The first uniportal video-assisted thoracoscopic surgery masterclass in New Zealand

Background

New Zealand (NZ), a small country with a population of approximately 4.8 million people at the bottom of the South Pacific Ocean, has five main centres offering cardiothoracic surgical services.

Multiportal video-assisted thoracoscopic surgery (VATS) approach for lung resection has been performed by some cardiothoracic surgeons in NZ for several years. This approach has even been reported in complex and synchronous lung resection operations in NZ (1,2). However, only a small number of surgeons have applied uniportal techniques. In order to increase the exposure and penetration of uVATS in NZ, a 3-day Masterclass for uVATS was undertaken by Prof Diego Gonzalez-Rivas at AgResearch Ruakura and Waikato Hospital from 21 to 23 February 2018.

NZ masterclass

Dr. David McCormack, a cardiothoracic surgeon at Waikato Hospital, initially approached Prof Gonzalez-Rivas, who agreed to provide the Masterclass for NZ surgeons. Surgeons from throughout the country were invited to participate. The Masterclass consisted of a full day animal wetlab at AgResearch Ruakura, utilizing live porcine models. Following this, live surgery was performed over 2 days with 6 uVATS lung resection cases at Waikato Hospital in Hamilton.

Wetlab and equipment at AgResearch Ruakura

Many animal wetlabs worldwide have utilized live porcine or ovine models, most commonly with a tracheostomy to facilitate placement of a single lumen endotracheal tube into the contralateral main bronchus. Due to intubating resources that were no longer suitable for patient care (expired but still sterile), we had a number of options in order to avoid the creation of a tracheostomy. Initially, we utilized oral intubation with a 39 mm left-sided double-lumen endotracheal tube (VivaSight DL, ETView Ltd., Israel—we did not utilize the built-in scope). We employed a disposable flexible bronchoscope (aScope, Ambu, UK) to manipulate the tip towards the left main bronchus. We found, however, the length was inadequate to satisfactorily isolate the left lung in the porcine bronchial tree. We therefore utilized 2 separate solutions; the first was a standard single-lumen endotracheal tube (8.5 mm Flex-tip, Parker Medical, Germany), with a bronchial blocker (Arndt endobronchial blocker set, Cook Medical, USA) placed in the left main bronchus; the second was an integrated solution (Univent, Fuji Systems Corporation, Japan), which incorporates a bronchial blocker in the single lumen endotracheal tube. Both these strategies resulted in excellent lung isolation (Figure 1).

Figure 1 Uniportal VATS in porcine specimens using single lumen endotracheal intubation and bronchial blocker (3). VATS, video-assisted thoracoscopic surgery. Available online: http://www.asvide.com/article/view/27813

Live surgery

The live cases are described in Table 1. These were conducted over 2 days, with 3 cases each day to facilitate proctoring uVATS technique. All patients gave explicit consent to participate in the Masterclass, and optimal oncological principles were adhered to for each case, i.e., no compromise of resection due to the uVATS approach. The format of the Masterclass facilitated translation of the technical skills developed in the animal wetlab immediately to the operating room. There was very little alteration of our current patient anaesthetic and positioning that was required. Most of the live surgical cases were performed by our own surgeons, with Prof Gonzalez-Rivas assisting or demonstrating certain key techniques (Figure 2).

Figure 2 Uniportal VATS in live surgical cases (4). VATS, video-assisted thoracoscopic surgery. Available online: http://www.asvide.com/article/view/27814

Discussion

The clinical outcomes for the patients were superior to the existing multiportal VATS approach, particular in terms of improvement in length of hospital stay and noticeably less pain in uVATS patients. Although the case number was too small to statistically demonstrate a difference, it has been the authors’ ongoing experience that patients have less pain utilizing an uVATS approach compared to multiportal VATS. Other groups have also reported similar outcomes (5-7).

Since the Masterclass, the routine approach at Waikato Hospital has been uVATS for lung resection, and pleural-based procedures. Once the learning curve is completely overcome, more complex lung resection operation can also be safely performed via uVATS (8).

A key element to the Masterclass that ensured its success was the enthusiasm and specific tutorage from Prof. Gonzalez-Rivas. Along with the clinical benefits over multiport VATS and thoracotomy, has enabled uVATS to rapidly penetrate the thoracic surgical world. It is a model that, if emulated, could facilitate the uptake of other novel techniques in other areas of cardiothoracic surgery.

Acknowledgments

We are grateful to the sponsorship of Ethicon to facilitate the Masterclass, and the assistance of Obex NZ, Scanlan, Stortz and MedXus for providing equipment for the animal wetlab and live patient surgery. We are also grateful to Alison Callum and Stephanie Delaney at Ruakura AgReseach for facilitating the animal wetlab.

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the Guest Editor (Diego Gonzalez-Rivas) for the series “Teaching Uniportal VATS” published in Journal of Visualized Surgery. The article has undergone external peer review.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/jovs.2018.10.04). The series “Teaching Uniportal VATS” was commissioned by the editorial office without any funding or sponsorship. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in studies involving human participants were in accordance with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patient.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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