Ann Thorac Surg 2001;71:2015-2016
© 2001 The Society of Thoracic Surgeons
Case report
Extrapleural resection of lung metastasis in a patient with dense pleural adhesions using VATS
Atsushi Watanabe, MDa,
Akihiko Yamauchi, MDa,
Jun-ich Sakata, MDa,
Tomio Abe, MD, PhDa
a Department of Cardio-Thoracic Surgery, Sapporo Medical University School of Medicine, Sapporo, Japan
Accepted for publication May 4, 2000.
Address reprint requests to Dr Watanabe, Department of Cardio-Thoracic Surgery, Sapporo Medical University and Hospital, South 1, West 16, Chuo-ku, Sapporo 060-8543, Japan
e-mail: QZV07547{at}nifty.ne.jp
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Abstract
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We report the case of a 78-year-old man with dense pleural adhesion who underwent a resection of a lung metastasis by video-assisted thoracic surgery (VATS) through an extrapleural approach. The approach for diagnosis and therapeutic wedge resection of a lung tumor by VATS is easier and safer than an intrapleural approach if the patient has dense pleural adhesions.
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Introduction
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It is difficult to resect a lung tumor by video-assisted thoracic surgery (VATS) if there is dense pleural adhesion, and in such cases, the VATS procedure is often converted to standard open thoracotomy. Although an extrapleural approach for thoracic disease has been used in cases with dense pleural adhesion [1], invasion to the chest wall [2], and a pleural tumor [3], the use of an extrapleural approach for resection of a lung tumor by VATS is unusual. We performed a metastasectomy of the lung by VATS through an extrapleural approach for a patient with dense pleural adhesion, and the result was very satisfactory.
A 78-year-old man with a history of resection of colon cancer and of left pleuritis was admitted to our hospital for evaluation of an abnormal shadow on a chest roentgenogram. A chest computed tomographic scan revealed a homogeneous mass of 15 mm in diameter in segment 4 of the left lung and parietal pleural thickness (Fig 1). The level of serum carcinoembryonic antigen was 10.2 ng/mL (enzyme immune assay). The mass was suspected to be a metastatic tumor from colon cancer. Although a transbronchial lung biopsy was carried out, a definite diagnosis could not be made. No masses were detected on a whole-body computed tomographic scan or scintigram. Mediastinal and hilar lymph nodes were not swollen.
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Fig 1. Preoperative computed tomographic scan showing (left) parietal pleural thickness (arrowheads) and (right) a solitary mass of 15 mm in diameter in segment 4 of the left lung (arrow).
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A wedge resection of the mass by VATS was scheduled. General anesthesia with endotrachial intubation using a double-lumen tube was performed to enable selective contralateral lung ventilation. An incision 15 mm in length was made in the seventh intercostal space on a middle axillary line. Dense pleural adhesion was observed beneath the wound, and a thoracoscope could not be placed in the pleural space. A minithoracotomy 40 mm in length was made in the fourth intercostal space on an anterior axillary line as an access port. The same dense pleural adhesion was observed beneath the minithoracotomy. It was thought that there was dense pleural adhesion throughout the left lung due to old pleuritis. Therefore, the extrapleural approach was chosen in order to prevent lung injury caused by dissection of the dense pleural adhesion. Blunt dissection was performed in a small area in order to secure a space in which the thoracoscope could be used. Then, with the aid of a video-assisted thoracoscope, the extrapleural space was entered on the anterior and half-cranial side between the parietal pleura and suprapleural sheath. Manipulation of the tumor was carried out through the minithoracotomy, and the tumor location was determined (Fig 2). A wedge resection of the tumor with parietal pleura was performed using two end staplers with 3.5-mm staples (End GIA; United States Surgical Corp, Norwalk, CT). Frozen-section pathologic examination was performed on a specimen, and the pathologic diagnosis was adenocarcinoma that had metastasized from colon cancer. At the end of the procedure, a chest tube 6 mm in diameter was placed in the extrapleural space through the incision, and the incisions were closed. The operation time, excluding the time required for frozen-section pathologic analysis, was 45 minutes. The chest tube was removed on postoperative day 2. The patient had an uneventful postoperative course and was discharged on postoperative day 4. He is now doing well without showing any sign of recurrence.
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Fig 2. Intraoperative view through a thoracoscope. (CW = chest wall; EPS = extrapleural space; MP = mediastinal pleura; PP = parietal pleura; SL = stapler line.)
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Comment
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The use of VATS to perform diagnostic and therapeutic resection of a lung tumor has gradually become accepted. We have also performed wedge resections of lung tumors by VATS. In some cases of dense pleural adhesion, the VATS procedure is often converted to standard open thoracotomy. Even using standard open thoracotomy in such cases, the dissection between parietal and visceral pleura usually causes lung injury with pulmonary bleeding and air leakage, the repair of which is costly in terms of both time and materials. Therefore, most surgeons would perform an extrapleural dissection in an area of dense pleural adhesion. We think that an extrapleural approach should also be used by VATS. However, an extrapleural approach is not selected if the tumor is in a diaphragmatic location, because dissection between parietal pleura and diaphragm is difficult. Likewise, an extrapleural approach is not used if there is thick, hard peel formation of parietal pleura lying over the tumor, because it is difficult to detect the tumor location intraoperatively. We conclude that an extrapleural approach in resection of a lung tumor by VATS is easier and safer than an intrapleural approach if the patient has dense pleural adhesion, if the tumor is not in a diaphragmatic location, and if there is no thick and hard peel formation.
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References
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Abstract
Introduction
