The evolution of uniportal video assisted thoracic surgery in Costa Rica

One of the most important advances in thoracic surgery of our generation has been video-assisted thoracic surgery (VATS) (1), it has evolved from the initial multiport approach to a less invasive approach using only a single incision or uniportal VATS.

As in multiport VATS, the first cases reported using the single port approach were procedures such as biopsies, wedge resections and pneumothorax surgery by the team lead by Gaetano Rocco (2). It was until 2010, that major pulmonary resections were completed successfully by uniportal VATS in La Coruña (3), starting and exponential growth that has allowed to perform even complex oncological cases through this approach (4).

Since Gonzalez-Rivas et al. performed the first uniportal VATS lobectomy, the approach has proven to be safe, feasible and reproducible, leading to a widespread of the procedure around multiple centers in the world. The growth of the technique cannot only be explained by its own advantages, a big part is due to the great effort by Dr. Diego Gonzalez-Rivas to teach it to any surgical team interested in learning it. It was in this process where he made another major contribution, he decided to travel around the world and teach the technique to thoracic surgeons in their hospitals, letting all the surgical team (nurses, assistants, anesthesiologist) to familiarize with the procedure, showing them that it could be done in their center and making the technique available to any thoracic surgical unit with a VATS program around the world.

In Costa Rica, VATS surgery started since the late 90s and uniportal VATS was used seldom for diagnostic procedures.

In May 2013, after attending a lecture from Dr. Gonzalez-Rivas in the ESTS conference in Birmingham, about his experience in major pulmonary resections, that included even sleeve resections, the author was convinced this was the present and future of thoracic surgery.

Our group started to use only the single port approach for every VATS surgery, including pleural biopsies, effusion drainage, wedges resections, drainage and decortication for empyemas and resection of mediastinal tumors. This was a step-by-step process, in which we gained confidence and skills with each procedure before progressing to another. Before we started using this approach for empyemas, many coagulated hemothorax were completed successfully. A lot of the skills of dissection in a uniportal approach were acquired during the decortication of phase 2 and 3 empyemas. Being able to completely decorticate this difficult cases gave us a push in our learning curve that prepare us for more difficult surgeries. Complex VATS surgery started in June 2014 with the first lobectomy being performed successfully. This process was only possible through the tutoring of Dr. Gonzalez-Rivas. The first case perform was a left lower lobectomy in a male patient with bronchiectasis.

After attending a uniportal VATS course in Shanghai Pulmonary Hospital directed by Dr. Gonzalez-Rivas, from October to November 2014 we started to carry out upper lobectomies also.

Thanks to the experience gained and in order to maximized our learning curve and teach the approach to other thoracic surgeons in our country, we decided to hold a course in our hospital with the help of Dr. Gonzalez-Rivas.

The course was divided into three days, the first day took place in the Medical and Surgeons College of Costa Rica (Figure 1), consisted in a lecture by Dr. Gonzalez-Rivas, directed to the medical community in general, this taught numerous general practitioners, pulmonologists and medical students the benefits and applications of uniportal VATS surgery. The second day consisted in a theory course directed to thoracic surgeons and the third day was reserved for three uniportal VATS surgeries performed by Dr. Gonzalez-Rivas, two lobectomies and one non-intubated wedge resection.

Figure 1 The master class was held with the collaboration of Dr. Diego Gonzalez-Rivas, Dr. Wentao Li and Dr. Yang Yang.

The first part of the course consisted in multiple lectures that explained the process and evolution of uniportal VATS, the steps to perform major lung resections and how to deal with complications that may arrive during surgery.

The second part consisted in live surgery (Figure 2), with three cases performed by Dr. Gonzalez-Rivas. All patients were placed in a lateral decubitus position, the incision was made in the fifth intercostal space, and no wound retractor was placed. All of the operations were completed without any complications.

Figure 2 Live surgery performed by Dr. Gonzalez-Rivas in Rafael Angel Calderón Guardia Hospital.

The first case consisted in a 77-year-old woman with a 1.5 cm spiculated nodule located centrally in the left lower lobe (Figure 3). A left lower lobectomy with a radical lymph node dissection was performed (Figure 4). The pathological staging and diagnosis was stage IA adenocarcinoma (T1aN0M0).

Figure 3 Chest CT shows a 1.5 cm central spiculated nodule in the left lower lobe.

Figure 4 This video shows a left lower lobectomy and lymph node dissection in a 77-year-old women with a 1.5 cm adenocarcinoma (5). Available online: http://www.asvide.com/articles/964

Secondly a right upper lobectomy was performed in a 76-year-old male with a 4 cm mass in the right upper lobe (Figure 5). Complete lymph node dissection was also performed (Figure 5) and the definitive pathological diagnosis was stage IB adenocarcinoma (T2aN0M0).

