recent advances in uniportal vats• teaching around the world • the concept of “advanced...

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

Evolution in technique

http://www.jthoracdis.com/article/viewFile/1378/html/8304

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]


• Operative time – ND

• Nodes dissected – ND

• Complications – ND • Chest drain duration – 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]


• Operative time – Multiportal portal faster

• Blood loss – ND


• Pain score – Uniportal lower




Liu et al (2105) [54]


• 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]




• Pain score – Uniportal lower

• Analgesic use – Uniportal less

• Paresthesia – Uniportal less frequent




• CPKmax – ND

• CRPmax – ND

Shen et al (2015) [56]





• Complications – ND • Length of stay – ND

Mu et al (2015) [57]





• 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

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

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

1815

19

10 10

0

5

10

15

20

25

30

35

40

45

50

Ind

ia

Isra

el

KSA

Ph

ilip

pin

e

Taiw

an

Ital

y

Ne

the

rlan

d

Po

lan

d

Ru

ssia

Spai

n

UK

USA

Bra

zil

Ch

ile

Egyp

t

Asia Europe North AmericaSouth AmericaAfrica

Top 15 Countries

0

5

10

15

20

25

Aze

rbai

jan

Ban

glad

esh

Mai

nla

nd

Ch

ina

HK

Ind

ia

Ind

on

esia

Isra

el

Jap

an

Jord

an

Ko

rea

Ku

wai

t

KSA

Mal

aysi

a

Pak

ista

n

Ph

ilip

pin

e

Sud

an

Taiw

an

Thai

lan

d

UA

E

Vit

nam

1

42 2

21

3

109

86

2

11

21

10

1

19

1 1 1

Surgeons from Asia

451 Surgeons from 68 countries & Taiwan/Hongkong

KEEP CALMAnd think Uniportal!!

recent advances in uniportal vats• teaching around the world • the concept of “advanced...

Documents