Electrocautery device does not provide adequate pulmonary vessel sealing in transumbilical anatomic pulmonary lobectomy.

INTRODUCTION: Safe pulmonary vessel sealing device plays a crucial role in anatomic lung resection. In 2014, we reported high rates of massive bleeding complications during transumbilical lobectomy in a canine model due to difficulty in managing the pulmonary vessel with an endostapler. In this animal survival series, we aimed to evaluate the outcome of pulmonary vessel sealing with an electrocautery device to simplify the transumbilical thoracic surgery. METHODS: Under general anesthesia, a 3-cm longitudinal incision was made over the umbilicus. Under video guidance, a bronchoscope was inserted through the incision for exploration. The diaphragmatic wound was created with an electrocautery knife and used as the entrance into the thoracic cavity. Using the transumbilical technique, anatomic lobectomy was performed with electrosurgical devices and endoscopic vascular staplers in 15 canines. RESULTS: Transumbilical endoscopic anatomic lobectomy was successfully completed in 12 of the 15 animals. Intraoperative bleeding developed in three animals during pulmonary hilum dissection, where one animal was killed due to hemodynamic instability and the other two animals required thoracotomy to complete the operation. There were five delayed bleeding and surgical mortality cases caused by inadequate vessel sealing by electrosurgical devices. Postmortem examination confirmed correct transumbilical lobectomy in the twelve animals that survived the operations. CONCLUSION: Transumbilical anatomic lobectomy is technically feasible in a canine model; however, the electrosurgical devices were not effective in sealing the pulmonary vessel in the current canine model.

Feasibility of Subxiphoid Anatomic Pulmonary Lobectomy in a Canine Model.

Purpose Transthoracic thoracoscopic approach is the gold standard in surgical treatment for thoracic disease. However, it is associated with significant chronic postoperative wound discomfort. Currently, limited data are available regarding the subxiphoid approach to the thoracic cavity. The present study is aimed to evaluate the performance of a subxiphoid anatomic pulmonary lobectomy (SAPL) in a canine model. Methods The SAPL procedure was performed in 10 beagle dogs using a 3-cm incision over the xiphoid process. After thoracic exploration, SAPL was performed under flexible bronchoscopy guidance. The pulmonary vessel was divided with Ligasure and secured with a suture ligature. The bronchus was divided with endostapler. Surgical outcomes were evaluated by the success of SAPL and operative complications. Results SAPL was successfully completed in 9 animals. One animal required conventional thoracotomy to resuture the pulmonary artery stump. Another animal encountered small middle lobe laceration after SAPL and died at 8 days postoperation due to respiratory distress. Conclusion Subxiphoid anatomic pulmonary lobectomy is technically feasible. Refinement of endoscopic instruments combined with more research evidences may facilitate the development of subxiphoid platform in thoracic surgery.

Feasibility of endoscopic transoral thoracic surgical lung biopsy and pericardial window creation.

BACKGROUND: The thoracic cavity approach for natural orifice transluminal endoscopic surgery (NOTES) is technically challenging. The aim of this study was to evaluate the feasibility of a transoral endoscopic technique for a surgical lung biopsy and pericardial window creation METHODS: Under general anesthesia, a 12 mm incision was made over the vestibulum oris region. Under video guidance, a homemade metallic tube was introduced through the incision, extending along the pre-tracheal space to the substernal space with blunt dissection technique, and used as the entrance into the thoracic cavity. A surgical lung biopsy and a pericardial window creation were performed in 12 canines, using the transoral NOTES technique. RESULTS: The transoral endoscopic surgical lung biopsy and pericardial window creation were successfully completed in 11 of the 12 canines. Intraoperative bleeding and death from an injury to the pulmonary hilum developed in one animal during the electrosurgical excision of lung tissue. CONCLUSIONS: Transoral surgical lung biopsy and pericardial window creation in canine models is technically feasible and can be used as a novel experimental platform for studies of NOTES for intra-thoracic surgery.

The lateral decubitus position improves transoral endoscopic access to the posterior aspects of the thorax.

BACKGROUND: The success of natural orifice transluminal endoscopic surgery (NOTES) depends on an adequate exploration of surgical regions. Currently, limited data are available regarding the optimal position for the NOTES approach for thoracic surgery. This study therefore aimed to evaluate the effectiveness of transoral thoracic exploration in a canine model placed in a lateral decubitus position. METHODS: A total of 14 dogs were used in this study. Transoral thoracoscopy was performed using a custom-made metal tube via an incision over the vestibular incision with the animal in a supine position. After thoracic exploration, the animal was placed in a lateral decubitus position. The thoracic intervention (surgical lung biopsy, pericardial window creation, and dorsal sympathectomy) was performed by passing a flexible bronchoscope through the lumen of a metal tube. RESULTS: The mean operative time for this procedure was 70 min (range 45-100 min). For 12 dogs, all procedures were completed without major complications. However, for one dog, the exploration of the thoracic cavity was incorrect (the right lower lobe had been misinterpreted as the left lower lobe). Another dog had minor bleeding because of an intercostal artery injury that occurred during sympathectomy. CONCLUSION: The posterior aspect of the thoracic cavity can be exposed via a transoral approach with the animal in a lateral decubitus position. This approach may be considered as an adjuvant to the supine approach, in which exploration of the posterior thoracic cavity is restricted.