Figure 5 Chest CT shows a 4 cm mass with cavitation, located in the right upper lobe.

The last patient of the course had a previous history of right breast cancer, and had a 1.4 cm nodule located in the right upper lobe (Figure 6). This case was performed without intubation (the first case performed like this in our country), vagus blockage with lidocaine was done in order to avoid coughing and the patient was sedated through the procedure. After location of the lesion a wedge resection was carried out and the procedure was completed successfully. The frozen section was not able to differentiate between a primary and a metastatic lesion. The definitive diagnosis was atipic carcinoid tumor with vascular and lymphatic invasion. A reVATS right upper lobectomy was performed two weeks later, also by uniportal approach, without complications.

Figure 6 This video shows a right upper lobectomy with an incomplete fissure in a 76-year-old male with a 4 cm adenocarcinoma (6). Available online: http://www.asvide.com/articles/965

Comments

VATS lobectomies are now the standard approach for early stage lung cancer and uniportal VATS has proven to be safe and feasible not only for early stage lung cancer but for advance cases also (3,7). The team from La Coruña has the biggest series of lobectomies perform by a single port approach and their experience includes already complex bronchial and vascular reconstructions (7-9). Other thoracic units, especially in Asia had also reported their experience with the approach (10), were a lot of centers had adopted the technique and even started training programs.

In our hospital, uniportal VATS is now the standard approach in minimally invasive surgery, and the majority of our procedures are carried out this way. Currently more than 170 cases, 15 of the major lung resections had been achieve successfully with a uniportal approach. The success of the program is in a big way thanks to the guidance and continuous cooperation of Dr. Diego Gonzalez-Rivas. Being able to learn from his experience and incredible surgical technique has allowed our team to grow as surgeons and improve our results.

Uniportal VATS is a very innovating procedure in our country, and we are one of the few centers that are doing it as a standard approach for all the VATS cases. Because of this, a lot of press and media coverage was done to the visit of the pioneer of the approach and the master class taking place in our hospital. Most of the national newspapers and television news reported on the event (Figure 7).

Figure 7 Chest CT shows a 1.4 cm nodule located in the right upper lobe. This patient had a prior right mastectomy.

After the course we have been able to emulate his surgical process and follow his recommendations, which has facilitated the procedure considerably and also improve our surgical time. We gained confidence and experience, letting us progress to more difficult cases including advance stage lung cancer.

Acknowledgements

None.

Footnote

Conflicts of Interest: The authors have no conflicts of interest to declare.

References

1. Sihoe AD. The evolution of minimally invasive thoracic surgery: implications for the practice of uniportal thoracoscopic surgery. J Thorac Dis 2014;6:S604-17. [PubMed]
2. Rocco G, Martin-Ucar A, Passera E. Uniportal VATS wedge pulmonary resections. Ann Thorac Surg 2004;77:726-8. [Crossref] [PubMed]
3. Gonzalez D, Paradela M, Garcia J, et al. Single-port video-assisted thoracoscopic lobectomy. Interact Cardiovasc Thorac Surg 2011;12:514-5. [Crossref] [PubMed]
4. Gonzalez-Rivas D, Fieira E, Delgado M, et al. Is uniportal thoracoscopic surgery a feasible approach for advanced stages of non-small cell lung cancer? J Thorac Dis 2014;6:641-8. [PubMed]
5. Guerrero WG, Gonzalez-Rivas D, Yang Y, et al. This video shows a left lower lobectomy and lymph node dissection in a 77-year-old women with a 1.5 cm adenocarcinoma. Asvide 2016;3:208. Available online: http://www.asvide.com/articles/964
6. Guerrero WG, Gonzalez-Rivas D, Yang Y, et al. This video shows a right upper lobectomy with an incomplete fissure in a 76-year-old male with a 4 cm adenocarcinoma. Asvide 2016;3:209. Available online: http://www.asvide.com/articles/965
7. Gonzalez-Rivas D, Paradela M, Fernandez R, et al. Uniportal video-assisted thoracoscopic lobectomy: two years of experience. Ann Thorac Surg 2013;95:426-32. [Crossref] [PubMed]
8. Gonzalez-Rivas D, Delgado M, Fieira E, et al. Double sleeve uniportal video-assisted thoracoscopic lobectomy for non-small cell lung cancer. Ann Cardiothorac Surg 2014;3:E2. [PubMed]
9. Gonzalez-Rivas D, Fieira E, Delgado M, et al. Uniportal video-assisted thoracoscopic sleeve lobectomy and other complex resections. J Thorac Dis 2014;6:S674-81. [PubMed]
10. Ng CSH. Uniportal VATS in Asia. J Thorac Dis 2013;5:S221-S225. [PubMed]