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Ann Thorac Surg 1998;66:1155-1158
© 1998 The Society of Thoracic Surgeons
a Division of Cardiothoracic Surgery, Prince of Wales Hospital, Hong Kong, China
b Department of Thoracic Surgery, Allegheny General Hospital, Pittsburgh, Pennsylvania, USA
Accepted for publication April 30, 1998.
Address reprint requests to Dr Yim, Division of Cardiothoracic Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, NT, Hong Kong, SAR, China
e-mail: (yimap{at}cuhk.edu.hk)
Abstract
Background. Few surgeons worldwide currently perform video-assisted thoracoscopic (VAT) lobectomy. We conducted a questionnaire survey of this selected group of surgeons to gain insight into their current practice.
Methods. A survey with 25 questions on VAT lobectomy including operative approaches, techniques, its role in their practice, and limitations were mailed to 45 thoracic surgeons worldwide who are believed to perform this operation.
Results. Thirty-three completed questionnaires were analyzed. Among those surgeons practicing VAT lobectomy, the vast majority work in an academic or government institution and have at least 5 years of practice experience. Two thirds reported that at least 40% of all their thoracic procedures are currently performed using VAT techniques. However, considerable variations exist regarding preference for VAT lobectomy (one third uses VAT techniques in less than 10% of all lobectomies performed, whereas another third uses it in more than 40% of lobectomies), their approaches to mediastinal and hilar lymph nodes, and their operative techniques. The latter range from a purely endoscopic technique to one that is more appropriately termed minithoracotomy with video-assistance when the surgeons operate primarily by looking through the utility thoracotomy. There were no significant differences in the practices of surgeons working in different continents, except that Asian surgeons were more likely to use suture ligation as opposed to a staple-cutter on pulmonary vessels.
Conclusions. Video-assisted thoracoscopic lobectomy is not a unified approach. Considerable variations exist among the small group of surgeons performing this procedure, in their approach to surgical oncology as well as the operative technique. Distinctions in these different operative approaches must be made before one can make a meaningful comparison of results. Different terms should probably be introduced to further clarify the exact techniques used.
Although video-assisted thoracic surgery (VATS) has been shown to be safe and effective in the management of a variety of thoracic conditions [1], its application in major lung resection remains controversial [2]. Among surgeons performing VATS, only a few use this approach for lobectomy. To gain better insight into the practice of VATS lobectomy worldwide and to attempt to better define its current role in thoracic surgery, we conducted a questionnaire survey of a selected group of thoracic surgeons who are believed to practice video-assisted thoracoscopic lobectomy. Their response to this survey forms the basis of this report.
Material and methods
The questionnaire consisted of 25 questions on the demographics and opinions of thoracic surgeons on video-assisted thoracoscopic lobectomy including operative approaches and techniques, the role of their practice, and limitations. The questionnaires were mailed to 45 thoracic surgeons worldwide who are believed to practice video-assisted thoracoscopic lobectomy, because of either their publications or personal knowledge of the authors. Responses were entered on a spreadsheet format. Statistical analysis was performed using Statistical Package for the Social Sciences (SPSS Inc, Chicago, IL).
Results
Of the 45 questionnaires mailed, 42 (93.3%) were completed and returned. Nine respondents replied that they do not or no longer perform VATS lobectomy, and these were excluded from further study. Of the remaining 33, 16 (48.4%) were from North America, 10 (30.3%) from Asia, 5 (15.1%) from Europe, 1 (3.0%) from South America, and 1 (3.0%) from Australia.
Role of VATS in their practice
The majority of surgeons (78.8%) surveyed practice in an academic or government institution, whereas 21.2% work in a largely private practice setting. A total of 57.6% have a thoracic residency training program in their hospitals. Of the respondents, 84.8% have at least 5 years of practice experience and 24.2% have more than 20 years experience. A total of 78.8% declared that their practice is predominantly or exclusively noncardiac thoracic surgery in nature. The percent distribution of all thoracic procedures and major lung resections being performed using VATS is detailed in Figures 1 and 2, with two thirds reporting that at least 40 % of their thoracic procedures are performed by VATS (Fig 1). One third of the surgeons surveyed use VATS in less than 10% of all lobectomies performed, whereas another one third use this in more than 40% (Fig 2); 54.5% responded that there has been little change in the proportion of lobectomies being performed with VATS over the years, whereas one third said there has been an increase and 12.1% reported a decrease.
