SURGERY


Speaker: Vladimír Čan, M.D.

Topic: Clarification of the resection line non-intubated segmentectomy using indocyanine green
Can V 1, Frola L4, Hudacek K2, Ivicic J1, Kalis V2, Kodytkova A1, Mitas L1, Moravcik P1, Rybnickova S3, Skrivanova K1, Spankova M1, Vach R2 Vomela J1, and Horvath T 1
1 – Dept. of Surgery 2 – Dept. of Anesthesiology, Resuscitation, and Intensive Care
3 – Institute of Pathology 4 – Dept. of Radiology of Masaryk Memorial Cancer Institute
Faculty Hospital Brno, Faculty of Medicine Masaryk University, Czech Republic, European Union

e-mail: Can.Vladimir@fnbrno.cz

Abstract
A reflection on the measure of fluorescence specificity of indocyanine green in non-intubated pulmonary segmentectomy.
An ICG-navigated segmentectomy was performed in a 60-year-old woman with a solitary lesion 13 mm in diameter in the posterior segment of the upper right pulmonary lobe. The operation was performed using a non-intubated thoracic surgical procedure. After cutting the segmental pulmonary artery, ICG was applied in concordance with the protocol of the ethical committee and the free and informed consent of the patient. We used ICG, specifically the commercially-available ICG pulsion from Sigma Aldrich. We applied 2ml of the solution, which contained 5 mg of ICG (0.1 mg/kg).
The ICG was excited using laser radiation from endoscopic Novadaq Pinpoint Endoscopic Fluorescence Imaging display system, system wave length 805 nm, 20 pulses/sec, output 2mW, and 75° (+ - 5°) divergence of the ray beam. The emitted ICG fluorescence was detected by a CMOS camera and visualized on a screen via video convertor of the same endoscopic system.
We were surprised to find that the visual demarcation of the segment borders using ICG fluorescence was not very sharp in any interval of the observed progression time. This posed many questions, and serve as an invitation to future tests:
1. Biological – the influence of general and local regulation of perfusion and ventilation by partial pneumothorax; presence/involvement of system circulation via bronchial artery.
2. Surgical – reflex response of pulmonary tissue and vessels to mechanical manipulation under sedation.
3. Pathological – post-inflammatory field with bronchiectasis.
4. Pharmacological – vagus nerve block, intercostal block, topic local anesthesia of visceral pleura, drug interaction with ICG, and propofol administration.
5. Technological – impact of infrared electromagnetic wave motion on the lung in the location of partial pneumothorax; high flow rate nose oxygen application.
6. Physical-chemical – fluorescence quantum yield of ICG, ICG concentration, aggregation of ICG in the solution, pH of surroundings, the dispersion of emitted light in the tissue.
7. Technical – the sequence of closing segmental pulmonary artery and segmental bronchus.
8. Particular – only one case study.
Indocyanine green fluorescence stimulated by infrared electromagnetic wave motion did not make it easier to pinpoint the intersegmental plane during non-intubated thoracic surgery in our patient. Further study is needed.


Speaker: Teodor Horvath, M.D.

Topic: Surgery - CZ cohort NITS 1804

Institution: Departmenf of Surgery, Faculty Hospital Brno, Faculty of Medicine,Masaryk University

E-mail: thahorvath@hotmail.com

Abstract
Eleven pacients were indicated to NITS since Dec. 2016 to May 2018. Twelve NITS procedures were implemented in ten patients (5F/5M). They are 2 lobectomies, 1 segmentectomy, 8 wedge resections, 1 foreign body extraction. One operation was converted on classical open thoracotomy with intubation on account of bleeding. One planned NITS operation (in 31-years old man) was impossible because of significant movement of thoracic wall immediately after introduction of propofol sedation. After double lumen intubation VATS procedure with one lung breathing the operation was quietly implemented. Particular examinations of the patient including careful clinical, exact electromyography and MRI investigation of spinal cord and brain were completely normal. Another significant movement of thoracic wall, apparent at the beginning of the procedure (in 57years old woman) retreated spotaneously in about ten minutes (?).
Postoperative conditions of the patients were surprisingly good with sufficiently reexpanded pulmonary parenchyma under water sealed drainage. Less need of nursing care and analgetics is evident. The convalescence is faster. Interdisciplinary cooperation between surgeon and anesthetist is more demanding. Highly soft surgical diction is needed during preparative phases of the operation including multiple intercostal block and vagal blockade. Physiological behaviour of the surgeon in NITS procedure is accented. The limitation of empirically allowed maximum BMI 28 is done by Czech population. It represents an invitation for future programme of NITS together with other factors such as thoracic surgery cultivation within department of general surgery, low VATS experience, and absence of Czech early detection programme. Imperative, promising and strictly accountable are these assigments in the light of currently created High Specialized Surgical Oncology Lung Centre Brno.


