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Innovations: Technology & Techniques in Cardiothoracic & Vascular Surgery:
doi: 10.1097/IMI.0000000000000066
Abstracts

Thoracic Track Abstracts

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T1 Robotic Anatomic Segmentectomy for Early Stage Lung Cancer

Duy Nguyen, Mark Meyer, Mohammad Moslemi, Barbara Tempesta, Keith Maas, Robert Poston, Farid Gharagozloo. The University of Arizona Medical Center, Tucson, AZ USA.

Objective: Anatomic segmentectomy is advocated as a curative procedure in select patients with early stage non-small cell lung cancer. We investigated the feasibility and suitability of robotic thoracic segmentectomy with complete mediastinal exenteration (CME) as a less invasive alternative to open thoracotomy. This technique was performed in patients with impaired lung function, small peripherally located tumors, and advanced age.

Methods: We included patients who underwent robotic thoracic segmentectomy over 9 years, then analyzed those with early stage lung cancer. Robotic dissection of the pulmonary artery, vein, and bronchus was followed by division of segmental structures and CME. Inclusion criteria were pre-operative clinical T1 disease in patients with impaired pulmonary function (FEV1 < 800 or DLCO < 50) and advanced age. Specimens were confirmed to be complete segments by pathology.

Results: 80 patients underwent robotic segmentectomy. Of these, 60 were for early stage lung cancer. There were 31 men, 29 women, mean age 73±9 years. All patients underwent R0 resection. Operating time was 132±30 minutes. Median hospital stay was 6 days. Pathologic upstaging occurred in 10% of patients. Histology was squamous cell in 17 patients, adenocarcinoma 28, adenosquamous 7, basaloid 1, giant cell 1, bronchoalveolar 3, and spindle cell carcinoma 1. Tumor size was 2 cm or less in 19 patients and > 2 cm in 17 patients. Complications were seen in 16/60 (27%) of patients including AFib 9/60 (15%), reintubation 2/60 (3%), c-diff 2/60 (3%), pneumonia 1/60 (2%), UTI 1/60 (2%), and pericardial effusion 1/60 (2%) patients. There were no mortalities.

Conclusions: Robotic segmentectomy with CME is a safe procedure which may represent a less invasive oncologic procedure to patients with small lung cancers and limited cardiopulmonary reserve.

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T2 Do We Still Need a Randomized Prospective Trial Comparing VATS to Open Lobectomy?

Thomas J. van Brakel, Ad F.Verhagen. Radboud University Nijmegen Medical Center, Nijmegen, Netherlands.

Objective: Lobectomy by video-assisted thoracic surgery (VATS) has become a widely adopted treatment for early stage non-small cell lung cancer. However, the percentage of VATS over OPEN lobectomies remains less than 40%, with a considerable variation between centers. Furthermore, a guideline indicating a preferential procedure is still lacking. The objective of this study was to evaluate the evidence comparing VATS to OPEN lobectomy and to investigate the need for a randomized controlled trial (RCT).

Methods: We performed a systematic review of the available literature from 1994 to present. All studies comparing VATS lobectomy with OPEN surgery (thoracotomy) for non-small cell lung cancer (stage I/IIa) with data on oncologic completeness of resection, hospital length of stay (LOS), postoperative complications and quality of life, were included. 880 references were identified and after systematic exclusion of irrelevant studies, 190 were abstracted by two independent reviewers. Two RCTs and 48 observational studies were selected for data extraction.

Results: 33 of 48 were retrospective studies without case matching (69%). In 14 studies a historical control group was used (29%). Conversion to thoracotomy was reported in 11 studies (22%) and 45 out of 50 studies (including both RCTs) did not follow an intention to treat principle. Both RCTs (1995, n=61 and 2013, n=66) reported no differences on primary endpoints (LOS/complications and number of lymph nodes/stations respectively). Ten studies (20%) reported on number of dissected lymph nodes/stations or completeness of resection. Only 3 studies reported data on functional outcome or quality of life. Overall (50 studies), VATS compared to open lobectomy was associated with a shorter median LOS (5.1 versus 7 days). Postoperative complication rate as composite endpoint was lower for VATS compared to open lobectomy (median 27 versus 39%).

Conclusions: Although VATS lobectomy has become a common procedure in many centers, the available evidence is based on comparative non randomized cohort- and patient control studies, resulting in imbalanced patient groups. To recommend VATS lobectomy as a standard of care, randomized controlled trials are necessary both with regard to functional- and oncologic outcome. Currently, we conduct a multi-center RCT (SCOPE trial, NCT01933828) comparing VATS to OPEN lobectomy.

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T3 Cases of Chylothorax and Recurrent Laryngeal Nerve Injury Associated with Mediastinal Lymph Node Dissection During Robotic Video Assisted Thoracoscopic Lung Resection

Inderpal S. Sarkaria, David J. Finley, Manjit S. Bains, Prasad S. Adusumilli, Nabil P. Rizk, James Huang, Robert Downey, Valerie W. Rusch, David R. Jones. Memorial Sloan-Kettering Cancer Center, New York, NY USA.

Objective: Robotic Video Assisted Thoracic Surgery (RVATS) is increasing for lung resections. While improved visualization and instrument dexterity are potentially advantageous compared to standard thoracoscopy, our initial experience suggests complications associated with systematic lymph node dissection during these procedures, specifically recurrent laryngeal nerve injury (RLNI) and chylothorax, may be significant.

Methods: Consecutive patients undergoing RVATS anatomic lung resections for suspected or confirmed cancer performed during the study period and with a complication of RLNI or chylothorax were identified and reviewed from a prospectively maintained database. Complications were graded according to the Common Terminology Criteria for Adverse Events v. 3.0 (CTCAE).

Results: From July 28, 2010, to December 20, 2013, 251 patients underwent RVATS segmentectomy, lobectomy, or bilobectomy with MLND. 11 patients (4.4%) experienced MLND related complications and comprised the study group. There were 6 cases (2.4%) of RLNI and 6 cases (2.4%) of chylothorax. Case-specific data are presented in Table T3-1. The majority of cases (81.8%) were right-sided resections, and median lymph node counts in right station IV and station VII were 9 (range 1-23) and 5.5 (1-10), respectively. 74.5% of cases were performed for early stage I and II lung cancers. Complications requiring procedural intervention (Grade 3) included 4 cases of RLNI undergoing percutaneous vocal cord medialization and 3 cases of chylothorax undergoing image guided thoracic duct embolization or maceration. No operative interventions were required and there was no operative mortality.

Conclusions: Chylothorax and RLNI are rare complications with reported occurrence rates of 1.7% and 1.0%, respectively, after systematic MLND during open or VATS pulmonary resections.1 RVATS MLND during anatomic lung resections may be associated with increased rates of chylothorax and RLNI, notwithstanding improved magnification and dexterity. Further prospective studies are warranted to understand potential technical advantages and pitfalls of RVATS MLND and allow adjustment of surgical technique accordingly.

1. Allen MS, Darling GE, Pechet TT, et al. Morbidity and mortality of major pulmonary resections in patients with early-stage lung cancer: initial results of the randomized, prospective ACOSOG Z0030 trial. Ann Thorac Surg. 2006;81:1013-1020.

