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VATS for mediastinal masses
Diego Gonzalez-Rivas, MD, FECTS
Minimally Invasive Thoracic Surgery Unit (UCTMI)
Coruña Hospital, Spain
Masters of Minimally Invasive Thoracic Surgery
Waldorf Astoria, Orlando, September 19-21 19-21, 2013
Learning curve
Carefully, step by step!
Lesiones benignas:
Miastenia Gravis
Quiste tímico
Timoma:
I = No invasión capsular
II = Invasión capsular
III = Invasión de órganos adyacentes
IVa = Diseminación pleural o pericárdica
IVb = Diseminación linfática o hematógena
MEDIASTINAL MASS
Indication and procedure of video-assisted thoracoscopic surgery to thymic disease. Kyobu Geka.
2006 Jul;59(8 Suppl):742-8
The role of surgery in the management of thymoma: A sistematic Review. Eric Davenport.
Ann Thorac Surg 2008;86:673-84
I y II- VATS III - Sternotomy
IV – Sternotomy + RT
?
VATS
DERECHO:
Identificación de la cava
superior y disección de la
vena innominada desde la
confluencia entre ambas
Mejor visión del área cervical
Disección más ergonómica
para los cirujanos diestros
Side of approach
Selective intubation
Gas?
Ports?
Minithoracotomy?
Optic?
Drain?
DERECHO:
Identificación de la cava
superior y disección de la
vena innominada desde la
confluencia entre ambas
Mejor visión del área cervical
Disección más ergonómica
para los cirujanos diestros
LEFT:
La grasa mediastínica se
localiza mayoritariamente en
el lado izquierdo
Menor riesgo de lesionar el
Nervio Frénico
Mejor acceso para la disección
tímica del área contralateral
Thoracoscopic Thymectomy Mid-Term Results. Tomulescu et al. Ann Thorac Surg 2006;82:1003-8
Thymectomy for myastenia gravis by video-assisted thoracoscopic surgery through right anterior-lateral aproach.
Tan Qy et al. Zhonghua Wai Ke Za Zhi 2008;46(6): 408-10
Side of approach
Selective intubation
Gas?
Ports?
Minithoracotomy?
Optic?
Drain?
Thoracoscopic Thymectomy Mid-Term Results. Tomulescu et al. Ann Thorac Surg 2006;82:1003-8
Thymectomy for myastenia gravis by video-assisted thoracoscopic surgery through right anterior-lateral aproach.
Tan Qy et al. Zhonghua Wai Ke Za Zhi 2008;46(6): 408-10
Doble luz
BI
BD
BT BB
THYMECTOMY
Side of approach?
Selective intubation?
Gas?
Ports?
Minithoracotomy?
Optic?
Drain?
Thoracoscopic Thymectomy Mid-Term Results. Tomulescu et al. Ann Thorac Surg 2006;82:1003-8
Thymectomy for myastenia gravis by video-assisted thoracoscopic surgery through right anterior-lateral aproach.
Tan Qy et al. Zhonghua Wai Ke Za Zhi 2008;46(6): 408-10
GAS CO2:
6-10 mmHg
Camera trocar
Better view
THYMECTOMY
Lado de abordaje?
Ventilación selectiva?
Neumomediastino?
Ports?
Minithoracotomy?
Optic?
Drain?
Thoracoscopic Thymectomy Mid-Term Results. Tomulescu et al. Ann Thorac Surg 2006;82:1003-8
Thymectomy for myastenia gravis by video-assisted thoracoscopic surgery through right anterior-lateral aproach.
Tan Qy et al. Zhonghua Wai Ke Za Zhi 2008;46(6): 408-10
GAS CO2:
6-10 mmHg
Camera port
Bettter view
THYMECTOMY
GA
Partial lateral position
Selective intubation
Gas CO2
Óptic 30º Drain Nº20
1-3 entry ports
AG
IOT selectiva
Semidecúbito lateral
Gas CO2
Óptica 30º Drain Nº20
Hemitórax izdo
3 puertas de entrada
AG
IOT selectiva
Semidecúbito lateral
Gas CO2
Óptica 30º Drain N 20
Hemitórax izdo
3 puertas de entrada
Triangulation
VATS thymectomy
Single port thymectomy
SILS fot thymectomy?
Thymectomy-From left side
Thymectomy-From right side
Supine position. Anti-trendelenburg
Double lumen intubation
Left approach
CO2
Video-assisted thoracoscopic extended thymectomy and extended transsternal thymectomy in non thymomatous
myastenia gravis patients: Remission after 6 years follow up.
Mantegazza et al. Neurol Sci. 2004 Aug 15;217
Video-assisted thoracoscopic extendedthymectomy for myastenia gravis. Yu L et al.
Zhonghua Wai Ke Za Zhi 2008 Nov 15;46(22): 1720-2
COMPRESSION
Enlarge the incision (avoid inflation if suction)
Suction
Clips, coagulation,ligasure,harmonic
If no control: Open surgery
(thoracotomy vs sternotomy)
Bleeding, what to do?
Extended Resection
Remove tumor-enlarge incison
Teratoma
Cyst
Single-port
Cystic mass
Thymoma-Single-port
Neurogenic tumor (single-port)
Huge mass resection (preop: fibrous tumor) Final diagnosis: Neurogenic tumor
16 cm Mediastinal mass (single port)
VATS limits? Huge tumors: open surgery
Videothoracoscopy is the less
invasive approach for mediastinal
lesions with excellent
postoperative results
The most important aspect is to
achieve a radical resection and
preserve the oncologic principles
in case of mediastinal tumors
“There is only one thing that
makes a dream impossible to
achieve: the fear of failure.”
Paulo Coelho
CORUÑA UNIVERSITY HOSPITAL
MINIMALLY INVASIVE THORACIC SURGERY UNIT (UCTMI)