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Operative technique
The respondents’ preferences for using a rib spreader, and the position and size of the utility thoracotomy are detailed in Figures 3 through 5. There is considerable variation in their use of a rib spreader (Fig 3). The vast majority (63.6%) use a utility thoracotomy in the anterolateral position (Fig 4). A total of 54.5% described their operative technique as primarily endoscopic (ie, they operate through watching the video monitor); 9.1% primarily operate by looking through the utility thoracotomy; whereas 36.4% use a combination of these techniques in about equal proportion. The vast majority (84.8%) use the individual ligation technique of pulmonary vessels and bronchus, whereas 15.2% simultaneously use a stapling technique [3]. The pulmonary vessels are staple transected in 66.7% and divided between suture ligatures in 18.2%, whereas 15.1% use a combination of techniques for the pulmonary vessels. The surgeons’ preferences for flexing the operating table on positioning [4], use of the retrieval bag for the specimen, use of intercostal nerve block, and use of epidural analgesia are shown in Table 1. There was no significant difference in response from surgeons who practice in different continents, except that Asian surgeons are more likely to use suture ligation (as opposed to a staple-cutter) on pulmonary vessels [5].
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In less than a decade, VATS has been embraced by the thoracic community as an acceptable, sometimes preferred approach to the management of a wide variety of thoracic conditions. The application of thoracoscopic technique, to complicated procedures such as lobectomy, however, remains controversial. In a recently published survey conducted in North America, 81% of the respondents considered VATS lobectomy to be investigational or unacceptable [2].
There is much concern within the thoracic community, even among surgeons practicing VATS, about using this approach for major lung resection. Anatomic dissection performed through a minithoracotomy in an essentially closed chest raised questions about the safety of the technique; resection for intrathoracic malignancy casts doubt on adequate clearance; the long-term benefits of VATS over conventional thoracotomy approach are uncertain [6, 7]; and the high cost of the consumables and endoscopic equipment questions the cost-effectiveness of this approach in the current era of cost containment [8]. Nonetheless, there is a relatively small group of enthusiastic surgeons worldwide practicing VATS lobectomy. Our survey was therefore conducted on a highly selected group.
There are several points worth discussing. First, in this survey, the majority (66.7%) reported that at least 40% of their thoracic procedures are currently approached with VATS (Fig 1). This is in sharp contrast with the survey by Mack and colleagues [2] on the General Thoracic Surgery Club members, most of whom practice in North America, and in whom the majority (60.2%) used VATS in 20% or less of all thoracic cases. This difference may be explained by the high selectivity of surgeons in the current survey. The time lag may be an additional factor, as the survey by Mack and colleagues was conducted 2 years before ours. This may represent an increased acceptance of the VATS approach with time and experience.
Second, considerable variations exist in the surgeons’ approach to mediastinal and hilar lymph nodes and their preference for mediastinoscopy, for sampling nodes before resection, for sampling mediastinal nodes, or performing mediastinal lymphadenectomy after resection. However, this reflects the individual surgeon’s approach to oncology more than the exact surgical approach [9].
Third, considerable variations in operative techniques exist among surgeons. The majority surveyed use a primarily endoscopic approach, whereas a small minority operates primarily through the utility thoracotomy, with the thoracoscope serving as a light source. The latter approach is also reflected in their routine use of rib spreader (Fig 3). In addition to individual ligation, the simultaneous stapling technique is practiced by one group of surgeons, with excellent results [3]. These surgeons referred to their technique as video-assisted thoracic surgical non–rib-spreading simultaneous stapled lobectomy.
Fourth, the report of five intraoperative deaths encountered by two individual groups was worrying. It illustrates that VATS lobectomy is technically demanding and a learning curve exists. Also, specific complications exist such as port site recurrence, which was encountered by 5 of 33 surgeons (15.2%) surveyed. This underscores the importance of routine use of specimen retrieval bags (Table 1) and attention to technical details.
