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Thoracic Track

Innovations:Technology and Techniques in Cardiothoracic and Vascular Surgery: June 2016 - Volume 11 - Issue - p S60–S70
doi: 10.1097/IMI.0000000000000267
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T1 VATS and RATS Lobectomy: What Access Is Better for Pulmonary Tuberculosis?

Peter Yablonskii, Grigorii Kudriashov, Sabriddin Nuraliev, Igor Vasilev, Armen Avetisyan. Saint-Petersburg Research Institute Phthisiopulmonology, Saint-Petersburg, Russian Federation.

Objective: Surgery of pulmonary tuberculosis associated with dense pleural and vascular adhesions and treatment has traditionally been through open thoracotomy. These reasons limited the use of minimally invasive surgery in these cases (Han, 2015). Robotic surgery aimed to improve the quality of surgery and learning curve of minimally invasive operations. Advancements in robotic-assisted thoracoscopic surgery (RATS) lobectomy for pulmonary tuberculosis are unknown. This study aimed to compare video-assisted thoracoscopic surgery (VATS) lobectomy and RATS lobectomy in patients with pulmonary tuberculosis.

Methods: Nineteen consecutive patients with tuberculous lesions (median age, 44 years; range 15–69 years; median Charlson Comorbidity Index, 1.5; range, 0–4; median FEV1, 100; range 72–124; median body mass index, 23; range 18–35) were divided into two groups according to surgical access, namely, RATS or VATS. The indications for surgery were persistent cavity in five cases, suspicion of neoplasm in six cases, positive sputum smear for mycobacterium tuberculosis in two cases, and multiple tuberculomas in the limits of one lobe in six cases. Patient pulmonary function as well as operative and postoperative data were compared between the groups.

Results: There were 9 patients who successfully underwent VATS lobectomy and 10 who underwent RATS lobectomy. The two groups were similar with respect to sex, age, body mass index, pulmonary function, pleural adhesions, severity of emphysema, and comorbidities (all, P>0.05). The median operative times were 241 and 186 minutes and the intraoperative blood loss was 137 and 107 mL for the VATS and RATS groups, respectively. The median duration of postoperative air leak was longer after VATS lobectomies (6.8 vs. 1.8 days). The operation time, intraoperative blood loss, number of postoperative complications, duration of postoperative analgesia with narcotic analgesics were all significantly less in the RATS group. The postoperative rates of conversion of sputum smear in MTB-positive patients were 100%.

Conclusions: Robotic technology that allows operation on patients with pulmonary tuberculosis is not less effective than VATS. Robotic-assisted thoracoscopic surgery provides better operative and postoperative data compared with VATS.

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T2 The Feasibility of Thoracoscopic Resection in Adhesive Infectious Lung Diseases

Talha Dogruyol 1, Volkan Baysungur1, Ilhan Ocakcioglu2, Aysun Misirlioglu1, Serdar Evman1, Serda Kanbur1, Levent Alpay1, Cagatay Tezel1. 1Sureyyapasa Pulmonology and Thoracic Surgery Training and Research Hospital, Istanbul, Turkey; and 2Karabük Training and Research Hospital, Karabuk, Turkey.

Objective: Minimally invasive surgery is the treatment of choice in early-stage lung cancer. However, experience in infectious lung disease, primarily bronchiectasis, is limited probably because of the presence of dense pleural adhesions, multiple lymph nodes, and spiral bronchial arteries. The present study shows our experience of video-assisted thoracoscopic surgery (VATS) lobectomy and segmentectomy in the treatment of bronchiectasis.

Methods: Patients who underwent VATS lobectomy or segmentectomy in our clinic between April 2008 and April 2015 were retrospectively evaluated. Surgery was indicated in patients with radiologically localized bronchiectasis who also have a history of recurrent lower respiratory tract infection or expectorating mucopurulent sputum. Patients were analyzed in terms of age, sex, conversion rate, postoperative drainage amount, chest tube removal time, length of hospital stay, morbidity, and mortality.

Results: Forty-four patients with bronchiectasis were initiated by VATS. Forty-one procedures were completed on 40 patients. One patient had bilateral resection. Fifteen patients were male, and 26 were female. Average age was 31.4 years (15–57 years). Forty lobectomies and one segmentectomy were performed. Conversion rate was 6.8%. Video-assisted thoracoscopic surgery was performed on 28 patients by three ports, 8 patients by two ports, and 5 patients by one port. In terms of anatomical resections, 18 patients underwent left lower lobectomy, 8 by right lower lobectomy, 8 by middle lobectomy, 6 by right upper lobectomy, and 1 by lingulectomy. No postoperative major complication or mortality was observed. Prolonged air leak was observed in two patients, and subcutaneous emphysema occurred in two patients. The average postoperative drainage amount, chest tube removal time, and length of hospital stay were 320 mL, 3.1 days (1–11 days), and 4.6 days (2–11 days), respectively.

Conclusions: Video thoracoscopy is a safe, feasible, and effective treatment in the surgery of bronchiectasis with low morbidity and mortality rates. Moreover, because of cosmetic results, patients with benign diseases such as bronchiectasis should be initiated by minimally invasive surgery options just like patients with malignancies.

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T3 Use of Hydrogen Peroxide and Povidone Iodine as an Intrapleural Wash

Narendra Agarwal 1, Shaiwal Khandelwal1, Ruchi Girotra2, Kamran Ali1, Mohd Fauzi1, Ali Zamir Khan1. 1Medanta the Medicity, Gurgaon, India; and 2Shkm Government Medical College, Gurgaon, India.

Objective: Surgical site infection is a serious complication of surgery. The article aimed to determine the efficacy of using povidone iodine and hydrogen peroxide irrigation to prevent surgical site infection.

Methods: A total of 1235 patients underwent complex thoracic resections from September 2010 to September 2015. Majority of resections were of infective etiology. The use of intrapleural 10% povidone iodine mixed with 30 mL of 3% hydrogen peroxide mixture diluted in normal saline was used for irrigation after resection.

Results: Surgical site infection was noted in 13 of 1235 patients. Majority of surgical site infections were in patients with multidrug-resistant tuberculosis. Two patients had arrhythmia. Both were cases of hydatid cyst. The combination used was a good hemostat especially for chest wall ooze after complex adhesiolysis. Postoperatively, no patient showed any signs of complication.

