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Thoracic Track Abstracts

Innovations:Technology and Techniques in Cardiothoracic and Vascular Surgery: March/April 2013 - Volume 8 - Issue 2 - p 110–120
doi: 10.1097/IMI.0b013e3182964e27
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T1 The Effect of Fissure Development Score on Video-Assisted Thoracic Surgery for Lung Cancer

Seokkee Lee, Dae Joon Kim, Seong Yong Park, Mi Kyung Bae, Chang Young Lee, Jin Gu Lee, Kyung Young Chung. Yonsei University College of Medicine, Seoul, Republic of Korea.

Objective: The nature of pulmonary fissure development was an important factor for performing complete VATS lobectomy. The purpose of this study was to establish objective criteria for the pulmonary fissure development by using fissure development score (FDS) and to evaluate the effect of FDS on video-assisted thoracic surgery (VATS) lobectomy for lung cancer.

Methods: We have prospectively recorded a FDS since 2007. From January 2009 to December 2011, data of 444 consecutive patients who underwent VATS lobectomy for lung cancer were analyzed retrospectively (Table T1-1). The FDS is defined as Figure T1-1.

Results: 414 patients had a FDS score < 6 (group 1) and 30 patients had a FDS score ≥ 6 (group 2). There were significant differences between two groups for operation time (148.0 ± 48.1 vs. 196.8 ±58.8, p=0.000), duration of postoperative air leak (2.53 ± 3.8 vs. 7.23 ± 8.8, p=0.000), and length of hospital stay (6.66 ± 4.3 vs. 9.60 ± 5.9, p=0.000). Multiple linear regression analysis revealed that FDS adversely affected the operation time (β ± SE=0.008 ±0.002, p=0.000), duration of air leak (β ± SE=0.093 ± 0.021, p=0.000).

Conclusions: This study demonstrated that we were able to classify the status of fissure by using FDS, and higher FDS (FDS ≥ 6) was independent predictors for making longer operation and prolonged air leak after VATS lobectomy for lung cancer.



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T2 Robotic vs. Open Lymphadenectomy in C-Stage I Non-Small-Cell-Lung-Cancer: Feasibility and Adequacy

Olivia Fanucchi, Alfredo Mussi, Federico Davini, Francesca Allidi, Marco Lucchi, Marcello Carlo Ambrogi, Franca Melfi. Division of Thoracic Surgery, University of Pisa, Italy.

Objective: Over the last ten years, the role of minimally-invasive robotic surgery for treatment of early-stage NSCLC has been increased. However, the adequacy of lymphadenectomy achieved with robotic approach is still a debated issue. The aim of the study was to analyze and compare the adequacy of lymph node dissection, for clinical stage I NSCLC patients, performed through the open or the robotic approach.



Methods: Between January 2009 and November 2012, we retrospectively reviewed all NSCLC patients judged cStage I who underwent major lung resection, by thoracotomy or robotic approach. Clinical and demographic data of each patient were collected. The total number of removed lymph node and the number of dissected lymph node mediastinal stations were recorded. Post-operative data were collected.

Results: 299 patients underwent thoracotomic lobectomy, while 93 patients underwent robotic lobectomy. The two groups were comparable in terms of age, sex ratio, FEV1 value. The mean total number of dissected lymph node was 15 (range 10–33) for the thoracotomic group, and 16 (range 11–29) for the robotic group, with no significant difference (p=0.34). The number of dissected mediastinal stations was 3.2 (range 3–4) in the thoracotomic group and 3.4 (range 3–5) in the robotic group. A tendency toward higher number of dissected lymph node mediastinal stations was observed for the robotic group in respect to the thoracotomic group, even if with no statistically-significant difference (p=0.08).

Conclusions: The adequacy of lymphadenectomy in patients who underwent lobectomy for early stage NSCLC appears to be comparable between the thoracotomic and the robotic approach. Further studies on large series are necessary in order to support this data.

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T3 Robotic Lobectomy is Financially Feasible Despite Inclusion of Capital Costs

Jordan R. Sasson, Hassan Sheik Moghaddas, Sadiq Rehmani, Sarah Almubarak, Cliff Connery, Scott J. Belsley, Faiz Y. Bhora. St Luke’s-Roosevelt Hospital Center, University Hospital of Columbia University College of Physicians and Surgeons, New York, NY USA.

Objective: Minimally invasive lobectomy (MIL) is felt to provide equivalent oncologic outcomes when compared with open lobectomy for early stage NSCLC. VATS lobectomy is a technically demanding procedure, hence its limited widespread adoption. The da Vinci robot, with wristed articulating instruments, provides significantly increased dexterity which may facilitate greater use of MIL. There remains concern however, regarding the cost-benefit of this emerging technology.

Methods: We conducted a retrospective review of 56 lobectomies performed at our institution by either VATS (n=29) or with robotic assistance (n=27) from 2010 to early 2012. Preoperative patient characteristics including demographics, cardiovascular co-morbidities and pulmonary function tests were noted. For all cases, disease stage, tumor size, number of lymph nodes sampled, post-operative complications and length of stay (LOS) were recorded. In addition, direct and indirect costs related to both surgical approaches were captured and a profit/loss margin was generated.

Results: Both cohorts were comparable based on preoperative patient profiles and disease stage. Mean LOS was 3 days in both groups. Average DRG based revenue per case was approximately $28,365 with an average case mix index (CMI) of 2.7. Total cost per robotic case is $23,179 which includes the capital expenditure of the robot that has been amortized over 8 years as well as annual maintenance fees. On the other hand, the total cost of a VATS lobectomy is approximately $17,000. Overall, the profit margin for robotic lobectomy is approximately $5,186 compared with $11,000 for VATS.

Conclusions: Robotic thoracic surgery is significantly profitable for the institution, despite the inclusion of overhead capital and annual service contract costs. With a further increase in volume of robotic cases at an institution, indirect costs attributed to each case would be decreased, and result in an increase in profit margin/case.

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T4 Non-Intubated Thoracoscopic Pulmonary Nodule Resection Under Spontaneous-Breathing Anesthesia With Laryngeal Mask

Olivia Fanucchi 1, Marcello Carlo Ambrogi1, Stylianos Korasidis1, Franca Melfi1, Federico Davini1, Raffaello Gemignani2, Fabio Guarracino2, Alfredo Mussi1. 1Division of Thoracic Surgery, Pisa, Italy, 2Division of Anaesthesia and Intensive Care, Pisa, Italy.

Objective: During the past twenty years, video-assisted thoracoscopic surgery has been increased as an important minimally-invasive tool. Recently, to further reduce its invasiveness, we experienced non-intubated spontaneous-breathing general anesthesia with laryngeal mask (LMA) for several thoracoscopic procedures. Herein we report our experience with peripheral lung nodule resections.

Methods: We prospectively selected 20 patients to undergo thoracoscopic wedge resection of peripheral lung nodules under LMA. General inhalatory anesthesia (sevoflurane) was performed in all cases through a laryngeal mask, without muscle relaxants, thus allowing spontaneous breathing. All procedures were performed in the lateral decubitus position. The maximum and minimum values of end-tidal carbon dioxide tension (EtCO2) and oxygen saturation (SaO2) were recorded during the procedure. The level of technical feasibility was stratified by the operating surgeon according to 4 levels: excellent, good, satisfactory and unsatisfactory.

