No Disclosures

9/17/2016

Thoracoscopic Lobectomy for Locally Advanced Lung Cancer

No Disclosures Todd L. Demmy Masters MITS '2016

5/13/15

What is Locally Advanced? Anatomic Definition

Procedural Definition • Pneumonectomy • Sleeve Lobectomy • Chest Wall Resection • Advanced exposure

Duke Series After Preoperative Chemo

• Lesion size >5 cm • Strong pleural adhesions • Adjacent structure involvement (parietal/mediastinal pleura, diaphragm, rib) • N1 or N2 • Centrally located tumors (endo- or peribronchial extension to lobar bronchus orifice) • Previous chemo- or chemoradiotherapy, or previous surgery

J Thorac Dis 2014;6(S6):S623-S630

Masters MITS '2016

MSK Series Preoperative Chemo

Propensity Matched

Yang, European Journal of Cardio-Thoracic Surgery (2015) 1–9

Masters MITS '2016

RPCI Local Advanced – UPDATE

Park, J Thorac Dis 2016;8(Suppl 4):S406-S413

Masters MITS '2016

Masters MITS '2016

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9/17/2016

RPCI Local Advanced – UPDATE EBL (ml) OR time (min) Time to start adjuvant (days) Size of tumor (cm) Total LNs Positive LNs Recurrence Overall survival (mon) Disease-free survival (mon) Path Stage > 1

VATS (n=224) 290.0341.6 312.4126.7 50.520.7

Conversion (n=55) 671.0619.3 373.0134.5 53.413.4

Open (n=37) 419.6314.1 307.3125.3 61.418.4

4.152.10 15.412.4 0.71.8 63 (28.1%) 41.227.8 36.128.4

4.402.33 14.411.3 1.52.5 22 (40.0%) 32.627.2 25.721.9

4.732.39 15.79.5 1.53.4 15 (40.5%) 36.234.8 31.434.7

62%

92%

54%

Visualization Tools 5 mm Optimal For Sharing ports p value < 0.001 < 0.01 0.07

0.29 0.86 < 0.01 < 0.05 0.10 < 0.001

Masters MITS '2016

Masters MITS '2016

Common 3D Systems today

Importance of Low Profile and Angles

Olympus ENDOEYE Flex 3D Laparoscopy

Viking ConMed.com bbraun.com

Masters MITS '2016

Masters MITS '2016

Lymph Node Grasping

Multiple retractors

No Grasp - Metal Endoscopic Sucker -- Liu et al. BMC Surgery (2015) 15:38

00:26

Masters MITS '2016

Masters MITS '2016

2

9/17/2016

PA control - Loops

PA control - Bulldogs

• #1 Silk

A. Watanabe et al. / European Journal of Cardio-thoracic Surgery 31 (2007) 129—131 Masters MITS '2016

Masters MITS '2016



Dong, J Thorac Dis 2014;6(12):1855-1860

Masters MITS '2016


Dong, J Thorac Dis 2014;6(12):1855-1860

Masters MITS '2016

Follow the “Fs” when you are stuck- 1 • Free All Adhesions, All Lobes • Find Somewhere else to work or view – Pleurae and lymphatic tissue – Divide more distally • Fissure Division (also opens camera angles) – Partially (outside in) – Completely (blunt clamp technique)

Dong, J Thorac Dis 2014;6(12):1855-1860

Masters MITS '2016

Masters MITS '2016

3

9/17/2016

Follow the “Fs” when you are stuck - 2

Exposure Problems Vessel Access

• Flip order of anatomical divisions (eg. Change to Fissure Last Technique) • Fill the port/access incisions (“fers”) – Traction – Countertraction to define anatomy (eg. “Two-fer” and vessel loops) • Fresh planes (eg. Open pericardium) • Flatten the diaphragm

00:20

Masters MITS '2016

Masters MITS '2016

Left Lower Lobe

Left Lower Lobe Access Work Camera 00:11

Masters MITS '2016

07:13

Masters MITS '2016

VATS Sleeve N=118 He Team - GuangzhouUniversity

VATS Sleeve Resection

3.0 Prolene, running memb, inter cart

Lobe

Number

RUL

59

RML

7

RLL

8

LUL

34

LLL

10

Huang (He), J Thorac Dis 2016;8(3):553-574 Masters MITS '2016

Nakanishi, 2007, Ann Thorac Surg 84(1): 191-195.