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T4 Thermal Ablation for Stage IA Non-Small Cell Lung Cancer: Long-Term Follow-Up

Chaitan K. Narsule, Divya Nair, Avneesh Gupta, Roy G. Oommen, Michael I. Ebright, Virginia R. Litle, Hiran C. Fernando. Boston University School of Medicine, Boston, MA USA.

Objective: Thermal ablation, using radiofrequency ablation (RFA) or microwave ablation (MWA), can be used to treat medically inoperable patients with non-small cell lung cancer (NSCLC). We report long-term outcomes following thermal ablation from a single center in patients with Stage IA NSCLC.

Methods: Medically inoperable patients with Stage IA NSCLC underwent RFA or MWA. Follow-up imaging included serial CT scans every 3 months and PET scans every 6 months for 24 months, and then at reduced frequency. Factors influencing the incidence of local progression (LP) at the ablation site and overall survival (OS) were analyzed.

Results: From July 2005 through September 2009, 21 patients underwent 25 ablations (21 RFA, 4 MWA). Fifteen patients had T1a (≤2 cm) and 6 had T1b (>2-3 cm) tumors. Mean age was 69 (42-84) years. Ten patients were women. The mean nodule diameter was 1.88 (0.8-3) cm. NSCLC was biopsy-confirmed in 17 patients, and 4 were suspicious on biopsy. The median percent-predicted FEV1 was 39%, and DLCO was 47%. Mean follow-up was 42 months. Three-year overall survival (OS) was 52% (median 39 months) and was not significantly different between nodules diagnosed as NSCLC or suspicious (36 months vs. 51 months, p=0.20), T1a nodules compared to T1b nodules (36 months vs. 39 months, p=0.29), or nodules treated with RFA compared to MWA (36 vs. 50 months, p=0.80). LP occurred in 10 patients (47.6%). Median time to LP was 35 months, and was not significantly different between T1a nodules compared to T1b nodules (22 vs. 35 months, p=0.94) or RFA compared to MWA (35 vs. 17 months, p=0.18). OS was not impacted by LP (median 32 vs. 39 months with and without LP, p=0.68). Repeat ablation was performed in 3 patients (once in 2 patients, and twice in 1 patient who remains disease free at 40 months). Mean local progression time following repeat ablation was 14.75 months.

Conclusions: Thermal ablation was effective for treating medically inoperable patients with Stage IA NSCLC. The 3-year overall survival exceeded 50% and local progression did not impact overall survival. Thermal ablation remains a viable option for high-risk patients with NSCLC.

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T5 Wedge Resection vs. Radiofrequency Ablation to Treat Early Stage NSCLC in High-Risk Patients

Olivia Fanucchi, Marcello C. Ambrogi, Franca M.A. Melfi, Paolo Dini, Federico Davini, Stylianos Korasidis, Pietro Bertoglio, Alfredo Mussi. Division of Thoracic Surgery, University of Pisa, Pisa, Italy.

Objective: Surgeons are frequently faced with patients with early stage NSCLC who are at high risk for major pulmonary resection due to their poor clinical status. So limited resections, such as wedge resection (WR), or non-surgical therapies, like radiofrequency ablation (RFA), can be considered as alternative treatments. The aim of the study was to retrospectively compare results of both procedures in our recent experience.

Methods: We reviewed patients with stage I NSCLC who underwent wedge resection or RFA during the period 2006-2010. We compared mortality and morbidity, recurrence rate, actuarial overall and cancer-related survival for each cohort.

Results: Forty-one patients (8 females, 33 males, mean age 70 years) underwent minimally-invasive wedge resection, while 43 patients (10 females, 33 males, mean age 74 years) were treated with percutaneous RFA. There was no mortality in either group, while morbidity rates were 31.7% and 9.3%, respectively (p=0.011). Despite a higher local recurrence rate for RFA (33%) in respect to WR (12%)(p=0.026) at a median follow-up of 29 and 34 months, respectively, the 1- and 3-year actuarial survival (cancer-related) rates were 94% (100%) and 54% (67%), 100% (100%) and 67% (94%), respectively, without significant differences.

Conclusions: Wedge resection and RFA appear to be safe and viable compromises for treatment of early stage NSCLC, in patients with inadequate pulmonary reserve or high co-morbidity score. RFA is associated with an increased risk of local recurrence, so it should be reserved for patients with true contraindication to surgery.

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T6 Use of a Saline-Coupled Bipolar Tissue Sealer in Thoracic Surgery

Ara S. Klijian. Sharp/Scripps Hospitals, San Diego, CA USA.

Objective: Standard practice in thoracic surgery is to use electrocautery to provide sealing of soft tissues. A saline-coupled bipolar tissue sealer that uses radiofrequency (RF) energy is frequently used in orthopedic and spinal surgery with resulting reductions in transfusion rates by minimizing blood loss.1,2 There is a paucity of data for use of the bipolar sealer in thoracic surgery, so this study was conducted to assess surgical outcomes comparing the two types of energy-based sealers in patients who underwent a variety of thoracic surgeries.

Methods: Consecutive patients over a 6-month period were included in this study. Medical records were reviewed for surgical outcomes, including time to chest tube removal, ambulation, and discharge, estimated blood loss (EBL), and postoperative pain on a 10-point visual analog scale.

Results: Twenty-eight patients were included in the results; 14 subjects (9 females; mean age 75.6 [range, 58-84]) in the RF bipolar sealer group and 14 subjects (7 females; mean age 67.5 [range, 55-80]) in the electrocautery (control) group. There was a significant (p<0.0024) difference in age between the two groups. Significant reductions in mean EBL (310 ccs vs. 54.3 ccs, p<0.0001), postoperative pain (6.8 vs. 2.6, p<0.0001), time to chest tube removal (3.1 days vs. 1.1 day, p<0.0001), time to ambulation (2.6 days vs. 1.1 day, p<0.0001), and time to discharge (4.7 days vs. 2.1 days, p<0.0001) were found when the control was used compared to the RF bipolar sealer, respectively.

Conclusions: The results of this single-center, single surgeon, retrospective, small case series demonstrate a significant improvement in recovery outcomes, including reduced blood loss and less pain, when a saline-coupled RF bipolar sealer is used in thoracic surgery. Faster recovery also could represent cost-savings due to a shorter hospital stay. A larger, prospective study is advocated to confirm these findings.

1. Marulanda G, Ultrich S, Seyler T, et al. Reductions in blood loss with a bipolar sealer in total hip arthroplasty. Expert Rev Med Devices 2008;5:125-131.

2. Weeden S, Schmidt R, Isabell G. Haemostatic efficacy of a bipolar sealing device in minimally invasive total knee arthroplasty. J Bone Joint Surg Br Proceedings 2009;91-B:45

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T7 Robotic Thymectomy in Patients with Myasthenia Gravis: Neurological and Surgical Outcome

Marlies Keijzers, Marc de Baets, Monique Hochstenbag, Marcel van der Linden, Anne-Marie C. Dingemans, Jos G. Maessen. Maastricht University Medical Center, Maastricht, Netherlands.

Objective: Thymectomy is accepted in the treatment of myasthenia gravis (MG). Indication, timing and surgical approach remains controversial. Our study reports our surgical and neurologic experiences with robotic thymectomy in a large group of patients with MG.