Results: They were 13 males and 7 females (mean age 57 years). The mean induction anesthesia time was 6 (range 5–10) minutes, while mean operative time was 38 (range 25–55) minutes. The values of SaO2, and minimum and maximum EtCO2 were 99.1%, 33.6 mmHg, and 39.1 mmHg, respectively. No mask displacement occurred. The level of technical feasibility was defined excellent in 19 cases, good in 1. No mortality occurred. Morbidity consisted in minimal pleural effusion in 1 case. The mean post-operative stay was 3.5 days (range 3–5).

Conclusions: This study suggests that non-intubated thoracoscopic wedge resection of lung nodule is safe and feasible under spontaneous breathing anesthesia with laryngeal mask. The technique permits a confident manipulation of lung parenchyma and a safe stapler positioning, without cough, pain or panic attack described for awake epidural anesthesia, avoiding the risks related with tracheal intubation and mechanical ventilation.

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T5 Patients’ Selection for the VATS Anatomic Pulmonary Resections

Vadim Pischik, Eugeny Zinchenko, Alexander Obornev. Federal Hospital N

122, Saint Petersburg, Russian Federation.

Objective: VATS became the preferable approach for anatomic pulmonary resections. However, rate of conversion to open surgery is still around 10–15%. Hence, proper patients’ selection for VATS-lobectomy is the point for the discussion.

Methods: Eighty-three cases of anatomic pulmonary resection by VATS as well as 4 conversions to open surgery performed by the single surgeon from January 2011 to October 2012 at Federal Hospital in St. Petersburg, Russia, were retrospectively analyzed. Thirty-nine patients were males and 44 females, aged from 21 to 87 years. Anatomic resections included 5 segmentectomies, 76 lobectomies and 2 left pneumonectomies. Procedures included two bronchoplasties for the centrally located tumors and two chest wall resections. Most of the cases comprised I–III staged lung cancer together with bronchiectasis and tuberculomas. Eighteen percent of patients had FIV1 <70% of predicted, 45% had Charlson comorbidity index of 5 points and more and 32% were older than 70 years old. Five patients had tumor size more than 5 cm.

Results: There was one case of intraoperative bleeding after a stapler fault, and no cases of 30-day mortality. The most common morbidity was prolonged air leak and hyperexudation after lymphonodes dissection. Time in ICU ranged from 0 to 2 days, chest tube removed from day 1 to 24 (mean 4.8 ± 5.4). Postoperative length of stay consisted of 3–24 days (mean 7.7 ± 4.8). Neither pleural adhesions nor pulmonary emphysema or fissure absents did not lead to conversion. Most of the unplanned thoracotomies were caused by mediastinal lymph nodes calcification after recovery from pulmonary tuberculosis clearly revealed on preoperative chest CT.

Conclusions: VATS should be considered the primary surgical approach for anatomic lung resections because of low postoperative morbidity and shorter hospitalization. It is reasonable to attempt a thoracoscopic approach for stage I to III NSCLC and benign pulmonary diseases. Peribronchial and perivascular lymph node calcification at preoperative image is able to complicate and even preclude VATS while pleural adhesions, tumor size, emphysema and lack of fissure do not.

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T6 Mediastinal Lymph Node Dissection in Totally Thoracoscopic Surgery Using a Bipolar Sealing Device

Mitsuhiro Kamiyoshihara 1, Hitoshi Igai1, Takashi Ibe1, Natsuko Kawatani1, Seshiru Nakazawa2, Jun Atsumi2, Yoichi Otak2, Kai Obayashi2, Toshiteru Nagahima2, Seiichi Kakegawa2, Masayuki Sugano2, Osamu Kawashima2, Kimihiro Shimizu2, Izumi Takeyoshi2. 1Maebashi Red Cross Hospital, Maebashi, Japan, 2Gunma University Graduate School of Medicine, Maebashi, Japan.

Objective: Radical surgery for primary lung cancer by thoracoscopy has been widely adopted. As thoracoscopic surgery provides a magnified visual field, it facilitates visualization of fine vessels and lymphatics in mediastinal lymph node dissection. However, thoracoscopic surgery has a number of disadvantages compared with thoracotomy. To resolve these problems, we adopted a new bipolar sealing device. The use of a bipolar sealing device has not been reported previously. The purpose of this study was to investigate the use of a new bipolar sealing device in mediastinal lymph node dissection during thoracoscopic surgery.

Methods: The study population consisted of 42 consecutive patients undergoing lobectomy with right superior mediastinal lymph node dissection for primary lung cancer. Operative results were compared with those of conventional surgery in 42 background-matched controls. The primary end point for the present analysis was the success of mediastinal lymph node dissection during thoracoscopic surgery using a bipolar sealing device. The secondary end points included the duration of the operation, number of dissected lymph nodes, chest drainage volume and duration, postoperative hospital stay, morbidity, and mortality.

Results: The bipolar sealing device was used successfully in 42 patients. No significant difference in duration of lymph node dissection, chest drainage volume, drainage duration, or number of dissected lymph nodes was observed between the study group and controls. Total blood loss was significantly less in the bipolar sealing device group than in the control group. Due to a learning curve, the procedure initially took more than 20 min. to complete, but surgical time was reduced to about 15 min. after the procedure was performed in 15 patients.

Conclusions: Our method is safe and in no way inferior to the conventional procedure. The tendency of the learning curve suggests that a significantly shorter duration of lymph node dissection is possible using this method.

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T7 Thoracoscopic Decortication is Better than Open Decortication: A Comparative Study in Empyema Advanced Stages

Miguel Congregado, Sergio Moreno-Merino, Rafael Jimenez-Merchan, Gregorio Gallardo, Fernando Cozar, Jesus Loscertales. Virgen Macarena University Hospital, Sevilla, Spain.

Objective: Empyema is a severe condition, which needs adequate and expeditious treatment. Different modalities can be considered, from single-drainage placement to open-window thoracostomy. Videothoracoscopic decortication joints the goal of good lung re-expansion with minimally invasive surgery, but in chronic pleural empyema sometimes this procedure is not easy and requires conversion to open surgery. The aim of this paper is to evaluate the feasibility of this approach in such cases and to perform a comparative study with open decortication.

Methods: We have performed a retrospective comparative analysis of a prospective database. From 2000 to 2011,186 patients were admitted in our department suffering empyema. Sixty (32.8%) of them needed decortication, 27 by videothoracoscopy (Group A) and 34 by thoracotomy (Group B). Variables: operative time, complications, days of drainages, postoperative length of stay (LOS) and mortality. Statistical analysis: homogeneity between videothoracoscopic and thoracotomy groups was evaluated. t-Student test was used for continuous variable, unpaired t-test was used for operative time, LOS and days of drainage. Chi2 test was used for categorical data. Significance level p=0.05 (SSPS 17 Software).

Results: Pleural decortication was performed in stage III chronic empyema with excellent results and only 3 patients needed conversion (11.1%). Comparison: operative time: Group A 135 minutes (65–175), Group B 160 min. (90–240) NS; complications: An 8.2%, B 14.7% p<0.05; days of drainage: A 5.9 ± 2 days, B 9.3%±2 days p<0.05; LOS: A 7.8 days, B 11.4 days p<0.05; mortality: A 1 (1.6%), B 3 (4.9%) NS.

