La chirurgia videoassistita nella gestione dei tumori polmonari rappresenta un approccio sicuro, affidabile e riproducibile che garantisce un’eccellente sopravvivenza a lungo termine. Questo approccio è raccomandato nella gestione dei carcinomi polmonari non a piccole cellule (CPNPC) di stadio iniziale. Per gli stadi avanzati del CPNPC, alcune equipe di esperti possono realizzare un approccio videoassistito. Le asportazioni polmonari effettuate attraverso questa via obbediscono alle stesse regole di resezione della via aperta. L’anticipazione delle possibili variazioni anatomiche è essenziale, al fine di eseguire una procedura sicura e conforme alle buone pratiche oncologiche. Per fare questo, l’uso delle ricostruzioni tridimensionali (3D) della TC del torace con contrasto è uno strumento molto rilevante. La conversione in toracotomia è un ostacolo allo sviluppo di questa via da parte delle “equipe non esperte” in chirurgia videoassistita. Tuttavia, per quanto riguarda le conversioni per complicanze maggiori e incidenti emorragici intraoperatori, alcune equipe hanno riportato il ricorso a un’assistenza sistematizzata e a una check-list in caso di crisi, al fine di ottimizzare la gestione dei pazienti. Se il futuro della chirurgia sarà probabilmente aiutato e assistito dallo strumento robotico, al momento, a breve e a lungo termine, non vi sono differenze di sopravvivenza tra le vie video- e robot-assistita. Nel 2023, la via d’accesso videoassistita è giustificata nella gestione curativa moderna dei tumori polmonari ed è uno strumento complementare legittimo in un funzionamento di reparto e istituzionale. Questo articolo è un aggiornamento del precedente articolo del 2015 e si basa sulla perizia in chirurgia videoassistita della via anteriore detta di Copenhagen. Qui vengono esposti in maniera standardizzata i grandi principi delle resezioni polmonari lobari videoassistite e gli allegati forniscono ulteriori informazioni sulle tecniche, sulle indicazioni estese, sulle altre vie d’accesso videoassistite e sulla gestione delle complicanze.

Robotic-assisted thoracic surgery (RATS) is a new platform to perform minimally invasive surgery. This innovative tool has been developed to overcome surgical difficulties in video-assisted thoracic surgery (VATS) for major lung resection and advanced cases. Advantages as 3D vision, wrist instruments, ergonomics and precision are well known (Dylewski et al.) (1). However RATS, as VATS, presents some operative risks with rare but catastrophic adverse events, including vascular tear leading to potential uncontrolled hemorrhage (2,3). Because the operative surgeon works on a console located outside the operating field, RATS has radically modified teamwork and inter-professional communication (4). This may create a specific safety risk, which should be given special consideration. Cerfolio et al. (3) described the management of vascular complications during a robotic procedure using the 4P concept (Poise, Pressure, Prepare, Proximal control). However, this concept may be difficult to apply in a crisis situation such as a major vascular tear, not only for the console surgeon but also for the entire team. The stress level experienced by the surgeon is even higher than in VATS. Training in this process has become essential and should be addressed. The use of checklists and simulation-based training have been demonstrated to improve the management of major crisis in the operating room and to decrease perioperative mortality (5,6). Models of training have evolved from lifelike manikins to an entire range of systems, from synthetic models to highfidelity simulation suites. These models can be adapted to new technologies and used to train an entire surgical team. To improve safety in RATS we have to follow a complete process with checklists and crisis checklists and also acquire a perfect knowledge of human factors (5,6). To set this “safety and performance package” we have to learn and train with the entire team (7-9). Team simulation and crisis resource management (CRM) are innovative pedagogical tools but also represent a valuable evaluation method (8-11). Simulation has been described to enhance the skills of surgical teams (12). Repetitive training sessions using high-fidelity simulation models have been advocated as a promising method for building teamwork skills because they mimic low-frequency, high-risk events in a safe, learner-friendly but stressful environment (13). Recently, training sessions using a scenario of airway obstruction were demonstrated to be effective in differentiating non-technical skills (NOTECHS) between thoracic surgery learners and experts (14). In our center, we have developed a pilot simulation program in major lung resection to manage situations of Surgical Technique