Conclusions: The use of hydrogen peroxide and povidone iodine as an intrapleural wash was safe, and we recommend the use of the combination in the infective etiology as it prevents surgical site infection and acts as a good hemostat after chest wall adhesiolysis.

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T4 Claims and Outcomes of Lawsuits After Antireflux Surgery in the United States

Joshua A. Boys 1, Brian Hoffman2, Daniel S. Oh1, Brenda Radmacher2, Evan T. Alicuben1, Steven R. DeMeester1. 1University of Southern California, Los Angeles, CAUSA; and 2Wood, Smith, Henning & Berman LLP, Los Angeles, CAUSA.

Objective: Antireflux surgery should have a low morbidity rate. Major complications might lead to a lawsuit. The aim of this study was to determine factors that led to a lawsuit after antireflux surgery and the outcome of the lawsuit.

Methods: We queried two major legal databases, the Physician Insurers Association of America and the Westlaw database, for liability claims related to antireflux surgery from 2004 to 2013.

Results: There were 175 claims. Three medical factors led to 82% of all claims: improper performance of the procedure (68%), failure to recognize a complication (9%), and errors in diagnosis (5%). The most common injury leading to a claim was perforation. Of the 175 claims, 81 (46%) were withdrawn or dismissed, 55 (32%) were settled or arbitrated, 34 (19%) went to a trial verdict, and in 5 (3%), the disposition was unknown. The average settlement or arbitration award was $331,354. In the 34 cases that went to a trial verdict, 32 were found in favor of the defense. Of the two trial verdicts for the plaintiff, the award ($1.5 million) was known in one case. The claim associated with a trial verdict case was known for 12 of the 34 cases, and in 7, it was related to a perforation. Overall, a claim related to perforation led to payment in only 28% of the cases.

Conclusions: Lawsuits after a fundoplication were usually related to improper performance of the procedure or failure to recognize or manage complications. Perforation was the most common injury leading to a claim but most commonly was not associated with a monetary payment. Trials that went to a verdict were nearly always found for the defense. Therefore, when appropriate, surgeons should insist on a trial.

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T5 Incorporating Robot-Assisted Surgery Training Into Integrated Thoracic Surgery Residency Programs

Chyun-Yin Huang, Adnan M. Al-Ayoubi, Ahmad Al-Taweel, Adil Ayub, Khalid Alshehri, Sadiq Rehmani, Wissam Raad, Faiz Y. Bhora. Mount Sinai Health System, New York, NY USA.

Objective: With increased use of robotic techniques across surgical fields, there is a need for residents in integrated thoracic surgery residency programs to have early exposure and familiarity with the robotic platform. Various curricula for robot-assisted surgery have been published for general surgery, but there are no standardized curricula for training residents in robot-assisted thoracic surgery. We propose a curriculum that can be incorporated into I6 programs to increase resident competency.

Methods: We surveyed all 24 integrated thoracic surgery program directors in the United States and performed a PubMed search using the following key words: robotic surgery, robotic curriculum, robotic thoracic surgery, and resident education. We reviewed various robotic surgery training curricula and evaluation tools currently being used in the training of general surgery residents. We then designed a framework adapted toward I6 residents based on our review and program directors’ survey consensus.

Results: There is an increase in the interest for formal training in robot-assisted thoracic surgery. A suitable training curriculum is integrated during postgraduate years (PGYs) 2 to 6 and is divided into preclinical (PGYs 2 and 3) and clinical (PGYs 4–6) stages (Table T5-1). In the preclinical stage, residents are required to complete introductory online modules, virtual reality and simulator training, as well as in-house workshops. During the clinical stage, the resident will serve as a supervised bedside assistant and progress to a console surgeon. Each case will have defined steps where the resident must demonstrate competency. Evaluation will be based on guidelines set by Global Evaluative Assessment of Robotic Skills (GEARS). For programs that do not meet robotic case volumes for resident training, we recommend collaboration with a high-volume center performing robotic surgery.

Conclusions: Expansion and use of robotic assistance in thoracic surgery have increased. The proposed curriculum enables thoracic residents in integrated thoracic surgery residency programs to have increased exposure to robotic platform and to master basic skills required in robot-assisted thoracic surgeries.



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T6 Intrapleural Airflow Signal Processing to Predict Duration of Pulmonary Air Leak: A Preliminary Analysis

Daniel French, Sebastien Gilbert. University of Ottawa, Ottawa, Ontario, Canada.

Objective: The ability to accurately predict patients who will develop a prolonged air leak in the early postoperative period is very useful in optimizing patient management, discharge planning, and use of hospital resources. Digital drainage systems allow airflow signals to be captured and analyzed. The objective of this study was to analyze the characteristics of the airflow signal in the early postoperative period to identify patients who will develop a prolonged air leak.

Methods: The airflow signals of patients who underwent anatomical lung resections were prospectively captured using digital drainage systems and were retrospectively analyzed. The absence of an air leak was defined as no airflow signal greater than 20 mL/min for 8 hours. The volume of airflow in the first 12 hours was computed by calculating the area under the airflow curve. The mean volume of airflow for each class of signal was compared. A receiver operating characteristic (ROC) curve was plotted, and sensitivity and specificity were computed for multiple volume thresholds.

Results: Of the 67 patients included in the analysis, 43 (64%) never developed an air leak, 16 (24%) had an air leak that resolved within 5 days, and 8 (12%) had a prolonged air leak. The ROC curve is shown as Figure T6-1. The area under the curve of the ROC is 0.94 (95% confidence interval, 0.88–0.99). With the use of different thresholds, the sensitivity and specificity were computed as follows: 1055 mL (sensitivity, 1; specificity, 0.73), 5530 mL (sensitivity, 1; specificity, 0.85) and 10,706 mL (sensitivity, 0.75; specificity, 0.88).



Conclusions: The volume of airflow measured in the first 12 hours after a pulmonary resection can predict patients who will develop a prolonged air leak. Further investigations are needed to validate these findings on a larger set of airflow signals and should include analysis of other airflow signal characteristics that can predict duration of air leak after pulmonary resection.

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T7 Evaluation of Thoracoscopic Ultrasonography for Localization of Pulmonary Nodules in Resected Ex Vivo Human Lungs

Hideki Ujiie 1, Tatsuya Kato1, Suhaib Hasan1, Hsin-pei Hu1, Priya Patel1, Hironobu Wada1, Daiyoon Lee1, Kosuke Fujino1, David Hwang2, Marcelo Cypel1, Marc de Perrot1, Andrew Pierre1, Gail Darling1, Tom Waddell1, Shaf Keshavjee1, Kazuhiro Yasufuku1. 1Division of Thoracic Surgery, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada; and 2Department of Pathology, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada.