Methods: We retrospectively analyzed 125 patients with MG who underwent a robotic thymectomy using the da Vinci robotic system (Intuitive Surgical, Inc., Sunnyvale, CA USA) between 2004 and 2012. Ninety patients had a neurological follow-up of more than 12 months. The Myasthenia Gravis Foundation Classification was used to determine pre-operative and postintervention status. MGFA preoperative classification were Stage I in 14.4%, Stage II 20%, Stage III 28.8%, Stage IV 31.2%, and Stage V 2.4%.

Results: 110 women and 15 men underwent a robotic thymectomy. Median procedure time was 123 minutes (range, 45-353 minutes). There were no peri-operative complications or deaths. Postoperatively 2 patients suffered from a myasthenic crisis requiring prolonged ventilation. The median postoperative hospital stay was 3 days (range, 2-24 days). Histological analysis showed a thymic rest in 41 patients (32.8%), follicular hyperplasia in 52 patients (41.6%), thymoma in 31 patients (24%), lipoma in 1 patient (0.8%) and a cyst in 1 patient (0.8%). Steroid use was significantly increased in patients with a thymic remnant (p=0.01). With a median follow-up of 33 months (range, 12-101 months) 76.7% of the patients improved neurologically according to MGFA. Follow-up showed a 5-year probability remission rate (complete stable remission and pharmacological remission) of 37% (Fig. T7-1). In 90% of the patients steroid treatment was decreased or interrupted. There was no significant difference in neurological outcome regarding the timing of surgery (<12 months vs. >12 months after onset MG).

Conclusions: Robotic thymectomy in patients with MG is safe and feasible. A neurological benefit and decreased use of steroids can be obtained in the majority of patients. No significant difference in neurological outcome was observed as the result of timing of robot thymectomy after the onset of MG.

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T8 Robotic First Rib Resection for the Treatment of Thoracic Outlet Syndrome: Redefining Diagnosis and Treatment

Mark Meyer, Duy Nguyen, Mohammad Moslemi, Barbara Tempesta, Keith Maas, Robert Poston, Farid Gharagozloo. The University of Arizona Medical Center, Tucson, AZ USA.

Objective: Thoracic outlet syndrome (TOS) is a highly under-diagnosed disease process that has poor medical and surgical results due to poor understanding of the disease process. Despite the majority of patients being diagnosed with neurogenic symptoms, we hypothesize that the majority of neurogenic symptoms are the result of subclavian artery (SCA) compression and neural ischemia from a tubercle in the medial aspect of an abnormally developed first rib. We present our experience in diagnosing and treating thoracic outlet syndrome with robotic first rib resection.

Methods: In a retrospective analysis of prospectively accrued data, patients referred for thoracic outlet syndrome and underwent robotic first rib resection were evaluated for diagnostic and clinical history, operative data, complications, symptomatic relief, and follow-up diagnostic and interventional imaging if needed. The medial portion of the first rib ipsilateral to clinical symptoms and radiographic findings was resected with robotic assistance.

Results: 24 patients (14 men, 10 women, mean age 35) underwent robotic first rib resection over a 24-month period. 11/24 patients presented with neurogenic symptoms. 8 had magnetic resonance arteriography showing compression of the SCA on abduction along with CT 3D reconstruction of the first rib showing a compressive tubercle. These patients underwent successful first rib resection with symptomatic improvement on follow up. 3 patients had other causes of compression (1 cervical rib, 2 cervical bands). 13/24 patients presented with arm swelling and were diagnosed with Paget-Schrotter’s Disease. All 13 patients had robotic first rib resection and following surgery and had a patent subclavian vein at 3- and 6-month follow-up. Mean operative time was 163 +/- 39 minutes. Median hospitalization was 3 days. There were no surgical complications and no mortality.

Conclusions: Neurogenic TOS is mainly caused by compression of the subclavian artery from a congenital tubercle of the first rib. Both dynamic MRA and 3D-CT reconstruction of the first rib are essential to accurate diagnosis of thoracic outlet syndrome. Robotic transthoracic first rib resection is feasible and safe, allowing for removal of the offending portion of the first rib, and symptomatic relief of a previously poorly understood disease process.

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T9 Application of a New Wristed Instrument for Bipolar Coagulation and Mechanical Transection During Minimally-Invasive Robotic Thymectomy

Olivia Fanucchi, Franca M.A. Melfi, Federico Davini, Paolo Dini, Stylianos Korasidis, Marcello C. Ambrogi, Alfredo Mussi. Division of Thoracic Surgery, University of Pisa, Pisa, Italy.

Objective: During the last decade, the role of minimally-invasive thymectomy has been increasing. One of the most critical moments of this procedure is represented by the control and division of thymic veins. The aim of this study was to verify the safety of a new robotic instrument for performing the dissection of thymic tissue and for dividing thymic vein.

Methods: We retrospectively reviewed 10 consecutive patients that underwent robotic thymectomy by using this new device for bipolar coagulation and mechanical transection. Operative time, intraoperative complication, blood loss, post-operative complication and post-operative hospital stay were analyzed.

Results: There were 1 male and 9 females, with a mean age of 32 (range 23-35 years), that suffered from myasthenia gravis. The mean operative time was 102 minutes (90-120 minutes). No intraoperative complications occurred. The new instrument was safely applied for thymic dissection and for division of thymic veins in all cases. The mean blood loss was 39 ml (30-60 ml). No post-operative complication occurred. The mean post-operative stay was 2 days (range 2-4).

Conclusions: This preliminary experience appears to be favorable for the application of this device, resulting useful for dissection of thymic gland, and providing a safe division of thymic vein. However, further study on larger series are necessary.

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T10 Thoracoscopic Sympathectomy using Single Port vs. Multiple Ports as a Treatment for Palmar Hyperhidrosis

Magdi Muhammad, Abdulla Allam. King Fahad Hospital, Al Madina Al Munawara, Saudi Arabia.

Objective: Hyperhidrosis can cause significant professional and social handicaps. Thoracic endoscopic sympathectomy has become the surgical technique of choice for treating intractable palmar hyperhidrosis. Endoscopic thoracic sympathectomy can be carried out through multiple ports or by using a single port. A prospective study was undertaken to compare outcomes between two methods.

Methods: Between January 2008 and June 2012, 71 consecutive patients [30 male and 41 female; aged 22 ± 5.3 years] underwent video-assisted sympathectomy for palmar hyperhidrosis are included in this study. In all cases, the procedure was bilateral. The procedure was performed in one stage in all patients. All patients were seen 1 month and follow-up to one year after the operation. Patients were subdivided into 2 groups: Group A-35 patients underwent multiple ports video-assisted sympathectomy and Group B-36 patients underwent single port video-assisted sympathectomy. Preoperative, intraoperative and postoperative variables, morbidity, recurrence, and survival are compared in both groups.

Results: Successful sympathectomies were performed in 100% of the patients; the follow-up was from 1 to 12 months (mean 6 ± 3.4 months). There was no recurrence of palmar hyperhidrosis. No Horner’s syndrome was reported. No mortality or serious postoperative complications. There was no conversion to an open procedure. Residual minimal pneumothorax occurred in two patients (5.7%) in group A and in one patient (2.8%) in group B. Minimal hemothorax occurred in one patient (2.9%) in group A and in three patients (8.3%) in group B. Compensatory hyperhidrosis encountered in seven patients (20%) in group A and in eight patients (22.2%) in group B.

