Cardiothoracic Surgery SC035: Minimally Invasive Thoracic Surgery

Question 1

Thoracic surgery

Answer 1

1. Airway
   - Endobronchial obstruction
   - Extrinsic compression (e.g. LN)
   - etc.
2. Mediastinum
   - Masses (e.g. Thymoma, LN)
3. Chest wall
   - Deformity (e.g. Pectus excavatum)
4. Ribcage + sternum
   - Fracture
5. Diaphragm
6. Thoracic duct
   - e.g. Chylothorax
7. Pleura
   - mass / effusion
8. Lung
   - tumour / transplant
9. Sympathetic trunk
   - hyperhydrosis

Question 2

Traditional surgery

Answer 2

Surgery (double edge sword):

• Cure patient disease
• Cause surgical trauma

Trauma of surgery:

1. GA + intubation
2. Access wound trauma (fracture of rib, costocartilage joint dislocation, nerve injury)
3. Resected tissue
4. Physiological
5. Psychological

Effect of trauma of surgery on cancer patient:

1. Mortality
2. Morbidity
3. Adjuvant therapy
4. Survival
5. QoL

Question 3

Concept of Minimally invasive surgery

Answer 3

1. Minimise trauma / complications / SE
2. Achieve same / better outcomes

How?

1. Multimodal, multidisciplinary approach
2. Access wound trauma
3. Extent of target organ resection
4. Simply the procedure

Question 4

Development of Minimally invasive surgery

Answer 4

Stage 1: Infancy

1. Safety
2. Feasibility
   - utmost importance for development of a new technique

Stage 2: Childhood
1. Crude benefit

Stage 3: Adolescence
1. Objective, quantifiable benefit

Stage 4: Adulthood
1. Treatment efficacy (require large scale study, systematic review)

Question 5

Advantages of VATS

Answer 5

1. Improved vision
2. Less post-op pain
3. Fast recovery
4. Early discharge
5. Less complication
6. Less inflammatory response
7. Same oncological outcome

Question 6

Further minimise wound

Answer 6

1. Small instrument
2. Minimise port number
   - Uniportal VATS
   —> Minimise access trauma
   —> Limit incision to one intercostal space + nerve only
   —> Reduce pain + paresthesia

Question 7

Advantages of Uniportal VATS

Answer 7

Significant reduction in:

1. Complication rate
2. Hospital stay
3. Chest drain duration

No difference:

1. Mortality
2. OT time
3. Blood loss
4. Conversion rate

Question 8

Reduce post-op pain

Answer 8

1. Preoperative counselling
   - explain procedure
2. Intra-op surgical techniques
   - Pre-emptive LA (before incision)
   - Paravertebral block
   - Intercostal nerve block
3. Post-op protocol
   - Multimodal analgesia
   - Pain measurement scale

In thoracic surgery:

4. Limit extent of lung resection
   - reduce surgical trauma
   - lung parenchymal preservation
   - improve post-op lung function

Question 9

Lung resection terminology

Answer 9

1. Pneumonectomy
   - Whole lung resected
2. Lobectomy
   - One lobe resected
3. Sublobar / Limited resection
   —> Segmentectomy (19 total segments in lungs —> each segment has own blood supply)
   —> Wedge resection

Previous studies show inferiority of Limited resection compared to Lobectomy
—> but now patient cohort has changed
1. Small sized early stage lung cancer ↑ (∵ early detection of cancer)
2. Specific group of adenocarcinoma (i.e. minimally invasive type of adenocarcinoma) having low risk of nodal metastasis / recurrence
3. Multiple synchronous primary lung cancer ↑
4. Limitations of previous trials
—> Need to balance Oncological clearance vs Functional preservation

Question 10

Tumour size

Answer 10

• <20mm: Segmentectomy
• 21-30mm: Further study required
• > 30mm: Lobectomy only

Question 11

Tumour histology

Answer 11

Based on HRCT scan:

• Air-containing type —> more associated with less aggressive adenocarcinoma
• Solid density tumour type —> more aggressive

Adenocarcinoma-in-situ (AIS) / Minimally invasive adenocarcinoma (MIA)
—> Low grade tumour
—> can consider Limited resection

Others:
—> Lobectomy

Question 12

Current evidence of Segmentectomy for lung cancer

Answer 12

1. For stage 1A (size <=2cm)
2. Low grade pathology
   - No nodal metastasis
   - Radiologically pure GGO on HRCT instead solid component within mass (ground glass opacity) (aka Air-containing type)

Question 13

Anaesthesia for thoracic surgery

Answer 13

1. GA
2. Double lumen tube
3. One lung ventilation (i.e. Operated lung will be collapsed —> allow operation on it)

Question 14

Non-intubated VATS technique (NIVATS)

Answer 14

Non-intubated VATS technique:

1. Spontaneous breathing
   - avoid airway injury
   - avoid mechanical ventilation
   - reduce systemic inflammatory response
   - dependent lung can perform better (∵ perfusion better, lung recruitment by maintained diaphragmatic function, intrapulmonary shunt and hypoxaemia is reduced)
2. Regional / Local anaesthesia
   - avoid deep sedation
   - avoid muscle relaxant (esp. MG patients)
   - reduce SE of GA

Applications:

• Pleural biopsy
• Lung wedge resection
• Sympathectomy
• Thymectomy
• Anatomical lung resection
• Segmentectomy
• Sleeve resection
• Cardinal reconstruction
• Bullectomy

Conclusion:

1. Safe procedure
2. Technically feasible
3. Less invasive alternative for selected patient
4. Early recovery
5. Long term benefit unclear

Question 15

Important elements in Clinical pathway for VATS

Answer 15

1. VATS
2. Regular communication
3. Mobilisation schedule
4. Wound care protocol
5. Investigations algorithm
6. Air leak management
7. Chest drain documentation
8. Multimodality analgesic strategies
9. Physiotherapy

Question 16

Summary of Minimally invasive surgery

Answer 16

1. Pre-op counselling
2. Pain management
3. Size of wound
4. Number of incision
5. Extent of surgical resection
6. Anaesthesia
7. Clinical pathway
   —> Early recovery + Better surgical outcome + Patient satisfaction

Question 17

Enhanced Recovery After Surgery (ERAS)

Answer 17

• Fast tract surgery
• Multimodal, multidisciplinary perioperative care pathway for surgical patient
• Improved quality of care i.e. reduced number of complication, hospital stay, re-admissions
• Reduced healthcare costs while increasing patient + staff satisfaction