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Ann Thorac Surg 1999;67:1808-1810
© 1999 The Society of Thoracic Surgeons

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How to Do It

Video-assisted approach for transxiphoid bilateral lung metastasectomy

^a Department of Thoracic Surgery, Tor Vergata University, Rome, Italy

Accepted for publication December 20, 1998.

Address reprint requests to Dr Mineo, Cattedra di Chirurgia Toracica, Università Tor Vergata, Ospedale S. Eugenio, P. le Umanesimo, 10, 00144 Rome, Italy
e-mail: mineo{at}utovrm.it

	Abstract

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Radical resection has proved to be the most effective treatment of lung metastases, and manual palpation is considered the most accurate method for detection of occult metastases. To allow bilateral manual palpation during video-assisted metastasectomy, we developed a transxiphoid approach without sternotomy. Twenty-one lesions were successfully resected in 6 patients without mortality or morbidity. This approach allows easy manual palpation of the lungs and facilitates bilateral video-assisted metastasectomy.

	Introduction

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Complete surgical removal has proved the most effective treatment of lung metastases when the primary tumor is controlled and there is no evidence of extrapulmonary localization [1]. This treatment often entails bilateral and iterative surgical approaches. Whatever approach is used, manual palpation of the lung is still the most accurate way to detect metastases [2]. Video-assisted thoracic surgery (VATS) has quickly been applied to the treatment of lung metastases, although the impossibility of manually palpating the lung is regarded as its major limitation in this setting [2]. We have developed a transxiphoid approach that allows bilateral manual palpation of the lung at VATS metastasectomy.

	Technique

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After double-lumen intubation, the patient is placed in the 60-degree off-center position (Fig 1). A flexible trocar (Ethicon Endo-Surgery, Pomezia, Italy) is inserted in the fourth intercostal space along the midclavicular line to verify the absence of adhesions that would contraindicate the procedure. A midtransverse arcuate skin incision extending for about 8 cm is made along the inferior margin of the rib cage. The rectus abdominis muscles are separated along the linea alba, and the xiphoid process is resected without entering the peritoneal cavity. Two other trocars are inserted in the fifth and seventh intercostal spaces along the posterior axillary and midaxillary lines, respectively.

View larger version (47K): [in this window] [in a new window]   Fig 1. (A) Position of patient and setup of surgical approach. (B) Intraoperative view showing the hand palpating the right lung and the disposition of the ports for excision of lower lobe nodules.

View larger version (46K): [in this window] [in a new window]   Fig 2. Bilateral palpation of both lungs through transxiphoid approach.

	Material and results

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Preoperative study included digital chest roentgenography, spiral computed tomography, and bone scan. Exclusion criteria were the presence of metastases deeply located in the lung parenchyma (more than 2 cm from the visceral pleura) or more than 3 cm in maximal size, history of pleuritis or pleurodesis, previous thoracic or cardiac surgical procedure, and presence of cardiomegaly or ventricular arrhythmia.

Twenty-one nodules were palpated and resected, whereas 16 had been predicted by computed tomography. Two patients had unilateral resection of two and three nodules. Of the 4 patients who had bilateral resection, 2 had unilateral nodules predicted at computed tomography. The mean size of the nodules was 1.5 cm (range, 0.3 to 3.2 cm), and a mean of 3.5 nodules (range, 2 to 6 nodules) per patient were resected. Seven nodules were located in the upper lobes (four on the right, three on the left), ten in the lower lobes (six on the right, four on the left), and four in the middle lobe. Seventeen nodules proved metastatic histologically. The mean operative time was 138 minutes (range, 100 to 160 minutes). There were no operative deaths or major morbidity. All patients were immediately extubated. The mean hospital stay was 4.6 days (range, 3 to 8 days). After a mean follow-up of 10 months (range, 5 to 28 months), there was no evidence of pulmonary relapse or subxiphoid incisional hernia.

