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Single port video-assisted thoracic surgery: Advancing scope technology

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... To improve ergonomics and particularly to avoid the fencing from individual instruments placed through the small incision of single-port VATS, rapid progress in instrument design has taken place. The narrower shafted double-hinged single-port instruments and thoracoscopes that have greater degrees of vision may all contribute to a reduction of some of the challenges associated with single-port VATS [13,17]. The greater lens flexibility improves visibility in single-port VATS when all the instruments and the scope pass through a single small incision in a parallel manner, particularly for surgeons on the learning curve and in difficult cases [13,17]. ...
... The narrower shafted double-hinged single-port instruments and thoracoscopes that have greater degrees of vision may all contribute to a reduction of some of the challenges associated with single-port VATS [13,17]. The greater lens flexibility improves visibility in single-port VATS when all the instruments and the scope pass through a single small incision in a parallel manner, particularly for surgeons on the learning curve and in difficult cases [13,17]. Further innovations that have led to a reduction in thoracoscope-instrument interference include the replacement of the conventional thoracoscope with remote wireless camera systems, such as the magnetic anchoring guidance system (MAGS) [17]. ...
... The greater lens flexibility improves visibility in single-port VATS when all the instruments and the scope pass through a single small incision in a parallel manner, particularly for surgeons on the learning curve and in difficult cases [13,17]. Further innovations that have led to a reduction in thoracoscope-instrument interference include the replacement of the conventional thoracoscope with remote wireless camera systems, such as the magnetic anchoring guidance system (MAGS) [17]. The MAGS uses magnets to hold and control a remote wireless camera placed within the operating cavity, eliminating the need for light and transmission cables. ...
Article
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Single-port video-assisted thoracic surgery (VATS) has slowly established itself as an alternate surgical approach for the treatment of an increasingly wide range of thoracic conditions. The potential benefits of fewer surgical incisions, better cosmesis, and less postoperative pain and paraesthesia have led to the technique's popularity worldwide. The limited single small incision through which the surgeon has to operate poses challenges that are slowly being addressed by improvements in instrument design. Of note, instruments and video-camera systems that are narrower and angulated have made single-port VATS major lung resection easier to perform and learn. In the future, we may see the development of subcostal or embryonic natural orifice translumenal endoscopic surgery access, evolu-tion in anaesthesia strategies, and cross-discipline imaging-assisted lesion localization for single-port VATS procedures. Key words: 1. DynaCT 2. Hookwire 3. Hybrid 4. Magnetic anchoring and guidance systems 5. Non-intubated lung resection 6. Natural orifice translumenal endoscopic surgery INTRODUCTION
... spVATS was done for curative intent in 203 (69.7%) patients, of which 69 (34%) had a diagnosis of primary non-small cell lung cancer (PLC) and 134 (66%) had pulmonary metastasis (PM) (Fig. 1). PLC and PM were further divided according to the type of resection into: limited resection (28, 40.6% and 120, 89.5%), lobectomy (28, 40.6% and 7, 5.2%), and complex procedure (13,18.8% and 7, 5.2%). The latter group included patients who underwent bronchial sleeve upper lobectomy, bilobectomy, lung resection enblock with chest wall, diaphragm or pericardium, and one case with resection of a small part of the left atrium. ...
... One of the technical issue discussed at length was the limitation of the visual field during spVATS; this was solved by utilizing a rotating prism mechanism at the tip of a rigid scope allowing vision between 0° and 120°. A more advanced flexible scope has been suggested by Yang et al. utilized in right upper lobectomy, which was criticized due to the soft scope's delicate tip [18]. Both techniques might be replaced by the recently developed magnetic anchoring and guidance system (MAGS) camera that could result in a larger viewing angle and eliminate instrument fencing [19]. ...
Article
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Background Video-assisted thoracoscopic surgery (VATS) is a safe and effective surgical approach for pulmonary resection. VATS can be accomplished with only a single incision, resulting in less postoperative pain and paresthesia, better cosmetic results, and greater patient satisfaction. Single-port VATS (spVATS) has become increasingly common for lung resection. We assess the early surgical and oncological outcomes after adopting this new technique at our tertiary cancer center as the first institution to do so in the country. Method Medical records for 257 patients in a tertiary cancer center, with a diagnosis of non-small cell lung cancer, pulmonary metastasis, or other chest-confined pathology, were accessed to obtain perioperative outcomes, pathologic results, post-operative follow-up data, and early surgical and oncological outcomes. All patients underwent spVATS for limited or major lung resection. Simple descriptive analysis was utilized. Results spVATS was either performed with curative intent (79.8%, N = 205), or as a diagnostic procedure (20.2%, N = 52). Resection types were subcategorized for curative intent group as limited (73.6%, N = 151), lobectomy (16.6%, N = 34), and complex (9.7%, N = 20). Resection with a negative margin (R0) rate was 100% for the primary lung cancer (PLC) patients and 97% for the pulmonary metastasectomy (PM) group. The complication rate was 5%. Three-year disease-free survival was 87% and 68.5% for PLC and PM group, respectively. The 3-year overall-survival was 91.3% for the PLC and 82.8% for PM. Operation duration showed a downtrend over the study period in each curative subcategory with a borderline difference in the limited resection (P value = 0.05). Conclusion All the spVATS procedures were successfully performed without perioperative severe complications or mortality, regardless of complexity. R0 resection was excellent. Middle- and long-term efficacies of spVATS for lung cancer require further follow-up. With proper training, appropriate indication and meticulous application, adopting spVATS is safe and feasible technique that does not compromise surgical and oncological outcomes.