Conclusions: No difference between bilateral multiple ports and single port video-assisted thoracoscopic sympathectomies and both are effective, safe and minimally invasive procedures improving permanently the quality of life in patients with palmar hyperhidrosis.

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TMP1 Re-Thinking Robotic Privileges for Major Lung Resection: Departmental Quality Improvement Process Prompting Credentialing Reorganization

Cliff P. Connery1, Faiz Y. Bhora2, Scott Belsley3, Martin Karpeh4. 1St Luke‘s Roosevelt, Beth Israel, New York, NY USA, 2St Luke‘(tm)s Roosevelt, New York, NY USA, 3St. Luke‘s Roosevelt, New York, NY USA, 4Beth Israel, New York, NY USA.

Objective: Robotic-assisted thoracic surgery is evolving as an effective modality to employ for thoracic surgery. The robotic system may increase the limited penetrance of video-assisted major lung resection for a larger number of surgeons. Optimal patient outcomes demand a close scrutiny of the credentialing process and on-going monitoring of outcomes including potentially important “near misses” that are sometimes missed by commonly applied database parameters.

Methods: A retrospective analysis of our prospectively maintained database patterned on The Society of Thoracic Surgeons (STS) and used for hospital quality improvement (QI) was analyzed. This was compared with data from Morbidity and Mortality conference and other hospital sources. A departmental QI team review with referees from outside the division reviewed 75 cases over approximately 24 months and compared the results to the outcomes of 136 cases performed at the other system site since initiation of the program as well as the relevant outcomes in the published literature

Results: Our system QI process utilizing STS database parameters identified disparity in lobectomy outcomes between two sites in a major academic medical center. Focused review suggested a higher than average incidence of perioperative bleeding and conversion at one of the two sites using the robot. Results of further intensive review demonstrated that the ability to successfully perform uncomplicated basic robotic-assisted procedures did not always translate to safe performance of major lung resection. It was recognized that there are drawbacks to the STS database, other hospital data sources and the surgical morbidity and mortality process in being able to identify potentially important “near misses.”

Conclusions: Recommendation was made to revise our previously robust credentialing process to separately privilege major anatomic resection and advanced procedures after successful completion of the basic robotic credentialing, proctoring and supervision process. While patient safety was paramount, sensitivity to the surgical team, concerns regarding the appearance of restraint of trade and state reporting requirements were addressed. An extended period of provisional approval was proposed designed with review of volume, outcomes and appropriateness of robotic usage.

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TMP2 General Thoracic Surgery Turnover Time Improvement Project

Daniel L. Miller, Barry Bryant, Avina Goel, Lorraine James, Maquitha Mitchell, Matt Klopman. Emory University, Atlanta, GA USA.

Objective: In the majority of minimally invasive thoracic procedures, operative times are longer. Because of the longer operative times, turnover time between cases become an important issue in determining the number of cases that can be performed on a daily basis. Analysis at our institution found that our general thoracic surgery (GTS) turnover time (TOT) was greater than 60 minutes. Therefore, we set out to reduce the TOT to 30 minutes or less.

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Methods: We focused on the areas that we had control–preop holding, operating room, and recovery room. The factors that were identified as the areas of greatest need for improvement were preparation of cases carts, clarification of equipment needs, definition of room readiness, and definition of patient readiness. We then implemented the project and met on a monthly basis to review the data and make improvements to the process as needed.

Results: The project started in January, 2012, in all GTS operating rooms, seven rooms a week and approximately 80 cases a month. TOT was calculated as from wheels out to wheels in. The data was divided into AM (0730-1159) and PM (>1200) and Overall. The first month’s TOT was 43 min for AM, 56 min for PM, and 49 min Overall. By July, 2013, we reached our Overall goal of 30 minutes (Fig. TMP2). In our GTS operative rooms, an average of 3 to 4 cases are performed each day. By decreasing our TOT from 60 min. to 30 min., we decreased the total TOT from 120-180 min to 60-90 min and the total operating room time per day.

Conclusions: Prolonged operative TOT can negatively affect patient care. By working as a team, our GTS service was able to reduce TOT by 50 percent. This reduction in TOT has lead to greater patient and employee satisfaction as well as decreased cost.

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TMP3 An Objective Classification System for Nomenclature of Minimal Access Thoracic Surgery Procedures

Rashid Mazhar, Nasir Moghul. Heart Hospital, HMC, Doha, Qatar.

Objective: Presently there is significant variation in the nomenclature used to describe thoracic operation done by minimal access. Commonly used terms are: “Video Assisted Surgery” (VATS), “Minimally Invasive Thoracic Surgery” (MITS) and “Minimal Access Thoracic Surgery” (MATS). VATS is further categorized by some as c-VATS (Complete VATS) and a-VATS (assisted VATS). Its operative technique also varies from being completely endoscopic to having an access thoracotomy, Utility Port, Working Port or Utility Thoracotomy of anywhere from 4-10 cm. Such variation obviously raises the question as to where does mini-thoracotomy join in or deviate from the larger of these “access/working” incisions’ of VATS. And which incision should be crowned as standard “Thoracotomy? There is a need to clearly define the boundaries and criteria which would set these procedures apart.

Methods: The authors suggests a simple system of streamlining these terminologies, in an adult patient of average built, based upon the following four criteria: 1, length of the incision 2, use of spreader 3, use of VATS or non-VATS instruments and 4, the intra-cavity use of surgeons’ hand/s. The issue of chest wall muscle cutting is not taken into definition as a utility port or a mini-thoracotomy can be made by division as well as separation of muscle fibres. A hybrid term of “Thoracoto-scopy” (Thoracotomy + Thoracoscopy) is suggested to make the definitions smoothly graduated. A visual depiction of the proposed nomenclature is presented in Table TMP3-1

Results: Our clinical experience with 100 non-oncological procedures is presented. It is feasible and easy to categorize minimal access operations with this method.

Conclusions: The question of nomenclature is more than a matter of semantics. It is necessary to streamline these differences, clarifying the exact technique used, so as to make meaningful comparison of results from different surgeons. Our suggested system of classification could fill in that need.


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T11 Initial Experience with Minimally Invasive Esophagectomy at a Major Cancer Center: First 100 Cases

Rachel Grosser, Inderpal S. Sarkaria, Manjit S. Bains, David J. Finley, Amanda Ghanie, Prasad S. Adusumilli, James Huang, ValerieW. Rusch, David R. Jones, Nabil P. Rizk. Memorial Sloan-Kettering Cancer Center, New York, NY USA.

Objective: Minimally invasive esophagectomy (MIE) is steadily increasing in utilization, with a growing body of evidence supporting equivalent oncologic outcomes compared with open approaches. In this study, we report on the initial experience with this approach at a major high-volume cancer center over progressive interquartile divisions after inception of an MIE program.

Methods: All consecutive patients undergoing hybrid MIE, standard total laparoscopic/thoracoscopic MIE, and robotic-assisted laparoscopic/thoracoscopic MIE approaches at Memorial Sloan-Kettering Cancer Center during the study period were retrospectively reviewed from a prospectively maintained database. Outcomes were analyzed by interquartile divisions.

