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Single Incision Video-Assisted Thoracic Surgery Using a Laparoscopic Port To the Editor: We read with interest the report by Rocco and colleagues [1] describing ambulatory, single incision, video-assisted thoracic surgical (VATS) resection of peripheral pulmonary nodules. The use of multiple ports in most VATS procedures remains a major cause of early pain and persistent parietal disorders [2]. For the last decade, only a few publications describing the use of single incision VATS have been reported, and in these studies authors performed interventions either through a single, classical thoracic port or directly through an incision without any port [1, 3, 4]. The persistence of multi-port VATS is probably due primarily to a lack of development of appropriately dedicated instruments. In our department, we have used single incision laparoscopic surgery (SILS [Covidien, Elancourt, France]) technology for thoracoscopy for varied indications and have found the use of a single laparoscopic supple port in single incision VATS feasible and safe. We have performed a prospective evaluation of video-assisted thoracoscopic surgery using a single laparoscopic supple port (SILS, Covidien). This study was approved by the Committee of Human Subject Research of the French Society of Thoracic and Cardio-Vascular Surgery. Between June and September 2009, 10 patients were enrolled. The surgical indications were primary spontaneous pneumothorax (7 patients), secondary pneumothorax due to emphysematous bullae (1 patient), post-pneumonic empyema (1 patient), and an indeterminate lung nodule (hamartoma) (1 patient). Patients included 8 men and 2 women with a median age of 47 years (range, 18 to 56). In each case, a 2.5-cm incision in the sixth intercostal space in the posterior axillary line was placed. After a digital exploration of pleural space, the SILS device was introduced using a curved forceps. Three ports (two 5-mm and one 10-mm in diameter) were placed into the operative channel (Fig 1). A 0°
Fig 2. Two reticulated forceps grasping apical bullae (black arrow); this figure shows the triangulation offered by the reticulation of the instruments. The asterisk shows apical intercostal space. video-thoracoscope and two reticulating instruments (Fig 2) were then inserted. In the pneumothorax cases, a bullectomy was performed using reticulated staplers (Endo-GIA Universal [Covidien]), and a subtotal parietal pleurectomy was performed by using electrocautery. The patient with empyema was decorticated to allow re-expansion of the entire lung, along with wide irrigation of the pleural space using saline. The benign tumor was removed by a simple wedge resection. There were no intraoperative complications that required either placement of a supplementary port or conversion to a thoracotomy. In an attempt to avoid injury to the intercostal nerve, Rocco and colleagues [4] advised, in a previous article, to take full advantage of laterality given by the intercostal space incision without applying an excessive leverage on the thoracoscope instruments ensemble. In our experience, the spongy character of the laparoscopic port seems probable to reduce the likelihood of intercostal nerve injury while allowing and offering more amplitude to the instruments. The development of a dedicated device (with ports and specific grasps) is far more important to enlarge the place for this approach in our daily practice.
We thank Dr Robert J. Downey (Thoracic Surgery Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY) for careful reading and English revision of the manuscript. Jalal Assouad MD, PhD Stéphane Vignes, MD Joseph Nakad, MD Dominique Grunenwald, MD, PhD Department of Thoracic Surgery Hôpital Tenon 4 rue de Chine Paris 75020, France e-mail:
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References
Fig 1. Spongy laparoscopic port inserted into the intercostal space; two 5-mm ports and the optic are introduced through the single port into the thoracic cavity. © 2011 by The Society of Thoracic Surgeons Published by Elsevier Inc
1. Rocco G, Romano V, Accardo R, et al. Awake single-access (uniportal) video-assisted thoracoscopic surgery for peripheral pulmonary nodule in a complete ambulatory setting. Ann Thorac Surg 2010;89:1625–7. 2. Rusch VW, Bains MS, Burt ME, McCormack PM, Ginsberg RJ. Contribution of video thoracoscopy to the management of the cancer patient. Ann Surg Oncol 1994;1:94 – 8. Ann Thorac Surg 2011;91:2020 –7 • 0003-4975/$36.00 doi:10.1016/j.athoracsur.2010.11.050
3. Martinez-Ferro M, Duarte S, Laje P. Single port thoracoscopy for the treatment of pleural empyema in children. J Pediatr Surg 2004;39:1194 – 6. 4. Rocco G, Ucar AM, Passera E. Uniportal VATS wedge pulmonary resections. Ann Thorac Surg 2004;77:726 – 8.