Conclusions: Videothoracoscopic decortication is a feasible procedure in stage III empyema with equally effective resolution as thoracotomy. Furthermore, in our series, it has better results in operative time, postoperative morbidity and length of stay. Multicentric-randomized trial should be performed to suggest this approach as gold standard of pleural empyema.

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T8 One-Stage Approach to Bilateral Pulmonary Metastasis Assisted by Thoracoscopy: Is It Feasible?

Kook Nam Han 1, Chang Hyun Kang1, Young Tae Kim1, In Kyu Park1, Joo Hyun Kim2. 1Seoul National University Hospital, Seoul, Republic of Korea; 2Lung Cancer Center, Dongnam Institution of Radiological and Medical Sciences, Busan, Republic of Korea.

Objective: It has not been verified whether simultaneous bilateral pulmonary metastasectomy (BPM) on each hemithorax is feasible risky with a staged-approach. The aim of this study was to elucidate the outcomes and feasibility of simultaneous BPM by thoracoscopic surgery in bilateral pulmonary metastasis from extrathoracic malignancy.

Methods: From June 2005 to July 2012, 94 planned BPMs were performed as a staged (n = 43) or simultaneously (n = 51) operation. The approaches in both staged and simultaneous operations included bilateral thoracotomy, thoracoscopic surgery, a combination of both methods, and sternotomy. We retrospectively analyzed the feasibility by reviewing the completion time of BPM, operative morbidity and changes in pulmonary reserves after BPM for each of the approaches and sequences. Intrathoracic recurrence of one-stage thoracoscopic BPM was compared to those of staged bilateral thoracotomy.

Results: Bilateral thoracotomy was performed in 31 staged BPMs and there were 484 positive nodules out of 861 nodules resected at the time of pathologic examination (56.2%). Forty-two simultaneous BPMs by thoracoscopy were done and out of 273 nodules, 159 (58.2%) were positive. In a staged BPM, the median postoperative time after the first resection was 6 days (3–36). The second operation was performed after a median interval of 24 days (8–97) and the second median postoperative time was 6 days (3–35). The median total completion time for staged BPM was 37 days (17–111) while it was 5 days (2–15) for one-stage BPM. One-stage thoracoscopic BPMs (n = 42) had a low operative morbidity (p=0.024) and less reduction in pulmonary function (FVC; 11.9%, FEV1; 7.3%) compared to staged BPMs (FVC; 25.9%, FEV1; 24.1%) over a mean follow-up period of 28 months (Figure T8-1). One-stage BPMs by thoracoscopy were able to achieve comparable intrathoracic recurrences than that of staged BPMs by thoracotomy (p=0.143).



Conclusions: A simultaneous bilateral thoracoscopic metastasectomy is a feasible strategy in indicated patients with acceptable operative morbidity and intrathoracic recurrences.

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T9 Thymoma: The Role of VATS Thymectomy and Analysis of the Relationship Between Istology WHO, Staging Masaoka and Myasthenia Gravis

Giorgio Cavallesco, Pio Maniscalco, Francesco Quarantotto, Nicola Tamburini, William Grossi, Elena Garelli. Department General and Thoracic Surgery, Ferrara, Italy.

Objective: The objective goal of our study is to identify the possible relationships between WHO histologic classification, staging Masaoka and MG in terms of survival.

Methods: Between 1995 and 2010, 81 patients submitted to our department, 37 (41%) were affected by thymomas. Histologic subtype and clinicopathological staging were classified according to WHO (group 1 and 2) and Masaoka (early stage E, invasive stage I) criteria. We performed a multivariate analysis using three variables (MG, WHO subtypes and Masaoka stages) and the statistical significance of values was examined with Fisher exact test (p<0.05).

Results: Patients were divided according to WHO classification and Masaoka staging system: group 1 (%) and group 2 (%); stage E (%) and stage I (%). Myasthenic patients (33%) showed early Masaoka stages in 83% of cases. In the matter of WHO classification: group 1 was shown in 75% of cases, group 2 in 25% of cases. We performed 37 thymectomies: 15 VATS and 22 OPEN. 95% of patients underwent resection with radical aim (R0) and the remaining 5% underwent debulking surgery. VATS had less time of surgery and postoperative hospital stay than OPEN technique. Multivariate analysis shows significant relationship (p<0.003) respectively between groups 1 and 2 and stages E and I. The overall survival at 12, 24 and 60 months was respectively 100%, 91.0% and 79.0%. Furthermore, early stages show significantly better survival (p<0.0226) than invasive stages.

Conclusions: There exists a statistically significant correlation between WHO classification and staging Masaoka; the latter appears to have the most important prognostic impact on outcome and survival of patients. Myasthenia gravis is related to early Masaoka stages and it is not a bad prognostic factor; however, it appears to influence negatively on post-operative outcome in terms of postoperative complications and period of hospitalization. VATS is a safe operation and has comparable effectiveness to OPEN technique in terms of oncological radicality, for early stages. Open approach is to prefer in invasive stages, because it allows a good control in the extension of disease in terms of observing oncological radicality.

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T10 Pectus Excavatum: A Comparison of the Ravitch Repair with the Nuss Thoracoscopic Technique with a Standard Metallic Bar or an Absorbable Bar

Magdi Ibrahim Ahmad Muhammad. Department of Cardio-Thoracic Surgery, Faculty of Medicine, Suez Canal University, Ismaïlia, Egypt; Department of Cardio-Thoracic Surgery, King Fahd Hospital, Al-Madina Al-Munawara, Saudi Arabia.

Objective: The aim of this study is to identify the preoperative characteristics and to compare operative variables and postoperative outcomes in adult patients with pectus excavatum undergoing thoracoscopic repair using different bar stabilizers versus surgical repair.

Methods: We conducted a prospective study from July 2009 to July 2012 in our Thoracic Surgery Department at King Fahd Hospital. They were 31 patients (26 male and 5 female) aged 18–35 years. Patients were subdivided into three groups: group (A) 9 patients underwent modified Ravitch repair, group (B) 11 patients underwent video-assisted thoracoscopic repair using metal stabilizers and group (C) 11 patients underwent video-assisted thoracoscopic repair using absorbable stabilizers. Preoperative, intra-operative, postoperative variables and mortality are compared in all groups.

Results: In all groups, preoperative variables were well matched for age and sex. Operative time was statistically highly significant; it was longer in Group (A). There was no intra-operative complication in all groups. Postoperative length of hospital stay was statistically significant; it was shorter in Group (A). Postoperative complications occurred in seven patients (22.6%) mostly in group (B) and group (C). There was no perioperative mortality in all groups. All patients were satisfied with the cosmetic results.

Conclusions: Video-assisted thoracoscopic repair of pectus excavatum in adult patients can be performed safely using either metallic or absorbable bar stabilizer with no intra-operative complications and excellent immediate results, but absorbable bar stabilizers are more vulnerable and break easier than metal stabilizers.

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TMP1 Transcollation Technique vs. Stapler Resection for the Treatment of Spontaneous Pneumothorax

Carmelina C. Zirafa, Marcello C. Ambrogi, Olivia Fanucchi, Federico Davini, Franca Melfi, Alfredo Mussi. Division of Thoracic Surgery, University of Pisa, Pisa, Italy.

