| Background and Purpose:Since it emerged in the early 1990s,the Video-assisted Thoracic Surgery(VATS)pulmonary lobectomy and systematic mediastinal lymph node dissection has long been written into the guidelines for the treatment of the early stage lung cancer,which is the gold standard surgical method for it.With the development of minimally invasive thoracoscopy technology gradually from porous to single hole.Since Spanish professor Diego GonzalezRivas reported the first case of single-port thoracoscopic lobectomy in 2011,the Uniportal Video-assisted Thoracic Surgery(U-VATS)has become a hotspot of minimally invasive thoracic surgery.This technique is another leap forward on the basis of the traditional VATS lobectomy.Compared with the traditional VATS,the U-VATS has obvious advantages:(1)Fewer incisions.(2)The chest wall is less traumatized.(3)Postoperative pain is less severe.(4)More in line with beauty requirements.Despite its obvious advantages,it also has obvious disadvantages:(1)The U-VATS,with only one surgeon and one endoscopic operator participating in the operation and only one incision,increases the difficulty of exposing the surgical field and improves the coordination requirements of the surgeon and the assistant.(2)The limited number of the endoscopic instruments placed through one incision increases the difficulty of exposing the surgical field and performing the operation.Excessive instrument placement will increase the congestion at the incision(i.e.the single hole),which is more unfavorable to the operation.(3)There are obvious differences between the traditional VATS technique and the changes of the camera angle and the placement position of the instruments,as well as the interference between the instruments during the operation.(4)Due to individual differences and different anatomical locations,if the operation technical process is not fully considered,especially the treatment sequence and method of bronchus,pulmonary artery and pulmonary vein are inappropriate,it will increase the difficulty of the surgery.The main purpose of this research is to simulate and plan the design effect of intraoperative suspension and operation table rotation angle of the transthoracic suspensory method and the operation process through computer 3D(Three-Dimension)dynamic simulation technology,and standardize the operation process of one-way sequential lobotomy with the U-VATS by the transthoracic suspensory method,so as to make it procedural and simple.It can reduce the difficulty of operation and improve the safety and smoothness of operation.Methods:1.Preoperative 3D Guidance:Preoperative 3D computer dynamic simulation technology was used to plan and design the intraoperative process,in order to guide the intraoperative suspension,posture rotation and one-way sequential lobectomy.In other words,the thinlayer enhanced chest computed tomography(CT)scan was performed on the patient before surgery,and 3D reconstruction of the patient’s chest anatomical structure was performed using 3D reconstruction software to form a visual 3D model,so as to understand the mutual anatomical relationship and variation of hilar bronchi and pulmonary vessels in detail,and to determine the size,location and surrounding anatomical structure of the tumor.Threedimensional computer dynamic simulation technology was used to simulate the location of surgical incision,chest wall puncture point,target lung suspension point,intraoperative lung traction direction and effect,operation table rotation angle design effect,simulate the planning of the surgical process,and accurately grasp the structure and sequence of target lung resection to be dissected.Procedure one-way sequential lobectomy was performed according to preoperative simulation planning.2.Transthoracic Suspension:A 20G(Gauge)self-made transthoracic needled suspension device was used to ligation the target tissue through the chest wall,or wire or band was set,and the target tissue was suspended at an appropriate specific position on the chest wall.During the operation,the surgical field was exposed by this means to reduce the difficulty of the operation.3.Rotation of Patient Position:According to the different position of the surgical target area,the patient’s position can be changed by rotating the operating table during the operation,and the lung tissue can be kept away from the surgical target area by utilizing the dual effects of gravity and suspension to play an auxiliary role in exposing the surgical field.4.Operation Mode of Pulmonary Lobectomy:According to the principle of easy first and difficult later,the procedure of one-way sequential resection was adopted.When the interlobular artery was easily exposed,unilateral sequential lobectomy with interlobular fissure approach was used.When the interlobular artery was not easily exposed,one-way sequential lobectomy with non-interlobular fissure approach was used.Under the guidance of preoperative planning,the surgical procedures were carried out in a single direction and promoted successively to reduce frequent turnover of the target lung and keep the field of vision in the operating area in a good state.Thus,the procedure of operation can be programmed to ensure the safety and smooth operation.5.Retrospective Cohort Study:A total of 601 cases of patients who underwent the UVATS lobectomy for lung cancer in our hospital from July 2015 to July 2019 were retrospectively analyzed.Observation group:308 cases of patients who underwent the UVATS lobectomy through chest wall suspension under three-dimensional guidance;Control group:293 cases with the traditional VATS lobectomy.Surgical field exposure,surgical fluency,operative time,intraoperative blood loss,postoperative drainage,extubation time,length of hospital stay,number of lymph node dissection,VAS(Visual Analogue Scale)and postoperative complications were compared between the two groups.Results:In the observation group,308 patients underwent lobectomy and systematic mediastinal lymph node dissection by the U-VATS one-way sequential lobectomy via transthoracic suspensory method by 3D guidance.There were 2 cases of small pulmonary artery variation in the observation group,which could not be found in the 3D reconstruction model or could not be clearly displayed.The rest cases were operated according to the 3D dynamic simulation before surgery,and the accuracy of 3D simulation was 99.35%.There was no severe bleeding,rib fracture,brachial plexus injury or other serious complications caused by puncture or body position,and no surgical death.In the control group,293 patients underwent the traditional U-VATS lobectomy and systematic mediastinal lymph node dissection.No patients were transferred to thoracotomy,no serious complications occurred,and no surgical deaths occurred.There were no baseline differences in age,sex,pathological type,and tumor stage between the two groups.Compared with the control group,the exposure of operation field and operation fluency in the observation group were better than those in the control group(P<0.05),and the operation time was significantly shortened(108.83±12.53 vs.124.44±21.81)(P<0.05).The number of lymph node dissection was significantly increased(15.43±8.65 vs.13.19±7.75)(P<0.05),and the postoperative pain was less severe(VAS score 2.54±1.24 vs.2.92±1.37)(P<0.05).There were no significant differences in operative blood loss,postoperative extubation time,postoperative drainage volume and hospital stay between the two groups(P>0.05).Conclusion:Combined with the technique of the preoperative computer 3D dynamic simulation,the transthoracic procedural suspension of target tissue,the intraoperative position rotation,and the one-way stylized order lobectomy,the U-VATS pulmonary lobectomy via the transthoracic suspensory method in one-way order under the 3D guidance for the early lung cancer,compared with the traditional U-VATS lobectomy,is safer,easier to operate and more minimally invasive. |
PDF Full Text Request