Objective: Localization of small, nonvisible, and nonpalpable nodules is challenging during video-assisted thoracoscopic surgery. The purpose of this study was to evaluate the feasibility of thoracoscopic ultrasonography for nodule localization in resected ex vivo human lungs.

Methods: Resected ex vivo specimens from 25 patients with malignant lung tumors who underwent either lobectomy or segmentectomy were used. The lung was positioned in its appropriate anatomical orientation on a surgical table and deflated or semi-inflated using a syringe and catheter. The tumor was localized and measured in its greatest dimension with a prototype convex probe ultrasound thoracoscope (XLTF-UC180, Olympus Medical Systems Corp, Tokyo, Japan) in different frequencies (5.0–12.0 MHz). Ultrasound measurements of tumor size and depth from lung surface were compared and correlated to the true diameter and depth from lung surface acquired from pathological morphology.

Results: Ex vivo evaluation was performed in 16 solid tumors and 9 part solid ground-glass opacity (GGO) nodules. All tumors were successfully localized in the deflated lung specimens (mean±SD, 13.73±5.22 mm) (Fig. T7-1). Solid tumors were more easily visualized than GGOs. Part solid GGO tumors were not easily detected in the semi-inflated specimen because of peritumoral air surrounding the tumor. In all cases, the prototype convex probe ultrasound thoracoscope produced better image quality than the commercially available laparoscopic ultrasound device. The tumor boundaries were best evaluated with an ultrasound frequency of 10 MHz. Tumor boundaries were less defined on the ultrasound images of tumors with greater depth and lungs with underlying disease. A strong positive correlation exists between the ultrasound measurement and the true measurement of tumor size (R 2=0.89, P<0.001).



Conclusions: The newly developed convex probe ultrasound thoracoscope can be used to localize nodules in resected ex vivo human lungs. The clarity of the tumor boundaries is influenced by the tumor type, its depth from lung surface, and the lung’s underlying pulmonary disease. Complete lung deflation and the use of 10-MHz ultrasound frequency optimizes the visualization of target tumors.

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T8 Geometric Mapping of Small Pulmonary Nodules

Mitsuhiro Kamiyoshihara, Takashi Ibe, Natsuko Kawatani, Hitoshi Igai. Maebashi Red Cross Hospital, Maebashi, Japan.

Objective: Computed tomography–guided lung needle marking is useful to identify pulmonary nodules. However, certain complications infrequently trigger severe after-effects or death. We thus present a convenient and safe method by which small pulmonary nodules can be identified using a certain dye [Pyoctanine; 2% (wt/vol]) gentian violet].

Methods: Figure T8-1 shows that a patient is initially placed in the lateral position identical to the operative position. Under computed tomography guidance, a “magic marker” is used to identify skin above the pulmonary nodule. During the operation, the chest wall is punctured at that mark using a needle loop retractor (Mini Loop Retractor II, Tyco Healthcare Japan, Tokyo, Japan). A swab saturated in a dye solution and attached to a silk thread is passed through the loop. The loop and string are subsequently retracted. When the lung is inflated, a dye stamp is apparent on the lung surface above the nodule.



Results: We used this technique to treat 35 lesions of 34 patients presenting from April 2014 to May 2015. The average tumor diameter was 7 mm. If the scapula, any vertebra, or the clavicle compromised access to a nodule, we used our geometric technique to locate that nodule (Fig. T8-1). All lesions were identified via thoracoscopy, all nodules were constrained by ring forceps, and wedge resections (using staplers) followed. All lesions lay very close to the staple markings, as judged by finger or instrument palpation. No complication was encountered. The advantages of our technique are that it is simple and easy, air embolism is not an issue, skin marking is rapid, safety is absolutely assured, and skin marking does not require hospitalization. There are no disadvantages.

Conclusions: Our method locates nodules, defines the margins of the cut line upon anatomical segmentectomy, indicates where skin incisions are required, and identifies impalpable nodules (such as those that are “ground glass” in nature), aiding not only lung resection but also provision of frozen sections to the pathologist.

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T9 Electromagnetic Navigational Bronchoscopy With Dye Marking for Identification of Small Peripheral Lung Nodules During Minimally Invasive Surgical Resection

Juan A. Munoz, Virginia Litle, Michael I. Ebright, Hiran C. Fernando. Boston University School of Medicine, Boston, MA USA.

Objective: Identification of small peripheral lung nodules during minimally invasive resection can be challenging. Electromagnetic navigational bronchoscopy (ENB) with injection of dye to identify nodules is an approach that can be performed by the surgeon in the operating room immediately before resection. We evaluated the effectiveness of ENB with dye marking to aid minimally invasive resection.

Methods: Patients with peripheral nodules underwent ENB before planned thoracoscopic or robotic-assisted thoracoscopic resection. Methylene blue (0.5 mL) was injected directly into the lesion for pleural-based lesions or peripherally for lesions deep to the pleural surface. Surgical resection was then immediately performed. Technical success was defined as identification of the dye marking within/close to the lesion with pathological confirmation of the lesion within the initial wedge resection.

Results: Sixteen patients with 18 lung nodules underwent ENB with dye marking followed by resection. Mean age was 59 years (44–81 years), and 88% (14/16) were women. Mean lesion size was 11.5 mm (range, 4–32 mm), and the median distance from the pleura was 9.7 mm (1–40 mm). Overall success rate for the 18 nodules was 78% (14/18). In 2 (11%) of the 18, the dye was not visualized (one requiring conversion to thoracotomy). In two (11%), there was extravasation of dye into the pleural space with no helpful tattooing of the lung parenchyma. There were trends favoring technical success for nodules that were larger or closer to the pleural surface (Table T9-1). Unlike previous studies, the presence of a bronchus sign had no impact on success rate. Five patients required adhesiolysis to visualize the target lesion, and all of them were successful. There were no significant adverse events, and a definitive diagnosis was ultimately accomplished in all patients.



Conclusions: Electromagnetic navigational bronchoscopy with dye marking is useful for guiding minimally invasive resection of small peripheral lung nodules. This can be performed by surgeons immediately before resection, improving workflow and avoiding the need for a separate interventional radiology procedure.

