Single-Port vs Conventional Three-Port Video-Assisted Thoracoscopic Pulmonary Wedge Resection: Comparison of Postoperative Pain and Surgical Costs.

PURPOSE: Single-port video-assisted thoracoscopic (VATS) pulmonary wedge resection was reported in 2004. We started using single-port VATS (SPVATS) pulmonary wedge resection in 2017 and compared results between conventional three-port VATS (VATS group) and SPVATS (SPVATS group). METHODS: We identified 145 consecutive patients with VATS group and SPVATS group. Perioperative characteristics including pain and the number of stapler cartridges used were examined as the surgical outcomes, retrospectively. RESULTS: In all, 66 cases of SPVATS group and 79 cases of VATS group pulmonary wedge resection were compared. The rate of epidural anesthesia (p <0.0001) was significantly higher and operative time (p <0.0001) was significantly longer with VATS group than with SPVATS group. The number of stapler cartridges used, duration of drain insertion, and rate of postoperative complications did not differ significantly between groups. Average numerical rating scale (NRS) score on postoperative day 1 and postoperative day 7 (p <0.0001 each), maximum NRS score on postoperative day 7 (p = 0.0082) and amount of 25 mg tramadol (p = 0.0062) were significantly lower in SPVAS group than in VATS group. CONCLUSION: Our results suggest that SPVATS pulmonary wedge resection offers better pain control and cost-effectiveness than three-port VATS pulmonary wedge resection. These findings should contribute to the body of evidence for SPVATS.

Cost-effective homemade automatically opening endobag for video-assisted thoracic surgery.

Because specimen removal is often required during video-assisted thoracic surgery, an easily produced, simple-to-use and cost-effective endobag is necessary to avoid wound metastasis. However, commercial endobags are expensive. Here I describe a homemade automatically opening, cost-effective, safe and easily produced endobag for video-assisted thoracic surgery that is suitable for use in low-income locations with limited health budgets.

MesoTRAP: a feasibility study that includes a pilot clinical trial comparing video-assisted thoracoscopic partial pleurectomy decortication with indwelling pleural catheter in patients with trapped lung due to malignant pleural mesothelioma designed to address recruitment and randomisation uncertainties and sample size requirements for a phase III trial.

Introduction: One of the most debilitating symptoms of malignant pleural mesothelioma (MPM) is dyspnoea caused by pleural effusion. MPM can be complicated by the presence of tumour on the visceral pleura preventing the lung from re-expanding, known as trapped lung (TL). There is currently no consensus on the best way to manage TL. One approach is insertion of an indwelling pleural catheter (IPC) under local anaesthesia. Another is video-assisted thoracoscopic partial pleurectomy/decortication (VAT-PD). Performed under general anaesthesia, VAT-PD permits surgical removal of the rind of tumour from the visceral pleura thereby allowing the lung to fully re-expand. Methods and analysis: MesoTRAP is a feasibility study that includes a pilot multicentre, randomised controlled clinical trial comparing VAT-PD with IPC in patients with TL and pleural effusion due to MPM. The primary objective is to measure the SD of visual analogue scale scores for dyspnoea following randomisation and examine the patterns of change over time in each treatment group. Secondary objectives include documenting survival and adverse events, estimating the incidence and prevalence of TL in patients with MPM, examining completion of alternative forms of data capture for economic evaluation and determining the ability to randomise 38 patients in 18 months. Ethics and dissemination: This study was approved by the East of England-Cambridge Central Research Ethics Committee and the Health Research Authority (reference number 16/EE/0370). We aim to publish the outputs of this work in international peer-reviewed journals compliant with an Open Access policy. Trial registration: NCT03412357.

Intraoperative costs of video-assisted thoracoscopic lobectomy can be dramatically reduced without compromising outcomes.

OBJECTIVE: To determine whether surgeon selection of instrumentation and other supplies during video-assisted thoracoscopic lobectomy (VATSL) can safely reduce intraoperative costs. METHODS: In this retrospective, cost-focused review of all video-assisted thoracoscopic surgery anatomic lung resections performed by 2 surgeons at a single institution between 2010 and 2014, we compared VATSL hospital costs and perioperative outcomes between the surgeons, as well as costs of VATSL compared with thoracotomy lobectomy (THORL). RESULTS: A total of 100 VATSLs were performed by surgeon A, and 70 were performed by surgeon B. The preoperative risk factors did not differ significantly between the 2 groups of surgeries. Mean VATSL total hospital costs per case were 24% percent greater for surgeon A compared with surgeon B (P = .0026). Intraoperative supply costs accounted for most of this cost difference and were 85% greater for surgeon A compared with surgeon B (P < .0001). The use of nonstapler supplies, including energy devices, sealants, and disposables, drove intraoperative costs, accounting for 55% of the difference in intraoperative supply costs between the surgeons. Operative time was 25% longer for surgeon A compared with surgeon B (P < .0001), but this accounted for only 11% of the difference in total cost. Surgeon A's overall VATSL costs per case were similar to those of THORLs (n = 100) performed over the same time period, whereas surgeon B's VATSL costs per case were 24% less than those of THORLs. On adjusted analysis, there was no difference in VATSL perioperative outcomes between the 2 surgeons. CONCLUSIONS: The costs of VATSL differ substantially among surgeons and are heavily influenced by the use of disposable equipment/devices. Surgeons can substantially reduce the costs of VATSL to far lower than those of THORL without compromising surgical outcomes through prudent use of costly instruments and technologies.

