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MMCTS (January 21, 2005). doi:10.1510/mmcts.2004.000356
Copyright © 2005 European Association for Cardio-thoracic Surgery

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Procedure


VATS lung biopsy: the uniportal technique

Gaetano Rocco*

The Price-Thomas Thoracic Unit, Directorate of Cardiothoracic Surgery, Northern General Hospital, Sheffield Teaching Hospitals, Herries Road, Sheffield, S5 7AU, UK

* Corresponding author: * Tel.: +44-114-2714950, fax: +44-114-2610350. E-mail: Gaetano.Rocco{at}btopenworld.com


   Summary
Top
 Summary
Introduction
 Surgical technique
 Results
 Discussion
 References
 
Presentation of the uniportal VATS technique for lung biopsy: through a single port incision, a videothoracoscope, a lung grasper, and a roticulating endostapler are introduced into the pleural cavity. Based on the preoperative CT findings, the target areas are addressed from a cranio-caudal perspective instead of from a lateral one. Multiple wedge resections of different sizes can be obtained and the specimens removed through the same port.

Key Words: VATS, lung biopsy


   Introduction
Top
 Summary
 Introduction
Surgical technique
 Results
 Discussion
 References
 
Although uniportal VATS is commonly used to diagnose pleural conditions presenting with pleural effusions, uniportal VATS lung wedge resections have recently been introduced in the clinical practice [1]. The single port VATS approach has been used to treat primary spontaneous pneumothoraces, resect solitary pulmonary nodules and diagnose interstitial diseases of the lung [1].


   Surgical technique
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 Summary
 Introduction
 Surgical technique
Results
 Discussion
 References
 
Under general anesthesia and via a double lumen tube, the patient is positioned in a standard lateral decubitus while the operating team is distributed in the standard fashion for a classic VATS approach (Schematic 1-1).



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  		Schematic 1 Theatre set-up for uniportal VATS pulmonary biopsy. (1) Traditional distribution of the operating team for a VATS procedure; (2) Set-up for right-sided uniportal VATS; (3) Set-up for left-sided uniportal VATS. S;ieSurgeon; A;ieAssistant; SN;ieScrub Nurse; M;ieMonitor.

 
The site of the incision is determined based on the target area selected according to the preoperative CT findings. The surgical principles of the uniportal approach are: a) the target area is approached along a sagittal plane, according to a cranio-caudal perspective; b) enough distance is allowed between the port site and the target area to avoid mutual interference of the thoracoscope and the instrumentation; c) the surgeon has to take full advantage of the laterality offered by the incision in order to avoid leverage on the uppermost rib and its intercostal nerve. After a standard antiseptic preparation, a thoracotomy line is drawn to include the planned incision site. Once the pleural cavity is entered, the surgical team distributes in a convenient fashion to approach the target area (Schematics 1-2 and 1-3). The assistant — whose main role is to ensure adequate visualization of the intraoperative field—is positioned between the operating surgeon and the scrub nurse.

For the middle lobe or the lingula, the incision is placed on the scapular line in the sixth intercostal space. For the posterior segments of the upper lobes, the incision is placed on the anterior axillary line in the fifth intercostal space. For the apical segment of the lower lobes, the so-called safety triangle — i.e., the area at the base of the hairline in the axilla usually selected for chest drain insertion (usually the fourth intercostal space in the mid-posterior axillary line) — is used.

Following pleural puncture to ensure the absence of lung parenchyma stuck to the chest wall in correspondence of the selected port site, a 2–2.5 cm incision is created extending the dissection down to the uppermost edge of the rib where the pleura is entered with a Roberts clamp (Photo 1). Enough room is created to accommodate the surgeon's index finger and the cavity explored for adhesions. A long 5 mm trocar is introduced to insert a 5 mm video thoracoscope. The trocar sleeve is then removed back on to the shaft of the videothoracoscope to avoid wasting of precious room in the intercostal space.



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  		Photo 1 Blunt dissection of the chest wall muscles down to the intercostal space.

 
The target area is identified (Photo 2) and suspended cranially with an endograsper (see MMCTSLink 10) provided with a roticulating arm (Video 1). An EndoGIA roticulator stapler (see MMCTSLink 15) is inserted lateral to the grasper (Photo 3) making sure that the roticulating head of the stapler will face upward to be positioned caudal to the grasper (Video 2). This maneuver can be facilitated by roticulating the head of the stapler outside the chest with the convexity facing cranially. At all times, the videothoracoscope will identify any instrument entering the chest and follow it to the target area through a zoom-in and zoom-out maneuver. This is crucial to avoid the frustration deriving from the acquisition of a different perspective than the one resulting from the traditional lateral three-port approach and entails close cooperation between the surgeon and the assistant, who at this point holds the thoracoscope standing on the same side as the surgeon.