Results: From a total of 310 esophageal resections performed during the study period, 100 patients (32%) underwent MIE from February 18, 2010, to October 14, 2013, with an operative mortality of 2%. The median age was 60.3 years (range, 37-86 years), and 73% of patients underwent induction chemoradiation. Operations included 85 Ivor Lewis resections, 13 McKeown (3-hole) resections, 1 transhiatal resection, and 1 colon interposition. Study results are summarized in Table T11-1. Hybrid approaches were common in the 1st quartile and absent in the 2nd-4th quartiles. Unplanned conversions from MIE to open procedures decreased from the 1st to 3rd quartiles, and were absent in the fourth quartile. There were predominant in the1st quartile, decreased over the 2nd and 3rd quartiles, and absent in the 4th quartile. There were no emergent conversions and no intraoperative deaths. Operating room time, median length of hospital stay, and mortality decreased over successive quartiles, while the median number of lymph nodes resected increased (Table T11-1).

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Conclusions: With the inception of an MIE program, initial performance of hybrid approaches combined with a low threshold for conversion early in the experience may be beneficial for the safe, progressive transition to completely laparoscopic/thoracoscopic MIE with oncologic and operative outcomes comparable to those with open esophagectomy.

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T12 Transthoracic, Extracorporeal Gastric Conduit Preparation: A Simple Alternative to Mini-Laparotomy in Minimally Invasive, Ivor-Lewis Esophagectomy

Anna McGuire, Sebastien Gilbert. University of Ottawa, Ottawa, ON Canada.

Objective: During totally minimally invasive esophagectomy (MIE), the gastric conduit is typically constructed via laparoscopy. Trauma from laparoscopic instruments, inability to palpate the gastroepiploic arcade, and challenges in optimal positioning the stomach for intra-abdominal stapling have led to widespread use of laparotomy as part of hybrid MIE procedures. Our objective was to evaluate the safety of transthoracic, extracorporeal gastric conduit preparation. We hypothesize that this alternative technique is equivalent to the laparoscopic approach.

Methods: The gastric conduit was fashioned through the intercostal access incision (6-8 cm) normally used to retrieve the surgical specimen and insert the EEA stapler during Ivor-Lewis MIE. Retrospective comparison with laparoscopic gastric conduit preparation was performed with emphasis on anastomotic and respiratory outcomes.

Results: From June, 2010, to May, 2013, there were 30 MIEs (extracorporeal conduit = 15; laparoscopic conduit = 15) (Table T12-1). Mean age, tumor location and histology were similar between groups (Table T12-1). Anastomotic technique and location, and operating surgeon were the same for all patients. Patients in the laparoscopic gastric conduit group were slightly more likely to have undergone induction chemoradiotherapy (Table T12-1). There was no significant difference between groups with respect to anastomotic complications, including anastomotic leak and anastomotic stricture (Table T12-1). There was a trend toward fewer respiratory complications in the transthoracic conduit preparation group (Table T12-1).

Conclusions: Transthoracic, minimally invasive gastric conduit preparation is a safe alternative to hybrid esophagectomy with laparotomy. It overcomes shortcomings of the laparoscopic approach. This technique allows the surgeon to commit to Ivor-Lewis esophagectomy only once resectability of the thoracic esophagus has been confirmed.

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T13 Prone Position Thoracoscopy with Modified Dual Lung Ventilation for Minimally Invasive Esophagectomy: Implications for the Surgeon and Anesthesiologist

Selvaraj Palanichamy, N.S. Balaji, R. Parthasarathy, S. Venkatachalam, D. Vivod, C. Palanivelu. GEM Hospital, Coimbatore, India.

Objective: Prone position thoracoscopy with Modified DLV (MDLV) and conservative ventilation strategies is more physiological with no compromise to surgical technique or patient safety during Minimally Invasive Oesophagectomy (MIO). We aim to analyze and measure the outcome in terms of (1) modification in default ventilator settings, (2) hemodynamic instability and (3) change in surgical strategy.

Methods: In this observational study of 46 consecutive patients who underwent prone position thoracoscopy as a part of MIO with modified dual lung ventilation using a single lumen portex endotracheal tube. Conservative respiratory settings (FiO2 - 40%, no PEEP, tidal volume – 6 ml) formed the default with Co2 insufflation pressure at 8 mmHg. Respiratory parameters, hemodynamic and surgical variables were monitored at 0, 15, 30 and every 30 minutes thereafter until completion.


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Results: All patients were evaluated on various variables mainly the O2 saturation, PO2, PH, Pco2, hemodynamic parameters and need for the change in default ventilator settings. O2 saturation and PO2 are mentioned as in Table T13-1 at various intervals. 100% O2 and PEEP 5 applied in 16 patients predominantly following air entry into contralateral lung. 3 patients had hypercarbia with hemodynamic compromise needed increase in minute ventilation. Hypotension was present in 24 patients who was treated with fluids and intermittent doses of ephedrine and no inotrope support was needed in any. 29 patients had hypertension (9 patients received nitroglycerin infusion). Bradycardia noted in 14 patients predominantly following thoracic epidural, treated with IV atropine. Tachycardia was present in 7 patients required IV beta blockers. Intraoperative arrhythmias needing correction was noted in 2 patients. Surgery was temporarily stopped in 3 patients (2 had arrhythmias and 1 had tension pneumothorax). Change in surgical strategy noted in 1 patient where because of persistent hypoxia instead of Ivor Lewis procedure cervical anastomosis was done. Fan shaped retractor was used in 3 patients to collapse lung.

Conclusions: This study highlights that prone position thoracoscopy with Modified Dual Lung Ventilation (MDLV) and conservative ventilation strategies are more physiological with no compromise to surgical technique or patient safety.

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T14 Modifications to Total Minimally Invasive McKeown Esophagectomy Reconstructed Through the Retrosternal Tunnel

Yawei Zhang, Yihua Sun, Hong Hu, Bin Li, Haiquan Chen. Fudan University Shanghai Cancer Center, Shanghai, China.

Objective: The aim of this study was to examine the morbidity, mortality, and efficacy of the modified minimally invasive McKeown esophagectomy (McKeown MIE) reconstructed through the retrosternal tunnel.

Methods: Between February and June, 2013, 10 patients underwent such modified McKeown MIE. The patient was placed supine firstly. Gastric conduit was completed through laparoscopic mobilization. An end-to-end cervical esophagogastric anastomosis through the retrosternal tunnel was completed with a double-layer manual suture. A feeding nasogastric tube was placed through the pylorus. Then tumor resection and mediastinal lymphadenectomy was performed through the thoracoscopy.

Results: There were 7 male and 3 female patients, with a mean age of 57 years (range, 47 to 63 years). 6 patients had tumor located in the upper thoracic esophagus and the other 4 in the middle. T stage was T1, T2, and T3 in 4, 3 and 3 patients, respectively. The mean number of lymph nodes harvested was 21. The mean postoperative hospital stay was 28 days. No major complication and hospital death occurred in this cohort except 2 anastomotic leaks.

Conclusions: McKeown MIE procedure with retrosternal reconstruction is a feasible and safe approach for thoracic upper and middle esophageal tumors, and also probably beneficial for postoperative treatment.

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TMP4 Use of Medela Digital Suction Device Allows Avoidance of Surgery in Sick Patients

Ali Zamir Khan, Shaiwal Khandelwal, Narendra Agarwal, Kamran Ali, Sangeeta Khanna. Medanta, The Medicity, Gurgaon, India.

