Clinical experience of sleeve lobectomy with bronchoplasty using a continuous absorbable barbed suture

Extended Pulmonary Resection by Sleeve Lobectomy and Carinal Pneumonectomy: Selection and Technique

Minimally invasive surgical approaches for extended pulmonary resections are becoming increasingly common as more surgeons gain experience in thoracoscopic and robotic technique. Outcome studies demonstrate improved decreased morbidity as compared with an open surgery.

Carinal resection

Tracheobronchial tumors with involvement of the carina represent a challenging problem in the pulmonary surgery. Carinal resection is referred to removal and reconstruction of the airway itself, whereas concomitant removal of the lung parenchyma (usually a whole lung) is termed as carinal pneumonectomy. Thorough preoperative workup of these patients is mandatory. Meticulous surgical technique and aggressive postoperative management is required for the best outcomes in these difficult cases. In the paper authors review surgical technique, evaluation and management of this challenging patient population.

Our tips for bronchoplasty using suture holder and tourniquet

Bronchial anastomosis is an important part of successful bronchoplasty, but it takes time to achieve stable results because of few opportunities to do it. To ensure a stable outcome, we have applied some tips for bronchial anastomosis. One of the tips is the use of a suture holder to obtain appropriate suture pitches, adjusting the discrepancy of the bronchial diameter, and another one is the use of a tourniquet to obtain an adequate tension upon tying the knots, ensuring good operative view.

Comparison of two different barbed suture materials for end-to-end jejuno-jejunal anastomosis in pigs

BACKGROUND

Hand-sewn intestinal anastomoses are a fundamental procedure in both open and laparoscopic intestinal surgery. Self-retaining barbed suture devices have been tested for a variety of surgical applications. With the exception of clinical reports and various experimental studies on enterotomy, little has been published so far on the use of barbed suture for end-to-end intestinal anastomoses. The aim of the study was to compare two different barbed suture materials for end-to-end jejuno-jejunal anastomosis in pigs. End-to-end jejuno-jejunal anastomosis were performed with unidirectional barbed (A group), bidirectional barbed (B group) or normal (C group) sutures in each animal. A comparison was then made between the groups based on adhesions scoring, suturing time, bursting pressure and histopathology.

RESULTS

Mean construction times in the A group (518 ± 40 s) and in the B group (487 ± 45 s) were significantly lower than in the C group (587 ± 63 s) but were not different between A and B group (P = 0.10). Mean bursting pressures were significantly higher in the intact intestine (197 ± 13 mmHg) than in any other group (group A 150 ± 16 mmHg, group B 145 ± 22 mmHg, group C 145 ± 24 mmHg). Among anastomotic techniques, the bursting pressures were not significantly different. Histologically no difference could be detected in the grade of inflammation, collagen deposition and neovascularization at the anastomotic sites.

CONCLUSIONS

Barbed sutures can be effectively used for handsewn end-to-end jejunojejunal anastomosis in pigs. They are comparable to normal suture but could provide a shorter surgical time.

Outcomes of minimally invasive sleeve resection

Background

Sleeve resection allows for preservation of lung parenchyma and improved long-term outcomes when compared with pneumonectomy. Little is known about minimally invasive sleeve resection, especially indications, feasibility, technical aspects, complications, and outcomes. We reviewed our institutional experience with sleeve resections via a minimally invasive approach.

Methods

We performed a retrospective review of a prospectively maintained database from 01/01/2010 to 11/01/2017. Indications, operative details, pathology, postoperative complications were reviewed and longer-term follow-up was reviewed.

Results

Fifteen patients were identified (5 males, 10 females). Details are presented in Table 1. Patients ranged in age from 7 to 82 years (median, 57 years). Approaches included video-assisted thoracoscopic surgery (VATS) and robotic. Airway sleeve resection was performed in all patients with an additional arterioplasty in 4, one patient having a double sleeve. Length of stay ranged from 3 to 10 days (median, 5 days). Indication for surgery included carcinoid in 5 (1 atypical), NSCLC in 6, and 4 additional pathologies. Complications occurred in 6 patients: air leak [2], pericardial effusion [1], transient brachial plexopathy [1], and atrial fibrillation [2]. There were no anastomotic complications. Median follow-up was 4.2 years. There were no anastomotic strictures.