Speaker: Ke-Cheng Chen, M.D.
Topic: Non-Intubated Thoracoscopic Surgery: a 9-year surgical experience in
a single institution
Ke-Cheng Chen, MD, PhD, Jin-Shing Chen, MD, PhD, Ya-Jung Cheng, MD, PhD
From the Division of Thoracic Surgery, Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan; Department of Anesthesiology, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
E-mail: cskchen@gmail.com

Abstract
Non-intubated thoracoscopic surgery became more and more popular recently. Our institute performed this procedure since 2009. Avoidance of intubation, mechanical ventilation, muscle relaxants, and routine use of intraoperative intercostal blockage in these patients was reflected in less intubation-associated discomfort and immediate return to many daily life activities including eating and walking. It can be a valid alternative of single-lung ventilated thoracoscopic surgery in managing early-stage lung cancer.


Speaker: Marketa Spankova, M.D.
Topic: My touch with non-intubated thoracic surgery
Institution: Department of Surgery, Faculty Hospital Brno, Faculty of Medicine Masaryk University
E-mail:spankova.marketa@gmail.com

Abstract
Po promoci jsem se rozhodla splnit si svůj sen stát se chirurgem. Nastoupila jsem na chirurgické oddělení v menší Městské nemocnici. Postupně jsem získávala základní chirurgické návyky a zdokonalovala jsem se v operativě.
Po mateřské dovolené jsem získala místo na chirurgické klinice ve Fakultní nemocnici. Brzy po nástupu jsem dostala nabídku od Doc. MUDr. T.Horvátha být náhradním členem stáže NITS v NTUH. Následně jsem se mohla stáže plnohodnotně účastnit.
Brzy po příletu do Taipei mě uchvátila vstřícnost a pohostinnost našich Taiwanských kolegů. Po společném seznámení s místním chirurgickým a anesteziologickým týmem jsem na operačních sálech měla možnost vidět poprvé neživo non-intubační metodu a pacienta, který se po takové operaci probouzí hladce a bez bolestivého výrazu.
Také jsme měli tu čest asistovat Prof. Chenovi a dokonce jsem provedla svoji první klínovitou resekci plic. Překvapila mě obdivuhodná skromnost vedoucích kapacit Taiwanské hrudní chirurgie i souhra a jakoby souznění operujícího chirurga s anesteziologem. Pracovitý a precizně organizovaný zdravotnický personál byl vždy pozitivně naladěný i při dlouhé pracovní době. (motivace peníze nebo čínská povaha)
A to nebylo vše, při společných obědech a společenských akcích jsem se zamilovala do bohaté Taiwanské kuchyně, po které se mi stýská…
A co dál? Přes malý soubor pacientů operovaných na naší klinice NITS metodou, způsobený zejména fyziologickými odlišnostmi české populace včetně vyššího BMI, vidím možnosti rozvoje techniky směrem k uniportálním přístupům či použití ICG například k odlišení hranic segmentu určeného k resekci. Velkým přínosem by bylo také barevné označení ložiska ve spolupráci s radiologickou klinikou, případně uplatnění 3D navigačních CT systémů k lokalizaci ložisek v hloubce plicního parenchymu.
V neposlední řadě se zážitky a pocity v mé prozatím krátké chirurgické kariéře promítly také do rozhovoru s Prof. Švecem z Pedagogické fakulty a při spolupráci v týmu Půvab chirurgie..
A co z toho plyne na závěr, že někdy se vyplácí být i náhradníkem...



Speaker: Petr Moravčík M.D.

Topic: Charming Surgery

Horváth T, Švec V*, Moravčík P, Španková M. a Kala Z.

Faculty of Medicine and Faculty of Pedagogy* Masaryk University Brno

Est modus in rebus, sunt certi denique fines.
Everything in moderation, there are certain limits.

Horatius

Abstract
A reflection on
the surgical specialty. Contrary to the etymology of its name, surgery is (should or could be) a very complex matter.
Surgery is not a story of golden hands. This is of team´s heart and soul: lesser perfection in unity is better than great perfection without unity.

The DECALOGUE of SURGERY

1. HANDICRAFT





mentors

patients

colleagues

personnel -

- nursing, non-medical, and service

subordinates

superiors

students

supporters

rivals

haters

2. RULES

3. GROWTH

4. VARIATIONS

5. CREATIVITY

6. MASTERY

7. TEAMWORK

8. COLLABORATION

9. SERVICE

10. FULFILMENT

 

In addition to the relationships between surgeon and patient and vice versa, mentor and disciple and vice versa, between colleagues, superiors and subordinates, nurses, non-medical and service personnel, also take a look at relationships with supporters, rivals and haters in all the full diversity of life. With this approach to the decalogue of surgery, its every part is in continual interaction - internal and external – with all the others.
The v
alues of this prism are seen by every subject attracted by its charm from a different point of view until, in their sum, the beauty of the whole truth shines. In each link listed in this article, it is possible to reach immense depths. It depends on all of us.