Ann Thorac Surg 2002;74:615-623
© 2002 The Society of Thoracic Surgeons
Review
VATS major pulmonary resection revisited—controversies, techniques, and results
Anthony P.C. Yim, MD*a
a Division of Cardiothoracic Surgery, Department of Surgery, The Chinese University of Hong Kong, Hong Kong, China
* Address reprint requests to Prof Yim, Division of Cardiothoracic Surgery, Department of Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, N.T., Hong Kong, China
e-mail: yimap{at}cuhk.edu.hk
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Abstract
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The application of video-assisted thoracoscopic surgery (VATS) in major pulmonary resections has remained infrequent, despite earlier demonstration of its technical feasibility. The early postoperative benefits of this approach to patients are now well documented. The intermediate to long-term clinical results of VATS major resections for primary cancer are now available and appear extremely encouraging. There are few, detailed descriptions of this technique in the literature. This article reviews the current status of VATS major resection with emphasis on its controversies, techniques, and results.
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Introduction
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For a whole century since the first lung resection was performed in 1891 by Tuffier [1], posterolateral thoracotomy and occasionally median sternotomy and clam-shell incision for bilateral pulmonary procedures have been the preferred modes of surgical access. Although these incisions generally provide good surgical exposure, they unfortunately are also among the most painful incisions ever to be encountered by patients—not only because of its length and muscle division, but primarily because ribs (or sternum) have to be separated to gain access into the chest. Unlike other incisions, this pain does not only last for weeks, but often persists for years and decades to remind the patient of his or her previous thoracotomy.
Although it has been realized for some time that the trauma of access is often worse than the procedure per se, the use of smaller incisions alone to access the chest (ie, without video-assistance) like the French incision [2] never gained wide popularity in the surgical community. Conventional wisdom relates minimal access to limited surgical exposure, and complicated intrathoracic procedures performed under suboptimal surgical exposure are generally considered unsafe. On the other hand, any attempt to spread the ribs to compensate for a small skin incision would defeat the purpose of minimal access surgery. This situation was changed by the advent of videoendoscopic surgery. Fueled by the success of laparoscopic cholecystectomy in the 1980s, video-assisted thoracoscopic surgery (VATS) plays a part in a revolution that now affects all surgical disciplines. The thoracoscope-camera unit with its own light source provides a well-illuminated, magnified operative view with very high resolution for details, and actually surpasses that provided by the conventional headlight and magnifying loops.
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The concerns and the controversies
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VATS major resection, particularly for primary lung cancer was not well received initially. An early, small, multi-institutional, randomized, prospective study of lobectomy performed through VATS compared to thoracotomy showed no benefits for using VATS. That study was later criticized to be premature and the VATS techniques used were not standardized [3]. A subsequent survey of the General Thoracic Surgery Club members showed that the majority considered this application unacceptable [4]. Several concerns were raised in the thoracic surgical community (including those who were practicing VATS). First, anatomical dissection of the hilum in an essentially closed chest immediately begged the question of safety. Second, for an oncological resection with a curative intent, skepticism was raised regarding adequacy of clearance. Third, the long-term benefits of VATS over conventional surgery remained unclear. Fourth, the high cost of the endoscopic equipment, particularly the consumables, cast doubt on the cost-effectiveness of this approach in the current era of cost awareness.
Above and beyond these concerns, it is important to point out that VATS major resection is not a unified technique, as several variations exist [5]. This is not surprising as this procedure was developed almost simultaneously at different centers, with each unit carrying its own characteristics. There is currently little consensus over some details of the technique. For example, how long an incision does one allow for "minithoracotomy" before it becomes a "thoracotomy"? How often should one operate through the minithoracotomy as opposed to the video monitor? How much rib spreading can we afford before the benefits of minimal access surgery are lost? For the sake of description, we define VATS major resection as a video-assisted, minimal access technique in which the surgeon operates primarily by watching the television monitor, and little or no rib spreading is required throughout the entire procedure. For those surgeons who use rib-spreaders and operate primarily by looking through the minithoracotomy wound, we suggested the term minithoracotomy with video assistance to describe such a technique [5]. Lewis and colleagues described a technique of simultaneous stapling of the pulmonary vessels and bronchus with excellent results [6]. This represents, however, not merely a new approach, but a new operation. The majority of surgeons practicing VATS major resections continue with the individual ligation technique.