Objective: We present our experience of facilitation of conservation management of air leaks and malignant pleural effusion by bedside pleurodesis due to use of Medela Digital Suction Device thus avoiding surgery and general anesthesia for very sick patients.

Methods: 52 patients unfit for general anesthesia underwent bedside talc pleurodesis for prolonged air leak or malignant pleural effusion. Talc slurry with lignocaine was introduced via the drain and digital suction was applied at 2 Kpas for 48 to 72 hours.

Results: 48/52 patients underwent successful talc pleurodesis due to complete lung expansion. 8/46 patients needed 2 doses of talc over 4 days. Early mobilization was facilitated by portable digital suction device. 2/52 patients had small localized apical pneumothorax with no clinical significance. 4 patients with tuberculosis were put on a flutter bag and discharged home. Drain was removed at follow-up. All patients had successful conservative management of clinical problems. Referral rates have increased from Cardiac Surgery, Oncology, Pulmonology and Urology Departments specifically seeking Medela Digital Suction Device.

Conclusions: Use of Medela Digital Suction Device facilitates early expansion of lung and thus aiding in successful bedside talc pleurodesis in very sick patients who are unfit for general anesthesia.

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TMP5 Anterior vs. Posterior Approach VATS Lobectomy: A Limited Comparison

Khalid Amer1, Ali Zamir Khan2, Edwin Woo1. 1University Hospital Southampton, Southampton, United Kingdom, 2Medanta, The Medicity, Gurgaon - New Delhi, India.

Objective: The approach to VATS lobectomy has historically shifted from posterior (PA) to anterior approach (AA). One of the reasons is the direct access to the hilar structures. Diehard posterior approach surgeons still see merits in it such as familiar orientation to open thoracotomy and ease of systematic nodal dissection. This study compares two separate databases of two approaches in our institution, comparing operative speed and safety.

Methods: Historical data of two surgeons practicing the posterior approach between 2005 - 2010 were compared to data of the third surgeon 2010 - 2013 who practices the anterior approach. Systematic nodal dissection was routine in PA, whereas nodal sampling was practiced in AA. Data pertaining to PA include the initial learning curve of theatre team at the time of establishing the VATS program. Limited data were comparable between the two databases, including age, sex, WHO performance status, predicted post operative FEV1%, lobe removed, histology, drain dwell time, operative time, length of stay in hospital, conversion, and ITU admission

Results: Between April, 2007, and November, 2013, 276 consecutive patients were identified to have undergone first time VATS lobectomy, pneumonectomy or segmentectomy for early lung cancer. 84 were anterior and 192 were posterior approach. There was no sex or age preponderance. There was no difference in surgical spectrum between AA and PA. The median hospital stay remained 4.0±4.0 days in both approaches. There were 2 port site seedlings in PA and none in AA. There was significantly higher number admitted to ITU/HDU in PA, 24 (12.5%) compared to AA 3 (3.6%), p=.02. Overall operative time was considerably faster in the AA, 166 ± 43 min compared to PA, 210 ± 72 min, p=000. There was no difference in conversion, 8 (9.5%) in AA versus 24 (12.5%) in PA, p=.477. There was no in-hospital mortality in both groups.

Conclusions: Both AA and PA are equally safe in VATS lobectomy. The anterior approach seems to be quicker and fewer patients went to ITU for observation or treatment.

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TMP6 Feasibility, Safety and Effectiveness of Videothoracoscopy Performed Under Local Anesthesia and Sedation Without Tracheal Intubation

Alexandre Oliveira. Albert Einstein Israeli Hospital, Sao Paulo, Brazil.

Objective: To evaluate the feasibility, safety and effectiveness of videothoracoscopy (VT) with local anesthesia and sedation, and if this combination can be a feasible choice in selected patients.

Methods: A prospective study in which 23 patients underwent a VT with local anesthesia and sedation. Upon being admitted to the operating room, have been verified and recorded: oxygen saturation (O2 Sat), blood pressure (BP) and heart rate (HR). After that, fentanyl was administered intravenously 1.5 mcg/Kg, and this moment was standardized as time “0” and the continuous infusion of propofol 0.05 mg/kg/min was started. Intercostal block was performed at the point of introduction of the trocars. Changes in vital signs during the time of surgery were compared with the time “0”. The feasibility was evaluated by the number of cases that we could perform the procedure and whether there was some kind of memory of pain or discomfort of the operation. Safety was assessed by changes in vital signs during the operation, the necessity to perform tracheal intubation during the procedure and the need for postoperative in intensive care unit.

Results: No patients remembered discomfort or pain of the operation; none required tracheal intubation postoperatively or in the intensive care unit have been needed. VT reached in all cases their diagnostic or therapeutic purposes. All patients remained with satisfactory levels of oxygen during the procedure, and in no case was required tracheal intubation. Variations of BP and HR no compromising the procedure even in elderly or patients with cardiovascular risk. Cancer patients with worse functional status showed significant fall in vital signs during the operation, compared with the group with the best score.

Conclusions: VT with local anesthesia and sedation is feasible and safe, was successfully performed in all patients, without tracheal intubation, admission to the intensive care unit or dead.

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TMP7 Sequence of Interruption of Pulmonary Artery and Vein in VATS Lobectomy: Does It Matter?

Khalid Amer1, Ali Zamir Khan2. 1University Hospital Southampton, Southampton, United Kingdom, 2Medanta, The Medicity, Gurgaon - New Delhi, India.

Objective: This study aims at comparing the survival of patients who had their pulmonary vein stapled before the pulmonary artery during VATS Major Pulmonary Resection (VMPR) for Non Small Cell Lung Cancer (NSCLC), versus those who had the artery stapled before the vein. Ligating the vein first is claimed to reduce micrometastasis and tumor recurrence, at the expense of increased amount of blood retained in the lobe.

Methods: Retrospective analysis of consecutive patients undergoing first time VMPR for NSCLC, assessed within 3 groups: (A) patients who had all major lobar arteries stapled before lobar veins, Group (B) reversed sequence, vein before arteries, and (C) mixed group, e.g., arterial branch followed by vein then more arteries. Basic demographics were compared, as well as surgery required, operative time, drain dwell time, postoperative drainage, length of hospital stay, histology, conversion, intraoperative blood loss, need for blood transfusion, postoperative surgical and non-surgical events, readmission within 2 weeks, pattern of recurrence and overall survival.

Results: Between April, 2005, and March, 2010, operative details were complete in 155 patients. Artery first comprised 28 (17.4%), vein first 105 (65.2%) and mixed 22 (13.7%). The vein was interrupted first in all middle lobectomies, as this was the natural anatomical order of dissection. Group A were followed up significantly longer than Group B as it was historically the technique we started the VATS lobectomy program with. Three years later we changed to vein first. There was a significant conversion rate between the three groups, favoring mixed group, which represents taking the easy vessel that opens dissection and makes the next step easer. There was no survival benefit difference between groups

Conclusions: The sequence of vessel interruption in VATS lobectomy for NSCLC does not affect survival. It does not increase the level of difficulty of the operation, lobe congestion was not encountered, and there was no significant difference in recovery. Rate of conversion might be reduced if sequence of dissection is mixed, tackling easy vessel first.