Objective: Further improvements in the thoracoscopic treatment of spontaneous pneumothorax may reduce the already low invasiveness of the procedure. We recently experienced a new technique, with cold-coagulation of blebs and bullae (transcollation), in opposition to endostapler resection.

Methods: We reviewed from our surgical database those patients with recurrent or persistent spontaneous pneumothorax who underwent thoracoscopic treatment in the period 2004–2010. Those with blebs or small bullae (Stage III and IV according with Vanderschueren’s classification) were treated with standard stapler resection (Group 1) or transcollation (Group 2), according to the preference of the operative surgeon. Transcollation technique is performed by a 5-mm device which couples saline solution perfusion with radiofrequency energy. This allows coagulate tissues avoiding charring or burning.

Results: 126 patients were eligible, 74 in Group 1 and 52 in Group 2. They were 96 men and 30 women with a mean age of 29.6 years, without significant differences between the two groups. The procedure lasted on average 42 minutes in Group 1 and 33 minutes in Group 2 (p <0.05). Mean number of thoracoscopic incisions was 2.9 in Group 1 and 2.1 in Group 2 (p <0.05). A prolonged post-operative air leak occurred in 7 patients of Group 1 (9.5%) and in 2 patients of Group 2 (3.8%) (p = ns). Mean hospital stay was 5.1 and 3.8 days in Group 1 and 2, respectively (p = ns). At a mean follow-up period of 49 months (range 18-89), we recorded 6 relapses in Group 1 (8.1%) and one in Group 2 (1.9%) (p = ns).

Conclusions: Transcollation technique seems to be effective in the treatment of primary spontaneous pneumothorax. Due to its clear advantages (i.e., less invasiveness, easiness, quickness), it could be preferred to standard technique with stapler resection.

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TMP2 Clinical Features of Catamenial Pneumothorax

Mikhail Atyukov 1, Vadim Pischik2, Alexander Obornev2, Peter Yablonsky3. 1City Hospital № 2, Saint Petersburg, Russian Federation, 2Federal Hospital № 122, Saint Petersburg, Russian Federation, 3State University, Faculty of Medicine, Saint Petersburg, Russian Federation.

Objective: Catamenial pneumothorax is still considered to be a very rare condition. It is also considered to be rather difficult to diagnose and the rate of recurrences is very high. The aim of this work is to estimate the frequency of catamenial pneumothorax, to improve results of its treatment.

Methods: Retrospective analysis of clinical data of 86 women of reproductive age with spontaneous pneumothorax and visual examination of pleural cavity since January 2004 to January 2012.

Results: Catamenial pneumothorax consisted 16.2% of women with spontaneous pneumothorax, while in the group of recurrent right-sided pneumothoraces it comprised as much as 36%. Patients were divided into 2 groups: with catamenial pneumothorax (CP) (14 patients) and with other forms of spontaneous pneumothorax (SP) (72 women). Mean age in CP-group was 40.1 ± 5.9 years, meanwhile, in SP-group mean age was 32.3 ± 10.2 years. All cases of CP - 100%, were right-sided, while in the group of SP right lung was affected only in 68% of cases (49 women). In all 14 patients with CP diaphragmatic fenestrations and lesions were found. Neither pleural nor lung endometrial implants were discovered. In the SP group the diaphragm was intact in all patients. Different types of endometriosis were diagnosed in 7 of 14 (50%) patients with CP, while in another group it was present only in 2 patients (2.8%). All 14 women with CP were operated by VATS. Surgical treatment consisted of resection of porous diaphragm with induction of pleurodesis (13 costal pleurectomies, 1 scarification). Surgical treatment was accomplished with conservative treatment with GN-RH analogues or estrogens for 3–6 months After surgical treatment only 1 patient had recurrence within 1 month (without conservative treatment).

Conclusions: Catamenial pneumothorax accounts for about 16% of all pneumothoraces in women of reproductive age and up to 36% in women with recurrent right-sided pneumothoraces. Women with CP are significantly older then those with SP. Most reliable diagnostic signs of CP are diaphragmatic perforations and endometriosis of different localization. Combined surgical and conservative treatment is trustworthy, especially, when pleurodesis is performed.

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TMP3 A Clinical and Histopathological Study of the Intrathoracic Application and Resorption of Cotton-Derived Oxidized Cellulose Hemostatic Gauze

Biruta Witte 1, Stefan Gross1, Stefan M. Kroeber2, Michael Wolf1, Hubertus Hillebrand1, Martin Huertgen1. 1Katholisches Klinikum Koblenz-Montabaur, Koblenz, Germany, 2Institute of Pathology, Koblenz, Germany.

Objective: Pilot clinical human in-vivo study of the intrathoracic application of a cotton-derived oxydized cellulose gauze with regard to resorption, clinical performance and safety.

Methods: Prospective non-comparative observational study with the primary endpoint defined as the local presence of gauze remnants, fluid collections and adhesions, and a secondary safety endpoint defined as the number of adverse events and surgical re-interventions. For this purpose, a defined amount of gauze was inserted in the subcarinal space of patients with resectable lung carcinoma at staging video-assisted mediastinoscopic lymphadenectomy, and re-examined several days later at subsequent lung resection for macroscopic and histologic evaluation.

Results: 25 consecutive patients were included from June 2008 to January 2009. The desired hemostatic effect was achieved in all cases. No adverse events were observed. At reexploration, the subcarinal space appeared clean and free of inflammatory changes and scars. The residuals of oxidized cellulose were losing their solid structure five days after insertion, and were last detected two weeks after insertion.

Conclusions: The mediastinal application of cotton-derived oxidized cellulose is safe and effective. A piece of gauze measuring 5 × 20 cm is absorbed completely within 14 days. Beyond the known hemostatic effect, the absence of inflammation, and the reduced formation of seroma and adhesions are of surgical interest and should be confirmed by a larger comparative study.

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T11 Initial Experience with Intra-operative Near-infrared Fluorescence Imaging as a Novel Adjunct to Robotic-Assisted Minimally Invasive Esophagectomy

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

Objective: During robotic-assisted minimally invasive esophagectomy (RAMIE), identification and preservation of the right gastroepiploic vascular arcade is critical. The objective of this study was to assess the use of near-infrared fluorescence imaging (NIFI) as an aid to visualization of this structure during gastric mobilization.

Methods: After administration of 10 mg intravenous indocyanine green (ICG), a robotic platform with near-infrared optical fluorescence capability was used to examine gastric vasculature in consecutive patients undergoing RAMIE during the study period. Time from drug delivery to fluorescence was measured. The ability of NIFI to discern the termination of the gastroepiploic arcade from the short gastric arteries was assessed.

Results: From February 14, 2012 – October 22, 2012, 18 of 23 patients undergoing RAMIE were evaluated with ICG administration and NIFI during mobilization of the greater gastric curve and fundus. Five patients were excluded: 1 patient with documented allergy to iodinated CT contrast and 4 patients for which the NIFI optical system was not available. Median time from ICG bolus to detectable fluorescence was 45 seconds. NIFI was able to identify or confirm termination of the vascular arcade at the fundus as distinct from the short gastric arteries in 100% (18/18) of cases. Subjectively, NIFI often identified otherwise non-visualized small transverse vessels between the termination of the vascular arcade and first short gastric artery, as well as between the short gastric arteries. Identification and/or confirmation of the vascular arcade position during greater curve/omental mobilization was/were also aided by NIFI. In one patient, NIFI confirmed poor vascularization of the proximal conduit, which was resected and excluded from the anastomosis.

