Evaluation of video-assisted thoracoscopic surgery lobectomy requiring emergency conversion to thoracotomy

Shibata, Shigeki; Komori, Eisaku; Yamashita, Motohiro

doi:10.1016/j.ejcts.2009.04.004

Cited by 66 publications

(79 citation statements)

References 17 publications

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“…Significant nodal disease on preoperative imaging has been described as a key factor associated with increased risk of conversion. 11,[18][19][20] The low incidence of conversion secondary to nodal disease in our series suggests accurate interpretation of preoperative imaging and subsequent appropriate assessment of suitability for a thoracoscopic procedure. Emergency conversion associated with cardiovascular instability was uncommon, comprising fewer than 1% of all procedures commenced thoracoscopically.…”

Section: Discussionmentioning

confidence: 99%

“…Data regarding cancer recurrence and overall survival are also not presented but have been demonstrated to be comparable in previous series. 19,22 In addition, operative duration has not been reported. The exact time of conversion could provide an insight into intraoperative decision making and factors affecting the prompt anticipation of potential difficulties.…”

Section: Study Limitationsmentioning

confidence: 99%

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The evolution of intraoperative conversion in video assisted thoracoscopic lobectomy

Vallance

Tcherveniakov

Bogdan

et al. 2017

annals

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INTRODUCTION Unplanned conversion to thoracotomy remains a major concern in video assisted thoracoscopic surgery (VATS) lobectomy. This study aimed to investigate the development of a VATS lobectomy programme over a five-year period, with a focus on the causes and consequences of unplanned conversions. METHODS A single centre retrospective review was performed of patients who underwent complete anatomical lung resection initiated by VATS between January 2010 and April 2015. RESULTS In total, 1,270 patients underwent a lobectomy in the study period and 684 (53.9%) of these were commenced thoracoscopically. There were 75 cases (10.9%) with unplanned conversion. The proportion of lobectomies started as VATS was significantly higher in the second half of the study period (2010-2012: 277/713 [38.8%], 2013-2015: 407/557 [73.1%], p<0.001). The conversion rate dropped initially from 20.4% (11/54) in 2010 to 9.9% (15/151) in 2013 and then remained consistently under 10% until 2015. Conversions were most commonly secondary to vascular injury (26/75, 34.7%). Patients undergoing unplanned conversion had a longer length of stay than VATS completed patients (9 vs 6 days, p<0.001). There was a higher incidence of respiratory failure (10/75 [14.1%] vs 23/607 [3.8%], p<0.001) and 30-day mortality (7/75 [9.3%] vs 6/607 [1.0%], p=0.003) in patients with unplanned conversion than in those with completed VATS. CONCLUSIONS As our VATS lobectomy programme developed, the unplanned conversion rate dropped initially and then remained constant at approximately 10%. With increasing unit experience, it is both safe and technically possible to complete the majority of lobectomy procedures thoracoscopically.

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Section: Discussionmentioning

confidence: 99%

Section: Study Limitationsmentioning

confidence: 99%

The evolution of intraoperative conversion in video assisted thoracoscopic lobectomy

Vallance

Tcherveniakov

Bogdan

et al. 2017

annals

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“…While two other reports did identify increased operating times, blood loss, and length of stay in converted patients, there were no differences in post-operative complication, survival and recurrence rates (61,62).…”

Section: Conversion To Open Proceduresmentioning

confidence: 67%

Prevention and management of intraoperative crisis in VATS and open chest surgery: how to avoid emergency conversion

Safdie¹,

Sanchez²,

Sarkaria³

2017

J. Vis. Surg.

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Video assisted thoracic surgery (VATS) has become a routinely utilized approach to complex procedures of the chest, such as pulmonary resection. It has been associated with decreased postoperative pain, shorter length of stay and lower incidence of complications such as pneumonia. Limitations to this modality may include limited exposure, lack of tactile feedback, and a two-dimensional view of the surgical field. Furthermore, the lack of an open incision may incur technical challenges in preventing and controlling operative misadventures leading to major hemorrhage or other intraoperative emergencies. While these events may occur in the best of circumstances, prevention strategies are the primary means of avoiding these injuries. Unplanned conversions for major intraoperative bleeding or airway injury during general thoracic surgical procedures are relatively rare and often can be avoided with careful preoperative planning, review of relevant imaging, and meticulous surgical technique. When these events occur, a pre-planned, methodical response with initial control of bleeding, assessment of injury, and appropriate repair and/ or salvage procedures are necessary to maximize outcomes. The surgeon should be well versed in injuryspecific incisions and approaches to maximize adequate exposure and when feasible, allow completion of the index operation. Decisions to continue with a minimally invasive approach should consider the comfort and experience level of the surgeon with these techniques, and the relative benefit gained against the risk incurred to the patient. These algorithms may be expected to shift in the future with increasing sophistication and capabilities of minimally invasive technologies and approaches. hemorrhage within moments. While these events may occur in the best of circumstances, prevention strategies are the primary means of avoiding these injuries. When they do occur, premeditated and expedited intervention is the key to rescue (1). The current report focuses on the prevention and management of these emergency bleeding events in VATS pulmonary resections. Preoperative radiologic assessment of vascular and anatomic variationRigorous preoperative evaluation of fitness of surgery is a key component of any operative assessment. Preoperative identification and awareness of case-specific and patientspecific risk factors may help prevent hemorrhagic complications in most lung resections. These factors include body habitus, preoperative chemotherapy and radiation, bleeding diatheses including medical anticoagulants, previous thoracic surgery, lymph node calcification and/or granulomatous disease, tumor size and location.Computed chest tomography has become a standard of care in virtually all cases considered for major pulmonary resection. These high resolution scans, often available with three dimensional reconstruction, can provide valuable opportunities to identify standard and anomalous vascular variations prior to surgery in greater than 95% of cases (2-6). Imaging may also identify cal...

