Decaluwe Herbert, Sokolow Youri, Deryck Frederic, Stanzi Alessia, Depypere Lieven, Moons Johnny, Van Raemdonck Dirk, De Leyn Paul
Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium Department of Clinical and Experimental Medicine, KU Leuven, Leuven, Belgium
Department of Thoracic Surgery, Hôpital Erasme, Université Libre de Bruxelles, Belgium.
Interact Cardiovasc Thorac Surg. 2015 Jul;21(1):2-7. doi: 10.1093/icvts/ivv048. Epub 2015 Mar 31.
To minimize air leak after anatomical lung resections, many video-assisted thoracic surgery (VATS) surgeons use a 'fissureless' technique, using staplers to divide the hilar bronchovascular structures first and the main part of the fissure last. We describe a cohort of 198 consecutive patients operated with an alternative fissureless technique, opening the fissure completely with staplers at an early stage of the VATS anatomical lung resection.
To open the incomplete fissure first and with staplers, a tunnel dissection is started anterior between the triangle of pulmonary veins and the parenchyma. After identification of the pulmonary artery, the anvil of a first stapler is placed on top of the artery and the anterior part of the fissure is divided. Dissection between artery and parenchyma is continued until the fissure is completely stapled. From a prospectively managed single institution database, we retrieved 405 patients scheduled for VATS anatomical resection between October 2009 and December 2014. The patients were categorized in four consecutive periods: a learning curve with the first 50 cases of VATS lobectomy technique (LC), a period of consecutive 'hilum first, fissure last' (HF), a transition group (TG) during which both techniques were used and a period of consecutive 'fissure first, hilum last' (FF).
No significant differences in operating time, frequency of prolonged air leak or hospital stay were observed between HF (n = 45) and FF (n = 198). Chest tubes were removed earlier in the FF period (6.9 vs 5.2 days, P = 0.025). Excluding the learning curve, we found 2 patients (2.8%) operated 'hilum first' with an intraoperative complication that potentially could have been avoided by a 'fissure first' technique.
By making a tunnel between the bronchovascular structures and parenchyma from anteriorly to posteriorly, one can open the fissure completely with staplers at an early stage of an anatomical lung resection. This combines the advantages of both the 'fissureless' hilum first technique and classic (open) fissure first dissection, i.e. minimal air leak and optimal anatomical overview before bronchovascular structures are divided, potentially avoiding inadvertent transections. A cohort of 198 consecutive patients operated with this alternative fissureless technique demonstrates the feasibility and non-inferiority regarding hospital stay, chest tube duration, operation time and complications in comparison with the hilum first technique.
为了尽量减少解剖性肺切除术后的漏气情况，许多电视辅助胸腔镜手术（VATS）外科医生采用“无裂技术”，即先用吻合器分离肺门支气管血管结构，最后分离裂的主要部分。我们描述了一组连续198例患者，他们接受了另一种无裂技术的手术，即在VATS解剖性肺切除的早期阶段先用吻合器完全打开裂。
为了先用吻合器打开不完全的裂，在肺静脉三角和实质之间的前方开始隧道式分离。在识别肺动脉后，将第一个吻合器的钉砧置于动脉上方，然后分离裂的前部。继续在动脉和实质之间进行分离，直到裂完全用吻合器缝合。从一个前瞻性管理的单一机构数据库中，我们检索了2009年10月至2014年12月期间计划进行VATS解剖性切除的405例患者。患者被连续分为四个时期：VATS肺叶切除技术的前50例患者的学习曲线期（LC）、连续的“先肺门，后裂”期（HF）、两种技术都使用的过渡组（TG）以及连续的“先裂，后肺门”期（FF）。
在HF组（n = 45）和FF组（n = 198）之间，在手术时间、长时间漏气频率或住院时间方面未观察到显著差异。FF期胸管拔除时间更早（6.9天对5.2天，P = 0.025）。排除学习曲线期，我们发现2例（2.8%）患者采用“先肺门”手术方式且术中出现了并发症，而这些并发症可能通过“先裂”技术避免。
通过在支气管血管结构和实质之间从前向后建立隧道，在解剖性肺切除的早期阶段可以先用吻合器完全打开裂。这结合了“无裂”先肺门技术和经典（开放）先裂分离的优点，即漏气最少且在支气管血管结构分离前有最佳的解剖视野，有可能避免意外横断。一组连续198例采用这种替代无裂技术手术的患者表明，与先肺门技术相比，在住院时间、胸管留置时间、手术时间和并发症方面具有可行性和非劣效性。