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T10 VATS Sentinel Node Biopsy Reduces the Need for Systematic Mediastinal Lymphadenectomy in Early-Stage NSCLC

Nenad Ilic, Josko Juricic, Dragan Krnic, Nives Frleta Ilic, Duje Orsulic, Ivan Sinundza, Darko Ilic. University Surgical Hospital, Split, Croatia.

Objective: Systematic mediastinal lymphadenectomy is still essential for an adequate postoperative staging of non–small cell lung cancer (NSCLC). We tried to investigate the controversial role of sentinel node biopsy in early-stage NSCLC surgery using video-assisted thoracoscopic surgery (VATS).

Methods: A total of 52 patients with clinical T1N0M0 NSCLC underwent sentinel lymphnode navigation VATS lobectomy using Tc-99–labeled tin colloid followed by systematic mediastinal lymphadenectomy over 2 years (2010–2012). Mapping of the mediastinal lymph nodes by their number and station followed by histopathological evaluation was performed. Patients’ data were statistically analyzed.

Results: Intraoperative SN was identified in 45 (87%) of these patients, with 92% of accuracy. We found lobe-specific skip nodal metastases in five patients (10%) resulting in upstaging. The incidence of mediastinal lymphnodal metastases seemed to be higher in patients with adenocarcinoma (P<0.05), but skip nodal metastases showed higher rate in patients with squamous cell carcinoma. Intraoperative frozen section was not confirmed accurate for detecting micrometastases in two patients (4%). Operative time was prolonged for 10 minutes (8–25 minutes), showing no difference in complication rate.

Conclusions: Minimally invasive VATS procedure showed absolute safety and high accuracy. Our results indicated that SN identification could reduce mediastinal lymph node dissection in early stage NSCLC. Further clinical studies should be performed to prove that minimally invasive surgical procedures could be curative for T1N0M0 NSCLC.

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T11 Predictors of Actionable Results in Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration

Muneeb Mohammed, Saswata Deb, Kamyar Soghrati, Abdollah Behzadi. Trillium Health Partners, University of Toronto, Toronto, Ontario, Canada.

Objective: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive technique for obtaining tissue samples of mediastinal lymph nodes and masses. Factors associated with action-ability (subsequent management resulting from identification of diagnostic tissues in EBUS-TBNA) including utility of a rapid on-site evaluation (ROSE) are not clearly determined. The objective of this study was to determine predictors of action-ability after performing EBUS-TBNA.

Methods: A single-center retrospective chart review of patients undergoing EBUS-TBNA between April 2013 and May 2015 was performed. A multivariate model was used to determine the predictors of action-ability. An a priori subanalysis was also performed to compare the association of ROSE with respect to final pathology and action-ability.

Results: During the study period, 191 patients with a mean age of 61.5±15.0 years underwent EBUS-TBNA. Of these, 97 (50.5%) were female, and 138 (72.2%) had no history of cancer. Multivariate analysis revealed ROSE-positive cytology [ROSE(+), adequate diagnostic tissues present in TBNA samples as determined by a cytotechnologist] as the sole predictor of action-ability with an OR of 228.3 (P=0.0007). Subanalysis of the utility of ROSE showed that having a ROSE(+) compared with a ROSE-negative cytology [ROSE(−), inadequate presence of diagnostic tissues in TBNA as determined by a cytotechnologist] was associated with superior proportion of action-ability [ROSE(+), 153 (87.9%) vs. ROSE(−), 1 (5.9%), P<0.0001]. Furthermore, the proportion of positive pathology (adequate tissue for diagnosis as determined by a pathologist) [ROSE(+), 158 (90.8%) vs. ROSE(−), 3 (17.7%), P<0.0001] and diagnostic pathology (pathological diagnosis of benign or malignant) [ROSE(+), 158 (90.8%) vs. ROSE(−), 2 (11.8%), P<0.0001] were also higher in the cohort with ROSE(+).

Conclusions: A ROSE(+) is a strong predictor of action-ability after EBUS-TBNA and is associated with a greater diagnostic yield from this technique. Rapid on-site evaluation confirmation of tissue adequacy seems to be an important component of EBUS-TBNA. Other single-center or multicenter studies are required to corroborate our findings.

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T12 Learning Curve for Uniportal Video-Assisted Thoracoscopic Surgery Lobectomies: The Papworth Experience

Benedetta Bedetti 1, Luca Bertolaccini2, Piergiorgio Solli1, Marco Scarci1. 1Papworth Hospital, Cambridge, United Kingdom; and 2Sacro Cuore–Don Calabria Research Hospital, Negrar, Verona, Italy.

Objective: Uniportal video-assisted thoracoscopic surgery (VATS) gained importance in the thoracic surgery scenario in the last years. Major pulmonary resections such as lobectomies can be performed with a single 4-cm incision, reducing postoperative pain and often the length of stay and giving the surgeon the same operative perspective as open surgery.

Methods: We retrospectively analyzed the data of 73 patients who underwent uniportal VATS lobectomies from November 2014, when we started to introduce this technique in our institution, to December 2015. We divided the patients in two groups (group 1, first 30 patients vs. group 2, established phase, 43 patients) to compare and evaluate the data regarding the learning curve and the established phase. The surgeons were already experienced in triportal VATS lobectomies. To explore evolution of learning curve, data were plotted to calculate Spearman rank-order correlation. R (version 3.2.3) was used for the statistical analyses.

Results: The median ages were 69.9 (group 1) and 68.8 (group 2) years. In general, the indication to undergo surgery was for primary carcinoma of the lung in 67 patients (54 adenocarcinoma, 13 squamous carcinoma), for metastatic disease in 3 patients, and for infectious disease in 3 patients. Mean operative times were 84.9±33.0 minutes (group 1) and 84.8±31.5 minutes (group 2); median times were 97.5 minutes (group 1) and 91.3 minutes (group 2). The conversion rate was 13.3% in group 1 versus 9.3% in group 2, showing a significant learning reduction (ρ=0.590). Overall, the most common complication consisted of prolonged air leak, and blood transfusion rate was 0% intraoperatively and postoperatively. Interpolation line of complications showed a significant decrease due to learning curve (ρ=0.676). The median lengths of stay were 4 days in group 1 versus 3 days in group 2. Thirty-day mortality was 3.3% in the group 1 (one patient died because of aspiration and hypoxia on the second postoperative day) and 0% in group 2.

