1. 以單孔方式進行再次胸腔鏡手術做主要肺切除的可行性 The Feasibility of Major Lung Resection in Repeated Video-Assisted Thoracoscopic Surgery (VATS) by Single-Port Approach
Ying-Yuan Chen (陳盈元), Yau-Lin Tseng (曾堯麟)
Division of Thoracic Surgery
National Cheng Kung University Hospital, Tainan
2017/03/18

2. Introduction
A growing number of repeated pulmonary surgery has been adopted in metachronous or recurrent lung cancer, and pulmonary metastases, especially in thoracoscopic era
Adhesion makes repeated pulmonary surgery difficult for the surgeon and hazardous for the patients
Parenchymal hemorrhage, vascular injury, prolonged air-leak
Although VATS resulted in less adhesion to the chest wall than thoracotomy (54 vs. 100%), but there was no difference in mediastinal or interlobar adhesion.
Tanaka K, et al. (2010)

3. Introduction
Single-port VATS (SP-VATS) major lung resection is an established techniques
No article discussing about single-port approach in dealing with repeated VATS major lung resection.
To investigate the feasibility of single-port approach in repeated VATS major lung resection

4. Case 55 M Cholangiocarcinoma with pulmonary metastases
s/p 3-port VATS RUL lobectomy + RLL wedge resection on 2014/12/15

5. Case Chest CT (2017/01/12) 2 new nodules LUL: 0.85cm, peripheral
RLL: 3.1cm, central

6. Operation
Single-port VATS RLL basal segmentectomy + LUL wedge resection
Via previous 3rd ICS incision, 4cm
Operation time: 4 h 20m (total)
Blood loss: 300mL

7. Patients SP-VATS anatomical pulmonary resection in NCKUH
Prospective data collection since starting the SP-VATS
Lobectomy, segmentectomy
March 30th, 2015 to Feb 28th, 2017
290 operations
276 primary surgery, 14 repeated surgery

8. Repeated SP-VATS group
Suspect metastasis: 13/14 (93%)
1st operation: wedge:12(86%), segmentectomy: 1, lobectomy: 1
2nd operation: segmentectomy: 9 (64%), lobectomy: 5
OP time: 2h 56m (1h – 5h 5m) Blood loss: 150mL (0 – 750mL)
Significant adhesion: 7/14 (50%)

9. Patients SP-VATS anatomical resection in NCKUH (2015.04 – 2017.02)
Infectious disease, N=47
Double anatomical resection, N=11
Primary SP-VATS
N=222
Repeated SP-VATS
N=14

10. Repeated vs. Primary - Demographic characteristics
Table. Comparison between patients with repeated and primary VATS major lung resection
Repeated SP-VATS
(n=14)
Primary SP-VATS
(n=222)
p-value
Age (years)
57.3 ± 13.2 (26 – 76)
62.3 ± 10.6 ( )
0.089
Gender (male, %)
7 (50)
92 (41.4)
0.583
Bilateral surgery (n, %)
1 (7.1)
4 (1.8)
0.265
Combined procedure (n, %) 1 2
5 (35.7)
2 (14.3)
20 (9)
175 (78.8)
27 (12.2)
0.000
Diagnosis (n, %)
Primary lung cancer
Metastasis
Benign nodule
10 (71.4)
192 (86.5)
12 (5.4)
18 (8.1)
Resection (n, %)
Lobectomy
Simple segmentectomy
Complicated segmentectomy
3 (21.4)
6 (42.9)
102 (45.9)
33 (14.9)
87 (39.2)
0.697

11. Repeated vs. Primary – Peri-operative factors
Table. Comparison between patients with repeated and primary VATS major lung resection
Repeated SP-VATS
(n=14)
Primary SP-VATS
(n=222)
p-value
Operation time, mean (minutes)
177 ± 72 (60 – 305)
177 ± 58 ( )
0.957
Estimated blood loss, mean (mL)
150 ± 211 ( )
115 ± 228 ( )
0.575
Fissure adhesion/fusion (n, %)
7 (50.0)
48 (21.6)
0.023
Pleural adhesion (n, %)
5 (35.7)
18 (8.1)
0.006
Intra-operative complication (n, %)
2 (14.3)
20 (9)
0.626
Conversion (n, %)
2 (0.9)
1.000
Post-operative complication (n, %)
24 (10.8)
0.657
Chest tube drainage, median (days)
2 (2 – 25)
2 (1 - 31)
0.789
Postoperative stay, median (days)
3.5 (3 – 26)
4 (2 - 33)
0.665
30-day mortality (n, %)
1 (0.5)

12. Results
Higher proportion of significant adhesion/fussion in the fissure (50 vs.21.6%) and in the pleural space (35.7% vs. 8.1%) in repeated SP-VATS group
No increased in intra-operative vascular injury, conversion or post-operative complication rate
No difference in duration of pleural drainage and post-op hospital stay

13. Limitation Retrospective study Small size in repeated VATS group
Prospective data collection
Small size in repeated VATS group
Heterogeneity in operation
Selection bias
Single institute
Different operator, different experience

14. Conclusion
VATS pulmonary resection causes significant fissure and pleural adhesion when redoing the VATS lung resection
Careful management of such adhesion to complete major lung resection by single-port VATS approach yields comparable perioperative outcomes
Single-port VATS approach is a feasible method for major lung resection in repeated VATS lung resection.

15. 謝謝各位