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MY JOURNEY TO 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
The story begins here…Coruña University Hospital
“El viaje de los pioneros”TED talk-Diego Gonzalez Rivas
Searching for adrenaline..Surfing big waves..
Good friends in this story!
Learning VATS ?
Begining (2007)
• Visit other hospitals
• Meetings
• Literature, articles
• Wetlab
• Videos
VATS INCISIONS: DOUBLE PORT
X
Double port technique
First Uniportal VATS lobectomy29th June 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!
First upper lobe resection (after 6 lower lobes)Completion pneumonectomy (Nov 2010)
Learning curve-fighting
Single-incision VATS lobectomy
Advanced cases
30
Double sleeve 2014
Non intubated surgery
2014
No limitsCarinal resections 2015
Subxiphoid resections 2015
Unisurgeon surgery 2016
You just need a little help at thebeginning to fly and enjoy the way..
Con Gasol
• THE MOST COMFORTABLE APPROACH FOR THE SURGEON
What is the best approach?
• THE LEAST INVASIVE APPROACH
Evolution in technique
Incision: fifth intercostal space
POSITION OF INSTRUMENTS
Upper lobe vein management
Gonzalez-rivas et al. Advances in Uniportal video-assisted thoracoscopic surgery: pushing the envelope. Thorac Surg Clinics 2015.Review
Small vessels- Click aV-Grena-45 degree
• Symposia
• Workshops
• Visiting (Observer)
• Attachments
• Videos
• Training courses (2 weeks)
Train the Team !!!
Correct Training!!
• Absence of dihedral or torsion angle
• More anatomic instrumentation, ergonomy
Mathematics
Image plane
Line on ground plane
Vanishing point vCameracenter
C 0,0
pl
z
y
x
cba
DIRECT VIEW!
Reduced compression to the nerve
2-3 ports-More confortable for assistant-Camera lean on trocar
Single port-More uncomfortable for assistant-Camera is suspended,no trocar
Anatomic instrumentation
Paratracheal Subcarinal
Oncologic technique
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-Disease-free survival
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
• Complex hilum (lymph nodes or fibrosis)
• Use of energy devices for vessel dissection and division, new instruments
• Complex segmentectomies and lobectomies
• Sleeve broncho-vascular procedures, carinal
• Bleeding control
• Non intubated lobectomy
• Unisurgeon assisted with robotic arm
RECENT ADVANCES IN UNIPORTAL VATS
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
63
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
Uniportal vascular 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
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
Even less invasive..Non intubated surgery
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
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]
Single port is the best approach to stimulateindustry to develope new technology
Open gate to the futureUniportal Unisurgeon VATS lobectomy
Uniportal UNISURGEON VATS lobectomy
Uniportal VATS left hand double finger technique
Wireless Steerable Endoscope
Magnetic graspers
UNIPORTAL VATS IN 2017
• Improved staplers (electric, more angulated, 5mm)
• Energy devices for vessels and fissure
• Wireless cameras and graspers, remote control
• Robotic instruments (paralel instrumentation)
• 3D technology (naked eye)
• Non intubated surgery
• Portable drainage systems
• Subxiphoid approach, NOTES?
Uniportal VATS in the future
Shanghai Pulmonary HospitalLung resections 2004-2016
11441440
16742164
24132651 2788
3350
4042
5321
6855
8320
10392
2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Keep calm and think uniportal even in the end of the world…Antarctica, South Pole