... Interestingly, due to simultaneous development of uniportal VATS in many Asian countries, each VATS center has invented its own signature uniportal VATS approach based on its 3-port VATS experience. In Hong Kong, most centers prefer a 30-degree 5 or 10 mm scope, while others may prefer a more versatile 120-degree larger thoracoscope or flexible tipped thoracoscope for vision (26). While some surgeons prefer to stand at the posterior side of patient and operate through a lateral port incision, we prefer to approach from the anterior and work through a utility port which is usually centered over the anterior axillary line to take advantage of the wider intercostal spaces (27). ...
Article
In the era of modernized medicine, thoracic surgery has been focusing on achieving minimally invasive surgery and providing a one-stop solution in treating thoracic diseases. Particularly in the Asia population, where patients are keen to have smaller wound and shorter hospital stay, thoracic surgery in Hong Kong has evolved from the traditional open thoracotomy approach to video-assisted thoracoscopic surgery (VATS). In our institution, uniportal VATS for major lung resection was developed in 2012. While uniportal VATS has brought advantages into managing thoracic pathologies, it also brought challenges like instrument fencing during manipulation and suboptimal visualization angle. To improve the procedure and its outcomes, novel techniques and equipment have been developed, for example, double-hinged instruments, robotic assisted technology and magnetic anchored and guided endoscopes (MAGS). With advanced medical imaging nowadays, management of small lung nodules or ground glass opacity (GGO) is in higher demand than ever before. Our hybrid operating room (HOR) can incorporate instant and real-time imaging in lesion localization, and provide treatment via VATS or electromagnetic navigated bronchoscopic (ENB) ablation in a one-stop manner. This paper will review the literature related to the historical development and clinical outcomes of thoracic surgery in Hong Kong and discuss the future perspective of ongoing development.
... Another recent advancement is the development of variable wide angled thoracoscopes that allow up to 120 degrees of vision by either flexible scope tip or rotating prism mechanism. These thoracoscopes improve the surgeon's visual field and flexibility, even when the scope movement and position is limited within the confines of a small single incision (22). The laborious task of intracorporeal knot tying for bronchial anastomosis can now be significantly simplified by using an endoscopic "knot tying" device, such as TK Ti-KNOT® (LSI Solutions, Rochester, USA), that conveniently tightens and then secures the suture using a titanium crimp (23). ...
Article
In the past, thoracoscopic sleeve resection has been reserved for the most adventurous and capable minimal invasive thoracic surgeons. However, with improvements in thoracoscopic competency, greater exchange of knowledge and technical know-how, and advances in equipment, increasing number of centers are able to perform sleeve resections thoracoscopically. He Jianxing's team from China, a group known for their innovation and thoracoscopic excellence, has recently published their experience of bronchial sleeve resections (1). Among the 49 patients, 20 (41%) received the bronchial sleeve lobectomy thoracoscopically, with one patient requiring half-carinal reconstruction in combination with right upper sleeve lobectomy. A 3-port VATS technique was used, with the utility thoracotomy placed anteriorly, and the camera port inferiorly. In just under half of their initial cases, a modified interrupted suture anastomosis technique of closing the membranous posterior wall of the bronchus with continuous 4-O polypropylene followed by alternating figure-of-eight and mattress with 4-O single-strand absorbable suture for the cartilaginous anterior wall was used. For the subsequent remaining cases, a continuous suture technique was used for both the posterior and anterior bronchial walls. Neither covering nor buttressing techniques were needed for the anastomoses, and no postoperative anastomotic leakage was detected. With no perioperative mortality and excellent immediate results, this study seem to further support the relative safety and efficacy of thoracoscopic sleeve resection in experienced thoracoscopic surgery centers. In addition, the study has highlighted the evolution in thoracoscopic bronchial anastomotic technique from the traditional emphasis on the security of interrupted suturing (2), to the increasing use of the more convenient continuous suturing techniques over recent years (1,3,4). Evidently, continuous suturing techniques will result in less suture tangling and may be quicker, while proponents of interrupted suturing have emphasized the potential advantages of less anastomotic site ischemia and security of their technique. It seems impossible to have a meaningful comparison of clinical outcomes between the different anastomotic approaches for thoracoscopic sleeve lobectomy because of the relatively low case numbers, patient heterogeneity and the wide variations in technique within each anastomotic approach, for example, suture size and type used, or stitch spacing, just to mention a few. In thoracic surgery, perhaps more so in thoracoscopic surgery, it is often the technique which the surgeon has been trained and is most comfortable with which produces the best results. The bronchial anastomotic technique chosen should be the one most familiar to the surgeon. Doing less for more
... Lobectomy evolved from open thoracotomy to three-port VATS in 1994 and then to single-port VATS in 2012 [2]. Instrument crowding is a special concern for single-port procedures [3], leading to the development over the years of smaller, more manoeuvrable instruments [4,5]. In the design of endocutters with improved vessel accessibility, what has been needed is a narrower anvil and shaft, a wider range of articulation and consistent firing power while maintaining equivalent haemostasis to current devices. ...