In conclusion, VATS lobectomy does not represent a unified approach but a spectrum of operative techniques ranging from purely endoscopic to what may be more appropriately termed "minithoracotomy with video assistance." Variation in techniques for an evolving procedure is understandable; however, a distinction in these operative techniques must be made before we can make a meaningful comparison of results. This is also relevant to publishing the collective experience from different institutions. Perhaps the term VATS lobectomy should be reserved to the predominantly endoscopic technique with little or no rib spreading, whereas the term minithoracotomy with video assistance lobectomy should be used instead when rib spreading is routine and the surgeons operate predominantly by looking directly through the minithoracotomy. The role of these techniques in thoracic surgery can be defined only by carefully designed controlled trials with long-term follow-up.
Acknowledgments
We are grateful to all the participants in this survey for their response.
References
This article has been cited by other articles:
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  J. Loscertales, R. Jimenez-Merchan, M. Congregado, F. J. Ayarra, G. Gallardo, and A. Trivino Video-Assisted Surgery for Lung Cancer. State of the Art and Personal Experience Asian Cardiovasc Thorac Ann, June 1, 2009; 17(3): 313 - 326. [Abstract] [Full Text] [PDF]
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 K. Fukuhara, A. Akashi, S. Nakane, and E. Tomita Preoperative assessment of the pulmonary artery by three-dimensional computed tomography before video-assisted thoracic surgery lobectomy Eur. J. Cardiothorac. Surg., October 1, 2008; 34(4): 875 - 877. [Abstract] [Full Text] [PDF]
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 P. Solli and L. Spaggiari Indications and Developments of Video-Assisted Thoracic Surgery in the Treatment of Lung Cancer Oncologist, October 1, 2007; 12(10): 1205 - 1214. [Abstract] [Full Text] [PDF]
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 F. C. Detterbeck Subpleural Catheter Placement for Pain Relief After Thoracoscopic Resection Ann. Thorac. Surg., April 1, 2006; 81(4): 1522 - 1523. [Abstract] [Full Text] [PDF]
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R. J. McKenna Jr, W. Houck, and C. B. Fuller Video-Assisted Thoracic Surgery Lobectomy: Experience With 1,100 Cases Ann. Thorac. Surg., February 1, 2006; 81(2): 421 - 426. [Abstract] [Full Text] [PDF]
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 T. Ohtsuka, H. Nomori, H. Horio, T. Naruke, and K. Suemasu Is Major Pulmonary Resection by Video-Assisted Thoracic Surgery an Adequate Procedure in Clinical Stage I Lung Cancer? Chest, May 1, 2004; 125(5): 1742 - 1746. [Abstract] [Full Text] [PDF]
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H. Nomori, T. Ohtsuka, H. Horio, T. Naruke, and K. Suemasu Thoracoscopic Lobectomy for Lung Cancer With a Largely Fused Fissure Chest, February 1, 2003; 123(2): 619 - 622. [Abstract] [Full Text] [PDF]
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L. J. Daniels, S. S. Balderson, M. W. Onaitis, and T. A. D'Amico Thoracoscopic lobectomy: a safe and effective strategy for patients with stage i lung cancer Ann. Thorac. Surg., September 1, 2002; 74(3): 860 - 864. [Abstract] [Full Text] [PDF]
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A. P.C. Yim VATS major pulmonary resection revisited--controversies, techniques, and results Ann. Thorac. Surg., August 1, 2002; 74(2): 615 - 623. [Abstract] [Full Text] [PDF]
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W. W. L. Li, T. W. Lee, S. S. Y. Lam, C. S. H. Ng, A. D. L. Sihoe, I. Y. P. Wan, and A. P. C. Yim Quality of Life Following Lung Cancer Resection* : Video-Assisted Thoracic Surgery vs Thoracotomy Chest, August 1, 2002; 122(2): 584 - 589. [Abstract] [Full Text] [PDF]
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L. Solaini, F. Prusciano, P. Bagioni, F. Di Francesco, and D. Basilio Poddie Video-assisted thoracic surgery major pulmonary resections. Present experience Eur. J. Cardiothorac. Surg., September 1, 2001; 20(3): 437 - 442. [Abstract] [Full Text] [PDF]
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