Through the Looking Glass: Real-Time Video Using 'Smart' Technology Provides Enhanced Intraoperative Logistics.

INTRODUCTION: In the setting of increasingly complex medical therapies and limited physician resources, the recent emergence of 'smart' technology offers tremendous potential for improved logistics, efficiency, and communication between medical team members. In an effort to harness these capabilities, we sought to evaluate the utility of this technology in surgical practice through the employment of a wearable camera device during cardiothoracic organ recovery. METHODS: A single procurement surgeon was trained for use of an Explorer Edition Google Glass (Google Inc., Mountain View, CA) during the recovery process. Live video feed of each procedure was securely broadcast to allow for members of the home transplant team to remotely participate in organ assessment. Primary outcomes involved demonstration of technological feasibility and validation of quality assurance through group assessment. RESULTS: The device was employed for the recovery of four organs: a right single lung, a left single lung, and two bilateral lung harvests. Live video of the visualization process was remotely accessed by the home transplant team, and supplemented final verification of organ quality. In each case, the organs were accepted for transplant without disruption of standard procurement protocols. Media files generated during the procedures were stored in a secure drive for future documentation, evaluation, and education purposes without preservation of patient identifiers. CONCLUSIONS: Live video streaming can improve quality assurance measures by allowing off-site members of the transplant team to participate in the final assessment of donor organ quality. While further studies are needed, this project suggests that the application of mobile 'smart' technology offers not just immediate value, but the potential to transform our approach to the practice of medicine.

[A comparative study of Da Vinci robot system with video-assisted thoracoscopy in the surgical treatment of mediastinal lesions].

BACKGROUND: In recent years, Da Vinci robot system applied in the treatment of intrathoracic surgery mediastinal diseases become more mature. The aim of this study is to summarize the clinical data about mediastinal lesions of General Hospital of Shenyang Military Region in the past 4 years, then to analyze the treatment effect and promising applications of da Vinci robot system in the surgical treatment of mediastinal lesions. METHODS: 203 cases of mediastinal lesions were collected from General Hospital of Shenyang Military Region between 2010 and 2013. These patients were divided into two groups da Vinci and video-assisted thoracoscopic surgery (VATS) according to the selection of the treatments. The time in surgery, intraoperative blood loss, postoperative drainage amount within three days after surgery, the period of bearing drainage tubes, hospital stays and hospitalization expense were then compared. RESULTS: All patients were successfully operated, the postoperative recovery is good and there is no perioperative death. The different of the time in surgery between two groups is Robots group 82 (20-320) min and thoracoscopic group 89 (35-360) min (P>0.05). The intraoperative blood loss between two groups is robot group 10 (1-100) mL and thoracoscopic group 50 (3-1,500) mL. The postoperative drainage amount within three days after surgery between two groups is robot group 215 (0-2,220) mL and thoracoscopic group 350 (50-1,810) mL. The period of bearing drainage tubes after surgery between two groups is robot group 3 (0-10) d and thoracoscopic group: 5 (1-18) d. The difference of hospital stays between two groups is robot group 7 (2-15) d and thoracoscopic group 9 (2-50) d. The hospitalization expense between two groups is robot group (18,983.6±4,461.2) RMB and thoracoscopic group (9,351.9±2,076.3) RMB (All P<0.001). CONCLUSIONS: The da Vinci robot system is safe and efficient in the treatment of mediastinal lesions compared with video-assisted thoracoscopic approach, even though its expense is higher.

Physical assessment immediately after lobectomy via miniposterolateral thoracotomy assisted by videothoracoscopy for non-small cell lung cancer.