Article
Objective: Current endoscopic transection devices are not optimized to meet the unique challenges posed by the task of vessel transection in difficult-to-access locations within the pleural cavity. The ECHELON FLEX™ powered vascular stapler (PVS) has been designed with four rows of staples instead of six, to decrease its size and enable more precise placement on fragile pulmonary vessels, using a narrower anvil than other commercially available transecting devices. This study was performed to determine whether the reduced number of staple rows affects haemostasis, and to assess surgeons' initial impression of the smaller stapler during in vivo usage. Methods: The new four-row stapler was compared with commercially available six-row articulating staplers via expert graders using a validated scale of haemostasis in vivo after application on porcine gastroepiploic pedicles and other thin- and thick-walled vessels. The new stapler was then compared with current products by practising thoracic surgeons (n = 27) during in vivo usage of simulated pulmonary procedures in a porcine model. The surgeons were also surveyed on the key attributes of the four-row stapler in relation to the six-row predicates. Results: Haemostasis evaluated on an ordered scale was clinically equivalent between the test and predicate staplers, and was deemed acceptable for all thin- and thick-vascular tissue applications. Surgeons found no difference in haemostasis between the four- and six-row staplers (P = 0.486), and judged the four-row stapler superior in terms of access, reduced need for dissection, reduced stress of surgeon and precise control (P < 0.001 for all). Conclusions: The new ECHELON FLEX™ PVS provides haemostasis equivalent to six-row staplers. With a smaller anvil, narrower shaft and wider angle of articulation, the PVS demonstrated improved access capability for pulmonary vessel procedures.
... Over the past 20 years, minimally invasive surgical techniques have revolutionized the practice of surgery. More recently, significant advances have been made in the realm of thoracoscopic surgery, single-port surgery and robotics surgery, which have several advantages over conventional thoracotomy, such as decreased blood loss, shorter recovery time and hospitalization, and improved cosmesis and quality of life [1][2][3][4]. However, chronic postoperative problems, including chronic pain, numbness and dysaesthesia, are presented in 31.4% of patients [5]. ...
Article
Objectives: Thoracic sympathectomy is considered as the most effective method to treat palmar hyperhidrosis (PH). Here, we report our experience of transumbilical thoracic sympathectomy with an ultrathin flexible endoscope for PH in a series of 148 patients with up to 4 years of follow-up. Methods: A prospective database was used in this retrospective analysis of 148 patients (61 males, 87 females, with a mean age of 21.3 years) with PH who were operated on by the same surgeon in a single institution from April 2010 to March 2014. All procedures were performed under general anaesthesia involving intubation with a double-lumen endotracheal tube. Demographic, postoperative and long-term data of patients were recorded and statistical analyses were performed. All patients were followed up at least 6 months post procedure through clinic visits or telephone/e-mail interviews. Results: The procedure was performed successfully in 148 of the 150 patients. Two patients had to be converted to conventional thoracoscopic procedure because of severe pleural adhesions. The mean operating time was 43 min (ranging from 39 to 107 min) and the mean postoperative length of stay was 1 day (range 1-4 days). All patients were interviewed 6-48 months after surgery and no diaphragmatic hernia or syndrome was observed. The rate of resolution of PH and axillary hyperhidrosis was 98 and 74.6%, respectively. Compensatory sweating was reported in 22.3% of patients. Almost all of the patients were satisfied with the surgical results and the cosmetic outcome of the incision. Conclusions: This preliminary human experience suggested that transumbilical thoracic sympathectomy was a safe and efficacious alternative to the conventional approach. This technique avoided the chronic pain and chest wall paraesthesia that are associated with the chest incision. In addition, this novel procedure afforded maximum cosmetic benefits.
... Another issue to be considered when establishing a uniVATS programme is the operative resource allocation. Especially in the steepest segment of the learning curve, uniVATS lung resections may take longer and may require dedicated personnel and instrumentation [21][22][23]. Moreover, depending on the risk profile of the surgical candidates, dedicated intensive care or step-down beds should be contemplated for uniVATS patients undergoing awake or non-intubated procedures. ...
Article
Uniportal video-assisted thoracoscopic surgery (uniVATS) is currently being used to diagnose and treat several intrathoracic conditions with minimal morbidity and reduced hospital stay compared with standard multiport VATS surgery. The potential advantages of uniVATS can be also enhanced by the adoption of loco-regional anaesthesiological techniques in non-intubated or awake patients yielding the possibility of performing an ever larger proportion of thoracic surgical procedures in an outpatient setting. This review will look at organizational and technical aspects of implementing a non-intubated uniVATS program.