Masters MITS '2016

4

9/17/2016

Uniportal Sleeve Review

Diego-Rivas, European Journal of Cardio-Thoracic Surgery 49 (2016) i6–i16

Masters MITS '2016

Uniportal Sleeve Review


Masters MITS '2016

Uniportal Sleeve Review Diego-Rivas, European Journal of CardioThoracic Surgery 49 (2016) i6–i16


Masters MITS '2016

Masters MITS '2016

TiKnot Device Diego-Rivas, European Journal of CardioThoracic Surgery 49 (2016) i6–i16

Masters MITS '2016

Masters MITS '2016

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V-loc Device

LUL Sleeve Lobectomy

0:23 Masters MITS '2016

Masters MITS '2016

LUL Sleeve Lobectomy

Traction Sutures

Xu, J Thorac Dis 2013;5(S3):S298-S300.

0:25 Masters MITS '2016

Masters MITS '2016

Gigli/Rib Cutter/High Speed Burr

***Scanlon***

Midas Rex™ Masters MITS '2016

Methods-Retraction

• Wylie or similar • Self-retaining systems, Bookwalter • Fan-retraction

Black Max™ Masters MITS '2016

6

9/17/2016

Case Presentation LUL Chest Wall Invasion

Results – NSCLC Groups

0:26 0:26

Masters MITS '2016

Open (n=16)

p-value

2

6

0.028

7

13

0.002

6.7%

56.3%

0.001

66.7%

62.5%

0.594

53.3%

87.5%

0.036

In Hospital (days) Reconstruction with Patch Neoadjuvant Chemo or ChemoRT 90-Day Mortality/Major Morbidity

Open (n=16)

p-value

Age (years)

76

56

0.003

Operative Time (min)

500

410

0.167

EBL (mL)

450

525

0.441

Ribs Resected

3 (range 1-5)

3 (range 1-5)

0.105

Hennon, Ann Thorac Surg. 2015 Jun;99(6):1929-34

Less Variation for VATS Despite Older Patients

VATS (n=15)

ICU (days)

VATS (n=15)

Masters MITS '2016

Results Variable (median)

Variable (median)

Pneumonectomy

Neuro ? Other

Emergency

Hennon, Ann Thorac Surg. 2015 Jun;99(6):1929-34 Masters MITS '2016

Summary • Highly selected cases of primary or T3 lung cancer may be appropriate VATS resection candidates. • ? short-term recovery benefits • Not for all frail patients • Cooperative study is needed Masters MITS '2016

Colon ischemia

Hennon, Ann Thorac Surg. 2015 Jun;99(6):1929-34 Masters MITS '2016

Conclusions • Thoracoscopic chest wall resection is technically feasible – expanded our case selection – reduced prosthetic reconstruction • It did not, however, reliably protect all frail, elderly patients.

Masters MITS '2016

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VATS Brachytherapy

VATS Brachytherapy Video

Pract Radiat Oncol. 2016 May 7. pii: S1879-8500(16)30048-0. doi: 10.1016/j.prro.2016.04.006.

Masters MITS '2016

Masters MITS '2016

VATS Brachytherapy Video Access Work Camera

13:36

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Troubleshooting Guide

Troubleshooting Guide

• Ann Thorac Surg 2005;79:1744 –53 Masters MITS '2016

Masters MITS '2016

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RPCI Local Advanced

STS Database: % Thoracoscopic Lobectomy 4000

* 5/2010

42.8%

45% 44.7

Number of Pulmonary Resections

3500

Thoracoscopy Series 2 Thoracotomy

3000

2500

39.7%

33.3%

2000

26.2%

1500

1000

Ann Surg Oncol (2011) 18:3732–3736 0

986

617 790

15.6%

500

1541

11.6%