Glove-Finger Extraction Technique in Uniportal Video-Assisted Thoracoscopic Surgery

Introduction

Uniportal video-assisted thoracoscopic surgery (VATS) has gained popularity over the recent decade. Pioneers like Rocco et al. ¹ and Gonzalez-Rivas et al. ² introduced uniportal VATS for wedge resection and for lobectomy, including sleeve lobectomy. The scope of uniportal VATS has been broadened to include diverse surgical procedures because of its benefits, such as less pain, faster recovery, and better cosmesis in the early postoperative period. With the trend of minimal invasiveness in uniportal VATS, use of specialized instrumentation and associated devices has inevitably led to higher costs. A commercial specimen retrieval device (Ethicon ENDOPOUCH^®; Ethicon US LLC, New Jersey, USA or Covidien Endo Catch™; Medtronic, Minnesota, USA) is one of the products frequently used due to the advantages of time efficiency, convenience, and adaptation to different sizes of specimens during the operation; however, it is certainly expensive. Thus, we aimed to demonstrate the feasibility and cost effectiveness of the glove-finger technique for specimen extraction in uniportal VATS.

Materials and Methods

This study was approved by the Institutional Review Board of Kaohsiung Medical University Hospital (approval number: KMUHIRB-E(I)-20170006) and the need for informed consent was waived.

Fifty consecutive patients with peripheral lung lesions who underwent uniportal VATS wedge resection with 2-cm incisions between August 2015 and December 2016 were reviewed. Of the 50 patients, 55 specimens were collected and analyzed in terms of characteristics and lesion size by pathological examination. Glove-finger extraction technique was applied to all specimens and the detailed procedure is described as follows.

Operative technique

The uniportal VATS was performed by creating an ∼2-cm skin incision through the fifth intercostal space on the anterior axillary line (Fig. 1A). Instruments routinely used included the 3-mm grasping forceps, a ring forceps, and a 3-mm 30-degree thoracoscope (Karl Storz, Munich, Germany). We do not use a wound protector to allow more camera mobility and wider instrument manipulation, similar to the viewpoint of Gonzales-Rivas et al. ² Use of unfolded gauze to reduce disturbance of the surgical view from oozing blood was adopted when necessary, as mentioned previously. ³ Peripheral lung lesions that were considered small, relatively deeply seated, or with a ground-glass component were subjected to preoperative computed tomography-guided dye localization. Target peripheral lung lesions were all identified by visualizing the visceral pleural abnormality, dye marking, or direct finger palpation, then followed by wedge resection via an articulating Endocutter (ECHELON FLEX™ ENDOPATH^®; Ethicon US LLC).

OPEN IN VIEWER

FIG. 1.

(A) Approximately 2 cm skin incision made through the fifth intercostal space on the anterior axillary line. (B) The ring forceps is inserted into the glove-finger, which is passed into the thoracic cavity through the single incision. (C) The middle finger at its base from the surgical glove (Triflex^®; Cardinal Health, Illinois, USA) number 8. (D) Resected specimen of metastatic colorectal adenocarcinoma in cross section.

To remove the specimen, we cut the middle finger at its base from the surgical glove (Triflex^®; Cardinal Health, Illinois, USA) number 8 (Fig. 1C). The gloves used were without talcum powder coating to avoid causing adverse effects, such as adhesion formation and its potential carcinogenic effect.

The ring forceps was inserted into the glove-finger first and both were passed into the thoracic cavity through the single incision (Fig. 1B). The ring forceps was kept open to widen the glove finger's orifice (Fig. 2A). Next, the 3-mm grasping forceps was used to grasp the specimen and pack it into the glove-finger (Fig. 2B). Once the whole specimen was inside the glove, the ring forceps was retreated and the mouth of the glove-finger clamped, followed by extraction under thoracoscopic visualization (Fig. 2C, D). The extraction technique typically took 1 to 2 minutes (see Supplementary Video S1, Glove-Finger Extraction Technique in uniportal VATS; Supplementary Data are available online at www.liebertpub.com/lap).

OPEN IN VIEWER

FIG. 2.