... To reduce instrument fencing, surgeons have used 5 mm scopes for single port VATS to reduce the amount of space the scope occupies within the incision despite its more limited width of vision (22)(23)(24)(25). The advent of wide-angled rigid thoracoscope (Endocameleon, Karl Storz, Germany) (26), which has a rotating prism mechanism at the scope tip to allowed vision between 0° and 120°, can facilitate the manipulation of other instruments by reducing the need for wide movements of the scope to achieve the viewing angles. Meanwhile, the wide viewing angles can be achieved by making the scope more 'flexible' with the introduction of a 5.4-mm diameter deflectable tip thoracoscope (Olympus EndoEYE™ LTF-VP laparo-thoraco videoscope; Olympus, Tokyo, Japan). ...
Article
Single port video-assisted thoracic surgery (VATS) is the most recent evolution in minimally invasive thoracic surgery. With increasing global popularity, the single port VATS approach has been adopted by experienced thoracic surgeons in many Asian countries. From initial experience of single port VATS lobectomy to the more complex sleeve resection procedures now forming part of daily practice in some Asia institutes, the region has been the proving ground for single port VATS approaches' feasibility and safety. In addition, certain technical refinements in single port VATS lung resection and lymph node dissection have also sprung from Asia. Novel equipment designed to facilitate single port VATS allowing further reduce access trauma are being realized by the partnership between surgeons and the industries. Advanced thoracoscopes and staplers that are narrower and more maneuverable are particularly important in the smaller habitus of patients from Asia. These and similar new generation equipment are being applied to single port VATS in novel ways. As dedicated thoracic surgeons in the region continue to striving for excellence, innovative ideas in single incision access including subxiphoid and embryonic natural-orifice transluminal endoscopic surgery (e-NOTES) have been explored. Adjunct techniques and technology used in association with single port VATS such as non-intubated surgery, hybrid operating room image guidance and electromagnetic navigational bronchoscopy are all in rapid development in Asia.
... These challenges are more profound during uniportal VATS where all the instruments pass through one small incision in approximately the same direction. An endoscope with a distal flexible tip could reduce the chance of fencing between instrument and endoscope since the FOV could be modified by simply bending the tip section only without movement to the main body of the thoracoscopy (2). The EndoEye by Olympus (3) and the Cardioscope developed by Li et al. (4) are some examples. ...
Article
Uniportal VATS poses unique difficulties to the surgeon, mainly as a consequence of operating through a small single incision. The instruments in uniportal VATS have limited movement through the small incision. In addition, the approach to the surgical operating site is unidirectional, which may restrict vision and retraction, and unavoidably suffers from instrument fencing. Recent thoracoscopic technology in the form of a wide variable angled lens has to some extent improved these shortcomings. The development of an extendable flexible thoracoscope and wireless steerable endoscope (WSE) systems can further improve the visualization for surgery and reduce or even remove fencing between endoscope and instruments. New single incision access platforms both derived from Natural orifice transluminal endoscopic surgery (NOTES) and robotic surgery approaches are on the horizon. These may allow uniportal VATS to be performed through an even smaller ultra-minimally invasive incision, with improved vision, more freedom of movement of the instruments and greater precision. However, a number of problems remain to be resolved, including provision of a stable platform and payload, applied force limitations, and equipment sterilization. Advances in uniportal VATS major lung resection techniques have not only challenged the surgeon to acquire new skills and knowledge, but at the same time have rekindled the collaborative spirit between industry and clinician in developing novel equipment and technology to push the boundaries of minimally invasive surgery. These technological improvements and innovation may improve operating efficiency and safety during uniportal VATS surgery.
... In the near future, multiple small remote wireless video cameras can be placed into the thoracic cavity, being stuck then against the inner chest cavity by magnetic anchoring and guidance systems camera. Although initially developed for single-incision laparoscopy, these cameras may be more suited for thoracic surgery because the rigidity of the chest wall provides more stability and less movement for magnetic anchorage when compared with the abdomen (13). ...
Article
Full-text available
One of the greatest advances in Thoracic Surgery in our generation has been the advent of video assisted thoracic surgery (VATS). The more recent advance in VATS is the increasing use of Uniportal surgery. The development of single-port VATS has come a long way, from the beginning, when it was employed for performing simple procedures, to the last years with complex major lung resections. Nowadays, Uniportal VATS is not a Manichean law because there are several steps between open thoracotomy and Uniportal VATS. In thoracic surgery, a skilled surgeon alone cannot sustain new approaches or techniques; it is natural that minimally invasive thoracic surgery continues to evolve, since VATS is a never-ending story and Uniportal VATS is not the end of this history.
... These challenges are more profound during uniportal VATS where all the instruments pass through one small incision in approximately the same direction. An endoscope with a distal flexible tip could reduce the chance of fencing between instrument and endoscope since the FOV could be modified by simply bending the tip section only without movement to the main body of the thoracoscopy (2). The EndoEye by Olympus (3) and the Cardioscope developed by Li et al. (4) are some examples. ...