Hypoxic areas are typically resistant to treatment. However, the fluorine-18-fluoroazomycin-arabinoside (FAZA) and fluorine 18 misonidazole (FMISO) tracers have never been compared in non small cell lung cancer (NSCLC). This study compares the capability of 18F-FAZA PET/CT with that of 18F-FMISO PET/CT for detecting hypoxic tumour regions in early and locally advanced NSCLC patients. We prospectively evaluated patients who underwent preoperative PET scans before surgery for localised NSCLC (i.e., fluorodeoxyglucose (FDG)-PET, FMISO-PET, and FAZA-PET). The PET data of the three tracers were compared with each other and then compared to immunohistochemical analysis (GLUT-1, CAIX, LDH-5, and HIF1-Alpha) after tumour resection. Overall, 19 patients with a mean age of 68.2 ± 8 years were included. There were 18 lesions with significant uptake (i.e., SUVmax >1.4) for the F-MISO and 17 for FAZA. The mean SUVmax was 3 (±1.4) with a mean volume of 25.8 cc (±25.8) for FMISO and 2.2 (±0.7) with a mean volume of 13.06 cc (±13.76) for FAZA. The SUVmax of F-MISO was greater than that of FAZA (p = 0.0003). The SUVmax of F-MISO shows a good correlation with that of FAZA at 0.86 (0.66–0.94). Immunohistochemical results are not correlated to hypoxia PET regardless of the staining. The two tracers show a good correlation with hypoxia, with FMISO being superior to FAZA. FMISO, therefore, remains the reference tracer for defining hypoxic volumes.

More and more data are available on the benefits of minimally invasive thoracic surgery compared to open thoracic surgery in the curative treatment of early-stage non-small cell lung cancer. However, results are conflicting, especially when video-assisted thoracoscopic surgery (VATS) is compared to robotic-assisted thoracoscopic surgery (RATS) for lobectomy. Our goal is to report the main results of recent systematic reviews and meta-analyses comparing RATS, VATS, and open surgery for lobectomy. Using PubMed database, we selected systematic reviews and meta-analyses, which compared the short-term outcomes of patients treated by RATS, VATS, or open surgery for lobectomy. In all but one of the systematic reviews, robotic lobectomy allowed similar short-term outcomes as VATS lobectomy and better short-term outcomes than open surgery. One meta-analysis by O’Sullivan et al. found that robotic lobectomy was associated with fewer adverse events (P < 0.00001) and lower 30-day mortality (P = 0.001), compared to VATS lobectomy. Robotic lobectomy could be a valid alternative to VATS and open lobectomy. Shortterm outcomes do not appear to be different between VATS and RATS cohorts, except in one recent meta-analysis, which reported the superiority of RATS compared to VATS. Without cost analysis and randomized controlled trials with long-term outcomes, no strong conclusions can be drawn.

Contexte : La simulation en santé est un outil pédagogique incontournable en formation initiale. But : Rapporter notre expérience d’implantation d’un dispositif de type Objective structured assessment of technical skills (OSATS) pour mesurer les habiletés techniques des internes de chirurgie en phase socle de notre faculté, en évaluer les qualités psychométriques préliminaires et recueillir les opinions des internes sur ce dispositif. Méthodes : Un OSATS composé de quatre puis cinq et six stations de 10 minutes chacune a été administré successivement à trois cohortes d’internes. Chaque station avait pour objectif la réalisation d’une habileté technique de base. La performance des candidats était évaluée par un observateur à l’aide d’une grille préétablie. Les moyennes des scores obtenus aux stations et la cohérence interne des scores (coefficient alpha) ont été analysées. Les besoins ressentis des internes, la validité apparente et de contenu de l’examen ont été évalués par questionnaire. Résultats : Soixante-dix neufs internes ont été évalués sur trois ans. Les performances n’étaient pas corrélées au rang aux épreuves classantes nationales [0.13 (IC95% :−0,11 ; +0,36)]. Les indices de cohérence interne se situaient entre 0,61 et 0,87. Les habiletés pour le sondage urinaire masculin et la suture cutanée étaient acquises très tôt. Les internes ont estimé que les gestes proposés à chaque station étaient réalistes. Pour 93% d’entre eux, l’enseignement par la simulation est indispensable à leur formation. Conclusion : L’implantation d’un OSATS est faisable et fournit d’importants renseignements sur les habiletés techniques des internes en chirurgie. Le développement de ce type d’outil renforcerait la place de la simulation dans la formation chirurgicale.

BACKGROUND: Spinal myxopapillary ependymoma (SP-MPE) is a subgroup of ependymomas in which after initial gross tumor resection, recurrences occur in more than half of the patients. Anaplastic transformation may also occur and contributes to intraneural and extraneural metastatic dissemination. Extraneural metastases from SP-MPE are rare and worsen the prognosis. In this situation, the noninvasive detection of recurrent somatic mutations in the circulating tumor DNA (ctDNA) from plasma is challenging. Telomerase-reverse transcriptase gene promoter (TERTp) mutation has been identified in a subset of ependymomas with aggressive behavior. CASE DESCRIPTION: We report on a patient with TERTp mutated SP-MPE presenting with an extraneural anaplastic metastatic dissemination after iterative local recurrences. From the initial SP-MPE to pleural anaplastic lesion, TERTp C228T mutation was present with allele frequency varying from 33% to 39%. Interestingly, TERTp mutation was also detected by droplet digital polymerase chain reaction in the plasma with a frequency of 2.1% at the time of pleural metastases, highlighting that ctDNA is released in plasma of patients suffering from SP-MPE with extraneural metastatic dissemination. CONCLUSIONS: Despite the rarity of this evolution, plasmatic liquid biopsy appears d useful diagnostic and follow-up tool in a subset of primary brain tumors.