Conclusions

In experienced centers, sleeve resection via a minimally invasive approach is feasible with acceptable morbidity and mortality. Results in this small series appear comparable with the open approach.

Clinical Experience of Thoracoscopic Sleeve Lobectomy Using a Novel Needle Holder

Thoracoscopic bronchoplasty requires high technique to control stitching during bronchial reconstruction. Improved quality of suturing instrument may contribute to overcome this difficulty of bronchial anastomosis. Recently, a unique and expected articulated instrument for suturing has been launched on endoscopic surgery. We have successfully performed two cases of thoracoscopic sleeve lobectomy using this instrument.

Thoracoscopic partial resection without using a stapler. (complete republication)

Thoracoscopic partial pulmonary resection for small peripheral nodules without using a stapler has been introduced to our hospital. After partial resection was performed with electrocautery, two different methods of surface sealing were used: a coagulation method (C method) with Soft Coagulation alone, and a coagulation-suturing method (CS method) with Soft Coagulation combined with continuous suturing. The clinical outcomes of the two methods were retrospectively compared in this study. The C method was used in 19 lesions of 18 cases, and the CS method was used in 20 lesions of 19 cases. Primary lung cancer was the most frequent diagnosis (22 lesions of 21 cases). There were no differences between the two groups in the size and depth of the lesions. Operative time was longer with the CS method than with the C method. Postoperative air leakage was a complication in 4 cases with the C method, and one of them required re-do surgery, whereas only one case with the CS method had temporary air leakage. Postoperative computed tomography showed cavitation in 3 C method cases and 5 CS method cases, all without related symptoms. There were no local recurrences at resected sites. In conclusion, the C method was technically easy to perform, but air leakage may be prolonged after surgery. The CS method may have the advantage of causing less air leakage than the C method, but mastering the technique is important to shorten operative time.

Barbed suture tissue closure device in urological surgery – a comprehensive review

The development and implementation of barbed sutures has transformed the technique of tissue closure with increasing application across multiple surgical disciplines. Changes in design and handling such as the introduction of absorbable and non-absorbable bidirectional barbed sutures reflect an increasing applicability in tissues of varying qualities. We undertook a comprehensive review of available literature to provide an evidence-based rationale for the clinical use of barbed suture tissue closure devices. We summarise uses along with advantages and disadvantages reported across a number of surgical specialties such as urology, orthopaedics, gynaecology and plastic surgery. Tangible benefits noted were faster closure speed, maintenance of suture integrity, improved efficiency in closure, avoidance of knots and possibly a cost-benefit effect. In terms of complications, the barbed sutures compared equally with standard sutures with no significant differences. In conclusion, barbed sutures have demonstrated versatility and safety across surgical specialties and compares favourably with standard sutures. There appears to be an increasing popularity in the use of barbed sutures with clear advantages to both surgeon and patient.

Modified bronchial anastomosis in video-assisted thoracoscopic sleeve lobectomy: a report of 32 cases

BACKGROUND

Bronchial anastomosis is a key technical challenge in sleeve lobectomy, especially when using the video-assisted thoracoscopic surgery (VATS) approach. A retrospective study was conducted to evaluate the feasibility and safety of a modified bronchial anastomosis technique developed by the authors at Fujian Union Hospital.

METHODS

From October 2010 to October 2015, we performed 32 cases of VATS sleeve lobectomy through a three-port or single-port approach. All bronchial anastomoses were performed using modified bronchial anastomosis technique: the bronchial anastomosis was begun with an initial stitch on the posterior wall, and the bilateral quarters of the circumference were continuously sutured. The other two bilateral quarters were then similarly sutured, and the last knot was made outside the bronchial lumen.