Article
Uniportal VATS poses unique difficulties to the surgeon, mainly as a consequence of operating through a small single incision. The instruments in uniportal VATS have limited movement through the small incision. In addition, the approach to the surgical operating site is unidirectional, which may restrict vision and retraction, and unavoidably suffers from instrument fencing. Recent thoracoscopic technology in the form of a wide variable angled lens has to some extent improved these shortcomings. The development of an extendable flexible thoracoscope and wireless steerable endoscope (WSE) systems can further improve the visualization for surgery and reduce or even remove fencing between endoscope and instruments. New single incision access platforms both derived from Natural orifice transluminal endoscopic surgery (NOTES) and robotic surgery approaches are on the horizon. These may allow uniportal VATS to be performed through an even smaller ultra-minimally invasive incision, with improved vision, more freedom of movement of the instruments and greater precision. However, a number of problems remain to be resolved, including provision of a stable platform and payload, applied force limitations and equipment sterilization. Advances in uniportal VATS major lung resection techniques have not only challenged the surgeon to acquire new skills and knowledge, but at the same time have rekindled the collaborative spirit between industry and clinician in developing novel equipment and technology to push the boundaries of minimally invasive surgery. These technological improvements and innovations may improve operating efficiency and safety during uniportal VATS surgery.
... Double-hinged VATS-specific instruments with a narrow shaft help surgeons to reach further into the chest cavity. Greater lens flexibility, as with the wide-angled rigid 120° thoracoscope (EndoCAMeleon, Karl Storz, Germany), may improve visibility particularly for surgeons still mastering the technique and in difficult cases (7). Furthermore, it is possible that a 5-mm thoracoscope would avoid instrumental torqueing to some extent while providing unambiguous images. ...
Article
Full-text available
The concept of personalized medicine, which aims to provide patients with targeted therapies while greatly reducing surgical trauma, is gaining popularity among Asian clinicians. Single port video assisted thoracic surgery (VATS) has rapidly gained popularity in Hong Kong for major lung resections, despite bringing new challenges such as interference between surgical instruments and insertion of the optical source through a single incision. Novel types of endocutters and thoracoscopes can help reduce the difficulties commonly encountered during single-port VATS. Our region has been the testing ground and has led the development of many of these innovations. Performing VATS, in particular single-port VATS in hybrid operating theatre helps to localise small pulmonary lesions with real-time images, thus increasing surgical accuracy and pushes the boundaries in treating subcentimeter diseases. Such approach may be assisted by use of electromagnetic navigational bronchoscopy in the same setting. In addition, sublobar resection can also be more individualised according to pathologic tumour subtype that require rapid intraoperative diagnostic test to guide appropriate surgical therapy. A focus on technology and innovation for large tumours that require chest wall resection and reconstructions have also been on going, with new materials and prostheses that may be tailored to each individual needs. The current paper reviews the literature pertaining to the above topics and discusses recent related innovations in Hong Kong, highlighting the study results and future perspectives.
... This new thoracoscope provided a variable angle technology and allowed 0° and 120° range of vision. This wide viewing angle gives an exceptional vision to the whole thoracic cavity (9). Besides, the tip of this thoracoscope can be positioned away from the operating side, and this feature can minimize fencing with other thoracoscopic instruments and free up more instrument operating space (7). ...
Article
The popularity of video-assisted thoracic surgery (VATS) which increased worldwide due to the recent innovations in thoracic surgical technics, equipment, electronic devices that carry light and vision and high definition monitors. Uniportal VATS (UVATS) is disseminated widely, creating a drive to develop new techniques and instruments, including new graspers and special staplers with more angulation capacities. During the history of VATS, the classical 10 mm 0° or 30° rigid rod lens system, has been replaced by new thoracoscopes providing a variable angle technology and allowing 0° and 120° range of vision. Besides, the tip of these novel thoracoscopes can be positioned away from the operating side minimize fencing with other thoracoscopic instruments. The curved-tip stapler technology, and better designed endostaplers helped better dissection, precision of control, more secure staple lines. UVATS also contributed to the development of embryonic natural orifice transluminal endoscopic surgery. Three-dimensional VATS systems facilitated faster and more accurate grasping, suturing, and dissection of the tissues by restoring natural 3D vision and the perception of depth. Another innovation in VATS is the energy-based coagulative and tissue fusion technology which may be an alternative to endostaplers.
... Современная реализация методики однопортовой хирургии при раке легкого еще далеко несовершенна [43]. Возможности для однопортовой хирургии будут расширяться с появлением нового оборудования следующего поколения, например совершенных спайдерсистем и видеосистем [41]. ...
... In uniportal VATS, the problem is more severe as multiple instruments are inserted via the same crowded incision, and instrument fencing can easily occur while maneuvering the thoracoscope. Endoscopes that allow adjustment of viewing direction near the distal end can alleviate the problem by reducing rod body maneuvers (2). While the Olympus Swing Prism Borescope can achieve 120° viewing arc solely by rotation of the tip prism, it has seen more industrial application instead of surgical use, possibly due to limitations in preventions of debris contamination and sterilization (3). ...
