ABSTRACT
SUMMARY: Uniportal video-assisted thoracoscopic surgery may be the approach for any thoracic procedure, from minor resections to complex reconstructive surgery. However, anatomical lobectomy represents its most common and clinically proven usage. A wide variety of information about uniportal video-assisted thoracoscopic lobectomies can be found in the literature and multimedia sources. This article focuses on updating the surgical technique and includes important aspects such as the geometric approach, anaesthesia considerations, operating room set-up, tips about the incision, instrumentation management and the operative technique to perform the 5 lobectomies. The following issues are explained for each lobectomy: anatomical considerations, surgical steps and technical advice. Medical illustrations and videos are included to clarify the text with the goal of describing a standard surgical practice.
Subject(s)
Lung Neoplasms , Thoracic Surgery, Video-Assisted , Humans , Lung Neoplasms/surgery , PneumonectomyABSTRACT
The surgical approach to lung resections is evolving constantly. Since the video-assisted thoracoscopic surgery (VATS) anatomic lobectomy for lung cancer was described two decades ago, many units have successfully adopted this technique. The VATS lobectomy can be defined as the individual dissection of veins, arteries and bronchus, with a mediastinal lymphadenectomy, using a videothoracoscopic approach visualized on screen and involving 2 to 4 incisions or ports, with no rib spreading. However, the surgery can be performed by only one incision with similar outcomes. Since 2010, when the uniportal approach was introduced for major pulmonary resections, the technique has been spreading worldwide. This technique provides a direct view of the target tissue. The parallel instrumentation achieved during the single-port approach mimics the maneuvers performed during open surgery. It represents a less invasive approach than the multiport technique, and minimizes the compression of the intercostal nerve. As the surgeon's experience with the uniportal VATS lobectomy grows, more complex cases can be performed by using this approach, thus expanding the indications for single-incision thoracoscopic lobectomy.
ABSTRACT
Since the video-assisted thoracoscopic surgery (VATS) anatomic lobectomy for lung cancer was described two decades ago, many units have successfully adopted this technique. VATS lobectomy is a safe and effective approach for the treatment not only of early stage lung cancer but also for more advanced disease. It represents a technical challenge. As the surgeon's experience grows, more complex or advanced cases are approached using the VATS approach. However, as VATS lobectomy has been applied to more advanced cases, the rate of conversion to open thoracotomy has increased, particularly early in the surgeon's learning curve, mostly due to the occurrence of complications. The best strategy for facing complications of VATS lobectomy is to prevent them from happening. Avoiding complications is subject to an appropriate preoperative workup and patient selection. Planning for a VATS resection as safely as possible involves the consideration of the patient´s characteristics and the anticipated technical aspects of the case. Awareness of the possibility of intraoperative complications of VATS lobectomy is mandatory to avoid them, and the development of management strategies is necessary to limit morbidity if they occur.
ABSTRACT
The present article discusses the two most up-to-date clinical practice guidelines containing the recommendations of US and European scientific societies on preoperative assessment of the risk of lung resection. Despite some differences between the two documents, both guidelines agree on the importance of routine preoperative measurement of diffusion lung capacity for carbon monoxide (DLCO) in the predictive value of exercise tests, especially measurement of maximal oxygen uptake per minute (VO(2max)). Precisely because of its ability to predict the risk of operative death, VO(2max) should be measured in patients with a forced expiratory volume in 1 second (FEV1) or DLCO below 80% of the theoretical value. The authors recommend using one of the two above-mentioned guidelines in clinical practice and periodically auditing the results to compare them with in-hospital mortality for lung resection in Europe, currently available through the European Association of Thoracic Surgeons. There is currently no validated risk index that could be directly applied in clinical decision making in lung resection.
Subject(s)
Lung/surgery , Pneumonectomy/adverse effects , Practice Guidelines as Topic , Preoperative Care , Benchmarking , Databases, Factual , Europe , Exercise Test , Forced Expiratory Volume , Humans , Models, Theoretical , Pneumonectomy/mortality , Preoperative Care/standards , Pulmonary Diffusing Capacity , Pulmonary Medicine , Risk Assessment , Societies, Medical/standards , Thoracic Surgery , United StatesABSTRACT
En este artículo se comentan las 2 guías de práctica clínica más actuales que contienen las recomendacionesde las sociedades científicas europeas y norteamericana acerca de la evaluación preoperatoria del riesgo de laresección pulmonar. A pesar de algunas diferencias entre los 2 documentos, ambas guías coinciden en la importanciade la medición preoperatoria rutinaria de la difusión pulmonar de monóxido de carbono (DLCO) yen el valor predictivo de las pruebas de ejercicio, especialmente la medición del consumo máximo de oxígenopor minuto (VO2max). Precisamente debido a su capacidad predictiva del riesgo de muerte operatoria, se debemedir la VO2max en los casos de pacientes con FEV1 o DLCO por debajo del 80% de su valor teórico. Los autoresrecomiendan utilizar alguna de las 2 guías citadas en la práctica clínica y auditar periódicamente los resultadospropios para compararlos con la mortalidad hospitalaria de la resección pulmonar en Europa que, actualmente,están disponibles a través de la European Association of Thoracic Surgeons. Actualmente, no existeningún índice de riesgo validado y que se pueda aplicar directamente en la toma de decisiones clínicas enresección pulmonar(AU)
The present article discusses the two most up-to-date clinical practice guidelines containing therecommendations of US and European scientific societies on preoperative assessment of the risk of lungresection. Despite some differences between the two documents, both guidelines agree on the importance ofroutine preoperative measurement of diffusion lung capacity for carbon monoxide (DLCO) in the predictivevalue of exercise tests, especially measurement of maximal oxygen uptake per minute (VO2max). Preciselybecause of its ability to predict the risk of operative death, VO2max should be measured in patients with aforced expiratory volume in 1 second (FEV1) or DLCO below 80% of the theoretical value. The authorsrecommend using one of the two above-mentioned guidelines in clinical practice and periodically auditingthe results to compare them with in-hospital mortality for lung resection in Europe, currently availablethrough the European Association of Thoracic Surgeons. There is currently no validated risk index that couldbe directly applied in clinical decision making in lung resection(AU)