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Indications, patient selection, and contraindications
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VATS represents a new approach and not a new procedure. Therefore, the indications for VATS major resections remain the same as for conventional resection. In our institution, close to 80% of the resections are for early, primary lung cancer, with the remaining for metastatic lung cancer and benign diseases like localized bronchiectasis, or multidrug-resistant tuberculosis [7]. For primary lung cancer, preresectional staging (including mediastinoscopy) remains a critically important step in cancer management and should be strictly adhered to.
One major advantage of VATS resection is that it allows recruitment of older and sicker patients with multiple comorbidities who would otherwise not be suitable candidates for resection through a conventional thoracotomy approach [8, 9]. The lowest limits in lung function parameters that would still be considered acceptable for VATS lobectomy have not been scientifically studied [10], but this would depend upon, among other factors, the surgeon’s judgment, experience, and technique; the contribution of the excised lobe to overall lung function; and the exact location of the pathology (for example, upper lobe lesions in patients with bullous emphysema and middle lobe pathology are favorable candidates for resection). We have performed lobectomy on a few patients whose forced expiratory volume in 1 second (FEV1) was less than 1 liter or less than 40% predicted with excellent outcome. Patients who are not candidates for an anatomical resection could still be considered for VATS wedge resection [11].
There are few absolute contraindications that are specifically applicable to VATS major resections. Apart from the inability to tolerate single lung ventilation, all of them are anatomical considerations. We do not recommend VATS for tumors larger than 4 cm, not primarily because of technical difficulties but because ribs have to be excessively spread to retrieve the specimen; this tends to negate the benefit of minimal access surgery. True pleural symphysis that leads to abandonment of the VATS approach is uncommon in our experience. Once a space is created when the correct plane in the pleural space is entered, endoscopic adhesiolysis can proceed quickly and safely. VATS has the advantage over conventional thoracotomy in visualizing, with high resolution for details, the apex and base of the hemithorax. Redo-VATS surgery [12] has been reported, and prior surgery is no longer considered an absolute contraindication to VATS resection. The current, available data, however, does not support that a complete mediastinal lymphadenectomy can be faithfully reproduced through VATS compared with the thoracotomy approach. Naruke switched several years ago to systematic lymph node sampling [13] instead of lymphadenectomy for stage I cancer (personal communication). However, those patients with pathologically established N2 disease (either diagnosed through cervical mediastinoscopy or intraoperatively by frozen section) should be treated through an open surgical approach. Fused fissures present a technical challenge to VATS lobectomy. However, with experience and proper intraoperative planning, successful lobectomy can be accomplished—the fused fissure should be divided last following the pulmonary vasculatures and the bronchus. Lobectomy with en bloc chest wall resection through the VATS approach for primary cancer with chest wall invasion has been reported [14]. Although the benefit of VATS for this group of patients currently remains debatable, it is anticipated that, with increased experience and further refinement of technique, the application of VATS could be extended to include selected, locally advanced, primary lung cancer, beyond the current indication for clinical stage I tumor.
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Operative technique
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Compared to conventional surgery, VATS demands a new set of manual skills and hand-eye coordination. However, for someone who is experienced with open surgery, the learning curve is usually very steep [15]. Like any technical procedure, attention to fine details is crucial to ensure successful, reproducible outcome. There have been few detailed descriptions of this technique in the literature. Although the following description appears personal, similar techniques are shared by most surgeons practicing VATS major resections.
