learning VATS ?
Begining (2007)
Double port technique
First Uniportal lobectomyApril 2009
First reported Uniportal VATS lobectomyJune 2010
“In our experience, this technique is possible for lowerlobes. For upper lobes, the hilar dissection is possible viaone incision but there are difficulties stapling the uppervein, mediastinal trunk and the bronchus. Probably, thedevelopment of new technologies (angled optics, angledand curved staplers) will lead to single-port upper lobectomiesbecoming possible in experienced VATS groups”
Think Uniportal!
Upper lobes
Single-incision VATS lobectomy
Advanced cases
18
Double sleeve 2014
Non intubated surgery
2014
No limitsCarinal resections 2015
Subxiphoid resections 2015
Unisurgeon surgery 2016
Why to change?
Small vessels- Click aV-Grena-45 degree
Published in journals, atlas, textbook, etcData and survival
Gonzalez-Rivas D et al. Is uniportal thoracoscopic surgery a feasible approach for advanced stages of non-small celllung cancer? J Thorac Dis 2014 May 22. doi: 10.3978/j.issn.2072-1439.2014.05.17
Advanced cases
Stage IA-Overall survival
Study Uniportal patients
Multiportal patients
Study design Operation Pain & Morbidity Recovery
McElnay et al (2015) [50]
15 95 Retrospective Observational
- • Pain score – ND
• Analgesic use – ND
• Complications – ND
• Chest drain duration – ND
• Length of stay – ND
Chung et al (2015) [51]
90 60 Retrospective Observational
• Operative time – ND
• Nodes dissected – ND
• Complications – ND • Chest drain duration – ND
• Length of stay – ND
Liu et al (2015) [52]
46 46 Propensity matched
• Operative time – Uniportal faster
• Blood loss – Uniportal less
• Nodes dissected – Uniportal higher yield
• Complications – ND • Length of stay – ND
Zhu et al (2015) [53]
33 49 Retrospective Observational
• Operative time – Multiportal portal faster
• Blood loss – ND
• Nodes dissected – ND
• Pain score – Uniportal lower
• Complications – ND
• Chest drain duration – ND
• Length of stay – ND
Liu et al (2105) [54]
100 342 Retrospective Observational
• Operative time – Uniportal faster
• Blood loss – Uniportal less
• Nodes dissected – Uniportal higher yield
• Complications – ND • Length of stay – Uniportal shorter
Hirai et al (2015) [55]
60 20 Retrospective Observational
• Operative time – ND
• Blood loss – ND
• Pain score – Uniportal lower
• Analgesic use – Uniportal less
• Paresthesia – Uniportal less frequent
• Complications – ND
• Chest drain duration – ND
• Length of stay – ND
• CPKmax – ND
• CRPmax – ND
Shen et al (2015) [56]
100 100 Propensity matched
• Operative time – ND
• Blood loss – ND
• Nodes dissected – ND
• Complications – ND • Length of stay – ND
Mu et al (2015) [57]
47 47 Propensity matched
• Operative time – ND
• Blood loss – ND
• Nodes dissected – ND
• Complications – ND • Chest drain duration – ND
• Length of stay – Multiportal shorter
Abbreviations used: ND = no difference; CPKmax = maximum postop level of creatine phosphokinase; CRPmax = maximum postop level of C-reactive protein
Uniportal VATS Conventional VATS
Operation times (mins) 170179
191208
Blood loss (ml) 5356
9578
Nodes dissected 2728
2225
Operation
Operation
Pain
Pain
Recovery
Chin Med J 2015;128:2731-5
Recovery
Wu C,Fernandez R, De la torre M, Delgado M, Fieira E, Wu C, Hsieh M, Paradela M, Liu Y, Gonzalez-Rivas D. Mid-Term Survival Outcome of Single Port Video Assisted Thoracoscopic Anatomic LungResection: Two Center Experience. EJCTS 2018. In Press. DOI 10.1093/ejcts/ezy067
• Teaching around the world• The concept of “Advanced instrumentation” and “ultradvanced
instrumentation”• Complex hilum (lymph nodes or fibrosis)• Complex segmentectomies and lobectomies• Sleeve broncho-vascular procedures, carinal• Radical lymph node dissection• Bleeding control• Non intubated lobectomy• Subxiphoid and subcostal resections• Unisurgeon assisted with robotic arm• High volume Training courses
RECENT ADVANCES IN UNIPORTAL VATS
• Symposia
• Workshops
• Visiting (Observer)
• wetlabs
• Videos
• Training courses (2 weeks)
➢ Train the Team !!!
