Video-assisted thoracic surgery sleeve resection and bronchoplasty using 3D imaging system: its safety and efficacy

Abstract

Background: Video-assisted thoracic surgery sleeve resection with bronchial anastomosis or bronchoplasty is a technically demanding procedure. Three-dimensional endoscopic surgery has been reported to be helpful in decreasing operation time and improving spatial perception with less surgical errors, but there have been rare reports about relatively difficult thoracoscopic procedures utilizing 3D thoracoscope. We performed this study to evaluate early clinical outcomes of thoracoscopic sleeve resection and bronchoplasty utilizing 3D thoracoscope.

Methods: Data from a total of 36 patients who underwent thoracoscopic sleeve lobectomy or bronchoplasty at our institution from December 2015 to October 2017 were retrospectively reviewed. Three-port approach with one utility incision was used with a 10 mm, 30° three-dimensional thoracoscope. Twenty-three patients (81%) were male, and mean age was 65.9 ± 9.4 years. Fourteen patients (38.9%) underwent sleeve resection with bronchial anastomosis, 22 (61.1%) underwent wedge or simple bronchoplasty, and one patient received concomitant PA procedure. Bronchial anastomosis sites were not covered with viable tissue flaps.

Results: There was no (0%) suture needle injury from spatial misperception during bronchoplasty or sleeve anastomosis. There was no (0%) operative mortality. The pathologic report revealed squamous cell carcinoma (63.9%), adenocarcinoma (19.4%), carcinoid (6.9%), adenosquamous carcinoma (3.4%), and sarcomatoid carcinoma (2.8%). One (2.8%) late mortality was due to systemic recurrence of sarcomatoid carcinoma. There was no (0.0%) anastomotic failure. The mean number of dissected lymph nodes were 27.4 ± 13.2, and mean operation time was 216.8 ± 60.0 min. Median postoperative 24-h drain amount was 315 mL. Median chest tube days and hospital days were 4 and 6, respectively. Two patients (5.6%) had complications greater than Clavien-Dindo grade II-one case of ARDS, and the other case of a delayed bronchopleural fistula.

Conclusions: Thoracoscopic sleeve resection and bronchoplasty utilizing HD 3D thoracoscope is a safe and effective procedure with excellent early clinical outcomes. Further investigation for long-term outcomes will be needed.

Keywords: Bronchi; Imaging; Lung cancer; Surgical anastomosis; Suture techniques; Three-dimensional; Video-assisted thoracic surgery.

Fig. 1

Routine setting of the operating room during our 3D VATS major pulmonary resection. We avoid placement of a central venous catheter and a Foley catheter, but during sleeve resection and bronchoplasty we place a Foley catheter

Fig. 2

a Ports and instruments placement in right-side surgery. The operator always stands at the right side of the patient. Both of the operator’s arms are comfortably and ergonomically placed, b Ports in left-side surgery. Note the 10 mm posterior port placed anteriorly to the scapular tip (small arrow), which is different from the right-sided port placement (5 mm, posteriorly to the scapular tip). Sometimes the camera is inserted through this posterior port during subcarinal lymph node dissection, left paratracheal lymph node dissection, or lower lobar sleeve resection and bronchial anastomosis

Fig. 3

(Left) Bronchial anastomosis after sleeve left upper lobectomy. 3D vision with an endobronchial retracting instrument helps safely performing the anastomosis. (Right) tying down the interrupted sutures with an endoscopic knot-pusher

Fig. 4

a Dissection of the left upper pulmonary vein, showing clear vision of the web-like avascular plane between the pulmonary vein and the underlying left main pulmonary artery, b this clear vision of the avascular plane between mediastinal structure enables a safe dissection of the large hilar structures like main pulmonary artery, which is very challenging with a conventional 2D thoracoscope, c the HD 3D vision provides the precise direction and orientation of the suture needle, which enables avoidance of any injury to the nearby structures