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Anesthesia
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The procedure should be carried out under general anesthesia with selective single-lung ventilation. This can usually be accomplished using a double-lumen endobronchial tube (usually left-sided intubation unless a left pneumonectomy is anticipated). We prefer this over the commercially available endotracheal tube with a built-in bronchial blocker, as the latter technique makes it more difficult to collapse the lung, especially in patients who have emphysema. There is currently no endobronchial tube commercially available for young children and, in those situations, we use a single lumen endotracheal tube and position its tip in the appropriate main stem bronchus [16]. Interested readers are referred to specific reviews on this topic for details [17, 18].
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Patient positioning
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The patient is turned into a full lateral decubitus position. We advocate flexing the operating table at the level of the nipples. This allows the utility minithoracotomy which is to be made to naturally "gap" and hence render excessive rib retraction unnecessary (Fig 1).
The flexion of the table further opens up the intercostal spaces for insertion of the thoracoscope and instruments [19]. If there is any doubt, the position of the endobronchial tube should be confirmed or reconfirmed at this time using a fine bore flexible bronchoscope before the patient is prepared and draped as for thoracotomy.
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Fig 1. With the flexion of the operating table to 30 degrees at the level of the nipple, the minithoracotomy naturally opens up, rendering rib spreading unnecessary throughout the procedure. Note the position of the thoracoscope, and that only a soft tissue retractor was used. (Reprinted from Yim APC. Video-assisted pulmonary resections. In: Pearson FG, Cooper JD, Deslauriers J, et al, eds. Thoracic Surgery, 2nd ed, by permission of Churchill Livingstone [26].)
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Instruments
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We prefer a 10-mm thoracoscope and a three-chip camera system (Stryker 884TE, Kalamazoo, MI) for major resection. We utilize two television monitors so that the surgeon and the assistants can view simultaneously without having to turn their heads. We use a zero-degree lens for resections of the lower lobes and middle lobe, and a 30-degree lens for the upper lobes. The correct choice of lens for each operation cannot be overemphasized. It is crucial that the assistant be reminded at all times to avoid torquing the thoracoscope, because of the leverage, even slight torquing could result in significant pressure on the intercostal nerve and, hence, postoperative neuralgia [19].
We generally do not use ports except for the thoracoscope and for introducing mechanical staplers [20]. This is done not because of cost, but primarily because the presence of a trocar port makes it difficult to use conventional thoracic instruments [21]. Although complete sets of disposable endoscopic, as well as dedicated reusable, thoracoscopic instruments are commercially available, our preference is still to use conventional instruments (like sponge-holding forceps and Metzenbaum scissors) which are light, easy to use, familiar to all surgeons, universally available, and inexpensive [22].
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Routine VATS exploration prior to resection
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The routine use of VATS exploration to evaluate patients with known primary lung cancer prior to resection has been studied by several authors. Among a total of over 650 patients who were clinically staged as resectable, about 7% were found to have inoperable disease (pleural metastasis or direct invasion of vital structures) and hence were able to avoid an unnecessary thoracotomy [23]. VATS exploration adds very little time to the cancer operation and could yield important information that would markedly alter the treatment strategy. We therefore recommend the routine use of VATS exploration in all surgical cases of pulmonary malignancy, including those advanced cases in which we plan to use thoracotomy as the primary mode of access [24].
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Intercostal strategy and initial exploration
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The surgeon stands facing the patient. The thoracoscope is normally placed in the seventh or eighth intercostal space over the mid to anterior axillary line, depending on the body build of the patient and the location of the pathology. From this position, a panoramic view of the hemithorax could be obtained. The basic principle is to align the thoracoscope, the pathology, and the television monitor. This allows the surgeon to look straight ahead when he or she operates and this provides the best ergonomic position for the surgeon [25].
If there is no contraindication to proceed, a minithoracotomy (generally 6 to 8 cm in length) is placed over the fourth intercostal space in the anterolateral chest (Fig 2).
