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Ann Thorac Surg 1998;66:1466-1467
© 1998 The Society of Thoracic Surgeons

Correspondence

Is there a need for a utility thoracotomy during VATS major lung resections?

Eduardo A. Tovar, MDa

a Department of Cardiothoracic Surgery, St. Jude Medical Center, 100 E Valencia Mesa Dr, Suite 301, Fullerton, CA 92835, USA

e-mail: etovarmd{at}aol.com

To the Editor

I read with interest the article by Iwasaki and associates [1] regarding their video-assisted thoracic surgical lung resection and mediastinal lymphadenectomy. In the abstract and the Material and Methods section of their article they contend that their two-window method employs two 2- 3-cm incisions. In their comment, however, they admit that one of their incisions needs to be at least 3 cm to extract the specimen from the chest cavity. They also state that in their last 80 patients rib retraction was kept to a minimum. I could not help imagining what it would be like to try to remove a pulmonary lobe without rib retraction and through an incision slightly larger than the one needed for a chest tube insertion (Fig 1). I reviewed the literature to establish what the quoted sizes for the utility thoracotomy were and I found out that among eight authors there were eight different sizes reported (2 to 3 cm [1], 3 to 4 cm [2], 5 cm [3], 4 to 6 cm [4], 6 cm [5], 6 to 7 cm [6], 7 cm [7], and 6 to 8 cm [8]).



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  		Fig 1. Left lower lobe extracted from chest cavity via minithoracotomy.

 
I have long maintained that it is possible to perform a major lung resection using a thoracotomy incision similar in size to a utility or access approach needed to remove the specimen (Fig 2). I must acknowledge, however, that that would not be feasible through a 3-cm incision. By the same token, I doubt that any adult pulmonary lobe would fit through it.



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  		Fig 2. Seventy-year-old patient 10 days after right pneumonectomy with mediastinal lymphadenectomy.

 
Staging is just as important as resecting when dealing with cancer of the lung. As long as a utility thoracotomy remains a necessity to maintain the integrity of the specimen while removing it, video-assisted thoracic surgical major lung resection will have to compete with minithoracotomies as the minimally invasive approach of choice.

References

  1. Iwasaki M., Kaga K., Nishiumi N., Maitani F., Inoue H. Experience with the two-windows method for mediastinal lymph node dissection in lung cancer. Ann Thorac Surg 1998;65:800-802.[Abstract/Free Full Text]
  2. Roviaro G., Varoli F., Rebuffat C., et al. Major pulmonary resections: pneumonectomies and lobectomies. Ann Thorac Surg 1993;56:779-783.[Abstract/Free Full Text]
  3. Guidicelli 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/Free Full Text]
  4. Lui H.P., Chang C.H., Lin P.J., Chang J.P., Hsieh M.J. Thoracoscopic-assisted lobectomy: Preliminary experience and results. Chest 1995;107:853-855.[Abstract/Free Full Text]
  5. Lewis R.J., Sisler G.E., Caccavale R.J. Imaged thoracic lobectomy: should it be done?. Ann Thorac Surg 1992;54:80-83.[Abstract/Free Full Text]
  6. McKenna R.J. Lobectomy by video-assisted thoracic surgery with mediastinal node sampling for lung cancer. J Thorac Cardiovasc Surg 1994;107:879-882.[Abstract/Free Full Text]
  7. Walker W.S., Carnochan F.M., Pugh G.C. Thoracoscopic pulmonary lobectomy: Early operative experience and preliminary clinical results. J Cardiovasc Surg 1993;106:1111-1117.
  8. Kirby T.J., Mack M.J., Landreneau R.J., Rice T.W. Initial experience with video-assisted thoracoscopic lobectomy. Ann Thorac Surg 1993;56:1248-1253.[Medline]



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This Article
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