Conclusions: While standard visual identification of critical vascular structures during RAMIE is feasible in the majority of cases, NIFI is a useful adjunct to confirm, and in some cases identify, the position of these vessels. This may allow for safer and more confident dissection during gastric mobilization and conduit preparation, preservation of otherwise non-identified vascular supply to the proximal conduit, and potentially decrease serious vascular misadventures during mobilization of the stomach.

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T12 A Comparison of Minimally Invasive and Open Esophagectomy with Thoracic Anastomosis

Sebastien Gilbert 1, Andre Martel2, Azzi Alain2, Donna Maziak1, Andrew Seely1, Farid Shamji1, Patrick James Villeneuve1, Sudhir Sundaresan1. 1Division of Thoracic Surgery, University of Ottawa, Ottawa, ON Canada, 2University of Ottawa, Ottawa, ON Canada.

Objective: Comparisons of minimally invasive (MIE) and open esophagectomy (OE) have previously focused on MIE with cervical anastomosis. Our goal was to compare perioperative outcomes following MIE and OE with thoracic anastomosis.



Methods: Retrospective review of esophagectomy patients matched 1:1 using propensity scoring for age, gender, histology, neoadjuvant therapy, and pathologic stage. All patients had a thoracic, esophago-gastric anastomosis.

Results: From 2002–2012, a total of 60 patients were successfully matched (MIE=30; OE=30). Stapled anastomoses were more frequent in MIE patients (100% vs. 16.7%; p<0.001). Median lymph node yield was 28 ± 13 after MIE and 11 ± 8 after OE (p<0.001). Complete resection rates were similar (MIE=73%; OE=76.7%; p=0.52). Most incomplete resections (89%) were due to focally positive, microscopic radial margins. The proportion of patients who experienced at least one complication was similar (MIE=20/30 (66.7%); OE=25/30 (83.3%); p=0.23). On average, MIE patients had significantly less complications (MIE=1.6 ± 0.2; OE= 2.2 ± 0.2; p=0.01). Respiratory complications were equally common in both groups (MIE=36.6%; OE=33.3%; p=1.0). There was a trend toward a lower anastomotic leak rate in the MIE group (MIE=6.7%; OE=23.3%;p=0.07). There was no operative mortality and no significant difference in the severity (grades I-V) of complications (Table T12-1). Mean hospital stay was significantly shorter after MIE (11 ± 1.1 vs. 18 ± 2 days; p=0.005).

Conclusions: MIE was associated with a decreased number of complications and shorter hospitalization. MIE and OE appear equally safe and effective approaches to esophagectomy with thoracic anastomosis. Prospective data is needed to determine which approach, if any, is associated with optimal perioperative outcomes.

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T13 High Intrathoracic Anastomosis is Feasible with 28 mm Circular Stapler in Minimally Invasive Esophagectomy

Hyun-Woo Jeon, Sook Whan Sung, Byung Su Yoo, Kyung Soo Kim, Jae Kil Park, Kyo Young Song. St. Mary’s Hospital, Seoul, Republic of Korea.

Objective: Minimally invasive esophagectomy has been one of the fascinating treatment modality for esophageal cancer, though intrathoracic anastomosis using thoracoscopy is still difficult to be considered and a few centers tend to adopt this technique. While most studies demonstrated that intrathoracic anastomosis was carried out at the level of the azygos vein, we performed high intrathoracic anastomosis above the aortic arch using the 28 mm circular stapler. we are going to present our experience and outcomes in patients with esophageal cancer treated by high intrathoracic circular anastomosis under thoracosopy.

Methods: A retrospective review evaluated consecutive patients undergoing MIE for esophageal cancer with high intrathoracic anastomosis using 28 mm EEA circular stapler. From September 2010 to December 2012, 26 patients underwent minimally invasive Ivor Lewis esophagectomy. Stomach was mobilized laparoscopically, and esophagectomy followed by reconstruction with grafted stomach was performed thoracoscopically. The anastomosis was carried out at the level of T3 by a 28 mm circular stapler.

Results: Mean age was 66 years (51∼82). They were all squamous cell carcinoma. Mean operation time was 382 minutes (270∼540) and thoracoscopic procedure was 261 minutes (180∼355). Mean number of lymph nodes dissection was 28 (11∼49). Mean ICU and hospital stay was 1 day (0∼20) and 15 days (8∼54), respectively. There was no conversion to the thoracotomy. Three patients developed major complications (11%). Of which, one patient died from multi-organ failure after postoperative ARF and one other patient died of uncontrolled sepsis due to necrosis of gastric tube; overall hospital mortality was 7.7% (2/26). Two patients developed postoperative leakage including the above mentioned patient with gastric tube necrosis (7.7%). The other patient was managed with conservative measure for contained leakage. This patient developed anastomotic stricture 2 months after discharge. Three patients developed transient hoarseness, but was recovered without sequale. Median follow-up was 10 months (0∼27). 24 patients were alive without local recurrence and distant metastasis.

Conclusions: High intrathoracic anastomosis using 28 mm circular stapler under thoracoscopy is feasible and safe in minimally invasive Ivor Lewis esophagectomy for esophageal cancer, although the procedures of EEA anastomosis is time consuming and difficult in the early phase of technical maturation.

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T14 Video-Assisted Transhiatal Mediastinoscopic Approach of Transhiatal Esophagectomy Can Reduce Hemodynamic Instability during Surgery

Hyo-Chul Youn. Department of Thoracic and Cardiovascular Surgery, Kyung Hee University Medical Center, Seoul, Republic of Korea.

Objective: During transhiatal exploration of transhiatal esophagectomy (THE), blunt dissection could make heart displacement, especially left atrium, and induce unexpected systemic hypotention, which could interrupt the procedure. To reduce such an unexpected event during surgery, we introduced a new transhiatal approach method using video-assisted mediastinscopy.

Methods: Two patients underwent the video-assisted THE because of esophageal squamous cell carcinoma. One site was lower esophagus and the other was mid-esophagus. These patients’ physical status were not suitable for Ivor Lewis operation especially due to decreased lung function.

Results: The patients were supine positioned and upper median laparotomy was performed. After gastric mobilization and tube formation, we introduced a video-assisted mediastinoscopy through the esophageal hiatus into the posterior mediastinal space and dissected the esophagus from the adjacent tissue with a harmonic scalpel up to azygous vein level without making any hemodynamic instability. After cervical collar incision, we reintroduced a mediastinoscope into the posterior side of the trachea; then freed the esophagus and performed mediastinal lymph node dissection under direct vision with video-assisted mediastinoscopy. We gently pulled out the esophagus with gastric tube through the thoracic inlet without any unexpected bleeding and then completed esophagectomy and esophagogastrostomy with EEA.

Conclusions: THE has its drawbacks, such as incomplete mediastinal lymph node dissection and hemodynamic instability during surgery. So we introduced a transhiatal video-assisted mediastinoscopic THE, which can facilitate the procedure and also reduce unexpected hemodynamic event during surgery.

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T15 Early Experience of Minimally Invasive Esophagectomy in the Gulf Region

Mariam J. Almarashda, Awad M. Elkarim, Iman M. Albeloushi, Amgad E. Elsherif. Tawam Hospital, Al Ain, United Arab Emirates.