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“…Single-port left upper lobectomy is difficult (4). The location of the pulmonary artery in relation with the branching pattern of the left pulmonary artery and the aorta increases the difficulty of the procedure.…”

Section: Commentsmentioning

confidence: 99%

A “reverse direction” technique of single-port left upper pulmonary resection

Zhang¹,

Sihoe²,

Du³

2016

J. Thorac. Dis.

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Background: Single-port video-assisted thoracoscopic surgery (VATS) left upper lobectomy is difficult amongst all the lobes. At the beginning of single-port lobectomies, the upper lobes were believed not to be amenable for single-port approach due to the difficult angulation for staplers. Gonzalez reported the first single-port VATS left upper lobectomy in 2011. Methods: We report a new technique of single-port VATS left upper lobectomy with the concept of "reverse direction". We divide the apical-anterior arterial trunk with upper vein in the last. The procedure sequence is described as follows: posterior artery, lingular artery, bronchus and finally upper vein & apical-anterior arterial trunk. Results: This method could overcome the angular limitations frequently encountered in single-port VATS procedures; reduce the risk of injuries to pulmonary artery; broaden the indications of single-port the upper lobe of the left lung (LUL) to include hypoplastic lung fissures. Limitations of this new practice include the enlargement or severe calcifications of hilar and bronchial lymph nodes. articulations to allow the insertion of 3 or 4 instruments simultaneously. The surgeon and the cameraman stand in front of the patient. The camera was placed in the posterior part of the utility incision and the instruments were inserted in the anterior part. ConclusionsOptimal traction of the upper lobe to anterior was necessary in order to achieve an adequate exposure of the arterial branches of the pulmonary artery. The posterior artery was exposed and divided with a stapler which had been inserted through the anterior part of the incision (Figure 1). The next step was stapling the fissure from anterior to posterior. The lingular artery was then dissected and divided by a stapler (Figure 2).We continued the procedure by dissecting and stapling the bronchus of the LUL (Figure 3). Once the previous arterial branches are stapled, the bronchus is easily exposed. Dissection and stapling of the upper vein and apicalanterior arterial trunk was the last step and can be done together (Figures 4,5). Since the bronchus and arterial branches are stapled, the optimal angulation for the upper vein and apical-anterior arterial trunk can be easily achieved by staplers ( Figure 6). The specimen was finally removed in a protective bag. Systematic lymph node dissection of the subcarinal, aorto-pulmonary window and prevascular space finished the procedure. A single chest tube was placed in the posterior part of the utility incision. CommentsSingle-port left upper lobectomy is difficult (4). The location of the pulmonary artery in relation with the branching pattern of the left pulmonary artery and the aorta increases the difficulty of the procedure. At the beginning of single-port lobectomies, the upper lobes were believed not to be amenable for single-port approach due to the difficult angulation for staplers. Gonzalez-Rivas reported (2) and his operative procedures quickly became the mainstream surgical method for single-port LUL, which is si...

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Evaluation of video-assisted thoracoscopic surgery lobectomy requiring emergency conversion to thoracotomy

Abstract: The safety of the conversion was acceptable. Our findings suggest that VATS lobectomy for lung cancer is feasible from the viewpoint of safety, even after taking into account the potential need for conversion to thoracotomy in some patients.

Cited by 66 publications

References 17 publications

The evolution of intraoperative conversion in video assisted thoracoscopic lobectomy

The evolution of intraoperative conversion in video assisted thoracoscopic lobectomy

Prevention and management of intraoperative crisis in VATS and open chest surgery: how to avoid emergency conversion

A “reverse direction” technique of single-port left upper pulmonary resection

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