Dominique Gossot1, Kenney Hong2, Lucine M. Gao2
1Institut Mutualiste Montsouris, Paris, France; 2VATS Editorial Office, AME Publishing Company.
Correspondence to: Kenney Hong. VATS Editorial Office, AME Publishing Company. Email: vats@amegroups.com.
Editor’s Note
Video-Assisted Thoracic Surgery (VATS) aims to promote the development of video-assisted thoracic surgery around the world by providing a professional platform for the sharing of experiences in video-assisted thoracic surgery between peers so that all patients may benefit. It has published a number of special series reporting the cutting-edge findings and application of video-assisted thoracic surgery in recent years, and received overwhelming responses from academic readers around the world. Our success cannot be achieved without the contribution of our distinguished guest editors. Taking this opportunity, this year VATS launched a new series, “Interviews with Guest Editors”, to highlight our active contributors. We hope to express our heartfelt gratitude for their tremendous effort and to further uncover the stories behind the special series.
The special series “New Technologies for Advanced VATS” (1) and “Video-assisted major thoracic procedures: Approaches” (2) led by Prof. Dominique Gossot (Figure 1) from Institut Mutualiste Montsouris have attracted numerous readers since they were published. The first special series was dedicated to all helpful technologies for VATS (1). The second series was about the issue of the various approached for major chest procedures (2). Hereby, we are honored to have an interview with Prof. Gossot to share his experience in thoracic surgery and his insights on this special series.
Expert Introduction
Dominique Gossot is a thoracic surgeon at the Institut Mutualiste Montsouris, a private non-profit hospital in Paris, France. He has been chairing the thoracic surgery department until recently. Five years ago, the department merged with the thoracic oncology department of the Institut Curie, a major cancer institute also located in Paris, thus creating an entity entirely dedicated to the medical and surgical treatment of intrathoracic cancers.
From the very beginning, he was interested in the development of minimally invasive thoracic surgery techniques and in the use of new technologies that could make this surgery safer and more efficient. For example, he developed a dedicated instrumentation rather than using instruments designed for other surgical specialties. Last year, the 3rd edition of his atlas "Endoscopic Major Pulmonary Resections" was published by Springer, a book considered one of the references for minimally invasive thoracic surgery. He is also the initiator of the international conference "Sublobar Resections for Lung Cancer" whose 4th edition will be held in 2023 in Paris.
Figure 1 Prof. Dominique Gossot
VATS: When did you do your first minimally invasive thoracic surgery? What are the major factors that drove you to focus on minimally invasive thoracic surgery?
Prof. Gossot: During my training as a surgeon, I had a double specialty: thoracic surgery and digestive surgery. This combination was possible at that time. I was fortunate to arrive at the end of my training at the time of the laparoscopic revolution. The first laparoscopic cholecystectomies were performed by François Dubois in our hospital. I then observed the incredible and very rapid evolution towards more and more advanced and sophisticated laparoscopic techniques. At this time, there were opponents and enthusiastic supporters of this revolution. The important thing is that there were believers. In thoracic surgery, this move toward minimally invasive surgery had only a very moderate impact at the beginning. It just led thoracic surgeons to do pleuroscopies and wedge resections. I didn't understand this gap between the two specialties and thought that if surgeons were able to conduct laparoscopic hepatectomies, it should be possible to do major lung resections thoracoscopically. I was also doing esophageal surgery at that time and we published the first series of thoracoscopic esophagectomies in 1993 in the Annals of Thoracic Surgery. What is unique about thoracic surgery, compared to other surgeries, is the strong initial opposition to these techniques. Just an example: in 2010, Anthony Yim wrote an editorial in the Annals whose title was "Video-assisted thoracic lung surgery: is there a barrier to widespread adoption?".
Words are important. It is not insignificant to note that we used to speak of laparoscopic colectomy or laparoscopic nephrectomy but of video-assisted lobectomy (not thoracoscopic). This distinction has prevented us for a long time from conceiving thoracoscopic surgery as a technique in its own right. And, in addition, it partly explains the recent success of RATS because the gain compared to a rudimentary video-assisted technique is substantial.
VATS: As a prolific academic surgeon, would you like to give us a general picture of the publications on new technologies for advanced VATS? Any topics or papers that impressed you most in the past few years?