RESULTS

All cases were completed uneventfully. No perioperative deaths or serious complications occurred. The mean operative time, bronchial anastomosis time, and blood loss volume were 271.8±67.5, 37.6±12.0 min, and 177.5±102.9 mL, respectively. The mean follow-up time was 21.0±11.7 months, and the follow-up rate was 96.9% (31/32). An electronic bronchoscope scan was performed 6 months after surgery, and a fine healing stoma was detected in all cases. No anastomotic fistula, anastomotic stenosis, or other serious postoperative anastomotic complications occurred until the end of follow-up.

CONCLUSIONS

Modified bronchial anastomosis technique applied in bronchial anastomosis was safe and feasible in three-port and single-port VATS sleeve lobectomy with good short-term and long-term therapeutic results. Adequate management of the operative process and implementation of a skilled bronchial anastomosis technique could help to reduce the difficulty of VATS sleeve lobectomy.

Initial experience of single-port video-assisted thoracoscopic surgery sleeve lobectomy and systematic mediastinal lymphadenectomy for non-small-cell lung cancer

BACKGROUND

In this study, we evaluate the feasibility and safety of single-port video-assisted thoracoscopic surgery (VATS) sleeve lobectomy (SL) and systematic mediastinal lymphadenectomy and summarize our surgical experience.

METHODS

From October 2014 to December 2015, eight cases of single-port VATS SL [seven male patients and one female patient, median age 56.0 (range, 38-63) years] were performed by a single group of surgeons in Fujian Medical University Fujian Union Hospital. The median tumor size was 2.7 cm. Types of resection included four right upper, one right lower, and three left upper sleeve lobectomies. Systematic mediastinal lymphadenectomy was performed in all patients. A modified anastomosis technique developed by the author (Chen's technique) was applied for bronchial anastomosis. Postoperative outcome and short-term follow-up data were recorded and analyzed.

RESULTS

All eight operations were completed uneventfully with no conversion to thoracotomy or reoperation required. No perioperative death was observed. Major results (medians or percentages) were as follows: operative duration, 234.5 [185-345] min; bronchial anastomosis duration, 38.0 [30-43] min; blood loss, 65.0 [50-200] mL; number of lymph node dissected, 22.5 [18-37]. The postoperative complication rate was 37.5% (three of eight cases, including two pulmonary infections and one atrial fibrillation). All patients recovered and were discharged uneventfully with symptomatic therapy. Pathology showed squamous cell carcinoma in seven patients and adenocarcinoma in one patient; two patients were in TNM stage IB, three in stage IIA, one in stage IIB, and two in stage IIIA. The mean follow-up was 7.5 [2-15] months. There were no tumor recurrences or bronchial anastomotic complications.

CONCLUSIONS

Single-port VATS SL and mediastinal lymphadenectomy are safe and feasible. Improvements in operating procedures can help facilitate single-port VATS. The application of Chen's technique in bronchial anastomosis is easy and reliable and shows a satisfactory short-term clinical outcome.

Uniportal video-assisted thoracoscopic bronchoplastic and carinal sleeve procedures

Despite of the recent advanced with the video-assisted thoracoscopic surgery (VATS), the most common approach for bronchial and carinal resection is still the open surgery. The technical difficulties, the steep learning curve and the concerns about performing an oncologic and safe reconstruction in advanced cases, are the main reasons for the low adoption of VATS for sleeve resections. Most of the authors use 3-4 incisions for thoracoscopic sleeve procedures. However these surgical techniques can be performed by a single incision approach by skilled uniportal VATS surgeons. The improvements of the surgical instruments, high definition cameras and recent 3D systems have greatly contributed to facilitate the adoption of uniportal VATS techniques for sleeve procedures. In this article we describe the technique of thoracoscopic bronchial sleeve, bronchovascular and carinal resections through a single incision approach.