In females, the skin incision can be made (if the anatomy allows) over the inframammary fold for cosmesis. The location of this wound usually means only a small portion, if any, of the latissimus dorsi muscle needs to be divided. The serratus anterior muscle is split along the direction of its fibers. Division of the intercostal muscles permits access into the pleural cavity. The placement of the minithoracotomy in this position provides an easy direct access to the hilum, and because the anterior intercostal space is wider than the posterior space, it facilitates later retrieval of the specimen. We do not use a rib spreader, but only a soft-tissue retractor for the minithoracotomy wound.
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Fig 2. Postoperative picture of a typical patient who underwent video-assisted thoracoscopic surgery (VATS) major resection (a left pneumonectomy in this case). Note the position of the minithoracotomy scar. The anterior stab-wound scar (arrowhead) was from the thoracoscope, and the posterior scar (arrow) was from the sponge-holding forceps for lung maneuvering. (Reprinted from Yim APC. Video-assisted pulmonary resections. In: Pearson FG, Cooper JD, Deslauriers J, et al, eds. Thoracic Surgery, 2nd ed, by permission of Churchill Livingstone [26].)
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A sponge-holding forceps is introduced through a separate tiny incision in the seventh or eighth intercostal space in the posterior axillary line. With two sponge-holding forceps, one through the anterior minithoracotomy and the other through the posterior wound (Fig 2), the collapsed lung can be moved around and a thorough assessment made of the location and the extent of the primary lesion, as well as a search for associated pathology (satellite nodules and mediastinal or hilar lymphadenopathy could be missed even by high-resolution contrast computed tomography of the thorax).
Contrary to laparoscopic surgery which generally does not allow digital palpation (because of the need to use valved ports to sustain carbon dioxide insufflation), digital palpation through the minithoracotomy, in addition to instrument palpation, during VATS exploration can provide valuable information to the surgeon and this should be encouraged. By bringing the lung towards the palpating finger placed through different sites, a large portion of the lung surface can be palpated. This is important, as small nodules (less than 0.5 cm) which are not subpleurally located would almost certainly go undetected by thoracoscopic examination alone.
If a suspicious looking mediastinal lymph node is detected, it should be biopsied and a frozen section examination performed. Confirmation of N2 disease would mandate conversion to open surgery for complete mediastinal lymphadenectomy or neoadjuvant chemotherapy depending on the exact circumstances.
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Hilar dissection
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Conventional Metzenbaum scissors and DeBakey forceps are introduced through the minithoracotomy wound for sharp dissection of the hilum. The sponge-holding forceps from the posterior wound is used to provide appropriate traction and to position the lobes so that the hilum can be easily accessed through the minithoracotomy. If there are adhesions of the lung to the chest wall or mediastinum, this should be taken down before starting hilar dissection, as it is essential to be able to freely move the lobes around. Hilar dissection is often a cause of high anxiety for surgeons starting to learn this technique. Although manual (and bimanual) palpation is not possible with VATS, experienced VATS surgeons have all learned to feel with the tips of their instruments. One important reason why we advocate using conventional tools is because they are familiar to the surgeons and shorten the time needed to acquire this technique. Long (and hence heavier) instruments are generally not necessary for hilar dissection and would only decrease the sensitivity of that essential tactile feedback. The inherent decrease in tactile information due to the lack of manual palpation during VATS is compensated by the enhancement of visual information—the monitors provide a magnified view of the operative field with high resolution for details. Subtle displacement of a structure during dissection (which is usually not noticeable in conventional open surgery) provides important clues to an experienced VATS surgeon.
If the interlobar fissure is complete or near complete, a sharp incision of the visceral pleura and blunt dissection using a dental pledget mounted on a conventional curved clamp allow easy identification of the pulmonary artery. If the fissure is not complete, we find that a monopolar diathermy forceps (Olsen Electrosurgical, Inc, Concord, CA) at a low setting is useful for homeostasis when a layer of lung parenchyma has to be divided to access the hilar vessel.
