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Techniques in Minimally Invasive Thoracic Surgery Kwhanmien Kim Seokjin Haam Hyun Koo Kim Editors 123 Techniques in Minimally Invasive Thoracic Surgery Kwhanmien Kim • Seokjin Haam Hyun Koo Kim Editors Techniques in Minimally Invasive Thoracic Surgery Editors Kwhanmien Kim Seokjin Haam Department of Thoracic and Department of Thoracic and Cardiovascular Surgery Cardiovascular Surgery Seoul National University Ajou University Hospital Bundang Hospital Suwon, Republic of Korea Seongnam, Republic of Korea Hyun Koo Kim Department of Thoracic and Cardiovascular Surgery Korea University Guro Hospital Seoul, Republic of Korea ISBN 978-981-19-2471-2 ISBN 978-981-19-2472-9 (eBook) https://doi.org/10.1007/978-981-19-2472-9 © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022 This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Singapore Pte Ltd. The registered company address is: 152 Beach Road, #21-01/04 Gateway East, Singapore 189721, Singapore Preface In Korea, video-assisted thoracic surgery (VATS) was first used to treat pneumothorax in 1992. Thereafter, VATS lobectomy was introduced in Korea in a patient with benign lung disease in 1993. The first anatomical VATS lobectomy with complete mediastinal lymph node dissection was performed on a lung cancer patient in 2003 by Kwhanmien Kim, one of the editors of this book. Since then, VATS has rapidly replaced open thoracotomies and has become the dominant procedure in Korea through the well-designed training program formulated by the Korean Association of Thoracic Surgical Oncology (KATSO). Furthermore, robot-assisted thoracic surgery (RATS) has emerged as an alternative procedure for treating esophageal cancer, mediastinal tumor, and lung cancer. The surgical techniques developed by Korean thoracic surgeons have spread globally and received recognition owing to the enthusiasm of some pioneers and well-established training programs. Techniques in Minimally Invasive Thoracic Surgery is not intended to be a textbook of thoracic surgery. Instead, this book is designed to provide readers with a wide range of sound techniques and efficient measures that have proved safe and effective in our experience. Techniques in Minimally Invasive Thoracic Surgery comprises the three most popular thoracic surgery sections: pulmonary resections, esophagectomy and thymectomy by VATS or RATS and the management of postoperative complications, and nonintubated thoracic surgery. The editors and contributors have ably met their goal of inform- ing the reader about accurate surgical principles needed to treat thoracic diseases. We would like to gratefully acknowledge the favor of authors who are members of KATSO. Without their dedication and sponsorship from KATSO, this book could not have been compiled. We hope that Techniques in Minimally Invasive Thoracic Surgery will help readers consolidate their understanding of surgical procedures and promote their technical standards to a higher level. Seongnam, Republic of Korea Kwhanmien Kim Suwon, Republic of Korea Seokjin Haam Seoul, Republic of Korea Hyun Koo Kim v Contents Part I Lung 1 Establishment of a Minimally Invasive Thoracic Surgery Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Jong Ho Cho 2 Video-Assisted Thoracic Surgery Wedge Resection for Primary Spontaneous Pneumothorax . . . . . . . . . . . . . . . . . . . . . . 9 Duk Hwan Moon, Bong Jun Kim, Wongi Woo, and Sungsoo Lee 3 Surgical Planning and the Division of the Intersegmental Plane During Thoracoscopic Segmentectomy . . . . . . . . . . . . . . . 13 Ha Eun Kim, Young Ho Yang, and Chang Young Lee 4 Video-Assisted Thoracic Surgery Lobectomy . . . . . . . . . . . . . . . 23 Hong Kwan Kim 5 Video-Assisted Thoracic Surgery Bronchial Sleeve Lobectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 Hyeong Ryul Kim 6 Video-Assisted Thoracic Surgery for Pneumonectomy . . . . . . . . 37 Seokjin Haam 7 Video-Assisted Thoracic Surgery Mediastinal Lymph Node Dissection in Lung Cancer Surgery . . . . . . . . . . . . . . . . . . . . . . . . 43 Kwhanmien Kim 8 Prevention and Management of Complications During Video- Assisted Thoracic Surgery Lung Resection and Lymph Node Dissection . . . . . . . . . . . . . . . . 49 Yong Soo Choi 9 Robot-Assisted Thoracic Surgery in Non-Small Cell Lung Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 Jun Hee Lee, Kook Nam Han, and Hyun Koo Kim vii viii Contents Part II Esophagus 10 Thoracoscopic Esophagectomy for Esophageal Cancer: Detailed Procedures and Review. . . . . . . . . . . . . . . . . . . 75 Seong Yong Park 11 Video-Assisted Thoracoscopic Surgery Intrathoracic Anastomosis Technique ─ The Extracorporeal Anastomosis Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85 Yong Won Seong 12 Robot-Assisted Thoracoscopic Esophagectomy with Total Mediastinal Lymphadenectomy: A Guide to a Systematic Approach Using the Concept of Fascial Plane Dissection . . . . . . . . . . . . . . . . . . . . . . . 95 Byung Jo Park and Dae Joon Kim 13 Totally Robotic Esophagectomy . . . . . . . . . . . . . . . . . . . . . . . . . . 105 Chang Hyun Kang 14 Management of Anastomotic Leakage . . . . . . . . . . . . . . . . . . . . . 115 Jae Hyun Jeon Part III Others 15 Video-Assisted Thoracoscopic Surgery Thymectomy: Transpleural Approach . . . . . . . . . . . . . . . . . . . . . 125 In Kyu Park 16 Video-Assisted Thoracic Surgery Thymectomy: Subxiphoid Approach . . . . . . . . . . . . . . . . . . . . . . . 131 Sukki Cho 17 Robot-Assisted Thoracic Surgery Thymectomy . . . . . . . . . . . . . . 137 Samina Park 18 Non-Conservative Management of Chylothorax . . . . . . . . . . . . . 145 Hyo Yeong Ahn and Hoseok I 19 Non-Intubated Video-Assisted Thoracic Surgery . . . . . . . . . . . . 