Objective: Esophagectomy remains one of the technically challenging operations with a high perioperative morbidity. The main goal of minimally invasive esophagectomy (MIE) is to decrease the high morbidity of traditional esophagectomy. MIE is becoming standard approach in different institutions. Developing the skills for MIE is associated with a steep learning curve. We report our early experience of MIE in the Persian Gulf countries.

Methods: Fourteen patients (3 females) underwent MIE between 2009 and 2012. Indications for esophagectomy included: high-grade dysplasia, giant leiomyoma, neuroendocrine tumor and esophageal cancer. All cancer patients received neoadjuvant concurrent chemoradiotherapy after radiological staging.

Results: MIE approach was achieved in all patients (12 laparoscopic/thoracoscopic Ivor Lewis, 2 with laparoscopic/thoracoscopic with neck anastmosis). The median age was 44.5 (range from 22 to 65). All esophageal cancer patients had negative margins with complete pathological response (7 adenocarcinoma, 5 squamous). There was no operative mortality, postoperative morbidity included laryngeal nerve paresis (one patient) ARDS (one patient). At 35 months median follow-up (range 12–47) one patient died from lung metastasis and one developed brain metastasis. Other patients are with no evidence of disease.

Conclusions: With the learning curve, MIE is a reproducible technique and should gain more popularity in our region as it is in other countries. To our knowledge, this is the first cohort of MIE in the Gulf region. MIE is feasible following preoperative chemoradiation therapy.

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TMP4 Video-Assisted Thoracoscopic Resection of Suspected Metastatic Pulmonary Nodule after Microcoil Localization

Sami A. Alnassar Sr. King Saud University, Riyadh, Saudi Arabia.

Objective: Newly developed pulmonary nodule less than 20 mm in diameter in patients with a previous history of malignancy is highly suspicious to be metastatic. In this study we evaluate a new technique of computed tomography microcoils localization to facilitate thoracoscopic resection of deep pulmonary nodule.

Methods: 20 patients with past history of cancer who discovered to have lung nodules (less than 20 mm) during follow-up underwent CT-scan guided microcoil localization, then video-assisted thoracoscopic resection under fluoroscopy. The microcoil was deployed through or adjacent to the nodule with distal end of the coil placed deep to the nodule and the proximal end on the lung surface; then the coil was excised completely using endostaplers guided by fluoroscopy.

Results: CT-scan guided microcoil placement was successful in all cases; however, one coil was displaced at the time of lung isolation. There was no mortality, but a small pneumothorax occurred in 2 patients, who were managed conservatively. Mean operative time was 57.5 ± 25.5 minutes, microcoil localization time was 47 ± 15 minutes, and fluoroscopy time was 3 ± 1.2 minutes. The resected nodules showed 10 (50%) metastatic in origin, 7 (35%) nodules inflammatory or granulomatous disease, and 3 (15%) nodules were benign lung lesions.

Conclusions: CT-scan guided microcoil localization is safe and effective and increases the success rate of VATS resection of suspected metastatic pulmonary nodules.

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TMP5 Agar Blue Localization of Small Pulmonary Nodules for Thoracoscopic Resection and Technique to Minimize Air Leaks

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

Objective: Screening for lung cancer using high resolution computed tomography has produced encouraging early results. Extremely small nodules and non-palpable areas of opacifications are being detected and pose a challenge to the thoracic surgeon trying to resect these areas.

Methods: This single surgeon, single-center, prospective, and consecutive case study was conducted on sixteen patients with ground glass opacifications or small pulmonary nodules who underwent pre-operative CT-guided placement of blue-dyed agar and/or hookwire needle localization prior to thoracoscopic resections. Patients were resected, air leaks were identified, and application of a novel hydrogel sealant, Progel Pleural Air Leak Sealant, was applied to all sixteen patients.

Results: All lesions were successfully excised thoracoscopically. The blue agar aided in localization of these areas and did not affect the histological architecture during pathologic evaluation. The use of a sealant contributed to a reduction in the average length of stay and in the mean chest tube duration.

Conclusions: Careful pre-operative evaluation and planning, including use of selective CT-guided blue agar localization and hookwire placement, may greatly assist in thoracoscopically locating and resecting these often difficult to visualize lesions. Application of the Progel Pleural Air Leak Sealant aided in the recovery time of the patients by a reduction in chest tube duration and length of stay.

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TV1 Lymphadenectomy Along the Bilateral Recurrent Laryngeal Nerves by Non-lifting Technique with a da Vinci Robot System

Seong Yong Park, Seok Kee Lee, Mi Kyung Bae, Chang Young Lee, Jin Gu Lee, Kyung Young Chung, Dae Joon Kim. Yonsei University, College of Medicine, Seoul, Republic of Korea.

Objective: Robotic system offers a 3-dimensional magnified view and its instruments can mimic the motions of human wrist. These advantages enable the more meticulous dissection with minimal damage to adjacent tissues. However, the feasibility of robotic-assisted surgery in lymph node dissection along the bilateral recurrent laryngeal nerves (RLN) is still unclear.

Methods: We introduce a ‘non-lifting’ dissection technique using a da Vinci system (Intuitive Surgical, Sunnyvale, CA USA) for more complete and safe dissection along the RLNs. We use a single-lumen endotracheal tube with a bronchial blocker, and place a patient in semi-prone position. We use 3 robotic ports and one assistant port. After full mobilization of the esophagus, right RLN originating from vagus nerve is indentified at the inferior border of subclavian artery. We dissect lymph nodes along right RLN with a sharp dissector, a shear, and small clips. Then, trachea is retracted to right side to expose infra-aortic area. After identifying the left RLN, we dissect the fat pads over the nerve from aortic arch to the thoracic inlet. We first dissect fibroadipose tissues at the lateral side of the nerve, and all branches are clipped and divided. After retracting trachea to the right side, fibroadipose tissues medial to the nerve are dissected without any lifting or traction of the left RLN. Cardiac branches of sympathetic nerves are also saved.

Results: High quality of visuality and ergonomics of robotic system could facilitate the minimally invasive total mediastinal lymphadenectomy for esophageal cancer. The numbers of dissected lymph nodes were 48 and there was no operative complication including nerve palsy.

Conclusions: Lymphadencetomy along bilateral RLNs by ‘non-lifting technique’ using robotic system was a safe and feasible procedure.

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TV2 Robotic Belsey-Collis Fundoplication

Raghav Murthy, David Graham, Kemp H. Kernstine. University of Texas Southwestern Medical Center, Dallas, TX USA.

Objective: Belsey-Mark IV repair for GERD is a time-tested repair. The robotic approach to the same through the chest has not been described before.

Methods: A 62-year-old female presented with persistent GERD, dysphagia, and recurrent aspiration. She had failed 3 previous abdominal Nissen fundoplications and had a prior left lung resection 30 years prior. She had esophagitis on endoscopy and evidence of dysphagia on manometry. Impedance studies showed numerous low pH events corresponding to symptoms. Intraoperatively, she had numerous adhesions and her prior Nissen wrap was taken down. Esophageal shortening was evident. We performed a robotic Belsey-Collis fundoplication through the left chest.

Results: Successful fundoplication was created.