Conclusions: The comparison between the two groups shows that the median length of stay, operative time, conversion rate, and 30-day mortality statistically significantly improved in group 2 (established phase). In conclusion, the uniportal VATS lobectomy technique can be performed safely by experienced surgeons without major complications and with an acceptable mortality rate.

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T13 Two-Year Outcomes After Single-Port Video-Assisted Thoracoscopic Surgery Lobectomy With Mediastinal Lymph Node Dissection in NonYSmall Cell Lung Cancer

Yong Soo Choi, Seok Kim, Hong Kyu Lee, Jong Ho Cho. Sungkyunkwan University School of Medicine Samsung Medical Center, Seoul, Republic of Korea.

Objective: Several institutions have recently begun performing single-port video-assisted thoracoscopic surgery (VATS) lobectomy for lung cancer. However, data on recurrence and survival after this surgery are scarce. We evaluated midterm survival after single-port VATS lobectomy in patients with non–small cell lung cancer.

Methods: Single-port VATS lobectomy involved a single 4-cm incision at the fifth intercostal space without rib spreading, followed by lobectomy and lymph node (LN) dissection. From February 2013 to February 2014, 54 cases of single-port VATS lobectomy and LN dissection were performed by a single surgeon (RUL, 16 cases; RML, 6 cases; RLL, 9 cases; LUL, 9 cases; and LLL, 14 cases). We retrospectively analyzed the survival and recurrence of 54 patients who underwent successful single-port VATS lobectomy without conversion. Twenty-five patients (46.3%) were male, and the mean age was 61 years (36–78 years).

Results: There was no postoperative mortality; minor postoperative complications occurred in three patients (5.6%). Clinical stage was IA in 40 patients (74.1%), IB in 8 patients (14.8%), IIA in 2 patients (3.7%), IIB in 2 patients (3.7%), and IIIA in 2 patients (3.7%). Pathological stage was IA in 32 patients (59.3%), IB in 6 patients (11.1%), IIA in 6 patients (11.1%), and IIIA in 10 patients (18.5%). The median follow-up period was 25 months (range, 16–28 months). Recurrence was observed in six patients (11.1%): regional LN recurrence in one patient (1.9%) and distant metastasis in five patients (9.3%). Recurrence was not seen in any patient with stage IA or IB disease, whereas two patients with stage IIA disease exhibited distant metastasis, and four patients with stage IIIA disease demonstrated regional LN recurrence (one case) or distant metastases (three cases). Among these patients, five underwent additional treatment (chemotherapy in three, radiation therapy in one, gamma knife surgery in one). The overall 2-year recurrence-free survival rate was 88.5% (pathological stage I, 100%; II, 66.7%; and IIIA, 60%).

Conclusions: In patients with non–small cell lung cancer, single-port VATS lobectomy with LN dissection leads to satisfactory midterm survival.

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T14 Liposomal Bupivacaine Versus Bupivacaine/Epinephrine for Postoperative Pain Management in Patients Undergoing Video-Assisted Thoracoscopic Surgery Wedge Resection

Salvatore Parascandola, Jessica Ibanez, Graham Keir, Jacqueline Anderson, M. Blair Marshall, Deanna Flynn, Michael Plankey, Candice Cody, Marc Margolis. Georgetown University, Washington, DC USA.

Objective: There are limited data on the comparison of multivesicular liposomal bupivacaine (MVLB) and bupivacaine/epinephrine (BE) for the management of pain following thoracic surgery. The purpose of this research was to compare MVLB and BE for intercostal blocks related to analgesic use and length of stay after video-assisted thoracoscopic surgery (VATS) wedge resection.

Methods: An institutional review board–approved retrospective study of patients undergoing VATS wedge resection from 2010 to 2015 was performed. We subselected patients who stayed longer than 24 hours. Primary outcome measurements were length of stay and postoperative analgesic use at 12-hour intervals from 24 to 72 hours.

Results: We identified 821 patients who underwent VATS, of whom 194 underwent VATS wedge resection. Patients who went home within 24 hours (n=46), had an incomplete medication administration record (n=30), or whose procedure converted to thoracotomy or transferred to the intensive care unit (n=5) were excluded. In the remaining 113 patients, intercostal blocks were performed with MLVB in 62 patients and BE in 51 patients. A Wilcoxon signed rank test evaluated differences in median postoperative analgesic use and length of stay. At every interval postoperatively, those who received MVLB consumed fewer analgesics than those who received BE, with a statistically significant difference 24 to 36 hours postoperatively [20.25 mg (interquartile range [IQR], 12.5–39.0) vs. 45.0 mg (IQR, 22.5–81.0); P=0.0059) and 60 to 72 hours postoperatively [15.0 mg (IQR, 12.0–30.0) vs. 33.75 mg (IQR, 30.0–52.5); P=0.0350]. In patients who stayed longer than 72 hours, the median cumulative analgesic consumption in those who received MVLB was statistically significantly lower than those who received BE [120.0 mg (IQR, 112.5–272.5) vs. 296.5 mg (IQR, 212.25–412.0) P=0.0414] (Fig. T14-1). Median length of stay for the MVLB and BE groups were 45:05 hours (IQR, 36:49 hours) and 44:29 hours (IQR, 27:03 hours), respectively. There were no adverse events related to blocks performed with MLVB.



Conclusions: Thoracic surgery patients who have blocks performed with MVLB require less analgesics postoperatively. This may decrease complications related to poor pain control and decrease adverse effects related to narcotic use in our patient population.

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T15 Transsternal Versus Robotic Thymectomy for Thymoma: Feasibility and Results

Ian Paul, Kay See Tan, Joe Dycoco, Prasad Adusumilli, Manjit S. Bains, Matthew J. Bott, James Huang, David R. Jones, Valerie W. Rusch, Bernard J. Park. Memorial Sloan Kettering Cancer Center, New York, NY USA.

Objective: Minimally invasive approaches to isolated thymic lesions are becoming more common, but there are few data comparing robotic with transsternal thymectomy for the treatment of isolated thymoma. We reviewed our experience to assess the feasibility and oncologic outcomes of the robotic approach.

Methods: This is an institutional review board–approved, single-center retrospective cohort study comparing patients having thymectomy by sternotomy versus robotic approach for Masaoka stage I to III thymoma. Perioperative outcomes and follow-up were recorded prospectively. Survival estimates and statistical comparisons were calculated using standard software.