PURPOSE: We evaluated the invasiveness of videothoracoscopy-assisted mini-posterolateral thoracotomy (VAmPLT) for non-small cell lung cancer (NSCLC). METHODS: This study prospectively analyzed 50 NSCLC patients who underwent VAmPLT lobectomy. We measured maximal negative inspiratory pressure (PImax), maximal positive expiratory pressure (PEmax), quadriceps strength (QS), 6-min walk test (6mWT), and postoperative pain during the perioperative period. We then compared the results of the 6mWT and the postoperative pain of the VAmPLT lobectomy patients with those of a control group of 50 NSCLC patients who underwent standard posterolateral thoracotomy (PLT) techniques just prior to implementation of the VAmPLT lobectomy. RESULTS: The PImax and PEmax at the baseline, then on postoperative days (PODs) 1, 7, and 14 were 125% ± 5% and 120% ± 4%, 69% ± 4% and 62% ± 4%, 115% ± 5% and 100% ± 4%, and 123% ± 4%, and 110% ± 4%, respectively. The QS at the baseline, then on PODs 7 and 14 was 138% ± 5%, 129% ± 6%, and 133% ± 5%, respectively. Improvement from the baseline was seen in PImax by POD 7, and in PEmax and QS by POD 14. The 6mWT results and the level of postoperative pain after VAmPLT lobectomy were superior to those after PLT. CONCLUSIONS: The advantages of VAmPLT lobectomy over PLT include less postoperative pain and earlier recovery of physical function.

Comparing bipolar electrothermal device and endostapler in endoscopic lung wedge resection.

Video-assisted thoracoscopy (VATS) is gaining on thoracic surgery, having newly developed devices next to endostaplers for haemostatic and airtight sealing of lung parenchyma. Though the bipolar electrothermal Ligasure has good results for pulmonary wedge resection, its literature is small in numbers. Authors compared Ligasure and endostapler for pulmonary wedge resection of solitary pulmonary nodules (SPN). Authors performed a retrospective analysis of 44 consecutive patients. The indication of operation was non-verified SPN in all cases. They carried out pulmonary wedge resection for 22 patients with Ligasure-Atlas and 22 patients with ETS Flex endostapler via VATS. Authors examined the gender, average age (62 vs. 49 years), mean hospital stay (6.6 vs. 6.8 days), average operation time (55 vs. 50 min), number of complications (2 vs. 1), average drainage time (2.8 vs. 2.7 days), average fluid loss (190 vs. 160 ml), and instrumental costs (367 euro vs. 756 euro) of both groups. They accomplished the histological analysis of the coagulated lung parenchyma as well. According to the results, the Ligasure-Atlas is eligible for pulmonary wedge resection. The method is safe, easy to use, having minimal rate of complications. It can moderate costs of operation, compared to endostaplers.

[Contrivance for video-assisted thoracic surgery pulmonary resection; a new-shaped rib spreader and one port operatinon].

A new-shaped rib spreader, which was adapted from a ready-made reverse arch rib spreader, was orderd to consist of inverted-Y-shape blades which were 4 cm in length, 3.7 cm in width and bent at 250 angle with each other at the half of length. This rib spreader with long and angled blades make it possible to perform video-assisted thoracic surgery (VATS) lobectomy and segmentectomy with 4-5 cm access incision and only 1 port for almost all of the patients inclusive of a thick chest wall case. A lung grasping forceps and a thoracoscope together were inserted from the same port insicion. The surgeon operates by watching both monitoring vision and direct vision through the access incision. Pulmonary artery (PA) s were ligated by double tied and transfixion suture with silk threads. Pulmonary vein (PV) s and bronchus were stapled and divided with Endo-GIA. Lymph nodes division was performed for ND2a-2b in right side, however, ND2a in left side. These thoracoscopic pulmonay resectional procedure can be performed safely, certainly, cosmeticaly and for reducing cost.

Cost comparison of robotic, video-assisted thoracic surgery and thoracotomy approaches to pulmonary lobectomy.

The financial impact of employing minimally invasive techniques for lobectomy compared with traditional open thoracotomy was assessed. A retrospective review was conducted using ICD9 codes for thoracotomy, video-assisted thoracic surgery (VATS), and robotic VATS lobectomy to determine total average costs associated with the resultant hospital stay. The difference in total average costs was calculated for each group. Robotic VATS lobectomy had higher associated costs than VATS only, primarily attributed to increased costs of the first hospital day, but was still less costly than thoracotomy. The average cost of VATS is substantially less than thoracotomy primarily because of a decreased length of stay. The cost of robotic assistance for VATS is still less than thoracotomy, but greater than VATS alone.

[Risk and its management in video-assisted thoracic surgery].

To avoid intraoperative accidents or trouble with patients in video-assisted thoracic surgery (VATS), the surgeons should complete sufficient training. Patients tend to have excessive expectation for less invasive approach, proper information of VATS procedure must be given to the patients as well as the referring physicians. Sufficient cancer surgery should be considered prior to applying VATS approach. If cancer recurred after VATS operation, it is far from minimally invasive surgery. The lung and the pulmonary artery are very fragile. Surgeons who are performing VATS surgery must have a skill of suturing the lung and some bleeding control technique. These well trained technique and the ability of judge will manage the risk and the accident in VATS operations.