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TV1Uniportal SILS VATS Robotic Thymectomy

Fouad J. Taghavi, Yasir Abu-Omar, Marco Scarci. Papworth Hospital, Cambridge, United Kingdom.

Objective: Video-assisted thoracic surgery (VATS) is being enthusiastically used as a less-invasive diagnostic and therapeutic surgical procedure. VATS results in considerably less postoperative pain than traditional thoracotomy incisions. The current trend is to reduce the number of ports and minimize the length of incisions to further reduce postoperative pain, chest wall paresthesia, and length of hospitalization. We set out to utilize a new robotic instrument to aid with the excision of a thymic mass through a single 3 cm incision.

Methods: The Single Incision Laparoscopic Surgery (SILS) port is a flexible laparoscopic port that can accommodate up to 3 instruments through a single port. It was designed to perform laparoscopic surgery. This port was used in conjunction with a Kymerax Precision-Drive Articulating Surgical System. This hand held robotic instrument enabled precise instrument articulation and control. This system was non FDA approved at the time of use. CO2 insufflation was used to aid with tissue dissection and lung retraction.

Results: We report the case of a 45-year-old builder who was found to have an incidental anterior mediastinal mass on CT. This was excised via uniportal SILS VATS robotic surgery through a 3 cm incision.

Conclusions: To our knowledge, this is the first reported case of using the KYMERAX Precision-Drive Articulating Surgical System in thoracic surgery. The patient’s thymoma was excised through a single 3 cm chest wall incision. The patient was fit for discharge on his first post-operative day.

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TV2 Robotically Assisted Bilateral Bronchoplasty for Tracheobronchomalacia

Richard Lazzaro, John Lazar, Brian Mitzman. Lenox Hill Hospital, New York, NY USA.

Objective: This video documents the technique and outcome of the first totally thoracoscopic bilateral bronchoplasty for tracheobronchomalacia using the da Vinci robot (Intuitive Surgical Inc., Sunnyvale, CA USA).

Methods: Case Video Summary: A 79-year-old male with a past medical history of hypertension, temporal arteritis, melanoma, and GERD was seen over a year ago because of severely disabling cough and thick secretions associated with decreased appetite, weight loss, and fatigue. He was initially treated for pneumonia, but when symptoms worsened, he underwent further workup. Bronchoscopy showed severe right bronchomalacia. He underwent a palliative tracheal stent procedure in February, 2013, by a thoracic surgeon after it was determined he would not tolerate lobectomy. A second opinion was sought due to the continuous decline of the patient in May. The stent was removed and cultures showed multi-drug resistant pseudomonas requiring chronic antibiotics. A decision was made in July to admit the patient, start a week of TPN for his malnutrition, and attempt a minimally invasive right bronchoplasty. A right video-assisted thoracoscopic robotically assisted bilateral bronchoplasty with Prolene mesh was performed without any intra or post-operative complications. The patient spent the first night in the ICU for observation. The chest tube was removed post operative day 1 and then transferred to the ward. By post operative day 2 he noticed significantly decreased secretions, was able to walk the halls and eat without difficulty. Over the next several days, his clinical condition continued to rapidly improve with diminished secretions, increased deep respirations, complete resolution of his severe GERD and noticeable degree of weight gain. A repeat bronchoscopy post operative day 6 showed no airway collapse during inspiration.

Results: See below

Conclusions: To our knowledge, this is the first recorded completely minimally invasive bronchoplasty with or without an access port demonstrating that high technical tracheal repairs are feasible using the robot in high-risk patients.

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TV3 Video-Assisted Thoracic Surgery Bilobectomy with Bronchoplasty for Non-Small Cell Lung Cancer

Jae Hyun Jeon, Yoohwa Hwang, Hye-seon Kim, In Kyu Park, Chang Hyun Kang, Young Tae Kim. Seoul National University Hospital, Seoul, Republic of Korea.

Objective: This report describes a case report of bilobectomy with wedge bronchoplasty via video-assisted thoracoscopic surgery (VATS).

Methods: The patient was placed in the left lateral decubitus position. The pleural cavity was explored by VATS. Because there was suspicion of extra-nodal invasion to the right bronchus intermedius by metastatic subcarinal lymph nodes, bilobectomy with wedge bronchoplasty was performed by adjusting different sizes between the right main and upper lobe bronchus using 4-0 monofilament absorbable material.

Results: A 62-year-old asymptomatic woman was admitted to our hospital with suspicion of non-small cell lung cancer. A computed tomography of chest revealed a spiculated nodule in right lower lobe, as well as subcarinal lymph node enlargement. Subsequent biopsy revealed an adenocarcinoma with subcarinal lymph node involvement. The patient underwent bilobectomy with wedge bronchoplasty via VATS, and was discharged 8 days after operation without any complications.

Conclusions: VATS bilobectomy with wedge bronchoplasty is a feasible and safe technique of restoring the bronchial tree architecture.

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TV4 Robotic Segmentectomy, Previously Localized Lesion with Navigation Bronchoscopy and Dye Injection

Soni Chousleb, Michael I. Ebright, Virginia R. Litle, Hiran C. Fernando. Boston Medical Center, Boston, MA USA.

Objective: To present a novel approach for localization, for lesions that are not amenable to palpation.

Methods: Navigational bronchoscopy robotic segmentectomy.

Results: We present a case of a 7 mm nodule that was previously marked by navigational bronchoscopy that underwent a subsequent robotic segmentectomy.

Conclusions: We present an adjunct technique to help localize small lesions that may aid in the accuracy of our resections and also help the pathologist identify non palpable lesions.

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TV5 Left Upper Lobectomy Anterior Segmentectomy Guided by Preoperative Lipiodol Marking

Samina Park, Yoohwa Hwang, In K. Park, Chang H. Kang, Young T. Kim. Seoul National University Hospital, Seoul, Republic of Korea.

Objective: Persistent partly solid ground glass nodule (GGN) requires surgical resection, and VATS segmentectomy is often the preferred method.

Methods: However, when the lesion is deeply seated or located close to the intersegmental plane, it is difficult to determine an accurate resection plane which guarantees an adequate margin.

Results: In this video, we will be presenting a case of successful LUL anterior segmentectomy performed for a persistent partly solid GGN using a preoperative lipiodol marking technique.

Conclusions: Preoperative lipiodol localization technique enables us to perform complex segmentectomies in non-palpable GGN lesions.

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TV6 Robot-Assisted Bronchogenic Cyst Resection and Primary Repair of the Trachea

Raghav Murthy, Derek Williams, Kemp H. Kernstine. UT Southwestern Medical Center, Dallas, TX USA.

Objective: To demonstrate a robot-assisted method of bronchogenic cyst excision and primary repair of the trachea.

Methods: NA

Results: NA

Conclusions: This video demonstrates a bronchogenic cyst excision which is adherent to the trachea in a 16-year-old male. The surgical technique and tips for performing a successful operation are demonstrated.

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TV7 Minimally Invasive Resection of Large Duplication Cyst

Conor Hynes, Marc Margolis, M. Blair Marshall. Georgetown University Medical Center, Washington, DC USA.

Objective: The resection of large symptomatic intra-thoracic lesions may be an indication for a traditional open approach. Open approaches are associated with increased pain and morbidity when compared with their minimally invasive counterpart. However, some surgeons may not be comfortable using minimally invasive approaches for such lesions. We demonstrate the technical aspects of a minimally invasive resection of a large complex duplication cyst.

