Abstract Background Paraspinal tumors are rare neoplasms arising from neurogenic elements of the posterior mediastinum and surgical resection can be challenging. Here, we demonstrate feasibility and outcomes from the first European case series of combined laminectomy and video‐assisted thoracoscopic surgery (VATS) resection of thoracic neurogenic dumbbell tumors. Methods A retrospective review of all combined thoracic dumbbell tumor resections performed at our institution between March 2015 to February 2019 was undertaken. Outcomes included operative time, blood loss, length of stay and recurrence rate. Statistical analysis was performed with SPSS statistics (v26). Values are given as mean ± standard deviation and median ± interquartile range. Results Seven patients were included in the case series and there were no major complications or mortality. Mean tumor size and operative time were 66 (± 35) mm and 171 (± 63) min, respectively. Median blood loss and length of stay were 40 (± 70) ml and four (± 3) days, respectively. One patient required conversion to thoracotomy to remove a tumor of 135 mm in maximal dimension. Histology in all seven cases confirmed schwannoma. There was no disease recurrence at a maximum follow‐up of 54 months. Conclusions Our experience demonstrates favorable operative times, minimal blood loss and short length of stay when dealing with relatively large tumors compared to previous reports. Thoracotomy may be required for tumors exceeding 90 mm and chest drain removal on the operative day can facilitate early mobility and discharge. We advocate a combined, minimally invasive laminectomy and VATS resection as the gold‐standard approach for thoracic neurogenic dumbbell tumors.

Surgical intervention either by video-assisted thoracoscopic surgery (VATS) or open procedure proved its worth in reducing the incidence of recurrence in pneumothorax. However, many controversies surround the management of this common medical condition. Despite advances in knowledge and technology, chest physicians and surgeons could not be more divisive about the management of pneumothorax. There are no two thoracic surgical centres and possibly no two surgeons within the same hospital that agree on the management of the different aspects of pneumothorax. The variability in reported outcomes and the paucity of published multicentre randomised controlled trials (RCT) highlight the need for further studies investigating the best options for pneumostasis and pleurodesis. This chapter aims at discussing some of these controversies and reviews the literature at its current state of evidence.

Video-assisted thoracic surgery (VATS) is an established technique that purports less post-operative pain, early recovery and better cosmetic results compared to open thoracotomy.

Background: We set out to describe the Southampton experience with video-assisted thoracoscopic surgery (VATS) mediastinal nodal dissection. We aim to discuss our refined technique and the rationale behind it, as well as complications, caveats and trouble shooting. We describe our experience about how to avoid injury to the recurrent laryngeal nerves (RLNs). Methods: This is an observational descriptive review of the operation notes and video recordings of patients undergoing VATS mediastinal systematic nodal dissection (SND) performed during major pulmonary resections for non-small cell lung cancer (NSCLC). VATS-SND was routinely performed at the time of anatomical resection. Our SND conformed to the American College of Surgery Oncology Group (ACOSOG) Z0030 trial definition of SND. In addition, we routinely explore stations 3a, 3p, 4L and 2L. The majority of cases were performed using monopolar diathermy, but in the last 2 years this was replaced by a bipolar energy device. Knowledge about the nodal anatomy and that of the RLN was obtained by dissecting freshly embalmed human cadavers at the All India Institute of Medical Sciences. Results: Five video clips summarizing our current state of experience are presented. These include right nodal harvesting, left nodal harvesting, across midline harvesting of specific nodes, how to avoid damage to the RLN, complications and troubleshooting. Between 2007–2017, we operated on 600 patients (240 left side, 40%). Bleeding in excess of 500 mL which was directly related to SND occurred 3 times. Immediate conversion to thoracotomy was required in one case, and 2 cases required postoperative VATS re-exploration. There were three port-access site metastases, but none of the patients had nodal micrometastases. Three phrenic nerve palsies are reported, one right and two left-sided. There was no RLN palsy on the right side and 3 on the left side (1.3%). Two RLN palsies were due to thermal injury and one due to inadvertent transection of the descending vagal trunk. There was no RLN palsy attributable to energy spray after changing practice from monopolar to bipolar diathermy. The ligamentum arteriosum had to be transected in four patients without complications. Conclusions: Cumulative experience in a large throughput centre has improved the safety record of VATS comprehensive mediastinal nodal dissection. VATS allows the surgeon to access all nodal stations consistently, safely and with minimal complications. A better understanding of the RLN anatomy and the use of a bipolar energy device have contributed to the significant drop in phrenic and RLN palsies in our experience.

