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Ann Thorac Surg 1995;59:6
© 1995 The Society of Thoracic Surgeons
Section of General Thoracic Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota
The reports by Fry and associates [1] and by Walsh and Nesbitt [2] dealing with the diagnosis of an indeterminate pulmonary nodule in this issue of The Annals of Thoracic Surgery describe a devastating complication from minimally invasive surgical procedures. In both cases, limitation of video-assisted thoracic surgery (VATS) led to premature deaths by widespread cancer dissemination. The mechanism of dissemination in each instance was traced to contamination of the chest wall at the time of VATS biopsy. Almost certainly the specimen was larger than the opening in the chest wall through which it was removed and it became compressed during withdrawal with subsequent seeding of malignant cells into adjacent tissues.
When VATS is used as a diagnostic procedure, common sense must prevail. Nodules that are potentially malignant should not be excessively manipulated and they should have a margin of resection of at least 1 cm. Nodules that are deep in the lung or have an ill-defined margin should not be removed by VATS but instead should be excised after conversion to an open procedure. Moreover, conversion should not be viewed as a surgical defeat to be avoided at all costs, but rather as a safer operation. In more than 750 VATS procedures done at the Mayo Clinic, we continue to have a 25% conversion rate.
Once excised, the specimen must be placed in a protective container before removal. Enlarging the incision along the length of the intercostal space without placing the specimen in a container as was done by Fry and associates is false security because the amount of compressing force is determined by the distance between ribs. Likewise, withdrawing the specimen through an anterior site because the anterior intercostal space is larger also does not protect against seeding.
Many thoracic surgeons often espouse minimally invasive surgery by asserting that their patients are too sick to tolerate an open procedure. This was the situation in the report by Walsh and Nesbitt. They claimed that limited ambulation and chronic obstructive pulmonary disease precluded an open procedure. However, 3 months after VATS the patient tolerated en bloc resection of a portion of both the right middle and lower lobes, six ribs, and diaphragm and a subsequent contralateral lobectomy without pulmonary insufficiency! For patients with compromised pulmonary function, an open procedure provides a more controllable situation, which allows careful palpation of the lung and a more accurate resection. Moreover, with modern postoperative management, mortality and morbidity can be minimal.
As Walsh and Nesbitt have suggested, using VATS with curative intent for patients with pulmonary metastases is a mistake. Several reports have demonstrated that computed tomography underestimates the extent of pulmonary metastases [3, 4]. Palpation of the lung is extremely limited with VATS; consequently, associated nodules will remain undetected and cure rates may ultimately be lower. Thoracotomy remains the procedure of choice when pulmonary metastases are resected for cure.
Video-assisted thoracic surgery is a new and exciting adjunct in the management of intrathoracic disease, the full potential of which is just now being fully realized. As the principles of VATS become better understood, morbidity and mortality associated with this procedure eventually will be recognized and ultimately reduced by determining those patients who are better managed with thoracotomy.
Footnotes
Address reprint requests to Dr Allen, Department of Surgery, Mayo Clinic, 200 First St SW, Rochester, MN 55905.
References
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