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  		Photo 2 Endoscopic view of the diseased lingula.

 


Click on image to view video		 Video 1 The roticulating endograsper is positioned cranial to the selected target area. Care is taken to grasp the parenchyma distally enough to allow for deployment of the roticulating arm which in turn is crucial to obtain a complete visualization of the lung.
 


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  		Photo 3 External view of the instrumentation ensemble introduced through the single port incision.

 


Click on image to view video		 Video 2 The roticulating endostapler is introduced through the incision deep enough to position the fulcrum inside the cavity to obtain a prompt opening of the jaws. It is recommended to visualize the anvil (thinner component) at all times while operating the endostapler in the chest. The grasper has to actively ‘present’ the target area to the opened stapler by inserting one of the parenchymal edges between the jaws.
 
Depending on the parenchymal area to be biopsied and the desired size of the specimen, a 45 mm or 60 mm medium thickness (blue reload) stapler cartridge is selected (Video 3). As a rule, between two and three firings of the endostapler are needed to obtain an adequate specimen (Video 4) which is removed through the same incision as the instrument-thoracoscope ensemble either directly or using an endobag (Endo Catch — see MMCTSLink 16) inserted parallel to the thoracoscope in lieu of the endostapler. In order to ensure a firmer grasp of the specimen, the endograsper may be replaced by a long Roberts clamp (Videos 5 and 6).



Click on image to view video		 Video 3 The first firing of the endostapler is documented. The endostapler is then retracted for reloading.
 


Click on image to view video		 Video 4 Previous careful repositioning of the endograsper, the endostapler is reapplied and fired. Overlapping of the suture lines at the terminal ends is recommended for hemostasis.
 


Click on image to view video		 Video 5 The possibility of handing the lung with a long Roberts clamp introduced through the same incision is illustrated. The subsequent operative steps remain unaltered.
 


Click on image to view video		 Video 6 The final firing is applied and the specimen is ready to be removed from the chest. An endobag (Endo Catch) can be used or the specimen may be extracted directly through the same incision by removing the thoracoscope and the instruments at the same time. In the latter case, a diagnosis of cancer should have been reasonably ruled out to avoid dissemination.
 
The resection line is inspected for bleeding and air tightness (Video 7). At this point, the surgeon may decide whether to drain the pleural cavity. The chest drain is positioned at the apex under endoscopic guidance and connected to a water seal device to be replaced in the recovery room or on the ward by a flutter bag to prompt early mobilization thereby shortening the hospital stay.



Click on image to view video		 Video 7 The final result is visible. The suture lines are hemostatic.
 

   Results
Top
 Summary
 Introduction
 Surgical technique
 Results
Discussion
 References
 
The uniportal technique can be used with excellent results in terms of adequacy of the sample size, with attendant significant sensitivity, reduced morbidity and hospital stay (data from Rocco G et al., Uniportal VATS wedge biopsy in the diagnosis of interstitial lung diseases. J Thorac Cardiovasc Surg, in press). Its use has lead to an alteration of the treatment strategy for patients with interstitial lung disease in up to 70% of the cases (data from Rocco G et al., Uniportal VATS wedge biopsy in the diagnosis of interstitial lung diseases. J Thorac Cardiovasc Surg, in press). These results are in line with the current literature of VATS lung biopsy [2].


   Discussion
Top
 Summary
 Introduction
 Surgical technique
 Results
 Discussion
References
 
In the literature, the following controversial issues concerning lung biopsy are reported:

  1. Open versus VATS [3, 4].
  2. The selection of the biopsy site, the adequate specimen size and the proper technique for specimen fixation and preparation [5, 6, 7, 8].
  3. The specificity of the pulmonary biopsy and the potential for lung biopsy to alter subsequent management [5, 9].
  4. The need to often perform this procedure in patients with compromised cardiorespiratory function; accordingly, it becomes imperative to cause the least mortality and morbidity with the maximal result [10, 11].
  5. The inter-observer variability resulting from diverse expertise among radiologists and pathologists [12, 13].
  6. The issue of residual paresthesia after traditional VATS [14]. A single port should reduce the incidence of this bothersome complication by reducing the number of intercostal spaces (i.e., intercostal nerves) involved by the surgical dissection. A retrospective analysis of postoperative pain and paresthesia of standard versus uniportal VATS is currently being performed showing the superiority of the uniportal approach (unpublished data).