Conclusions: The thoracic Belsey fundoplication is ideal for patients with persistent GERD, esophageal dysmotility, esophageal shortening, and prior abdominal surgery. A thoracic robotic Belsey-Collis fundoplication can be performed successfully and exemplifies the minimally invasive approach by highlighting improved maneuverability and visualization.

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TV3 Experience with Thoracoscopic Pneumonectomies at a Single Institution

Anthony W. Kim, Annabelle L. Fonseca, Daniel J. Boffa, Frank C. Dettterbeck. Yale School of Medicine, New Haven, CT USA.

Objective: To review a single institution experience with video assisted thoracoscopic pneumonectomy (VATP).

Methods: From July, 2008 through December, 2012, the medical records of all patients undergoing pneumonectomy (total and completion) for lung cancer were reviewed. Clinical parameters were recorded and analyzed.

Results: During the time period, 7 of 45 (16%) pneumonectomies for malignancy were performed thoracoscopically. Patient selection was performed in the context of a multidisciplinary tumor board. Of the 7 VATPs, 5 were total and 2 were completion pneumonectomies. In terms of malignant indications, 6 were performed for primary lung cancer (adenocarcinoma - 3, squamous carcinoma - 1, large cell neuroendocrine carcinoma - 1, and mixed adenocarcinoma cell and small cell lung carcinoma - 1) and 1 performed for metastatic esophageal cancer. Of the 6 VATPs performed for primary lung cancer, preoperative selection was based on unfavorable location of the primary tumor and exclusion of possibility of a lesser resection such as sleeve resection. Preoperative pulmonary function tests demonstrated the mean FEV1 and mean DLCO to be 90 ± 19% and 76 ± 17%, respectively. Perfusion scans were performed on 4 patients and demonstrated mean perfusion of 34 ± 9% to the affected side. Pathologic upstaging occurred in 1 patient, but was otherwise consistent with preoperative clinical staging. Mean tumor size was 3.1 ± 2.4 cm. There were 2 complications: atrial fibrillation and bronchopleural fistula. The latter complications required an open reoperation with muscle flap coverage. Due to a complex postoperative course this patient experienced a prolonged length of stay (LOS) of 22 days. Excluding the patient with the extended LOS, the mean LOS was 4.8 ± 3.0 days. Disease recurrence occurred in 1 patient (15%) at 43 months and it developed in the brain and eventually the contralateral lung. Overall survival at 36 months was 72%.

Conclusions: The results of our early experience suggest that increasing the thoracoscopic armamentarium to include pneumonectomy is feasible with careful patient selection. Careful vetting by surgeons in the context of a multidisciplinary tumor board including the selection of smaller, left-sided malignancies can be associated with favorable outcomes.

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TV4 Transmediastinal Wedge Resection following Transcervical Extended Mediastinal Lymphadenectomy

Anthony W. Kim 1, David R. Kull1, Marcin Zieliński2, Daniel J. Boffa1, Frank C. Detterbeck1. 1Yale School of Medicine, New Haven, CT USA, 2Pulmonary Hospital, Zakopane, Poland.

Objective: Transcervical extended mediastinal lymphadenectomy (TEMLA) has shown that extensive mediastinal surgery via the neck is feasible and safe. This approach may be under-recognized for providing excellent access to the chest. The objective is to present a 60-year-old female who underwent TEMLA and transmediastinal right upper lobe (RUL) wedge resection to stage her known right lower lobe (RLL) non-small cell lung cancer (NSCLC).

Methods: Preoperative CT scan showed a 5 cm RLL mass and numerous bilateral upper lobe ground glass opacities. Pre-operative endobronchial ultrasound-guided biopsy (EBUS) confirmed a primary adenocarcinoma in the RLL and also was negative for mediastinal lymph node involvement. The bilateral upper lobe ground glass opacities remained concerning for malignancy. TEMLA was performed in a protocol driven invasive evaluation of the mediastinum. In the same anesthetic setting, the TEMLA procedure was extended to include a transpleural wedge resection of the RUL to rule out malignancy.

Results: By TEMLA, the right and left level 2 and 4 as well as the level 7 lymph node stations were negative for malignancy. The transmediastinal RUL wedge resection demonstrated atypical adenomatous hyperplasia (AAH). Clinical staging of the lung cancer was cT2bN0M0 (stage IB). Subsequently, a successful video-assisted thoracoscopic right lower lobectomy was performed. Final pathology also confirmed a RLL adenocarcinoma that was 5.0 × 4.0 × 3.0 cm in size. Therefore, her final stage of pT2bN0M0 (stage IB) was concordant with her clinical stage. There were no perioperative adverse events with both operations.

Conclusions: In this report, transpleural lung resection via a cervical approach was performed as a minor extension of TEMLA. TEMLA and transmediastinal lung resections may be performed safely during the same anesthetic setting. Prior to undertaking either one of these procedures, careful review of the technique for both and appropriate patient selection are crucial to a favorable outcome.

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TV5 Totally Robotic Ivor-Lewis Esophagectomy

Raghav Murthy, Kemp H. Kernstine. University of Texas Southwestern Medical Center, Dallas, TX USA.

Objective: Totally robotic Ivor-Lewis esophagectomy is a minimally invasive approach to esophagectomy. It is feasible and an oncologically sound operation.

Methods: The patient is a 53-year-old female with a cT3N1M0 squamous cell carcinoma of her distal esophagus. She underwent neoadjuvant chemoradiation. Restaging did not reveal any distant disease. She underwent a totally robotic Ivor-Lewis esophagectomy. This operation consists of an abdominal phase involving placement of a feeding J-tube, dissection of the esophagus and the stomach and the creation of a gastric conduit based off the right gastroepiploic vessels. The thoracic phase of the operation involves dissection of the esophagus, resection of the specimen and performing a stapled anastomosis between the proximal esophagus and the gastric conduit.

Results: Successful resection of the esophagus and construction of an intrathoracic anastomosis was performed using a robot. Excellent visualization of the structures is obtained.

Conclusions: Totally robotic Ivor-Lewis esophagectomy is a feasible and oncologically sound operation.

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TV6 First Experience with a New 5 mm Thoracoscopic Stapling Device

Gregor J. Kocher, Ralph A. Schmid. Division of Thoracic Surgery, University Hospital Berne, Bern, Switzerland.

Objective: We report our first experience with a new 30 mm cartridge-based cutter/stapler with a five millimeter shaft diameter in thoracic surgery. It is the device with the smallest profile (5 mm) and the highest possible degree of angulation of up to 80 degrees that is presently available on the market. The small diameter of the device was achieved by a new technical solution for the application of the staples.

Methods: The usage of the device is demonstrated during operative procedures in order to outline its benefits especially for minimally invasive thoracic surgery.

Results: The smaller shaft of the stapling device is much more adequate for small vessels and facilitates proper positioning without extensive tissue dissection. Furthermore, the deviation capability of up to 80 degrees allows exceptional access and visualization of the stapling site. The new stapling technology was reliable in 100% of the dissected pulmonary vessels.

Conclusions: Based on our first experience, this new reliable stapling device is an important development that may facilitate minimally invasive procedures in thoracic surgery. Tissue dissection and the risk of accidental tearing of vessels and lung parenchyma during manipulation with the stapling device can be minimized owing to its smaller shaft and higher tip flexibility.

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TV7 Robotic Plication of Diaphragm

Ali Zamir Khan, Shaiwal Khandelwal, Rajnish Kumar, Sangeeta Khanna, Dheeraj Gautum, Tarun Piplani, Jyotirmoy Das. Medanta, The Medicity, Gurgaon, India.