Objective: The aim of the study was to report the safety and efficacy of video-assisted thoracoscopic (VATS) plication of the diaphragm at our institution between 2006 and 2016. Methods: Adult patients selected on etiology and combination of investigations including plain chest x-ray, computed tomography of chest and abdomen, lung functions in supine and sitting positions, radiological/ultrasonic screening for diaphragmatic movement, and phrenic nerve conduction studies. We incorporated a triportal VATS and Endostitch device for plication, using CO2 insufflation to maximum 12mm Hg. Bilateral simultaneous plication and high-risk patients were electively admitted to intensive therapy unit postoperatively. Results: Thirty-five patients (24 males) had their diaphragm plicated. The mean age was 56.6 years (range = 23-76 years). The mean body mass index was 32.1 (range = 22.2-45.4). Twenty one were right, 13 left, 2 patients had VATS simultaneous bilateral plication, and 1 had sequential VATS bilateral plication. Paralysis was idiopathic in 17, posttraumatic in 5, postremoval of mediastinal tumor in 4, and postcardiac surgery in 3. All patients presented with lifestyle-limiting dyspnea and orthopnea, three were on nocturnal noninvasive ventilation. Five were diabetic and 16 were smokers. The mean supine forced expiratory volume in the first second was 62.5% of predicted. Twenty twowere performed by VATS (63%), three converted to thoracotomy, and 13 were open limited thoracotomy (historic). The mean hospital stay was 4.5 days (range = 1-18, mode 2 days). Intensive therapy unit admission was required in six patients for mechanical ventilation 0 to 3 days. Five patients (14%) had no improvement in symptoms. Therewere no deaths, no 30-day readmissions, and no long-term neuralgia in this series. Conclusions: We found minimal access VATS plication of the diaphragmto be feasible and safe, but no firm conclusions should be drawn from our limited resources. We report the feasibility of concomitant bilateral VATS plication of the diaphragm in two adults, and this was not previously reported in the adult population. There is a need for further good quality, prospective studies, and randomized controlled studies evaluating efficacy of VATS diaphragmatic plication.

The aim of this publication is to touch on selective examples of novel accesses to the chest, which are more minimal than the conventional triportal, or Robotic surgery. Thoracic surgery has moved quickly from open thoracotomy to video assisted thoracoscopic surgery (VATS) to robotic assisted thoracoscopic surgery (RATS) in less than 20 years. Making minimal invasive surgery more minimal is driven by many factors such as improved patient experience, cosmesis and industry opportunities. Some of these approaches will die a natural death; others will be a major milestone for future developments. Whereas it is easy to be skeptical and critical about new approaches, we are reminded how we felt about thoracotomy when we started a VATS programme. Therefore, new approaches should be seriously studied and peer reviewed, at the behest of them becoming fully adopted and recognized as standard by the generations to come.