Correct Training!!
Uniportal LUL and chest wall resection
Gonzalez-Rivas D, Xie B, Yang Y, Jiang G. Uniportal video-assisted thoracoscopiclobectomy with en bloc chest wall resection. J Vis Surg 2015;1:7.
Vascular reconstruction
41
Direct suture Patch Sleeve anastomosis
Bronchial sleeve
Uniportal bronchial sleeve
Gonzalez-Rivas D et al. Uniportal video-assisted thoracoscopic bronchovascular, trachealand carinal sleeve resections . Eur J Cardiothorac Surg 2015; doi:10.1093/ejcts/ezv410
Right carinal sleeve pneumonectomy
RUL and carinal resectionHigh frequency ventilation jet
Gonzalez-Rivas D et al. Advances in Uniportal video-assisted thoracoscopic surgery: pushing the envelope.Thoracic Surgery Clinics 2016. DOI: http://dx.doi.org/10.1016/j.thorsurg.2015.12.007
Gonzalez-Rivas D. Double sleeve uniportal video-assisted thoracoscopic lobectomy for non-small cell lung cancer. Ann Cardiothorac Surg 2014 Apr 11. doi: 10.3978/j.issn.2225-319X.2014.03.13
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:10.1093/ejcts/ezv136.
Non intubated Uniportal VATS lobectomy
Non intubated Uniportal carinal resection
Jiang L, Liu J, Gonzalez-Rivas D et al. Thoracoscopic Surgery for Tracheal and CarinalResection and Reconstruction under Spontaneous Ventilation. JTCVS 2018. In press. DOI: https://doi.org/10.1016/j.jtcvs.2017.12.153
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. 2016 Jul 11. pii: ezw189. [Epub
ahead of print]
Uniportal transcervical Right lower lobectomy
What means advanced instrumentation?
Ultra advanced instrumentation
Advanced instrumentation: Lymph node dissection
Open gate to the futureUniportal Unisurgeon VATS lobectomy
Uniportal UNISURGEON VATS lobectomy
Uniportal VATS left hand double finger technique
Robotic arm voice control
Wireless Steerable Endoscope
Magnetic graspers
Uniportal robotic platform
• Improved staplers (electric, more angulated, 5mm)
• Energy devices for vessels and fissure• Wireless cameras and graspers, remote control• Robotic instruments (paralel instrumentation)• Nano technology• 3D technology (naked eye)• Non intubated surgery• Portable drainage systems• Subxiphoid approach, NOTES?
Uniportal VATS in the future
Shanghai Pulmonary HospitalLung resections 2004-2017
11441440
16742164
24132651 2788
3350
4042
5321
6855
8320
10392
2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
2017- 13.341 major resections
Continent Participants %
asia 115 25.50%
Europe 228 50.55%
America 83 18.40%
Africa 17 3.78%
Australia & New Zealand 8 1.77%
Asia, 115, 25%
Europe, 228, 51%
America, 83, 18%
Africa, 17, 4%Oceania, 8, 2%
21
10 11 10
1922 21
27 28
45
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Top 15 Countries
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Surgeons from Asia
451 Surgeons from 68 countries & Taiwan/Hongkong
KEEP CALMAnd think Uniportal!!
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