The use of Transcollation Technology for Video-Assisted Thoracic Surgery lobectomy

All patients undergoing VATS lobectomy for lung cancer (November 2016–October 2018) were retrospectively included in this study. Exclusion criteria were: coagulative disorders, conversion to thoracotomy, previous thoracic or mediastinal surgery, intraoperative use of other hemostatic devices. Patients were divided in two groups; the TT Group with hilar and mediastinal lymphadenectomy performed using TT technology, and the TE Group using Traditional Electrocautery. The choice of using TT or TE was not randomized, however TT was routinely used from January 2018. Assessment of the operative time and surgical outcomes were the primary and secondary end-points of the study respectively. The study was approved by the Local Ethics Committee (Sapienza University of Rome, Italy. Code number: 105 SA_2016). All patients signed a written informed consent informing also that data could be anonymously used for scientific purposes. All surgical procedures were performed by surgeons with a wide expertise in VATS procedures.

All patients with NSCLC were considered as candidate for lobectomy based on standard oncological and functional criteria. Demographic data, preoperative comorbidities stratified according to the Charlson index, lung function test, histology, pathological stage, surgical approach (uniportal VATS versus tri-port VATS), procedure time (minutes), daily chest drainage amount (mL), length of chest drainage, length of hospital stay (LOHS) (days), postoperative morbidity and mortality were recorded for each patient.

The Aquamantys® Endo VS 8.7R (Medtronic, Minneapolis, MN, USA) is an instrument with double electrodes at the tip. The length of the disposable sealer provides the ability to perform thoracoscopic procedures. The hand piece is equipped with an on/off switch that simultaneously activates both RF energy and saline flow. A saline bag is connected to a pump on the device that pushes the saline through a tube to the hand piece.

Surgery was performed under general anesthesia and single-lung ventilation with the patient in the lateral decubitus position. Both the surgeon and assistant stood anteriorly facing the patient and a second assistant stood posteriorly. For uniportal VATS a single incision of approximately 4–5 cm was performed at the 5th intercostal space along the anterior axillary line, anterior to the latissimus dorsi muscle (muscle-sparing technique). In cases of triportal VATS, the procedure was performed through an anterior approach and two surgical incisions. The first surgical incision (1 cm) for the thoracoscope was performed at the 7th or 8th intercostal space along the anterior axillary line. The second incision was performed anteriorly, at the 5th intercostal space (4 cm), and was used for hilar dissection and removal of the lobe at the end of the operation. The third incision (1 cm) was performed at the 6th intercostal space along the posterior axillary line. Trocars or rib retractors were not used. A soft tissue separator was used. When uniportal VATS was performed, the video-thoracoscope (5 mm 30° optic) and multiple VATS instruments were inserted simultaneously. In order to avoid the overlap of multiple instruments that may strike the tip of the thoracoscope, and result in shaky movements on the video monitor, the scope was placed at the posterior angle of the incision. Long curved instruments were used to allow easy simultaneous insertion of two or three devices. No additional skin incisions were performed. Hilar structures were approached anteriorly following the sequence for VATS lobectomy. Mobilization of pulmonary vessels was performed using the TT device to isolate and prepare the pulmonary vein and the pulmonary artery with their branches (Fig. 1/A). Vessels were mechanically stapled individually, along with the lobar bronchus and the pulmonary fissures (ECHELON ENDOPATH, Ethicon Endo-Surgery, Norderstedt, Germany). The pulmonary artery was dissected at the hilum and within the fissure (Fig. 1/B). The fissure was stapled as a final step. Simultaneously, hilar lymph nodes (11R station) were divided and dissected using the TT device. Dissection of mediastinal lymph nodes was performed. No special caution to preserve the recurrent laryngeal nerve was needed in the dissection of the stations 4 and 3 nodes, since the TT device does not damage or char nerves. Pulmonary ligament dissection was performed with the TT device. The resected lobe was retrieved using a specimen bag (ENDOCATCH, Covidien, La Ciotat, France) through the same incision. Systematic mediastinal lymph node dissection was routinely performed. At the end of the operation, a 24 Fr chest tube was inserted at the posterior extremity of the thoracotomy. Pain management was ensured with a multilevel intercostal nerve block using ropivacaine (7.5 mg diluted in 20 ml of saline), 4 ml for each intercostal space, including the intercostal level of the incision and one level above and below. Patients received oral paracetamol (1 g 4 times per day) and oral Ketorolac (20 mg) depending on the clinical need.

Data are expressed as mean and standard deviation for quantitative variables and number and percentage for qualitative variables. Using published data [14], the mean operative time for patients undergoing VATS lobectomy was calculated to be 180 min (standard deviation: 23 min). We felt that a 20% reduction in operative time would be a clinically significant difference that might change operative management of future patients. With a power of 0.80 and alpha of 0.05, this required 21 patients in each group. Chi-square test was used to assess difference between qualitative variables while t-test calculated difference between quantitative data. A value of p < 0.05 was considered statistically significant. MedCalc® statistical software Version 12.4.0 was used for analysis.