Dissecting around a pulmonary vessel is basically the same as in conventional, open surgery. We use a right-angle mixter clamp (Downs Surgical, Surrey, UK) to go around a vessel, and then loop it with a heavy silk ligature (Fig 3).
With gentle traction on the suture, a dental pledget is used to gently dissect the undersurface of the vessel. A mechanical stapler (EndoGIA30V, Autosuture, United States Surgical, Norwalk, CT) is then introduced through one of the other two ports (depending on the alignment), but usually the camera port (with the thoracoscope repositioned to view through the minithoracotomy wound), to staple-transect the vessel. Appropriate traction (using a sponge-holding forceps from the other port) is crucial in aligning the vessel with the stapler for transection [26]. In recent years, more frequently we have been using ligation of pulmonary arterial branches with extracorporeal knots [27] instead of mechanical staplers, mainly to reduce cost. We tend not to use many endoclips for small pulmonary branches, as their presence could interfere with the subsequent use and functioning of the endostaplers.
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Fig 3. Management of the left main pulmonary artery (PA) in a video-assisted thoracoscopic surgery (VATS) pneumonectomy to illustrate our technique. (A) Under thoracoscopic vision, the PA was dissected around with a conventional right-angle clamp. A #2 silk tie was about to be pulled around the vessel. (B) With traction on the silk tie, a dental pledget mounted on a right-angle clamp was used to open up the space behind the PA. Any suspicious mediastinal lymph node, like level 5, was biopsied and frozen section performed before proceeding further. (C) The frozen section of the level-5 node was benign. A vascular stapler (EndoGIA30V, Autosuture, USC) was used to staple-transect the PA. (D) Three rows of staples were left on either side of the transected PA. The final diagnosis in this patient was T2N0M0 stage Ib squamous cell carcinoma. He was discharged on postoperative day 3 and returned to his country of origin the following week. (Reprinted from Yim APC. Video-assisted pulmonary resections. In: Pearson FG, Cooper JD, Deslauriers J, et al, eds. Thoracic Surgery, 2nd ed, by permission of Churchill Livingstone [26].)
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Doctor Lewis and his colleagues have accumulated very extensive experience on simultaneously staple-transecting the pulmonary vasculature and lobar bronchus with excellent results [6]. The author has modified and adopted this technique for lower lobectomy (for bronchiectasis) on a couple of occasions, during which individual isolation of the pulmonary artery and bronchus to the lower lobe proved to be technically difficult or even hazardous. On both occasions, the inferior vein was taken separately.
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Management of the bronchus
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Lobar bronchus is divided with a linear mechanical stapler with a built-in blade for transection (EndoGIA30 with closed staple height of 1.5 mm, Autosuture, USC, Norwalk, CT) and for a main stem bronchus, with a different stapler that requires manual transection (Roticulator 30 with closed staple height of 2 mm, Autosuture, USC). The integrity of the bronchial stump is then tested to 35 cm of airway pressure in the usual manner underwater.
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Release of the pulmonary ligament
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Release of the inferior pulmonary ligament is required following upper or middle lobectomies. Although this is usually a straightforward maneuver, the positions of the ports and minithoracotomy mean that paradoxical motion would be difficult to avoid. Paradoxical motion is generated when the camera and instruments are facing each other. We have found that by turning the camera 180 degrees, a normal spatial relationship is restored for the operator [28]. This simple maneuver allows the surgeon to use the camera and existing ports to his or her best ergonomic advantage.
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Systematic lymph node sampling
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We do not perform VATS mediastinal lymphadenectomy and if a complete lymph node dissection is considered necessary, it should be done through a thoracotomy. Nonetheless, there are surgeons who advocate routine VATS lymphadenectomy [29], but just like open surgery, their results have not been shown to be superior to those who perform lymph node sampling.