	Comment

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Surgical resection is the standard of care for select patients with lung metastases; it produces 5-year survival rates of 21% to 68% [1]. To achieve these results, aggressive surgical management is required, which entails bilateral metastasectomy in more than 60% of patients and redo procedures in 20% [1]. Further, the frequent discovery of occult metastases at manual palpation led to the suggestion of intentional bilateral exploration [1]. Video-assisted thoracic surgery was quickly applied to the treatment of undefined pulmonary nodules including pulmonary metastases, which are often peripherally located [4, 5]. It was reasoned that a less invasive but still radical approach might be better initially, with more aggressive operations reserved for recurrence. Also, VATS is likely to result in less morbidity than open surgical intervention after adjuvant treatment. However, VATS does not permit manual palpation of the lungs [1], and a prospective study undertaken to compare it with computed tomography and open thoracotomy was prematurely closed to accrual, with VATS showing a 50% probability of missing metastases [2].

Various methods have been proposed to improve thoracoscopic localization of pulmonary nodules including instrumental or digital palpation and intraoperative ultrasonography [6]. None has proved as effective as manual palpation.

With this in mind, we developed a transxiphoid approach without sternotomy to allow manual palpation of both lungs in VATS metastasectomy. It proved feasible and safe and allowed access for palpation of all regions of the lung including the posterior segments of the left lower lobe, which are difficult to reach through a median sternotomy. Having one hand inside the thorax during VATS was also useful for presenting the lesion targeted for resection. In addition, the transxiphoid access constituted another port for staple resection of nodules difficult to manage from the usual ports and was found to be a less painful site for chest tube placement. Recognized advantages of VATS over open approaches include better visualization of all lung segments, less postoperative pain, shorter hospital stay, and easier patient acceptance of the procedure. Nonetheless, diffuse adhesions and large or deeply located lesions are contraindications to VATS.

In conclusion, this transxiphoid approach without sternotomy allows easy and accurate manual palpation of both lungs and facilitates subsequent VATS metastasectomy in select patients. A wider experience is necessary to fully elucidate the advantages and limitations of this intriguing option.

	Acknowledgments

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This work was performed under appointment of Dottorato di Ricerca in Oncologia Toracica from Tor Vergata University and was supported at 60% by a grant from Ministero della Università e della Ricerca Scientifica e Tecnologica (MURST).

	References

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1. Pastorino U., Buyse M., Friedel G., et al. Long-term results of lung metastasectomy: prognostic analyses based on 5206 cases. J Thorac Cardiovasc Surg 1997;113:37-49.[Abstract/Free Full Text]
2. McCormack P.M., Bains M.S., Begg C.B., et al. Role of video-assisted thoracic surgery in the treatment of pulmonary metastases: results of a prospective trial. Ann Thorac Surg 1996;62:213-217.[Abstract/Free Full Text]
3. Mineo T.C., Ambrogi V., Pompeo E., Nofroni I. The value of the Nd:YAG laser for the surgery of lung metastases in a randomized trial. Chest 1998;113:1402-1407.[Abstract/Free Full Text]
4. Landreneau R.J., Hazelrigg S.R., Ferson P.F., et al. Thoracoscopic resection of 85 pulmonary lesions. Ann Thorac Surg 1992;54:415-420.[Abstract]
5. Schwarz C.D., Lenglinger F., Eckmayr J., Schauer N., Hartl P., Mayer K.H. VATS (video-assisted thoracic surgery) of undefined pulmonary nodules. Preoperative evaluation of videoendoscopic resectability. Chest 1994;106:1570-1574.[Abstract/Free Full Text]
6. Mack M.J., Shennib H., Landreneau R.J., Hazelrigg S.R. Techniques for localization of pulmonary nodules for thoracoscopic resection. J Thorac Cardiovasc Surg 1993;106:550-553.[Abstract]

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This Article Abstract 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 Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Tommaso Claudio Mineo Vincenzo Ambrogi Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Mineo, T. C. Articles by Pistolese, C. Search for Related Content PubMed PubMed Citation Articles by Mineo, T. C. Articles by Pistolese, C.