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Video Assisted Thoracic Surgery, Robotic Assisted Thoracic Surgery, 

Thoracotomy…Does it really matter? 

The role of ERATS

Reza Mehran MD

Professor of Surgery

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Conflict of Interest

• None

Pain

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Pain=Opioids

• Foundation of pain management

•Opioids related adverse events (ORAE): 50%

Multimodal Approach to painSites of Potential Targets

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Non‐Narcotics Adjuncts to Pain Management

•NSAIDS•COX 2 inhibitors•Acetaminophen

•Gabapentinoids•Clonidine•Ketamine

• Local/Regional Anesthesia

?

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ERATS = Enhanced Recovery After Thoracic Surgery

ERATS = No Guess work

?

Pre‐operative:•Counselling aiming at stress reduction.

•Gabapentin, pregabalin (Lyrica).

• Tramadol

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ERATS

Intra‐operative:

•Nerve blocks:

• Liposomal Bupivacaine

•Prostaglandin inhibitors (Toradol)

•Acetaminophen

•NO Epidural

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ERATS

Post‐operative:

•NSAID, Tramadol

•Early chest tube removal •No A, B, C

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Study Design

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35 MIS 19 open 35 MIS 19 open

ERATS Epidural

54 54

Posterior Intercostal Nerve Block With LiposomalBupivacaine: An Alternative to Thoracic Epidural Analgesia

David C. Rice, MB, BCh, Juan P. Cata, MD, Gabriel E. Mena, MD,Andrea Rodriguez MD, Arlene M. Correa, PhD, and Reza J. Mehran, MD

Ann Thorac Surg 2015;99:1953–60

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………. ThoracotomyVATS, RATS

ERATS Epidural

= =

ERATS

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VATS• Diagnosis or palliation of pleural effusions

• Wedge resections

• Pleurectomy

• Hyperhydrosis

• Treatment of early stage empyema

• Esophagectomy

RATS

• Only used when extra dexterity is paramount

• Dissection of mediastinal tumors• Thymoma

• Nerve sheath tumors

• Benign esophageal tumors

• Do not use when there is risk of bleeding

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Video‐Assisted Thoracoscopic Versus OpenThoracotomy Lobectomy in a Cohort of 13,619PatientsRaja R. Gopaldas, MD, Faisal G. Bakaeen, MD, Tam K. Dao, PhD,Garrett L. Walsh, MD, Stephen G. Swisher, MD, and Danny Chu, MD

Ann Thorac Surg 2010;89:1563–70

Preoperative anemia, blood transfusion, and neutrophil-to- lymphocyte ratio in patients with stage i non-small cell lung cancer

Juan P. Cata1,6, Cristina Gutierrez2, Reza J. Mehran3,4, David Rice3,4, Joseph Nates2, Lei Feng5, Andrea Rodriguez-Restrepo1, Fernando Martinez3, Gabriel Mena1,6, and Vijaya Gottumukkala1

Cancer Cell Microenviron. 2016 ; 3(1): e1116

60%

10% OS

Muscle Sparing Thoracotomy

• All anatomical lung resections

• All teaching cases

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Muscle sparing Thoracotomy

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Full thoracotomy with rib and muscle division

• “Anything Big” for maximum exposure

• Pleurectomy decortication/ EPP

• Extensive Chest wall or vertebral body resections

• Resection of tumors of the heart or great vessels on or off cardiopulmonary bypass.

Big tumor = Big incision

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In surgical oncology the size of the incision is not what matters.• Do it often and do it well 

• Principles of oncology

RJMehran@MDAnderson.org