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Retrieval of specimen
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A wound protector should be used to avoid any potential implantation of tumor cells on the wound. When the primary tumor is less than 4 cm, we generally have not found that a mechanical rib spreader would be necessary for retrieval of the resected lobe, bi-lobe, or even the entire lung (although some manual rib retraction may be needed at the time of retrieval).
The entire hemithorax is then copiously irrigated with warm saline. If there is any significant parenchymal leak, endoscopic suturing can be done through the minithoracotomy.
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Mortality and morbidity
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Some of the larger published series on VATS major resections are summarized on Table 1
[5, 29–35]; many of these are personal case series. Despite slight variations in individual techniques, the results universally ranged from good to excellent. The overall surgical mortality of 0% to 2% for VATS compared favorably with the conventional technique, even though it must be pointed out that the former was for highly selected patients.
Major complications from VATS resections are relatively uncommon [36, 37]. Persistent airleak beyond 7 days was the commonest morbidity in earlier experience [38]. This was almost certainly related to hilar dissection when the fissures were incomplete. However, like most technical issues, this improved with experience.
Tumor implantation following VATS has been reported [39]. However, this is relatively uncommon and could be further minimized by gentle handling of tissue, routine use of a wound protector, and copious irrigation of the hemithorax prior to closure. One of the most dreaded complications for surgeons is massive bleeding from pulmonary vessels. Both Craig and Walker, and the author and Ho, have reported mechanical failure of the staplers that resulted in massive bleeding [20, 40]. This was controlled by pressing on the bleeder with a sponge stick, and conversion to a thoracotomy. It should be pointed out that these are anecdotal cases, and the mechanical staplers available now are generally very reliable. Having now acquired the skill and experience in endoscopic suturing, we feel comfortable to use this technique in the unlikely event of minor to moderate bleeding from the pulmonary vasculature, and hence avoid the need for a conversion.
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Benefits over conventional surgery
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Decreased postoperative pain
It is now fairly well accepted that patients who undergo VATS resection are expected to experience less immediate postoperative pain compared with the thoracotomy approach. This has been documented in several large case-controlled studies either by objective assessment in terms of analgesic requirements [38, 41], or subjective assessment in terms of pain score, usually in the form of a visual analogue scale [9, 38, 42]. A trend in the decrease in analgesic requirement was seen in the early randomized, prospective study comparing VATS with thoracotomy for lobectomy [3]. The lack of statistical significance was likely to be due to the small sample sizes, and hence low statistical power. Landreneau and colleagues [43] reported earlier that the incidence of chronic postoperative pain at 6 months following VATS was not different from thoracotomy. Nomori and associates [44] retrospectively compared lobectomy performed using the VATS versus an anterior limited thoracotomy approach, and reported that patients in the VATS group experienced much less pain in the first postoperative week. However, no statistical differences could be found in the pain assessment after 1 week, nor were any differences detected between groups with respect to respiratory muscle strength or 6-minute walking distance. It should be pointed out, however, that a rib spreader was used in their VATS group [44].
Better preservation of pulmonary function
Kaseda and colleagues [45] recently reported that patients who underwent VATS lobectomy were able to preserve their lung function better compared with those who underwent a thoracotomy approach when the forced expiratory volume in 1 second and forced vital capacity values were measured both preoperatively and then 3 months postoperatively. The differences were shown to be highly significant (p < 0.0001). The same conclusion was reached in a similar but smaller study by Nakata and colleagues [46]. Nagahiro and associates showed that postoperative pain inversely correlated with how fast pulmonary function recovered [47].
Earlier return to normal activities
Sugiura and coworkers [48] recently showed that patients who underwent VATS lobectomy for early cancer were able to return to preoperative activities significantly earlier than patients who underwent the thoracotomy approach (2.5 versus 7.8 months). Demmy and Curtis [9] who compared VATS versus conventional major resections in high risk patients came to the same conclusion (2.2 versus 3.6 months).