Methods: A symptomatic 47-year-old woman presented with a symptomatic thoracic cyst measuring 9 by 8 cm spanning between the pulmonary veins. For surgical resection, she was positioned prone to facilitate exposure. We used 4 ports: (3) 5 mm and (1) 10 mm with a 5 mm 30 degree camera. A combination of blunt and sharp dissection was used to prevent injury to surrounding structures. Intra-operative endoscopy was used, detaching the light cord from the thorascope to demonstrate the integrity of the esophageal mucosa.

Results: Pathology revealed ciliated respiratory epithelium. There were no complications. The chest tube was removed on post-operative day 1 and the patient was discharged to home. She was seen in follow-up two weeks and is well without symptoms or recurrence at 18 months.

Conclusions: Large complex intra-thoracic lesions can be safely resected with a combination of techniques. The exposure obtained with a thorascopic approach with the magnified view may be better than that obtained with an open approach. Intra-operative esophagoscopy with trans-illumination of the esophageal mucosa is useful to insure the integrity of esophageal mucosa. Large size does not necessitate an open approach.

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TV8 Hand-Assisted Minimally Invasive Repair of Recurrent Hiatal Hernia

M. Blair Marshall, Trevor Upham. Georgetown University Medical Center, Washington, DC USA.

Objective: Re-operative repair of recurrent hiatal hernia is often performed through open technique, in particular when the previous repair has been performed with open techniques. However, the view of the hiatus with an open approach can be difficult when performed via thoracotomy or laparotomy. Minimally invasive techniques using angled cameras that magnify the view often provide better visualization but the lack of tactile feedback is of concern in re-operative surgery. We present a combined technique with the use of the hand-port to demonstrate the optimal visualization in concert with the ability to use tactile feedback in re-operative hiatal surgery.

Methods: We present a 62-year-old male who underwent previous hiatal hernia repair through open abdominal approach over 20 years prior, recurred and underwent a left thoracotomy with Belsey repair in 1996. He recurred and underwent an endoscopic repair by his gastroenterologist in 2004. He presented in 2011 symptomatic from another recurrence. He was counseled on the need for a larger procedure given his frequent recurrences but he requested attempt at a repeat repair.

Results: The repair was performed with an upper midline hand-port, 3 additional 5 mm ports and one 10 mm port. A 5 mm 30° camera was used. The adhesions were lysed, the previous repair taken down. The esophagus was not shortened, so a porcine based mesh was used to reconstruct the hiatus and a modified fundoplication was performed with a temporary gastrostomy tube. He was discharged home on post-operative day 2 and is well without recurrence 18 months following the procedure.

Conclusions: Re-operative hiatal surgery, in particular after open procedures can be performed with minimally invasive techniques. The use of an angled camera affords excellent visualization of the hiatus and lower mediastinum. The hand-port allows for tactile feedback, critical for the proper identification of structures during re-operative surgery. This combined approach is ideal for re-operative hiatal surgery.

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TV9 Minimally Invasive Surgical Repair of a Huge Morgagni-Larrey Hernia

Desislav Vrachanski, Teodor Atanasov, Stoyan Sopotensky, Peter A. Tcherveniakov, Anthony Philipov, Alexander Tcherveniakov. Pirogov University Hospital, Sofia, Bulgaria.

FIGURE TV9-1
FIGURE TV9-1
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Objective: We demonstrate a minimally-invasive technique for surgical repair of a giant Morgagni-Larrey hernia. At two-year follow-up a 3D-CT and laparoscopy were performed.

Methods: Chest radiographs and 3D-CT were used for diagnostics. Five port laparoscopy was performed to correct the diaphragmatic defect.

Results: A 55-year-old patient presented with chest pain following a blunt thoracoabdominal trauma. Chest radiographs and a 3D-CT scan demonstrated a dense mass in the precordial space suspected to be a diaphragmatic rupture (Fig. TV9-1). Laparoscopy was performed to correct the defect which was a huge Morgagni-Larrey hernia and not a rupture. At follow-up after two years, a 3D-CT and laparoscopy were performed to evaluate the previous operation, and then to repair a port-site hernia. There were no intra- or postoperative complications.

Conclusions: The minimally-invasive surgical approach is safe and effective for repair of giant Morgagni-Larrey hernias (Fig. TV9-1).

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TV10 Robotic Resection of Giant Esophageal Leiomyoma

Soni Chousleb, Virginia R. Litle, Michael I. Ebright, Chaitan K. Narsule, Hiran C. Fernando. Boston Medical Center, Boston, MA USA.

Objective: To present a novel approach for large esophageal myomas.

Methods: Robotic-assisted resection.

Results: The patient tolerated the procedure well and did well postoperatively. Currently, she doesn’t have any dysphagia.

Conclusions: Minimally invasive techniques have revolutionized the world of surgery by decreasing pain and shortening the length of stay. Robotic approach currently offers all those benefits plus the advantage of a 3D view for the surgeon.

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TV11 Robotic-Assisted Intra-Pleural Cytoreductive Surgery and Hyperthermic Perfused Chemotherapy in the Staged, Definitive Treatment of Stage IVa Thymic Malignancy

Cliff P. Connery, Muhammad Farhan Nadeem, Sadiq Rehmani, Adnan M. Al-Ayoubi, Abdulbadee Bogis, Faiz Y. Bhora, Scott Belsley. St. Luke’s-Roosevelt Hospital, New York, NY USA.

Objective: Thymic epithelial neoplasms presenting with intrapleural disease can effectively be treated with maximum cytoreductive therapy after initial induction chemotherapy. Achieving an R-0 resection is challenging due to micrometastatic disease. Hyperthermic perfused intrapleural chemotherapy (ITH) has been described as a method to treat minimal residual disease with effective cytotoxicity while avoiding systemic toxicity. We report the feasibility of employing a da Vinci robotic-assisted approach for the resection of intrapleural disease and combined ITH as part of a multi-modality treatment for advanced thymic malignancy.

Methods: A 47-year-old woman presenting with ocular myasthenia gravis was diagnosed with a Masoaka Stage IVa, WHO Type B3 thymic malignancy with mediastinal invasion, extensive intrapleural disease including bulky interfissural pleural masses on presentation. She responded to systemic chemotherapy induction which facilitated transsternal resection of mediastinal tumor, partial pericardiectomy and en bloc wedge resection of medial right lung. One month following this procedure a da Vinci robotic-assisted right-sided cytoreductive operation resected all residual gross tumor. A one-hour ITH perfusion with cisplatinum and Adriamycin at 42-43 degrees C was completed.

Results: Technical aspects and results of the cytoreductive procedure and perfusion technique will be demonstrated in the video.

Conclusions: A minimally invasive approach as part of aggressive maximally invasive cytoreduction surgery is technically feasible and may allow earlier completion of staged multi-modality therapy for selected intrathoracic metastatic disorders. The distal articulated instrumentation of the da Vinci robot facilitated the resection of tumors in a technically challenging workspace. Hyperthermic perfusion was facilitated by having a portal approach which limited the potential for leakage of perfusate.

Copyright © 2014 by the International Society for Minimally Invasive Cardiothoracic Surgery

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