In the past decade, robot-assisted thoracic surgery has become more popular in the domain of pulmonary resections (lobectomies and segmentectomies). 3D high definition vision, tremor filtering, and the 7 degrees of movement help the surgeon perform very precise and anatomical dissections indeed (1,2). Nevertheless, localizing the target lesion(s) notably in the case of lung metastases without actually palpating the lung, might prove to be a very difficult task.

Introduction. - Chylothorax is a rare cause of pleural effusion. The most common causes are iatrogenic or medical. We report an unusual and rare cause of bilateral chylothorax. Case report. - A 73-year-old woman with no past history was admitted to the emergency department for sudden onset of dyspnoea. Chest X-ray and thoracic CT scan revealed large bilateral pleural effusions. Analysis of the fluid revealed a chylothorax. The patient was treated by chest tube drainage and a fat free (medium chain triglyceride) diet. This led to drying up of the effusions and rapid discharge. Complementary imaging examinations with chest-abdomen-pelvis CT, PET CT and pelvic MRI did not reveal any underlying cause. The final diagnosis was bilateral traumatic chylothorax caused by tearing of the thoracic duct during stretching exercises. Conclusion. - Following a literature review, similar cases with the same clinical presentation were found. Combined treatment with thoracic drainage and medium chain triglyceride diet was effective in drying up the effusions. Our diagnosis was a diagnosis of exclusion. It is important to exclude a medical cause by thorough investigation. (C) 2019 SPLF. Published by Elsevier Masson SAS. All rights reserved.

BackgroundThe objective of our pilot study was to assess if three-dimensional (3D) reconstruction performed by Visible Patient™ could be helpful for the operative planning, efficiency and safety of robot-assisted segmentectomy.MethodsBetween 2014 and 2015, 3D reconstructions were provided by the Visible Patient™ online service and used for the operative planning of robotic segmentectomy. To obtain 3D reconstruction, the surgeon uploaded the anonymized computed tomography (CT) image of the patient to the secured Visible Patient™ server and then downloaded the model after completion.ResultsNine segmentectomies were performed between 2014 and 2015 using a pre-operative 3D model. All 3D reconstructions met our expectations: anatomical accuracy (bronchi, arteries, veins, tumor, and the thoracic wall with intercostal spaces), accurate delimitation of each segment in the lobe of interest, margin resection, free space rotation, portability (smartphone, tablet) and time saving technique.ConclusionsWe have shown that operative planning by 3D CT using Visible Patient™ reconstruction is useful in our practice of robot-assisted segmentectomy. The main disadvantage is the high cost. Its impact on reducing complications and improving surgical efficiency is the object of an ongoing study.

Minimally invasive sublobar anatomical resection is becoming more and more popular to manage early lung lesions. Robotic-assisted thoracic surgery (RATS) is unique in comparison with other minimally invasive techniques. Indeed, RATS is able to better integrate multiple streams of information including advanced imaging techniques, in an immersive experience at the level of the robotic console. Our aim was to describe three-dimensional (3D) imaging throughout the surgical procedure from preoperative planning to intraoperative assistance and complementary investigations such as radial endobronchial ultrasound (R-EBUS) and virtual bronchoscopy for pleural dye marking. All cases were operated using the DaVinci SystemTM. Modelisation was provided by Visible Patient™ (Strasbourg, France). Image integration in the operative field was achieved using the Tile Pro multi display input of the DaVinci console. Our experience was based on 114 robotic segmentectomies performed between January 2012 and October 2017. The clinical value of 3D imaging integration was evaluated in 2014 in a pilot study. Progressively, we have reached the conclusion that the use of such an anatomic model improves the safety and reliability of procedures. The multimodal system including 3D imaging has been used in more than 40 patients so far and demonstrated a perfect operative anatomic accuracy. Currently, we are developing an original virtual reality experience by exploring 3D imaging models at the robotic console level. The act of operating is being transformed and the surgeon now oversees a complex system that improves decision making.