(A) The ring forceps was kept open to widen the glove-finger's orifice. (B) The 3 mm grasping forceps was used to grasp the specimen and pack it into glove-finger. (C, D) The ring forceps was retreated and the mouth of the glove-finger was clamped, followed by extraction under thoracoscopic visualization.

Results

In our initial experience, 55 specimens were obtained through uniportal VATS wedge resection in 50 patients. There was no conversion to two-port nor three-port VATS. The study cohort composed of 28 men and 22 women, aged 58.43 ± 11.21 years. After intraoperative frozen section analysis for all 55 specimens, 24 were revealed to have primary lung cancer and subsequently underwent completion lobectomy or segmentectomy, by either single port or two-port VATS. The other 31 showed 10 pulmonary metastases (Fig. 1D showed metastatic colorectal adenocarcinoma), 9 pulmonary benign lesions, and 12 pulmonary infectious lesions, all listed in Table 1. All specimens were resected with free margins and the mean diameter of the lesions was 1.64 ± 0.59 cm. Table 2 shows the range of diameter of pulmonary lesions by pathological examination. No specimen disruption or wound contamination was present during the extraction process, and no wound infection or local recurrence occurred during the postoperative follow-up period (3–19 months).

Discussion

Jain and Sedman ⁴ were the first to use the glove-finger to extract a dissected appendix in laparoscopic appendectomy (LA). Later, Tebala ⁵ and Hennessey ⁶ described the refinement and modification of the Glove-Finger Extraction Technique in LA. Nazir et al. proposed that the glove-finger extraction technique allows clinicians to maintain an optimal standard of patient care while reducing the financial burden of the LA. ⁷ Mendoza-Sagaon et al. ⁸ also advocated the use of the glove-finger to remove the appendix in LA for its advantages of ease, safety, and inexpensiveness.

In uniportal VATS with a small incision less than or equal to 2 cm, instrument collision is frequently encountered, which increases operative time and surgeon's stress. Specialized articulating instruments, wound protectors, and commercial specimen retrieval devices were introduced to enhance the operative quality and shorten operative time. ⁹ It is obvious that financial burden is a great concern.

According to our experience in uniportal VATS wedge resection, with the routine use of the 3-mm 30-degree thoracoscope throughout the operation and good communication with the cameraman, we can still obtain space for multiple instruments manipulated together to minimize interference. Furthermore, we reduce the operative cost by using the glove-finger extraction technique. In our hospital, comparing the costs of specimen retrieval devices, one pair of surgical gloves (Triflex; Cardinal Health) merely costs US$0.3, which is significantly cheaper than the commonly used commercial devices, such as Covidien Endo Catch (Medtronic) and LapSac^® surgical tissue pouch (COOK MEDICAL, Bloomington, USA) (2 × 5 inch version), which cost US$60 and US$31.7, respectively. Also, since a wound protector (Alexis^®; Applied Medical, California, USA; US$121.3) is not used with this technique, the charges would be lowered even further.

It is worth mentioning that a pair of gloves has 2 middle fingers. If the index finger and ring finger are included, we have a total of 6 glove-fingers to extract specimens with, which is useful when multiple wedge resections have to be performed during the operation.

However, a limitation of this technique should be emphasized; specifically, that the glove-finger is not suitable for large tumors or bulky specimens that are beyond the capacity and elasticity of the glove-finger. When confronted with this situation, the glove-finger technique should be replaced by other methods. Sometimes, we pack the specimen into the “palm portion” of the glove and remove it entirely. Moreover, this often means that the skin incision has to be enlarged to avoid tumor spillage and wound contamination. Although our results are positive, this may be limited by the small sample size and the selection bias as to when to use the glove-finger technique. Based on our results, the technique causes no damage to the specimen and disruption of cancer cells if applied to patients having small peripheral lung lesions with a diameter <2 cm. With refinement of the technique and accumulation of experience, we are even able to deal with lesions between 2 to 3 cm successfully. Further studies with larger sample sizes are necessary to confirm our findings.

To the best of our knowledge, this is the first time that the glove-finger technique has been described for uniportal VATS. The technique possesses merits of availability of common thoracoscopic instruments, reduced costs, and ease of execution.

In conclusion, our glove-finger technique is feasible and cost-effective, enabling successful specimen extraction in uniportal VATS.