Congenital diaphragmatic hernias (CDH) are likely to present in early postnatal or infancy and are associated with significant morbidity and mortality due to associated pulmonary hypoplasia, pulmonary hypertension and heart failure. Symptomatic adult congenital Bochdalek hernia, on the other hand, is extremely rare with a prevalence of 0.17-6% of all diaphragmatic hernias. They present with recurrent abdominal pain and shortness of breath. Acute presentations could be life threatening especially if there is incarcerated or threatened bowel in the chest. Repair of symptomatic Bochdalek hernia is recommended in the adult population. We present two cases of right and left symptomatic Bochdalek hernias in adults, encountered over 15 years of practice in a tertiary referral centre in the UK. We discuss their presentation and surgical management and review the literature of similar cases treated by video-assisted thoracoscopic surgery (VATS). Thoracic surgeons are increasingly becoming involved in these cases, which used to be the domain of upper gastrointestinal surgeons. A synthetic patch may be required to close the defect, therefore; the thoracic surgeon must be familiar with such techniques. The recent expansion in video format publishing in the internet and social media has revolutionized the way knowledge and how-to-do-it expertise is distributed around the world. It has the advantage of reaching far more viewer than subscription paper-printed format journals and has a rising significance in encouraging thoracic surgeons to do things they were not used to do. Finally; Symptomatic Bochdalek hernia, and possibly Morgagni hernia in the adult population could be safely repaired by VATS with good and lasting results.

Influenza A virus causes considerable morbidity and mortality largely because of a lack of effective antiviral drugs. Viral neuraminidase inhibitors, which inhibit viral release from the infected cell, are currently the only approved drugs for influenza, but have recently been shown to be less effective than previously thought. Growing resistance to therapies that target viral proteins has led to increased urgency in the search for novel anti-influenza compounds. However, discovery and development of new drugs have been restricted because of differences in susceptibility to influenza between animal models and humans and a lack of translation between cell culture and in vivo measures of efficacy. To circumvent these limitations, we developed an experimental approach based on ex vivo infection of human bronchial tissue explants and optimized a method of flow cytometric analysis to directly quantify infection rates in bronchial epithelial tissues. This allowed testing of the effectiveness of TVB024, a vATPase inhibitor that inhibits viral replication rather than virus release, and to compare efficacy with the current frontline neuraminidase inhibitor, oseltamivir. The study showed that the vATPase inhibitor completely abrogated epithelial cell infection, virus shedding, and the associated induction of proinflammatory mediators, whereas oseltamivir was only partially effective at reducing these mediators and ineffective against innate responses. We propose, therefore, that this explant model could be used to predict the efficacy of novel anti-influenza compounds targeting diverse stages of the viral replication cycle, thereby complementing animal models and facilitating progression of new drugs into clinical trials.

Background: To report the first series of video-assisted thoracoscopic surgery (VATS) resection of mediastinal ectopic parathyroid adenomas (MEPAs) in the UK. Methods: A case series of seven cases undergoing VATS between 2004 and 2009 to treat single gland hyperparathyroidism. Methylene blue (MB) was used in 5/7 cases immediately before exploration to identify the adenomas. Carbon dioxide (CO 2 ) up to pressures of 10 mmHg was used safely to deflate the lung in two cases. Results: There were five women and two men with a mean age of 53 years (range, 27-72 years). Histopathology confirmed successful resection of the parathyroid adenoma in 6/7 cases. There was one conversion to open thoracotomy due to bleeding from the azygos vein resulting from excessive traction. Despite marked MB uptake, this patient proved to have tuberculoid adenopathy and no parathyroid tissue was identified. Postoperative plasma calcium returned to normal in 6/7 patients and parathyroid hormone (PTH) level in 6/7 patients. The median hospital stay was 2 days and there was no mortality in this series. Conclusions: MEPAs can be safely resected using VATS with minimal surgical morbidity, short drainage time and short hospital stay. CO 2 insufflation and the intraoperative use of MB are safe and help to accurately localise the ectopic adenoma. VATS should be considered as the first-line approach for resection of MEPAs.