Results: From 2004 to 2014, 87 patients underwent thymectomy for Masaoka stage I to III thymoma (46 by median sternotomy, 41 by robotic approach). Median age was lower in the robotic group (60 vs. 65 years, P=0.04). There were no differences between groups with respect to sex, body mass index, Masaoka stage, and World Health Organization histological subtype. Conversion rate in the robotic group was 4.9% (2 of 41), both due to extensive pleural adhesions. R0 resection rate was equivalent (100% robotic, 96% median sternotomy). Estimated blood loss was less in the robotic group (50 vs. 150 mL P<0.0001), but procedure duration was higher for the robotic group (3 vs. 2 hours, P=0.002). There were no differences in complication rates. Length of hospital stay was significantly shorter in the robotic group (2 vs. 4 days, P<0.0001). There was one perioperative death in the sternotomy cohort secondary to pulmonary embolism. Median follow-up was 27.1 versus 61.5 months for the robotic versus median sternotomy groups, respectively. Zero recurrences were identified in either group.

Conclusions: Robotic thymectomy for isolated thymoma is safe, achieving rates of complete resection and perioperative outcomes similar to sternotomy. Although operative time was longer, length of stay and estimated blood loss were significantly lower in patients undergoing a robotic approach. Interim follow-up suggests that oncological outcome is thus far acceptable.

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T16 An Early Series of Patients Undergoing Simultaneous Bilateral Thoracoscopy During Robot-Assisted Thymectomy

Inderpal Sarkaria1, Nicholas Hess 2, Neil Christie1, Ryan Levy1, James Luketich1. 1University of Pittsburgh Medical Center, Pittsburgh, PA USA; and 2University of Pittsburgh School of Medicine, Pittsburgh, PA USA.

Objective: Visualization of the contralateral phrenic nerve can present a challenge during thoracoscopic thymectomy. The purpose of this study was to assess the feasibility of simultaneous ipsilateral and contralateral mediastinal visualization during robot-assisted thymectomy.

Methods: This was a retrospective review of our early series of patients undergoing robot-assisted thymectomy with simultaneous bilateral visualization of the mediastinum using dedicated software available on current robotic platforms.

Results: From June 2014 to December 2015, 18 sequential patients underwent robot-assisted thymectomy with simultaneous ipsilateral and contralateral thoracoscopy. Contralateral mediastinal visualization was achieved through one or two contralateral ports. Thymectomy was most commonly performed for thymoma and thymic cyst/hyperplasia. In one case, ipsilateral en bloc resection of the phrenic nerve was required because of direct tumor invasion. There was one instance of persisted elevation of the ipsilateral hemidiaphragm occurring during nerve separation and skeletonization from a closely adherent tumor. Complete visualization of the bilateral phrenic nerves was achieved in all cases. Patient demographics and perioperative outcomes are reported in Table T16-1.



Conclusions: Simultaneous ipsilateral and contralateral mediastinal visualization during robot-assisted thymectomy is feasible and may improve visualization of key structures. Larger studies are needed to evaluate any potential incremental decrease in the rates of contralateral nerve injury during these cases.

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TV1 Three-Dimensional Reconstruction for Resection of a Growing Lung Nodule

John P. Costello 1, Dilip S. Nath2, Hank P. Rappaport3, M. Blair Marshall1. 1MedStar Georgetown University Hospital, Washington, DC USA; 2Children’s National Medical Center, Washington, DC USA; and 3MedStar Center for Innovation, Washington, DC USA.

Objective: We created this video to demonstrate the use of three-dimensional reconstruction and tissue sealing devices for the resection of a growing central hamartoma without parenchymal resection.

Methods: A 42-year-old man was found to have a right upper lobe nodule. This was unchanged in size for 7 years but began to grow, prompting referral for biopsy and subsequent resection. Given the diagnosis of a hamartoma, the patient, a lawyer, requested the least amount of parenchyma removed as possible. His DICOM files were loaded into three-dimensional modeling software and used to create a three-dimensional model. The images and model were studied to create a minimally vascular path from the hilum to the lesion.

Results: A minimally invasive approach was used with 5- and 3-mm ports, pediatric laparoscopic instruments, and a 5-mm 30-degree camera. The nodule was enucleated. There was a minimal air leak at the completion of the procedure. Fibrin sealant was used on the parenchymal laceration. Intercostal blocks were placed. The air leak resolved by the first postoperative day, and the chest tube was removed. The patient was discharged on the second postoperative day. He used no additional pain medication in the hospital or after discharge.

Conclusions: Three-dimensional imaging can be useful for operative planning. Deep benign lesions may be excised without parenchymal resection. Air leaks in patients with normal parenchyma do not appear to be problematic with the use of sealing devices and fibrin sealants. Multiple video-assisted thoracoscopic surgery ports can be associated with minimal pain.

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TV2 Robot-Assisted Right Upper Lobectomy With En Bloc Chest Wall Resection for a T3 Adenocarcinoma

Nguyen M. Le, Laurence N. Spier, Richard S. Lazzaro. Northwell Health, Lenox Hill Hospital, New York, NY USA.

Objective: This video demonstrates a robot-assisted right upper lobectomy with en bloc chest wall resection for a T3 tumor.

Methods: An 82-year-old woman was found to have a biopsy-proven adenocarcinoma of the right upper lobe, which was attached to the chest wall. Positron emission tomography revealed no extrathoracic or mediastinal disease. The patient was placed in left lateral decubitus. Five ports were used—four for the robot and one access port. A Gigli saw was used to resect part of the involved rib intrathoracically. A robot-assisted right upper lobectomy with en bloc chest wall resection and mediastinal lymph node dissection was performed without complication.

Results: Final pathology revealed a pT3N0 adenocarcinoma, solid pattern predominant with lepidic and acinar patterns. Tumor invaded through the visceral pleura into the parietal pleura. The bronchial and vascular margins were clear. Fourteen lymph nodes from seven levels were negative. The patient was discharged on postoperative day 3.

Conclusions: Robot-assisted lobectomies for T3 tumors invading the chest wall are safe and feasible.

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TV3 Uniportal Thoracoscopic Resection of Intralobar Pulmonary Sequestration

Alan D. Sihoe, Qigang Luo, Jinglong Li, Dazhi Pang. The University of Hong Kong Shenzhen Hospital, Shenzhen, China.