Reply To the Editor: Assouad and colleagues [1] should be commended for rightfully raising the point of how to expand the practice of uniportal videoscopic assisted thoracic surgery (VATS). However, although the indications for single-port VATS to manage pleural disease (ie, single incision VATS to obtain diagnosis and divide loculations) have been known since the inception of thoracoscopic surgery, operative uniportal VATS (ie, single incision VATS pulmonary resection) often requires interchangeability of the reciprocal position of the necessary instrumentation to address different areas in the chest cavity [2]. Accordingly, in the description of the original technique of uniportal VATS pulmonary resection [2], the use of a trocar was not contemplated to avoid space impediments. In this setting, the single-incision laparoscopic surgical (SILS) port (Covidien, Mansfield, MA) is a U.S. Food and Drug Administration-approved device for laparoscopic use that enables the surgeon to perform single-port laparoscopic procedures while establishing and maintaining the pneumoperitoneum. Once again, thoracic surgeons should rely on laparoscopic instruments adapted for thoracic surgical use. Indeed, the adaptation of this laparoscopic soft port duplicates the idea of introducing more instruments though a single incision introduced by operative uniportal VATS [2]. Along with flexing the patient’s trunk by increasing the intercostal space width, SILS could represent an additional protective factor against intercostal nerve injury—the latter significantly reduced compared with the traditional 3-port VATS if the uniportal VATS technique is carefully adhered to [3]— but I suspect it may also hinder maneuverability [4]. I am convinced Assouad and colleagues’ contribution will help clarify this issue in a future report of a larger institutional experience with SILS where more details about stapler introduction and specimen removal through SILS will be given. In the meantime, I would envisage the use of SILS in uniportal VATS to avoid or reduce tedious blood dripping on the thoracoscope lens, which is common if no port is used. In conclusion, I agree with Assouad and coworkers that specific instruments for operative uniportal VATS should be devised because the operative uniportal VATS technique is based on a totally different intrathoracic approach to the target lesion in the chest compared with conventional 3-port VATS [2– 4]. Moreover, unlike 3-port operative VATS, the contribution of articulating instrumentation is fundamental for operative uniportal VATS [2– 4]. In this setting, it is important to define a clear-cut distinction between uniportal operative vs diagnostic VATS, with the latter certainly benefitting from the use of SILS. Gaetano Rocco, MD, FRCSEd Department of Thoracic Surgery and Oncology Division of Thoracic Surgery National Cancer Institute, Pascale Foundation Via M Semmola, 81 80131 Naples, Italy e-mail:
[email protected]
References 1. Assouad J, Vignes S, Nakad J, Grunenwald D. Single incision video-assisted thoracic surgery using a laparoscopic port (letter). Ann Thorac Surg 2011:91:2020 –1. © 2011 by The Society of Thoracic Surgeons Published by Elsevier Inc
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2. Rocco G, Martin-Ucar A, Passera E. Uniportal VATS wedge pulmonary resections. Ann Thorac Surg 2004;77:726 – 8. 3. Jutley RS, Khalil MW, Rocco G. Uniportal vs standard threeport VATS technique for spontaneous pneumothorax: comparison of post-operative pain and residual paraesthesia. Eur J Cardiothorac Surg 2005;28:43– 6. 4. Rocco G, Romano V, Accardo R, et al. Awake single-access (uniportal) video-assisted thoracoscopic surgery for peripheral pulmonary nodules in a complete ambulatory setting. Ann Thorac Surg 2010;89:1625–7.
Dr Rocco discloses that he has a financial relationship with Covidien.
Factors Associated With the Development of Acute Heart Failure in Critically Ill Patients With Severe Pandemic 2009 Influenza A (H1N1) Infection To the Editor: We read with great interest the article by MacLaren and colleagues [1] on the use of central extracorporeal membrane oxygenation (ECMO) as rescue therapy in a patient with severe cardiac and respiratory failure caused by pandemic influenza A (H1N1). Direct viral myocarditis was excluded by myocardial biopsy. They consider ventricular dysfunction as a consequence of protracted acute respiratory distress syndrome and sepsis. The pathophysiologic mechanism contributing to the development of severe acute heart failure in these critically ill patients has not yet been completely defined. Martin and colleagues [2] identified reversible left ventricular dysfunction in 4.9% of patients hospitalized for H1N1 infection with a mortality of 33%. Brown and colleagues [3] reported right ventricular dilatation and systolic dysfunction in the majority of patients with lifethreatening H1N1 infection managed in the intensive care unit with concomitant left ventricular systolic dysfunction in 17% of patients complicated with septic shock. In a case series of 4 patients admitted to the cardiothoracic intensive care unit in our institution during the exacerbation period of H1N1 pandemic (December 2009 to March 2010) with acute respiratory distress syndrome not responding to conventional mechanical ventilation, severely depressed right and left ventricular function was evident in 2 young females, aged 39 and 48 years, with no predisposing risk factors and comorbidities. They were both managed with peripheral veno-arterial extracorporeal ECMO support 1 week after the onset of symptoms. An interesting finding at the time of H1N1 diagnosis was that both patients had positive bronchial and blood cultures for Candida species accompanied by significant myelotoxicity (ie, anemia, reduced white cell count), which could explain susceptibility of these patients to secondary opportunistic infections. Both patients subsequently had multiple organ dysfunction syndrome (renal and hepatic failure) develop. Extracorporeal support was weaned off after 11 and 13 days, respectively. At that point left and right ventricular function was significantly improved. One patient survived to discharge. Severe restriction was evident on lung function tests, diffusion capacity was markedly reduced, whereas computed tomography showed evidence of diffuse pulmonary fibrosis. At the patient’s 6-month follow-up, lung function and diffusion capacity returned to normal, whereas radiologic evidence of diffuse pulmonary fibrosis was stable. By evaluating the clinical course of these patients, we consider that adverse modulation of immune response in the initial 0003-4975/$36.00
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