Article
Abstract: Conventional rod lens endoscope has for decades facilitated minimally invasive surgery (MIS) procedures. Video-assisted thoracic surgery (VATS) has continued to evolve in pursuit of minimizing surgical access trauma leading to the development of uniportal VATS. However, operating through a single small incision using the rod lens endoscope proves to be challenging. The view and maneuverability of the endoscope is limited by the unidirectional approach, and in addition a crowded port site increases risk of interference and fencing between instruments. These challenges have inspired innovation in endoscopic systems to allow wider range of viewing directions and angles with minimum scope movement. In particular, flexible endoscopes and magnetic endoscopes have unique advantages and potential over conventional rigid equipment. Flexible endoscopes with articulating tips offer distal dexterity, and provide wide range of viewing angles despite limited motion of endoscope shaft. Whereas magnetic anchored and actuated endoscopes go beyond tip dexterity, abandoning the rod body completely, and exploit magnetic linkage to navigate along intrathoracic surface, overcoming limit of unidirectional approach. Through wireless actuation, magnetic endoscopes also provide many views without occupying the access port, reducing incision size and risk of instrument interference. To apply the devices clinically, current prototypes still require lens cleaning strategy and sensors to match image quality of commercial systems. With these issues addressed, these novel systems may allow safer and more efficient performance of uniportal VATS, benefiting both surgeons and patients.
... To expand the FOV and allow alternating view with minimal maneuvers, endoscopes with rotatable reflective prism or flexible distal joints were introduced (10). The Olympus Swing Prism Borescope has a rotatable reflective prism near the distal end, and offers 120° change of viewing direction, but prism contamination and postoperative sterilization complicates its surgical application. ...
Article
In the past three decades, rod lens endoscopes had facilitated the development and wide spread applications of video-assisted thoracic surgery (VATS). With the rise of uniportal VATS in recent years, innovations in surgical instruments should once again complement the advancement in surgical technique. While articulated flexible endoscopes have expand the field of view, and can alter viewing direction with minimal maneuvers, they still suffer from problems like trocar crowding and interference with other instruments. Magnetic anchored endoscopes, on the other hand, may provide unique benefits to VATS by replacing the endoscope rigid rod body with magnetic linkage, thus overcoming the challenge of port crowding in single incision surgery. Most magnetic anchored endoscopes reported in literature are not designed for thoracic surgeries. Many of these designs do not allow tilting of endoscopic view, rely on micromotors for actuation, or are ergonomically unfit to be operated within the spatial constraints seen in VATS application. Considering these limitations, we have designed two novel magnetic anchored and steered endoscopes targeted for uniportal VATS. Both designs could be wirelessly actuated by magnetic interaction. One has a silicone rubber formed soft body for compactness, lightweight and safety, while another is a 40 mm long capsule optimized for VATS spatial constraints.
... (b) In single-port VATS thymectomy, there may be ergonomic advantages in exchanging the positions of the principal surgeon and assistant from cranial to caudal during certain parts of the procedure, particularly when dissecting the superior and inferior extremes of the anterior mediastinum [20] ( Fig. 20.1). Apart from the availability of those instruments used for conventional VATS thymectomy, we have found 120 degree Endocameleon thoracoscope to be useful to improve visual field and reduce fencing during single-port VATS [21]. However, during thymectomy when the view and progress of dissection are more unidirectional compared with major lung resection, a 30 degree thoracoscope usually suffice. ...
Chapter
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From a historical perspective, myasthenia gravis (MG) was first described in 1672 by an Oxford clinician, Sir Thomas Willis, who noted a patient with temporary loss of speech [1]. It wasn’t until two and a half centuries later in 1911 that the first thymectomy was performed by Ferdinard Sauerbruch in Zurich on a 21-year-old woman with hyperthyroidism and MG. Thymectomy was performed in an attempt to treat her hyperthyroidism, and following surgery both conditions showed improvement temporarily. In 1934, Mary Walker recognized clinical similarities between MG and curaré poisoning and hence introduced the anticholinesterase treatment, physostigmine, producing significant improvement in muscle strength for a MG patient. This was an important discovery implicating the pathogenesis of MG at the neuromuscular junction. Later in 1944, Alfred Blalock at Johns Hopkins reported improvement in MG patients following resection of normal thymus and also introduced this as a surgical therapy for this condition. Clinical use of edrophonium was introduced around 1950 and later taken over by the more popular pyridostigmine. John Simpson first proposed in 1960 that MG might be an autoimmune disease, which was later confirmed in 1973 by Patrick and Lindstrom through animal studies by immunizing rabbits with purified acetylcholine receptors. It is now common knowledge that MG is an autoimmune disorder of the postsynaptic nicotinic acetylcholine receptor, characterized by weakness and fatiguability of voluntary muscles. The ocular muscles are frequently involved, rendering ptosis and diplopia the most common modes of presentation. Despite the discovery of the condition centuries ago, considerable controversies still remain over its diagnosis, natural history, and therapy both medical and surgical. Nevertheless, thymectomy is now an established therapy in the management of generalized MG in conjunction with medical treatment. A meta-analysis of 28 controlled studies has previously shown that MG patients undergoing thymectomy were twice as likely to attain medication-free remission, 1.6 times as likely to become asymptomatic, and 1.7 times as likely to improve. Different demographics and baseline characteristics however existed between groups [2]. A recent randomized prospective trial investigating the role of thymectomy for myasthenia gravis has shown improved clinical outcomes over a 3-year period in patients with nonthymomatous myasthenia gravis [3]. Uncertainties remain over the role of thymectomy for patients with purely ocular symptom and those with late onset of disease.