Objective: Pulmonary sequestration is an uncommon congenital condition for which surgical resection is usually indicated, either via open thoracotomy or conventional multiport video-assisted thoracoscopic surgery (VATS). Of the two types of sequestration, intralobar sequestration is technically more challenging to resect. The uniportal approach is the latest, most minimally invasive technique for ultra major thoracic surgery, but experience with its use in complex congenital pulmonary disease has thus far been limited.

Methods: We report the first case to our knowledge in which a uniportal VATS approach was used to perform a lobectomy for intralobar pulmonary sequestration.

Results: The patient was a 34-year-old man with a long history of symptoms, an extensively diseased right lower lobe, and three separate anomalous feeding vessels arising from the abdominal aorta. Uniportal right lower lobectomy was performed via only a 3.5-cm incision. The patient recovered well, was fully mobile from the morning after surgery, and was discharged home on the fourth postoperative day.

Conclusions: This case demonstrates the safety and feasibility of the uniportal approach even for the resection of a relatively challenging intralobar sequestration. Our video shows all the key features of the operation, with clear demonstration of the steps involved.

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TV4 Robot-Assisted Right Upper Lobectomy for an 11-cm Non–Small Cell Lung Cancer

Nguyen M. Le, Laurence N. Spier, Richard S. Lazzaro. Northwell Health, Lenox Hill Hospital, New York, NY USA.

Objective: This video demonstrates a robot-assisted right upper lobectomy for an 11-cm non–small cell lung cancer.

Methods: A 52-year-old man with a 20–pack-year smoking history and chronic obstructive pulmonary disease was found to have a 10-cm mass on computed tomography in the right upper lobe. Percutaneous biopsy revealed non–small cell carcinoma. Positron emission tomography and endobronchial ultrasound revealed no mediastinal disease. The patient was placed in left lateral decubitus. Five ports were used—four for the robot and one access port. A robot-assisted right upper lobectomy and mediastinal lymph node dissection was performed without complication.

Results: Final pathology revealed a 10.9×10.2×7.5-cm poorly differentiated non–small cell carcinoma with clear bronchial and vascular margin. Level 4 to 12, 1 out of 15 lymph nodes were positive (level 11). The tumor was pT3N1, stage IIIA. The patient was discharged on postoperative day 2 and referred for adjuvant chemotherapy.

Conclusions: Robot-assisted lobectomies for large tumors are safe and feasible.

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TV5 Electromagnetic Navigational Bronchoscopy With Cone Beam Computed Tomographic Guidance: Enabling Surgeons to Overcome Limitations

Sandeep Sachidananda 1, Cristobal Alvarado2. 1Waterbury Hospital, Waterbury, CT USA; and 2Hartford Healthcare Medical Group, Meriden, CT USA.

Objective: With the widespread implementation of low-dose computed tomographic screening for lung cancer, we have an increasing number of small solitary pulmonary nodules that require a diagnosis. Electromagnetic navigational bronchoscopy (ENB) is a new minimally invasive diagnostic modality. However, it is limited by its diagnostic accuracy of 60% to 80%. We propose the use of ENB with cone beam computed tomographic (CBCT) guidance to overcome the visual limitations of ENB and potentially increase the diagnostic accuracy of ENB-aided biopsy.

Methods: Patients with undiagnosed small pulmonary nodules (<20 mm) underwent biopsy where an initial CBCT of the chest under breath-hold was performed, followed by a three-dimensional (3D) model reconstruction of the lesion while the surgeon started the ENB. At the end of the bronchoscope navigation, the 3D model of the lesion was fused and automatically registered in real time over the two-dimensional fluoroscopic image, allowing visualization of the biopsy tool in the target lesion in three dimensions. Multiple samples were collected after confirmation of the tool position using various oblique views.

Results: In our initial experience with 10 cases, CBCT acquisition, reconstruction, and 3D overlay was successful in all cases. This technique enabled the confirmation of biopsy tool position within the target lesion in all cases. We were able to successfully and accurately obtain biopsies of nodules ranging from 8 to 20 mm in size.

Conclusions: The use of intraoperative CBCT with real-time 3D overlay to confirm positioning of biopsy tool within the lesion during ENB is technically feasible. It effectively combines the advantage of real-time computed tomographic imaging with the advantages of ENB-aided biopsy. This potentially increases the diagnostic accuracy of ENB-aided biopsy by enhanced visualization. This novel technique will facilitate early accurate diagnosis of lung cancer in small nodules with a minimally invasive approach. The enhanced visual capabilities of ENB with CBCT guidance paves way for the future use of minimally invasive catheter-based therapeutic platforms like microwave, radiofrequency ablation, and so on safely.

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TV6 Robot-Assisted Diaphragm Plication

Raghav Murthy 1, Kemp Kernstine2. 1Rady Children’s Hospital, San Diego, CA USA; and 2UT Southwestern Medical Center, Dallas, TX USA.

Objective: The video aimed to demonstrate the surgical technique, pearls, and pitfalls to performing robot-assisted diaphragm plication successfully.

Methods: The video demonstrates the procedure in a 53-year-old man with Parsonage-Turner syndrome and right diaphragm paralysis. The preoperative workup and imaging are discussed. The positioning of the patient, port placement, and technique of performing this procedure successfully are detailed in the video.

Results: The postoperative results with improvements in symptoms, imaging, and lung function are shown.

Conclusions: Robot-assisted diaphragm plication is a feasible operation with good results.

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TV7 Thoracoscopic Resection of Two Thoracic Outlet Schwannomas

Trevor C. Upham 1, Conor F. Hynes2, M. Blair Marshall2. 1University of California, San Diego, La Jolla, CA USA; and 2Georgetown University Hospital, Washington, DC USA.

Objective: Schwannomas are benign peripheral nerve sheath tumors that can occur anywhere in the body, but most commonly occur in the head and neck. Less frequently, they may occur in the chest. Originating mainly along the nerve roots, these tumors frequently occur in a central location that can cause local compression of critical structures for the patients and surgical access difficulty for the surgeon. Although thoracotomy, sternotomy, and other radical incisions can be made for excision, little information describes the thoracoscopic techniques to safely excise schwannomas at the apex of the thoracic cavity.

Methods: Here, we demonstrate two cases using a single-lumen endotracheal tube, CO2 insufflation, and pediatric instruments for the excision of apical schwannomas. Port placement, camera use, and instrument use are highlighted in each video to minimize injury to surrounding anatomical structures.