Uniportal video-assisted thoracic surgery for primary spontaneous pneumothorax: clinical and economic analysis in comparison to the traditional approach.

We aimed to verify the clinical and economic effects of uniportal video-assisted thoracic surgery (VATS) in patients with primary spontaneous pneumothorax (PSP) compared to traditional three-port VATS technique. We analyzed 51 consecutive patients (23 three-port VATS and 28 uni-port VATS), treated by bullectomy and pleural abrasion, to detect differences between the two groups with regard to intraoperative management, postoperative course, pain, paraesthesia and costs. Data about pain and paraesthesia were collected by telephonic interview within a minimum follow-up period of six months. Compared to three-port VATS, patients treated by the uni-port VATS were discharged more quickly (3.8 days vs. 4.9 days, P=0.03) and experienced paraesthesia less frequently (35% vs. 94%, P<0.0001). No difference in chronic pain was observed between the two groups (numeric pain score: 0.6 uni-port vs. 1.3 three-port, P=0.2). Compared to three-port VATS, we found a significant reduction in postoperative costs for the patients operated on by the uni-port technique (euro1407 vs. euro1793, P=0.03), without any increase in surgical costs. In conclusion, uniportal VATS appears to offer better clinical (postoperative stay and rate of paraesthesia) and economic (postoperative costs) results than the standard three-port VATS for treating primary spontaneous pneumothorax.

For more safety: no-knife stapling for vascular division during video-assisted thoracoscopic surgery.

Staple cutters facilitate video-assisted thoracoscopic surgery, but their potential malfunction at vascular division can threaten the patient's life. We have used no-knife staplers and have divided between the staple lines without event. We show this technique to be a risk management alternative.

Video-assisted thoracoscopic pericardial window for penetrating cardiac trauma.

OBJECTIVE: To report our experience with thoracoscopic pericardial window (TPW) for occult penetrating cardiac injury. PATIENTS AND METHODS: During the study period (1 January - 31 December 2000), a small group of haemodynamically stable patients with anterior left-sided praecordial wounds were selected for TPW. All patients underwent general anaesthesia with double-lumen intubation and collapse of the left lung. A rigid laparoscope was inserted through a 2 cm incision in the 5th intercostal space in the anterior axillary line. Another 3 cm incision was made in the fourth intercostal space over the cardiac silhouette. Conventional instruments were used to grasp and open the pericardium. Any myocardial injury identified was an indication to proceed to sternotomy. In the absence of a myocardial injury and bleeding, the procedure was terminated and considered therapeutic. RESULTS: Seventy-one patients with suspected penetrating cardiac injuries were seen. TPW was successfully completed in 13 patients. All were men, with a mean age of 29.8 (range 19 - 38) years. Ten and 3 patients sustained stab and gunshot wounds, respectively. The mean revised trauma score was 7.84. Ultrasound was performed in 12 patients; the results were equivocal for 2 patients, and positive for an effusion in 4 patients. Haemopericardium was found in 3 patients, 2 of whom proceeded to sternotomy. No cardiac injury was found in 1, a left ventricular contusion was identified in the second, and the third patient had no further procedure after good video-thoracoscopic visualisation of the anterior myocardium revealed no injury. In another patient, pericardial bruising was evident without any haemopericardium. The mean operative time was 13.4 (range 10 - 15) minutes, with a mean hospital stay of 5.4 (range 3 - 8) days. There were no complications. The use of a double-lumen endotracheal tube increased the cost of TPW by 23% when compared with subxiphoid pericardial window (SPW). CONCLUSION: TPW is a feasible, although in our setting not cost-effective, diagnostic option for occult penetrating cardiac injuries.

Robot-assisted surgery: the future is here.

According to L. Wiley Nifong, director of robotic surgery at East Carolina University's Brody School of Medicine, "Nationally, only one-fourth of the 15 million surgeries performed each year are done with small incisions or what doctors call 'minimally invasive surgery'." Robots could raise that number substantially (Stark 2002). Currently, healthcare organizations use robot technology for thoracic, abdominal, pelvic, and neurological surgical procedures. Minimally invasive surgery reduces the amount of inpatient hospital days, and the computer in the system filters any hand tremors a physician may have during the surgery. The use of robot-assisted surgery improves quality of care because the patient experiences less pain after the surgery. Robot-assisted surgery demonstrates definite advantages for the patient, physician, and hospital; however, healthcare organizations in the United States have yet to acquire the technology because of implementation costs and the lack of FDA (Food and Drug Administration) approval for using the technology for certain types of heart procedures. This article focuses on robot-assisted surgery advantages to patients, physicians, and hospitals as well as on the disadvantages to physicians. In addition, the article addresses implementation costs, which creates financial hurdles for most healthcare organizations; offers recommendations for administrators to embrace this technology for strategic positioning; and enumerates possible roles for robots in medicine.