... The wide-angled rigid thoracoscope, such as the EndoCAMeleon Telescope (Karl Storz, Germany), has therefore extended the viewing arc to 120° through the rotating prism mechanism (20). The direction of view is controlled with an adjustment knob without the need to switch scopes or move the scope shaft. ...
... Classically, VATS was performed with three ports to allow easier traction, dissection and visualization. With improvement in videoscopes and innovation of endostaplers which have slimmer profiles and flexible tips (20,21), single port VATS has emerged to be capable of major anatomical lung resections with equal margin clearance and efficacy, and the advantage of involving only one intercostal space and less pain (22)(23)(24). A problem with VATS, and perhaps more so in single port VATS, is the small access, instrument fencing and thus limited ability to palpate and localize small lung lesions (25). ...
Article
Uniportal video-assisted thoracic surgery (VATS) lung wedge resection usually requires three devices, thoracoscope, lung retracting instrument and an endo-stapler cutter to perform the procedure. With advances in miniaturization of the thoracoscope and lung retracting instruments, a major limitation to operating through a smaller uniportal incision has become the endo-stapler. We describe the surgical technique for uniportal VATS laser lung resection which uses a much narrower laser catheter device to replace the endo-stapler for resection. The new approach to limited lung resection can potentially reduce instrument fencing and the uniportal incision wound size, while achieving satisfactory hemostasis and pneumostasis.
Article
The surgeon’s ability to visualize the operating field and target, in conjunction with appropriate instruments to execute the procedure, has been the cornerstone of our specialty. The rod lens endoscopic system popularized in the 1990s has revolutionized how surgery is performed, by allowing the surgeon to ‘enter’ the body cavity to have a close-up, magnified and illuminated view of the operating site. Needless to say, the development of smaller thoracoscopes, high-definition charge-coupled device cameras, 3D vision systems and variable wide viewing angle endoscopes have further refined minimally invasive thoracic surgery, making it safer, more easily adoptable and less invasive [1, 2]. More recently, 3D thoracoscopic visualization can even be achieved by glasses-free 3D system by tracking the surgeon’s eye movement in lieu of heavy and cumbersome 3D glasses. Although such technology remains early in development, it has the potential for wide applications across minimally invasive surgery [3]. [truncated]
Article
Uniportal video-assisted thoracic surgery (VATS) represents a radical change in the approach to lung resection compared with conventional VATS. Because the placement of the surgical instruments and the camera is done through the same incision, uniportal VATS can pose a challenge for both the surgeon and the assistant. Recent industry improvements have made single-port VATS easier to learn. We can expect more developments of subcostal or embryonic natural orifice translumenal endoscopic surgery access, improvements in 3D image systems, single-port robotics, and wireless cameras. The advances in digital technology may facilitate the adoption of the uniportal VATS technique.
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Since its introduction in the beginning of this millennium, uniportal VATS has received great interests. Despite its advantages over conventional operations, uniportal VATS poses great challenges to the surgeon. This is mainly as a consequence of inserting and operating all the instruments via a small incision. In the uniportal VATS instruments have limited movement and instrument fencing is frequent with some haptic sensation loss. In addition, the vision is restricted as the endoscope is nearly parallel to the instruments. The advancement of technology has or will much alleviate these shortcomings. For example, wide-angled thoracoscope and flexible thoracoscope have to some extent lessen the fencing problem, and the wireless steerable endoscope system may further eliminate the instrument-endoscope fencing and provide panoramic view. New uniportal platforms derived from natural orifice transluminal endoscopic surgery (NOTES) and single-port access surgery approaches are on the horizon, which allows the uniportal VATS to be performed in a much easier way and via even smaller incisions. However, problems associated with provision of a steady platform, sufficient payload and applied force, tool change and equipment sterilization, haptic sensation, etc. remain to be solved. The diagnosis and intraoperative localization of small tumors can be challenging especially in uniportal VATS. Advanced multimodality image-guided operating room (AMIGO) and hybrid operating room can help in real-time diagnosis, localization and reduce the associated problems in patient transferring.
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The uniportal approach to video-assisted thoracoscopic surgery (VATS) sleeve resection may be considered for patients undergoing conventional VATS sleeve resection. In this chapter, we describe the technical details of the uniportal VATS approach for bronchial sleeve resection. Further study is needed to address the long-term outcomes and the ability of thoracic surgeons to carry out these crowded surgical techniques.
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Pneumonectomy is usually indicated for more complex or advanced lung cancers, that are centrally located. The decision to proceed with pneumonectomy should not be done lightly as the surgical procedure itself is often considered a disease in itself that can be associated with potentially severe and life-threatening complications [1–3]. A sleeve resection procedure to preserve a lobe should be the operation of choice when circumstances allow [4–6]. The general principles for lung cancer surgery regarding patient having adequate lung function to tolerate the procedure and adequate lung cancer staging is paramount when preparing a patient for pneumonectomy.