Results: Schwannomas at the apex of the chest can be excised safely using thoracoscopic techniques. Horner’s syndrome is a risk of the procedure but may resolve postoperatively.

Conclusions: Thoracoscopic excision should be considered for schwannomas at the apex of the chest.

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TV8 Uniportal Subxiphoid Video-Assisted Thoracoscopic Surgery Thymectomy

Giuseppe Aresu, Gianluca Masullo, Francesco Londero, Angelo Morelli. Santa Maria della Misericordia University Hospital Udine, Udine, Italy.

Objective: The aim of this video was to show the feasibility of extended thymectomy through a uniportal subxiphoid port as alternative to other minimally invasive anterior mediastinal approaches.

Methods: We operated on a 51-year-old woman presenting with a 2.5-cm thymoma and myasthenia gravis. A 3.5-cm longitudinal muscle-sparring incision was made below the xiphoid process through the linea alba. A trocar designed for single-incision laparoscopic surgery was inserted into the port, and CO2 was insufflated at a maximal pressure of 8 mmHg. Under visual guidance provided by a 10-mm variable angle telescope, the dissection was performed using grasping forceps designed for single-incision surgery, an ultrasonic dissection device, and a normal straight hook cautery. The bilateral phrenic nerves and the bilateral mammary arteries and veins were always under optimal control, as well as the cranial part of the mediastinum, permitting a safe dissection en bloc of the thymus, thymic tumor, and surrounding fatty tissue anterior to the phrenic nerves. The operation time was approximately 2 hours 36 minutes with minimal blood loss.

Results: No complications occurred during or after the operation, the drain was taken out after 1 day, and the patient was discharged home 2 days after surgery. Postoperative pain was very well controlled with just 1 g thrice daily of paracetamol until the second postoperative day.

Conclusions: The subxiphoid approach for thymectomy permits a very radical and safe dissection of the thymic and perithymic fatty tissues and can be considered a safe, esthetically excellent, and less painful minimally invasive approach even when compared with conventional intercostal video-assisted thoracoscopic surgery approaches.

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TV9 Robot-Assisted Radical Thymectomy With En Bloc Resection of Right Upper and Middle Lobe Wedges and Pericardium

Nguyen M. Le, Laurence N. Spier, Richard S. Lazzaro. Northwell Health, Lenox Hill Hospital, New York, NY USA.

Objective: This video demonstrates a robot-assisted thymectomy for a thymoma that was adhered to the right upper and middle lobes and the pericardium.

Methods: A 42-year-old woman who presented with stabbing chest pain was found to have an anterior mediastinal mass on computed tomographic scan. Percutaneous biopsy was consistent with thymoma. Imaging suggested adherence to the right upper and middle lobes but no definite evidence of invasion. It appeared to be adjacent to the pericardium with no convincing evidence of intrapericardial extension or great vessel invasion. The procedure was approached from the right with the patient supine and mildly rolled to the left. Four ports were used—three for the robot and one access port. A robot-assisted radical thymectomy with en bloc resection of the right upper and middle lobe wedges as well as the pericardium was completed without complication.

Results: Final pathology revealed a Masaoka stage IIA, World Health Organization type B3, R0 completely resected thymoma. The patient was discharged home on postoperative day 3. Two-year follow-up has demonstrated no recurrence on imaging.

Conclusions: Robot-assisted radical thymectomy with en bloc resection of the surrounding lung parenchyma and the pericardium is safe and feasible.

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TV10 Standardized Approach for Port Placement for Robot-Assisted Lobectomies With the Robotic Stapler

Nguyen M. Le, Richard S. Lazzaro, Laurence N. Spier. Northwell Health, Long Island Jewish Medical Center, New York, NY USA.

Objective: With the recently introduced robotic stapler, there is much variability in terms of port placement for robot-assisted lobectomies. We suggest a standardized technique that allows for stapling from both anterior and posterior directions.

Methods: Using the da Vinci Xi, we use five standard ports for robot-assisted lobectomy—two 8-mm cannulas, two 12-mm cannulas, and a 15-mm trocar. Port placement is arranged like the “five” on a dice, with the camera port serving as the center dot and the four remaining ports being placed 10 cm from the center. One hand width is used to approximate 10 cm. The patient is positioned in full lateral decubitus. We mark the inferior tip of the scapula. From the tip of the scapula approximately 10 cm inferior, our 8-mm camera port is positioned on the midaxillary line. Going anterior-superior from the camera port by 10 cm, we place a 15-mm accessory port. Going anterior-inferior 10 cm from the camera port, we place a 12-mm cannula with an 8-mm reducer. Again, from our midaxillary camera port, going in a posterior-superior direction by 10 cm, we place an 8-mm cannula. Finally, posterior-inferior 10 cm from the camera port, we place the second 12-mm cannula with an 8-mm reducer. We demonstrate this technique in this video of a patient undergoing robot-assisted right upper lobectomy (Fig. TV10-1).



Results: With our standardized port placement, the robotic stapler can be used through either the anterior or posterior 12-mm port. In addition, these two ports are placed very low in the chest, allowing for the 45-mm robotic stapler loads to be used with minimal space issues. Ultimately, our standardized port placement provides an optimal angle for safe stapling, which can be applied to any lobe on either side of the patient.

Conclusions: We propose a standardized approach to port placement for robot-assisted lobectomies using the robotic stapler, as it allows for excellent stapling angles bilaterally.

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TV11 Intraoperative Lymphatic Mapping in Esophagogastric Junction Adenocarcinoma

Daniela Molena. Memorial Sloan Kettering Cancer Center, New York, NY USA.

Objective: This aimed to evaluate the lymphatic drainage distribution in patients with esophageal adenocarcinoma of the esophagogastric junction.

Methods: Patients undergoing minimally invasive esophagectomy were injected with 2 mL (1.25 mg/mL) of Indocyanine Green into the esophageal submucosa at the four quadrants around the tumor before initiating the laparoscopic phase of surgery. Pattern of drainage was recorded.

Results: Visualization of the lymphatic drainage was prompt after injection. This video shows the injection technique and the laparoscopic visualization of the lymphatic drainage.

Conclusions: Understanding the pattern of drainage for esophagogastric junction tumors can guide the surgeon to a targeted lymphadenectomy. Sentinel node identification may also be possible and valuable.

©2016 by the International Society for Minimally Invasive Cardiothoracic Surgery