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Initial Experience of Multivision Thoracoscopic Surgery With Two Cameras

Dear Editor, Performing thoracoscopic surgery for lung diseases has become common in the past decade. However, thoracic surgery is still riskier, particularly with respect to vascular injury that could lead to critical complications during the procedure, than endoscopic surgery for other organs. This leads to various approaches for thoracoscopic surgery, such as a 2-window approach, a mirror image endoscopic method, and a 3-dimensional system. Dangerous areas for thoracic surgery are behind the organs, out of the endoscope’s view, and there is a risk of interrupted camera view by bleeding or the mist of ultrasonic devices. To address these issues, we developed a system named “dual-vision thoracoscopic surgery” using 2 cameras. This report describes how to do this procedure and its advantages for general thoracic surgery. This technique has been used for complete videoassisted thoracic surgery (cVATS) lobectomy for lung cancer. We use a type of cVATS with 1 access window (3-4 cm) and 3 ports (5.5-11.5 mm). In dual-vision VATS, 2 cameras and 3 monitors are used. The cameras are a 30° rigid scope with a 10-mm diameter and a 0° rigid scope with a 5-mm diameter, which are inserted through different ports and fixed by a camera holder without extra port or extra surgeon. Three ports and 1 access window are also used in this procedure as our standard cVATS lobectomy for either side approach. By using the cameras from 2 different directions, such as ventrally or dorsally, wide-angle and different views from the main camera are available (Supplementary Figures 1 and 2, Video 1; available online at http://sri.sagepub.com/content/by/supplemental-data). Many reports have shown advantages of VATS in general thoracic surgery. However, Gopaldas et al reported that the rate of intraoperative complication was 1.6 times higher than that of open lobectomy, based on analysis of a huge data set from the Nationwide Inpatient Sample [3]. Fournel et al also reported precise data for intraoperative complications, which could be underestimated. Kawachi et al reported that the incidence of pulmonary vessel injury in the VATS group was 4.8 times that in the thoracotomy group. Various reasons can be found for these adverse events, and one countermeasure to prevent them is to have many people view the surgical site from different angles. We proposed another approach for cVATS using multiple cameras, which view the surgical site from different angles. The advantages of this procedure are viewing the surgical site from multiple angles, viewing the thoracic cavity from a distant perspective to have a wide-angle view, and continuing the operation during cleaning of the main camera without extra surgeon. This procedure would be helpful when staplers are inserted into tunnels of a fused fissure, pulmonary artery, and pulmonary vein for stapling. When changing devices and inserting them into the cavity, it helps to avoid injury to other organs. In addition, when the main camera view is obscured by mist, blood, or fog, surgeons can continue the procedure using the auxiliary camera. These advantages help ensure that the procedure is performed safely and confidently, and may shorten operation time. No special devices, no extra ports or no extra surgeons are needed, only another camera. This approach could also be helpful to improve the quality of the operation. However, extra cost and the necessity of more stuff could be disadvantages of this procedure. This system could reduce the risk of mistakes during thoracic surgery when the view is lost with the 1-camera method and be helpful to educate immature thoracic surgeons safely.