The aim of this case report is to raise awareness about the use of 3-Dimentional Computed Tomography (3D-CT) virtual reality imaging as a routine pre-operative tool for evaluation of unusual anatomy such as Situs Inversus Totalis (SIT). We present a case of presumed lung cancer in a 58 years old lady with SIT successfully treated by VATS lobectomy via an anterior approach. She presented with an incidental solitary pulmonary nodule in her right lower lobe, which had moderate FDG uptake on the PET scan. The nodule was too deep to permit safe wedge biopsy, due to proximity of a large pulmonary arterial branch. 3D-CT images were invaluable in pre-operative assessment of the anatomy and were the key to safe completion of right VATS lower lobectomy. Sectioning the lung after retrieval of the specimen suggested a chondroid hamartoma; therefore, systemic nodal dissection (SND) was not contemplated. The final histology confirmed the diagnosis of chondroid hamartoma. In an unusual anatomy such as SIT, 3D-CT allows construction of virtual reality models that can be viewed and manipulated before and during the operation to understand the anatomy better, highlight caveats around target structures and enable localisation of lesions unlikely to be palpated intra-operatively.

OBJECTIVES:Video-assisted thoracoscopic surgery (VATS) for thymoma has uncertain safety and effectiveness in comparison with trans-sternal resection. This feasibility study compared short- and mid-term outcomes for patients undergoing these two procedures, highlights weaknesses in current research and makes recommendations for long-term technological evaluations in this field.METHODS:Consecutive thymoma cases between 2004 and 2010 were identified. Patients were divided into two groups according to surgical approach (Group I trans-sternal; Group II VATS) and comparisons were made between groups. The primary outcome was overall survival. Secondary outcomes included operative morbidity and mortality, hospital stay, recurrence rate and disease-free survival.RESULTS:Thirty-nine patients were included (Group I: n = 22 vs Group II: n = 17). There were no differences between groups at baseline for all measured covariates. No deaths occurred within 30 days of surgery. More patients in Group I developed complications (Group I: n = 10 vs Group II: n = 3; P = 0.093), while hospital stay was shorter in Group II (Group I: 6.4 ± 4.6 days vs Group II: 4.4 ± 1.8 days; P = 0.030). Five-year overall survival (Group I: 93.8 ± 6.1% vs Group II: 83.3 ± 11.2%; P = 0.425), 5-year disease-free survival (Group I: 71.0 ± 15.3% vs Group II: 83.3 ± 11.2%; P = 0.827) and recurrence rates at final follow-up (Group I: n = 2 vs Group II: n = 1; P = 0.363) were similar between the groups.CONCLUSION:VATS thymectomy for thymoma is feasible, safe and has comparable mid-term oncological outcomes to trans-sternal thymectomy. Future research is required to evaluate long-term oncological outcomes of VATS thymectomy for thymoma in national registries and randomized, controlled trials.

Influenza A causes considerable morbidity and mortality. Growing viral resistance to therapeutics that target viral proteins, such as neuraminidase and M2-channel inhibitors, has led to increased interest in anti-viral compounds with effects on host-cell mechanisms. We report a novel experimental approach that circumvents the inter-species differences in immune responses to respiratory viruses which limit the value of animal models for the development of anti-viral drugs that target host defences. Using genome-wide siRNA screening in the A549 human epithelial cell line, we first identified vacuolar ATPases (vATPases) as a key host mechanism for influenza infection. A specific vATPase inhibitor was found markedly to attenuate influenza-A infection in monolayer cultures. We next developed a human lung explant model to test the effectiveness of the vATPase inhibitor when compared with the current frontline anti-influenza therapeutic, oseltamivir. Using flow cytometry in conjunction with anti-viral nucleoprotein antibody applied to collagenase-dispersed bronchial and lung parenchymal tissues, infection was localised to epithelial cells and macrophages. The vATPase inhibitor completely inhibited epithelial cell infection, virus shedding and the associated induction of pro-inflammatory cytokines/chemokines, whereas oseltamivir was only partially effective. This study, therefore, demonstrates the value of the human lung explant model for pre-clinical development of anti-viral therapeutics.