session 1: thoracoscopic lobectomy presentation subtitle here · 3d printing enables novel...

©2014 MFMER | slide-1

Innovative Technology and instrumentation…

Shanda H. Blackmon, M.D., M.P.H., FACS

Duke Masters of Minimally Invasive Thoracic Surgery 2016


Disclosure

• I have no Disclosures


Objectives

• Review new enabling technology available for thoracoscopic lobectomy and lung cancer treatment

• Discuss advantages of the new technology

• Discuss potential pitfalls in the new technology


Outline

• Approaches

• Robotic Evolution

• Instrumentation

• Stapling

• Staging

• Nodule Localization

• Imaging

• Energy

• Ablation


What will the future of lung cancer treatment look like?


Approaches

MS VATS 3 VATS 2 VATS 1 Robotic Micro Subxyphoid


Sib-xiphoid Single-Incision VATS LUL

Chia-Chuan Liu, Bing-Yen Wang, Chih-Shiun Shih, Yun-Hen Liu JTCVS August 2014

*problem: L sided cases- the heart is in the way…


New Robotic Equipment

• Stapler

• Smaller Platform

• XI

• Other competitive systems (Johnson & Johnson)

Camera-VATS DaVinci Intuitive S Intuitive SI + teaching concole XI


Instrumentation

• Normal instrumentation (McKenna et al.)

• Port placement crucial

• Long double-action curved/articulating (D’Amico et al.)

• Flexible port placement/ more forgiving

• Hand-held devices

• Ergonomic design

• Articulating

• Smaller: 5mm instruments

Normal Instruments Longer double-action curved instruments Articulating

Ergonomic design


VATS Lobectomy Instrumentation has improved

Blackmon

East

West

North


Instrumentation

• Limiting ports:

• Drop-in clamps and deployable devices

• Trans-fascial suture passing devices

• SILS Instrumentation


Instrumentation

• Haptic Technology


Instrumentation

• New Suturing Tools

• Robotic suturing

• Knot pushing devices

• Cardiovations

• Scanlan

• TiKnot Device

• Endostitch

• Roticulating Needle Drivers


Endo360o


Endo 360o


New Stapler Technology

GI Staplers varying height Reinforcement Curve Tip Robotic

• Curved tip stapler

• Smaller profile

• More degrees of articulation/rotation

• Black loads

• Powered stapling

• Smaller hands

• Anvil Fixation


Smaller Platform Staplers

• 5mm stapler platform

http://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwiT4Je-j-rOAhVTySYKHfwVAtAQjRwIBw&url=http://www.cardica.com/International/minimally-invasive-surgery.php&psig=AFQjCNE-aTIF5sWk8ebOvqXsHZnnPjakAA&ust=1472680221819731


Small platform stapling


New Scope Technology

Low Definition High Definition 3-D Holographic/submersive


How do we do better staging of mediastinum?

• EBUS

• New N1 EBUS scope coming…

Mediastinoscopy CT Video med PET EBUS N1 EBUS


EBUS

Endobronchial ultrasound view


Lung Nodule localization

• Technetium injection (CT-Guided)

• Methylene blue injection with ENB guidance

• Indocyanine green injection

Anatomic Guide CT-Technetium Fluorescence ICG ENB-dye Hybrid


Hybrid Surgery


Hybrid Room Applications

• GE 750 Imaging System

• Novel Lung Mapping from CT Mapping from Cone Beam CT


Hybrid Localization of Nodules


Hybrid Needle Localization


Imaging

CT scan 3-D reconstruction 3-D printing Holographic Projection


3D Imaging Projection


Segment Localization

• Intraoperative Thermography to detect intersegmental plane for segmentectomy

CT scan 3-D reconstruction 3-D printing Thermography


Imaging Segmentectomy

• Varian (JTCVS)

3-d segmental

visualization to

detect and plan

segmentectomy


Pre-op planning for segmentectomy

http://meetings.westernthoracic.org/abstracts/2014/images/g248_1.png


(A) A 3-dimensional computed tomographic image of the right pulmonary vessels.

Hagiwara M et al. Eur J Cardiothorac Surg 2014;46:e120-e126

© The Author 2014. Published by Oxford University Press on behalf of the European Association

for Cardio-Thoracic Surgery. All rights reserved.


(A) The 3-dimensional computed tomographic image of the right pulmonary vessels showed

that this patient had triple middle lobe pulmonary artery branches.

Hagiwara M et al. Eur J Cardiothorac Surg 2014;46:e120-e126

© The Author 2014. Published by Oxford University Press on behalf of the European Association

for Cardio-Thoracic Surgery. All rights reserved.


3D Imaging

Blackmon 2014

• Chest wall cases

• Complicated anatomy

• Pancoast cases


Mayo Clinic 3-d printing


3D Printing Enables Novel Approaches to be Practiced


5D printing


Microsoft Hololens


Energy devices

Bovie Harmonic Argon Bipolar Aqua Mantis HiFU


New Hemostasis Tools

Surgicell Tisseel Bioglue Arrista


Lung Ablation- we may not always ne resecting by VATS…

• Cryo

• MWA

• RFA

• SBRT

XRT RFA SBRT Cryo MWA


Cryospray Therapy

• Pleural application

• Endobronchial application

• Clinical trials

• Early results


New Technology that may change the way we treat lung cancer outside of surgery…

• Ablation

• SBRT

• Targeted Therapy

• Screening

• Prevention


Questions & Discussion

session 1: thoracoscopic lobectomy presentation subtitle here · 3d printing enables novel...

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