Taking into account these controversies, Table 1 summarizes the pros and cons of uniportal VATS lung biopsy for interstitial lung diseases.


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  		Table 1

 


   References
Top
 Summary
 Introduction
 Surgical technique
 Results
 Discussion
 References
 
  1. Rocco G, Martin-Ucar A, Passera E. Uniportal VATS wedge pulmonary resections. Ann Thorac Surg 2004;77:726–728[Abstract/Free Full Text]
  2. Chang AC, Yee J, Orringer MB, Iannettoni MD. Diagnostic thoracoscopic lung biopsy: an outpatient experience. Ann Thorac Surg 2002;74:1942–1947[Abstract/Free Full Text]
  3. Miller JD, Urschel JD, Cox G, Olak J, Young JEM, Kay JM, McDonald E. A randomized, controlled trial comparing thoracoscopy and limited thoracotomy for lung biopsy in interstitial lung disease. Ann Thorac Surg 2000;70:1647–1650[Abstract/Free Full Text]
  4. Blewett CJ, Bennett WF, Miller JD, Urschel JD. Open lung biopsy as an outpatient procedure. Ann Thorac Surg 2001;71:1113–1115[Abstract/Free Full Text]
  5. Qureshi RA, Ahmed TA, Grayson AD, Soorae AS, Drakeley MJ, Page RD. Does lung biopsy help patients with interstitial lung disease? Eur J Cardiothorac Surg 2002;21:621–626[Abstract/Free Full Text]
  6. Temes RT, Joste NE, Allen NL, Crowell RE, Dox HA, Wernly JA. The lingula is an appropriate site for lung biopsy. Ann Thorac Surg 2000;69:1016–1018[Abstract/Free Full Text]
  7. Kadokura M, Colby TV, Myers JL, Allen MS, Deschamps C, Trastek VF, Pairolero PC. Patho-logic comparison of video-assisted thoracic surgi-cal lung biopsy with traditional open lung biopsy. J Thorac Cardiovasc Surg 1995;109:494–498[Abstract/Free Full Text]
  8. Khalil N, O'Connor R. Idiopathic pulmonary fibrosis: current understanding of the patho-genesis and the status of treatment. CMAJ 2004;171:153–60[Abstract/Free Full Text]
  9. Rena O, Casadio C, Leo F, Giobbe R, Cianci R, Baldi S, Rapellino M, Maggi G. Video-thoracoscopic lung biopsy in the diagnosis of interstitial lung disease. Eur J Cardiothorac Surg 1999;16:624–627[Abstract/Free Full Text]
  10. Utz JP, Ryu JH, Douglas WW, Hartman TE, Tazelaar HD, Myers JL, Allen MS, Schroeder DR. High short-term mortality following lung biopsy for usual interstitial pneumonia. Eur Respir J 2001;17:175–179[Abstract/Free Full Text]
  11. Flabouris A, Myburgh J. The utility of open lung biopsy in patients requiring mechanical venti-lation. Chest 1999;115:811–817[Abstract/Free Full Text]
  12. Aziz ZA, Wells AU, Hansell DM, Bain GA, Copley SJ, Desai SR, Ellis SM, Gleeson FV, Grubnic S, Nicholson AG, Padley SPG, Pointon KS, Reynolds JH, Robertson RJH, Rubens MB. HRCT diagnosis of diffuse parenchymal lung disease: inter-observer variation. Thorax 2004;59:506–511[Abstract/Free Full Text]
  13. Nicholson AG, Addis BJ, Bharucha H, Clelland CA, Corrin B, Gibbs AR, Hasleton PS, Kerr KM, Ibrahim NB, Stewart S, Wallace WA, Wells AU. Inter-observer variation between pathologists in diffuse parenchymal lung disease. Thorax 2004;59:500–505[Abstract/Free Full Text]
  14. Sihoe ADL, Au SSW, Cheung ML, Chow IKL, Chu KM, Law CY, Wan M, Yim APC. Incidence of chest wall paresthesia after video-assisted thoracic surgery for primary spontaneous pneumothorax. Eur J Cardiothorac Surg 2004;25:1054–1058[Abstract/Free Full Text]


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This Article
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Right arrow Author home page(s):
Gaetano Rocco
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Google Scholar
Right arrow Articles by Rocco, G.
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Right arrow Articles by Rocco, G.
Related Collections
Right arrow Videoendoscopic lung surgery

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