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The skill of the surgeon to visualise the operating field and the dedicated instruments has been the cornerstone of the revolution of minimally invasive thoracic surgery. The endoscopic lens allows the surgeon to have an adjacent-up, enlarged and illumined view of the operating field. The development of reduced thoracoscope, 3D systems, highdefinition cameras has further refined video-assisted thoracic surgery (VATS), making it harmless, more easily adaptable and less aggressive. Nevertheless, there are some drawbacks. Firstly, the assistant or the mechanical robotic arm occupy important extrathoracic space. Secondly, the thoracoscope stays in a port or part of the uniportal incision. The magnetic surgical devices could be attracted, and the magnetic elements attract dirt with a ferrous content. Also, the possible position of the scope and the directions of vision are limited due to the fixed thoracoscope position. A possible answer would be the project of a wireless remote VATS camera with wireless image transmission internalised in the pleural space and fixed to the trunk.
Article
Single-port video-assisted thoracoscopic surgery (VATS) has recently been proposed as an innovative minimally invasive alternative to the standard three-port VATS for lobectomies, most of which are performed using a conventional rigid thoracoscope. Here, we report a single-port VATS approach for right upper lobectomy and systematic lymph node dissection using a flexible endoscope. A 61-year-old male smoker presented with a pulmonary nodule. A single-port VATS procedure was performed through a 4-cm intercostal incision using a flexible laparo-thoraco videoscope. Right upper lobectomy and systematic lymph node dissection were performed. The total operating time was 106 min. The procedure was successful and the recovery uneventful. The patient's chest tube was removed on the third day, and he was discharged home on the fourth. The use of a flexible videoscope facilitated the single-port VATS procedure by avoiding interference between the videoscope and other operating instruments and providing ample space for the surgeon.
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Thoracic Surgery PostersSESSION TYPE: Poster PresentationsPRESENTED ON: Saturday, March 22, 2014 at 01:15 PM - 02:15 PMPURPOSE: Advances in video-assisted thoracic surgery (VATS) techniques and associated technology have allowed the rapid development of uniportal VATS (UniVATS) lung resection in recent years. UniVATS may be associated with less access trauma and pain, quicker recovery and improved cosmesis. We review our experience and early outcomes for patients following UniVATS wedge resections (W), lobectomies (L) and pneumonectomy (P). Retrospective study of UniVATS lung resection performed between May 2012 and July 2013 at our institution. Preoperative, intraoperative and postoperative data were reviewed. We performed UniVATS for 8 wedge resections (2 hook wire guided), 2 left lower lobectomies, 1 left upper lobectomy, 2 right lower lobectomies, 1 right middle lobectomy, 2 right upper lobectomies and 2 left pneumonectomy. The pathology for W were 3 benign, 3 granulomas, 2 metastatic lesions (both for colonic carcinoma metastases). Lobectomies and pneumonectomy were performed for early stage non-small cell lung carcinoma. Median port length were 3.5, 4.2, and 5.5 cm for groups W, L, and P respectively. Median intraoperative blood loss for W was 5 mls, L 80 mls and P 100 mls. Median operative durations were 47, 152, 175 minutes for W, L and P groups respectively. Median postoperative chest drainage in first day were W 90 mls, L 140mls, and P 180mls. Median chest drain duration were 1.5 days for W, 2 days for L and 1 day for P. Patients were discharged home at median postoperative day 2 for W, day 3 for L, and day 5 for P. There was no mortality or major morbidity. There were 2 minor wound infections in L group at follow-up. (median follow-up 7 months (range 0 to 14 months)). Our early experiences with UniVATS lung resections suggest that it is a safe procedure with good early clinical outcomes. The long term results will need further investigation. UniVATS approach for major lung resections can potentially further reduce surgical access trauma and improve clinical outcomes for patients. The following authors have nothing to disclose: Rainbow Lau, Calvin Ng, Micky Kwok, Randolph Wong, Eugene Yeung, Innes Wan, Song Wan, Malcolm UnderwoodNo Product/Research Disclosure Information.
Article
Magnetic anchoring guidance systems (MAGS) are composed of an internal surgical instrument controlled by an external handheld magnet and do not require a dedicated surgical port. Therefore, this system may help to reduce internal and external collision of instruments associated with laparoendoscopic single-site (LESS) surgery. Herein, we describe the initial clinical experience with a magnetically anchored camera system used during laparoscopic nephrectomy and appendectomy in two human patients. Two separate cases were performed using a single-incision working port with the addition of a magnetically anchored camera that was controlled externally with a magnet. Surgery was successful in both cases. Nephrectomy was completed in 120 min with 150 ml estimated blood loss (EBL) and the patient was discharged home on postoperative day 2. Appendectomy was successfully completed in 55 min with EBL of 10 ml and the patient was discharged home the following morning. Use of a MAGS camera results in fewer instrument collisions, improves surgical working space, and provides an image comparable to that in standard laparoscopy.
Keeping an “eye” on type A dissections
  • CSH Ng
  • IYP Wan
  • RHL Wong
  • MJ Underwood
Ng CSH, Wan IYP, Wong RHL, Underwood MJ. Keeping an "eye" on type A dissections. Eur J Cardiothorac Surg 2011;40:533.
Minimizing chest wall trauma in single port video-assisted thoracic surgery
  • CSH Ng
  • RHL Wong
  • RWH Lau
  • APC Yim
Ng CSH, Wong RHL, Lau RWH, Yim APC. Minimizing chest wall trauma in single port video-assisted thoracic surgery. J Thorac Cardiovasc Surg 2014; 147:1095-6.