Objective: We present a video showing our experience of 3 cases of robotic plication of diaphragm for eventration.

Methods: Using a da Vinci HDSi, we performed robotic plication of diaphragm using a prolene 2-0 suture. Plication was performed in multiple concentric layers to create a darning effect.

Results: Drains were removed on postoperative day 1 and patients discharged on day 2. Symptomatic relief was seen in all patients on follow-up. Chest x-rays confirmed good position of the diaphragm.

Conclusions: Robotic technique allows increased dexterity for suturing and tying of knots. Technical results are very good and patients have early discharge from the hospital.

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TV8 Robotic Assisted Pneumonectomy for Down Staged Left Lung Cancer

Ali Zamir Khan, Shaiwal Khandelwal, Sangeeta Khanna, Rajnish Kumar, Tarun Piplani, Dheeraj Gautum, Jyotirmoy Das, Sudhir Kumar, Dinesh Singla, Arvind Kumar. Medanta, The Medicity, Gurgaon, India.

Objective: We present a video of robotic and video-assisted pneumonectomy for a down-staged cancer of the lung.

Methods: An 80-year-old male patient having had chemo-radiotherapy for adenocarcinoma of the lung was referred to us for surgical resection following down staging. We performed a robotic assisted dissection of the adhesions of lung, systematic lymph node dissection and subsequent pneumonectomy.

Results: The patient was discharged on the 5th postoperative day. VATS and robotic combination enabled us to complete the pneumonectomy.

Conclusions: Robotic and video-assisted pneumonectomy is possible even in a patient who has had previous chemotherapy and radiotherapy. Visualization and dexterity is better with robotic techniques.

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TV9 Robotic Thoracoscopic Resection of Intralobar Sequestration in an Adult

Richard Lazzaro 1, Nguyen Minh Le2, Laurence Spier2. 1Cardiothoracic Surgery, Lenox Hill Hospital, New York, NY USA, 2Lenox Hill Hospital, New York, NY USA.

Objective: Intralobar pulmonary sequestration is a congenital malformation of the lung. It occurs when there is a failure of the pulmonary vasculature to develop in part of the lung tissue. An aberrant artery or arteries form from the aorta to feed the sequestered lung tissue. In addition, the sequestered tissue may have primitive connection to the bronchial tree, which often leads to pneumonia. Definitive treatment is surgical resection of affected segments, usually requiring lobectomy. Diffuse hilar adenopathy, which is encountered with adult presentation of intralobar sequestration, presents a challenge to the dissection, isolation and division of the pulmonary artery. In addition to the hilar adenopathy, scar tissue from recurrent infections can make dissection and control of systemic aberrant vessels challenging, which are often fragile and can be associated with significant hemorrhage. Consequently, a minimally invasive approach to pulmonary resection for adult intralobar sequestration is considered extremely difficult, and posterolateral thoracotomy remains the preferred approach. The video demonstrates the steps to perform minimally invasive thoracoscopic pulmonary lobectomy for adult intralobar pulmonary sequestration, associated with pneumonia, diffuse hilar adenopathy and aberrant systemic circulation.

Methods: Using a robotic port-based approach, we perform an anatomic lobectomy in a 37-year-old female with recurrent pneumonia. Left lower lobe intralobar sequestration was identified on computed tomography of the chest with IV contrast demonstrating multi-vessel systemic arterial supply, originating from the intra-thoracic descending aorta.

Results: The patient underwent port based robotic thoracoscopic left lower lobectomy for intralobar sequestration. EBL = 25 ml. No air leak was identified. A solitary 24 F chest tube was placed. Pleural drainage was 180 cc at 24 hours. The chest tube was discontinued on POD 1 and the patient was discharged home on POD 2 without complication.

Conclusions: The enhanced resolution, stereoscopic visualization, and 7 degrees of freedom associated with robotic surgery enables the surgeon to overcome the technical challenges associated with multi-vessel systemic aortic supply to the sequestered lobe as well as scarring from pneumonia and diffuse hilar adenopathy. Robotic pulmonary lobectomy for adult intralobar pulmonary sequestration can be performed safely.

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TV10 Robotic Resection of Second Rib Tumor

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

Objective: We present a video of robotic resection of second rib tumor. We show a new technique of cutting of the second rib using wire saw by minimally invasive technique.

Methods: An 18-year-old male patient, during a routine naval pre-selection medical screening, was found to have a tumor located on the posterior aspect of the second rib. Open resection would entail a thoracotomy and a definite medical test failure for naval selection. We did a robotic resection of the second rib tumor using innovative techniques to cut the two ends of the ribs by a wire saw. The specimen was delivered out through the port site with minimal chest wall injury.

Results: This patient was eventually selected for the Indian Navy, having passed his medical test with flying colors and is now a training naval officer.

Conclusions: Robotic resection of chest wall tumor is possible with minimal damage to chest wall and quick return to work. Innovative thinking and surgical techniques can benefit patients and help them to return to normal life and to choose fulfilling careers.

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TV11 Totally Endoscopic Ivor-Lewis Esophagectomy

Faiz Y. Bhora, Scott J. Belsley, Cliff Connery, Pejman Aflaki, Hassan S. Moghaddas, Jordan R. Sasson. St. Luke’s-Roosevelt Hospital Center, University Hospital of Columbia University College of Physicians and Surgeons, New York, NY USA.

Objective: Esophagectomy for malignancy is a formidable operation. For distal and mid-esophageal tumors, the Ivor-Lewis (IL) approach has certain advantages such as low rate of stricture, anastomotic leak, avoidance of injury to the recurrent nerve, and improved lymph node dissection. Traditionally, the chest anastomosis is performed using open thoracotomy; however, this is associated with significant pulmonary complications. Hence, there is a desire to perform this anastomosis using minimally invasive techniques. The EEA stapler has been used in several series; however, it is technically difficult to perform. We describe a technique that uses standard linear staplers to perform a side-to-side anastomosis that is expeditious, reliable and reproducible.

Methods: The patient was first treated with neoadjuvant chemotherapy and radiation for t4N1 adenocarcinoma of the esophagus. The operation was performed at 8 weeks. The abdominal portion was approached first, with laparoscopy. Our technique involves Botox injection of the pylorus, control of the GE junction with a penrose drain, significant dissection of the intrathoracic esophagus, tubularization of the stomach along with transection of the proximal stomach, and placement of a feeding jejunostomy. The thoracic portion is then begun with use of 4 ports, the largest being 15 mm. Using the penrose as a handle, the remainder of the thoracic esophagus is dissected and the azygous vein is divided. The stomach is then pulled into the chest with care taken to maintain orientation. The esophagus is then divided at the level of the thoracic inlet with a linear stapler. The esophagus and stomach are then placed side side-by-side with a 6 cm overlap. Using a linear stapler, the back wall of the anastomosis is created. The anterior wall of the anastomosis is hand sewn.

Results: A swallow study performed on post-operative day 6 showed no leak. The patient was subsequently discharged home without complications.

Conclusions: We describe our technique for totally endoscopic IL esophagectomy. This can be performed even after neo-adjuvant therapy, with reliable and reproducible results.

©2013 by the International Society for Minimally Invasive Cardiothoracic Surgery