Long-term survival
The success of a cancer operation is judged by the long term survival of patients. The published results to date from several centers on VATS major resection for stage I lung cancer consistently show that the intermediate to long term survival is at least as good, if not superior to the conventional thoracotomy approach (Table 1). Several prospective, non-randomized studies have shown improved survival in favor of VATS major resection for early non-small cell lung cancers compared to thoracotomy [6, 26, 29]. We are cautious in not drawing any premature conclusion that there is a definitive survival advantage until the results from larger prospective, randomized studies with long follow up become available.
Over the last few years, we have been intensively searching for mechanisms behind the possible survival advantage. There is now a wealth of literature showing that the body immune function is better preserved following laparoscopic surgery compared to its open counterparts, although few of these publications exist in the thoracic surgical literature. Significantly reduced postoperative release of both pro-inflammatory (interleukins 6 and 8) and anti-inflammatory cytokines (interleukin 10) in the plasma was found in the VATS group compared to the thoracotomy group in patients with stage I lung cancer [49]. These findings were consistent with two similar studies. Nagahiro and colleagues showed a significantly reduced cytokine release (interleukin 6 and 8) in the pleural fluid in the VATS lobectomy group compared to the open group [50]. Leaver and colleagues from Edinburgh showed in a small, randomized, prospective study that VATS lobectomy was associated with a lesser effect on the postoperative fall in circulating T (CD4) cells and natural killer (NK) cells. Lymphocyte oxidation was also less suppressed by VATS compared with open surgery [51]. We have independently studied NK cells in our unit, and our unpublished results were in agreement with the above findings. In essence, there is evidence now to believe that VATS is associated with lesser perturbation in both the humoral and cellular immune functions compared with open surgery, at least in the short term [52]. As immunosurveillance is still believed by many to be important, surgically induced immunosuppression may predispose to increased tumor growth or recurrence. Whether better preservation of the immune system by minimal access surgery may lead to improvement in long-term survival is unclear but certainly deserves further investigation.
On the other hand, caution was raised by Yamashita and colleagues [53] who studied a tumor marker, carcinoembryonic antigen messenger RNA (CEAmRNA) using reverse transcriptase polymerase chain reaction (PCR) in the peripheral blood in patients with early lung cancer who underwent VATS lobectomy. They found that in a high proportion of patients, CEAmRNA which was absent before surgery could be detected in the peripheral blood during the procedure. The proportion was more than that found in an historical group of patients who underwent conventional resection. Reverse transcriptase PCR is an extremely sensitive technique, and the significance of this observation is unclear. However, in several large case series with intermediate to long-term follow-up, VATS has not been shown to be associated with more distant metastasis than conventional surgery for clinical stage I cancer.
Cost-effectiveness
The high cost of the consumables is a serious concern and represents a major deterrent to adopt VATS in developing countries. However, by choosing the right patients for this technique, as well as relying on ligation and suturing, the consumable costs could be minimized [20]. In experienced hands, VATS major resection could be a quick operation, as little time is needed to open and close the chest. This represents significant cost saving in terms of operating room time. A recent Japanese study comparing VATS versus open resections for cancer showed that the overall hospital charges were lower for the former approach [54].
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Comment
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Initially viewed as a heresy, VATS pulmonary resection has matured to become an established, alternative approach to conventional open surgery for selected patients. VATS major resection has been shown to be a safe operation in experienced hands. Postoperative pain is significantly less following VATS than open surgery. Other documented advantages include better preservation of pulmonary function in the early postoperative period, earlier return to full activities, and possibly better quality of life. Older and sicker patients can thus be recruited for surgery. Intermediate to long-term survival for stage I lung cancer patients who underwent VATS resection appears at least as good, if not superior to, open surgery. Large, prospective, randomized studies will provide definitive data on the probable long-term benefits of VATS over thoracotomy for early lung cancer.
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Abstract
Introduction