153 Kyung Soo Kim and Won Jung Hwang Part I Lung 1 Establishment of a Minimally Invasive Thoracic Surgery Program Jong Ho Cho Abstract 1.1 I ntroduction The establishment of minimally invasive sur- In recent years, there has been a shift towards gery is a complex and difficult task. Video- video-assisted thoracic surgery (VATS) in the assisted thoracic surgery (VATS) refers to a field of thoracic surgery. VATS refers to surgery minimally invasive surgical technique that to remove lung cancer, esophageal cancer, or represents a less invasive approach to thoracic mediastinal tumors without rib cutting or ster- surgery using thoracoscopy. For lung cancer notomy, as was done in the past. In general, mini- or esophageal cancer surgery, planning and mally invasive surgery is associated with less establishing a team for minimally invasive pain, shorter hospital stays, and fewer complica- surgery for the first time is not a simple task. tions [1]. It also has allowed surgeons to perform Technical advances in surgical devices and the new, complex, and conventional procedures with- enhanced skill of surgeons are cornerstones of out the major risks associated with a large open the development of minimally invasive sur- incision. gery. Here, we review the meaning of mini- VATS is just one of the first types of minimally invasive thoracic surgery and discuss mally invasive surgery. One subtype of minimally how to establish a team approach for VATS invasive surgery is robotic surgery, which offers procedures. surgeons a magnified, three-dimensional view of the surgical site with better flexibility and con- Keywords trol. We can use these advanced robotic surgical Video-assisted thoracic surgery · Minimally techniques to achieve excellent surgical out- invasive surgery · Surgery comes and safety in most cases of thoracic surgery. The technical and oncological safety of thoracoscopic surgery for early-stage lung cancer is considered acceptable worldwide [2, 3]. It has recently been reported that the majority of thoracic surgical procedures can be performed with J. H. Cho (*) minimal invasive surgery due to advances in the Department of Thoracic and Cardiovascular Surgery, development of surgical techniques, even in com- Samsung Medical Center, Sungkyunkwan University plex cases of patients with lung cancer [4]. School of Medicine, Seoul, Republic of Korea However, even with minimally invasive surgery, e-mail: [email protected] © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022 3 K. Kim et al. (eds.), Techniques in Minimally Invasive Thoracic Surgery, https://doi.org/10.1007/978-981-19-2472-9_1 4 J. H. Cho there are risks of complications involving anes- Creating a Learning Team thesia, major bleeding, and infection [5]. The surgeon as a team leader should follow the Therefore, it is important to prepare for serious up-to-date knowledge in secondary medical text- complications, such as massive bleeding from the books, quickly acquire new medical skills, share pulmonary artery during VATS, with a backup them with fellow doctors, and build a system plan always in mind [6]. while maintaining the 4 components of team works [7]. The new paradigm of health care focuses increasingly on interdisciplinary teams 1.2 H ow to Set Up an Excellent as its core unit. The increasing complexity of the Surgical Team for Minimally surgical environment has changed the delivery of Invasive Surgery surgical care and has increasingly led to the for- mation of multidisciplinary provider teams Team Approach replacing the more traditional individualistic surgeon–assistant–nurse relationship. The chal- It is unusual for patients to receive more attention lenges are considerable, even if we are already from the medical team than during surgery. faced with tight competition, especially in the Patients are prepared by 1 surgeon, 1 or 2 assis- 80-h working-week environment of surgical resi- tants, anesthesiologists, and nursing staff. Each dent programs. It may be a good strategy for sur- member of the surgical team has his or her own gical educators to collaborate with other function, but the surgical team is like playing a colleagues who have conducted training for a symphony, so each team member must collabo- certain period. rate with his or her colleagues to achieve good results. The patient’s life is in the hands of the Framing the Challenge operating team, so there can be no such thing as Properly framing the challenge is critical to our properness for its own sake in the operating success in the field of surgery. A frame challenge room. To bring the best results for the patient, is where someone answers a question in a wholly everyone must work quickly and effectively, different way that the asker never expected, but in often in desperate situations. They need to be a way that he or she feels will solve the problem. familiar with surgical procedures, how to operate The difficulty of introducing new surgical proce- machines (e.g., surgical robot systems), instru- dures places more stress on team members than ments, and surgical items, understand each other, usual for minimally invasive surgery. Surgeons trust each other, cooperate, and be considerate. A must help their team embrace and internalize the person who does not devote his or her whole legitimacy of this important new challenge heart to working as a good member of the team, regarding new surgical techniques. Even so, and who instead tries to work at his own level, identifying the right challenge for innovation is creates dissonance in teamwork, making it diffi- particularly crucial for the surgical team. cult to work together in the operating room. A surgical team includes an array of special- Creating an Environment ists who need to work in close cooperation for the of Psychological Safety That Fosters operation to succeed. A single error, miscommu- Communication and Innovation nication, or slow response can have disastrous It is important to have an environment where the consequences. To develop the best surgical team, leader’s innovation and creativity are properly we have to be the best possible leader. An excel- accepted, and team members can exchange feed- lent article on the approach to building a surgical back with each other. A belief that one will not be team approach was published in the Harvard punished or humiliated for speaking up with Business Review [7]. They presented several fac- ideas, questions, or mistakes is important for both tors for the development of a successful team, as a leader and team members. This relates to assis- described below. tants feeling empowered to express an idea or