Background: Thoracic surgery is currently the optimal treatment for non-small cell lung cancer (NSCLC). However, it may be responsible for numerous postoperative complications and is often used in patients with multi co morbidities. In recent years, the optimization of a patient's physical capacity before surgery has been the subject of several studies. The objective of this study was to determine whether participation in a prehabilitation program would improve outcomes after surgery and lower morbidity according to the Clavien-Dindo classification. Methods: This retrospective cohort study was performed between 1st January 2014 and 31st January 2016 at Rouen University Hospital. All adult patients with NSCLC (IIIa or <) who had pulmonary lobectomy by minimally invasive surgery and cardiopulmonary exercise testing [CPET (VO2max <= 20 mL/min/kg)] were included. Results: The cohort included 38 patients. Two groups were formed: one group with prehabilitation (n=19) and one group without prehabilitation (n=19). Four patients were not included leaving 34 patients for the final analysis. Most patients with a Clavien-Dindo grade of <= 2 had received prehabilitation compared to patients who had not received prehabilitation, respectively 17/19 vs. 8/15; P=0.0252. Patients who had received prehabilitation had fewer postoperative complications than patients who had not received prehabilitation, respectively 8/19 vs. 12/15; P=0.0382. Conclusions: We have shown that prehabilitation has a positive impact on the occurrence and severity of postoperative complications after pulmonary lobectomy by minimally invasive surgery. Further studies conducted in larger populations are warranted to confirm these results.

Background: Minimally invasive surgery of pulmonary nodules allows suboptimal palpation of the lung compared to open thoracotomy. Objective: The objective of this study was to assess endoscopic pleural dye marking using radial endobronchial ultrasound (r-EBUS) and virtual bronchoscopy to localize small peripheral lung nodules immediately before minimally invasive resection. Methods: The endoscopic procedure was performed without fluoroscopy, under general anesthesia in the operating room immediately before minimally invasive surgery. Then, 1 mL of methylene blue (0.5%) was instilled into the guide sheath, wedged in the subpleural space. Wedge resection or segmentectomy were guided by visualization of the dye on the pleural surface. Contribution of dye marking to the surgical procedure was rated by the surgeon. Results: Twenty-five nodules, including 6 ground glass opacities, were resected in 22 patients by video-assisted thoracoscopic wedge resection (n = 11) or robotic-assisted thoracoscopic surgery (10 segmentectomies and 1 wedge resection). The median greatest diameter of nodules was 8 mm. No conversion to open thoracotomy was needed. The endoscopic procedure added an average 10 min to surgical resection. The dye was visible on the pleural surface in 24 cases. Histological diagnosis and free margin resection were obtained in all cases. Median skin-to-skin operating time was 90 min for robotic segmentectomy and 40 min for video-assisted wedge resection. The same operative precision was considered impossible by the surgeon without dye marking in 21 cases. Conclusions: Dye marking using r-EBUS and virtual bronchoscopy can be easily and safely performed to localize small pulmonary nodules immediately before minimally invasive resection.

A 37-year-old patient presented with a self-limiting episode of moderate haemoptysis. Contrast-enhanced chest computed tomography showed a tortuous and dilated right bronchial artery arising from the descending aorta at the level of T6. Therapeutic angiography was attempted, but in the presence of spinal artery arising from the bronchial artery in question, selective embolization was contraindicated due to risk of spinal cord ischaemia. After a multidisciplinary meeting, it was decided to attempt surgery to ligate this pathological artery. We performed minimally invasive robot-assisted ligation of this pathological artery. The postoperative course was uneventful with good clinical and radiological outcome at 3-month follow-up. A minimally invasive approach provides a real alternative to embolization and could be a therapeutic option.

Background. - Smoking induces complications in plastic surgery, in particular wound healing Smokers; delays. Despite a 4-weeks' abstinence asking before and after surgery, some patients denied or Abdominoplasty; hid their consumption. The aim of this study was to evaluate the effectiveness of a cotininury detection test in terms of improvement in outcomes after an abdominoplasty. Material and methods. - This retrospective cohort study included patients who underwent an Heating delay; abdominoplasty with umbilical transposition and lipoaspiration. Current smokers were asked to stop Wound heating smoking 4 weeks before and after surgery. After 2013, we performed a preoperative cotininury test for patients having abdominoplasty, with a cancellation of surgery in case of positive result. We analyzed the test's effectiveness on delayed healing and on other complications. Results. - Two hundred and thirty-five patients were included; 80 were tested and 21,3% had a positive test. There was significantly less delayed healing in the "screening" group than in the "no screening": 20,3% versus 41,5% (P = 0,002). Alike, complications were significantly less frequent in the "screening" group than in the "no screening": 18,1% versus 42,3% (P < 0,001). Conclusion. - The routine use of the cotininury test in preoperative abdominoplasties significantly reduces risk of delayed healing and other serious complications. It is an objective test, which is simple, quick and non-invasive. Smoking cessation must be at least 4 weeks before and after the surgery. Following medical advice to cease smoking by the surgeon and anesthetist, referral to an appropriate tobacco-addiction specialist clinic may be helpful for the patient who has difficulty stopping smoking. (C) 2018 Elsevier Masson SAS. All rights reserved.