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Ann Thorac Surg 1998;66:303-304
© 1998 The Society of Thoracic Surgeons

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Correspondence

Is it justified to ignore oncologic principles during VATS major lung resections?

^a Department of General Thoracic and Vascular Surgery, University of Parma, Via Gramsci, 14, 43100 Parma, Italy

e-mail: lspaggia{at}ieo.it

To the Editor

We read with interest the article by Lewis and colleagues [1] concerning their experience with one hundred consecutive simultaneously stapled lobectomies without rib spreading.

Apart from problems regarding technical aspects of this procedure, widely discussed and criticized elsewhere [2], we would like to focus on some important oncologic considerations arising from the article. Lewis and colleagues reported they operated with this technique on malignant lesions of different size, including tumors as large as 5 cm (n = 11 patients), 6 cm (n = 2 patients), and 8 cm in diameter (n = 2 patients). They underlined that large tumors can be removed from the pleural cavity through the trocar ports after division in thin sections within a plastic sleeve in the chest; this with the only rationale to definitely avoid any rib spreading at the end of the procedure to remove the surgical specimen.

In our opinion this strategy suggests two important oncological considerations. First, the section of the tumor and its fragmentation in little pieces inside the chest, even in a plastic bag, violate the cardinal oncologic principle of "en-bloc" resection for lung cancer without opening the malignant tissue in the pleural cavity. Second, fragmentation of specimens will make difficult the determination of the pathologic TNM stage and the assessment of other crucial prognostic factors. In fact, tumor size, visceral pleural invasion, bronchial margin infiltration, lymph node status, vascular invasion, and perineural diffusion might not be correctly evaluated, which could have an influence on correct final postsurgical pathologic examination and therefore the expected prognosis.

It is our opinion that major pulmonary resections by video-assisted thoracic surgery invariably require a utility thoracotomy to respect the oncologic principles before mentioned. According to this point of view, we have chosen as our standard approach a 5-cm muscle-sparing minithoracotomy through the auscultatory triangle with two small adjunctive incisions for the trocars. After sparing the trapezius and latissimus dorsi muscles and entering the chest, we create two small 1-cm incisions along the insertion of the intercostal muscle on the superior rib to place the upper arm of the Giudicelli rib spreader (Karl Storz, Tuttlingen, Germany) [3, 4]. This technique enables a suitable pleural cavity access without any compression of the intercostal nerve.

The entire surgical procedure is completed through the minithoracotomy, and we are used to performing the same surgical treatment as we conventionally do through a standard thoracotomy, including radical nodal dissection. Two trocar ports are used for the camera, principally used for lighting and exploring the pleural cavity, and for the Giudicelli forceps (Karl Storz), expressly created to retract the lung parenchyma during the dissection [3, 4]. The minithoracotomy is closed with a single transcostal absorbable suture (Vicryl-2; Ethicon, Somerville, NJ), and two chest tubes (28F) are positioned in the trocar access sites.

This absolutely conservative approach (Fig 1) (ie, no muscles divided or denervated, no intercostal nerve compression because of a special rib spreader, transcostal instead of pericostal suture for the closure) should provide theoretically comparable results respecting the oncologic principles that Lewis and colleagues’ technique appears to violate.

View larger version (154K): [in this window] [in a new window]   Fig 1. Result on postoperative day 21. The mini-invasive approach is evident together with the scar from the minithoracotomy and the two trocar ports.

1. Lewis R.J., Caccavale R.J., Glenn E.S., et al. One hundred video-assisted thoracic surgical simultaneously stapled lobectomies without rib spreading. Ann Thorac Surg 1997;63:1415-1422.[Abstract/Free Full Text]
2. Kirby T.J. Invited commentary to Lewis RJ, Caccavale RJ, Glenn ES, et al. One hundred video-assisted thoracic surgical simultaneously stapled lobectomies without rib spreading. Ann Thorac Surg 1997;63:1421-1422.[Free Full Text]
3. Giudicelli R., Thomas P., Lonjon T., et al. Video-assisted minithoracotomy versus muscle-sparing thoracotomy for performing lobectomy. Ann Thorac Surg 1994;58:712-718.[Abstract]
4. Giudicelli R., Thomas P., Lonjon T., et al. Major pulmonary resection by video-assisted minithoracotomy. Initial experience in 35 patients. Eur J Cardiothorac Surg 1994;8:254-258.[Abstract]

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This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Lorenzo Spaggiari Paolo Carbognani Michele Rusca Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Spaggiari, L. Articles by Rusca, M. Search for Related Content PubMed Articles by Spaggiari, L. Articles by Rusca, M.