Prof. Gossot: I couldn't name a specific paper. But I understood that our new surgery was going to be "technology-driven" because doing these procedures with conventional equipment could only allow unsatisfactory compromises in terms of safety and comfort. This is why we were interested in all the articles dealing with imaging systems or new energy technologies.
VATS: The approaches (hybrid, single-port, double-port, triple-port, robotics…) for lung surgery has evolved dramatically over time. Is there enough evidence from recent research to demonstrate which is the most optimal approach?
Prof. Gossot: The debate about single port or, in general, the number of ports is almost unworthy of surgeons. To say it abruptly, it is irrelevant. What is important is to recognize that major lung resections still have a mortality of 1 to 2% and a morbidity of 20 to 40%. Our goal should be to do everything possible to reduce the complication rate by rigorous patient selection and a meticulous technique. There are no satisfactory studies showing that single-port is better than multiple-port (and vice versa), because there are too many biases and too many postoperative pain triggers. We should never lose sight of the fact that most of our surgery is focused on cancer and that the goal is to cure patients. Just remember the title of an article published by Henrik Hansen in 2016 in the JTD "Does the number of incisions in video-assisted thoracoscopic surgery matter?" Arguing over technicalities like this is of little importance.
In our department, we use a multiport technique, either in VATS or in RATS. For thoracoscopic procedures, we are careful to use the thinnest instruments possible, i.e. 5 mm or 3 mm. Our impression, which is difficult to demonstrate, is that the impact on the chest wall of a 3 mm instrument is minimal or non-existent. On the other hand, the benefit in terms of exposure is substantial.
VATS: What do you think of the future of VATS and what should be set as a priority in future research on it?
Prof. Gossot: The priority is to understand how VATS, or indeed RATS, will fit in with non-surgical techniques such as SBRT and with new chemotherapies and immunotherapies. For example, it is conceivable that neo-adjuvant immunotherapy could make some VATS or RATS surgeries more delicate. The selection of patients and techniques will become more crucial.
VATS: Which part of the content impressed you most in the special series “New Technologies for Advanced VATS” (1) and “Video-assisted major thoracic procedures: Approaches” (2)? Compared with other similar projects, what do you think is the unique advantage of these two special series?
Prof. Gossot: In the "New Technologies for Advanced VATS" special series (1), the paper about simulation is one of the most important. This is one of the areas where we are lagging behind. A profession involving so many safety problems on the human being should be much more supported by an efficient simulation.
In the special series on “Video-assisted major thoracic procedures: Approaches” (2), all the articles seem to me to be important because they reflect the variety of techniques, each of us being convinced that we have the best technique. But the reader has to make up his own mind by choosing from each description what is best for his practice.
VATS: What kind of projects are you recently working on? How is the topic of these special series associated with some of them?
Prof. Gossot: We are continuing our efforts to develop a reliable closed-chest anatomic segmentectomy technique. Despite an experience of 1000 cases, some complex segmentectomies are still far from routine. We need to make better use of all the technologies at our disposal, such as ENB target marking, infrared imaging and 3D modeling. We are currently putting a lot of hope in mixed reality which allows us to better navigate in the 3D model. The development of endobronchial or transbronchial destruction techniques is also part of our focus.
VATS: If there is a chance to update these special series, what content do you want to moderate, and or emphasize more?
Prof. Gossot: The special series on technologies can be totally updated as they constantly evolve.
Acknowledgments
Funding: None.
Footnote
Provenance and Peer Review: This article was commissioned by the editorial office, Video-Assisted Thoracic Surgery for the series “Interviews with Outstanding Guest Editors”. The article did not undergo external peer review.
Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form. The series “Interviews with Outstanding Guest Editors” was commissioned by the editorial office without any funding or sponsorship. DG reports that he is the speaker for Medtronic and Johnson & Johnson companies and the consultant for Delacroix-Chevalier instrument manufacturer. KH and LMG report that they are full-time employees of AME Publishing Company. The authors have no other conflicts of interest to declare.
Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.
References
- New Technologies for Advanced VATS. Available online: https://vats.amegroups.com/post/view/new-technologies-for-advanced-vats
- Video-assisted major thoracic procedures: Approaches. Available online: https://vats.amegroups.com/post/view/video-assisted-major-thoracic-procedures-approaches