Ann Thorac Surg 2004;77:2230-2231
© 2004 The Society of Thoracic Surgeons
How to do it
Complete port-accessed lobectomy by the muscle-sparing method
Yoshinori Doki, MDa*,
Katsuyuki Ichiki, MDa,
Motoharu Tsuda, MDa,
Masayoshi Toge, MDa,
Takuro Misaki, MDa,
Katsuo Usuda, MDb,
Shigeki Sugiyama, MDa,b
a First Department of Surgery and Division of Endoscopy, Toyama Medical and Pharmaceutical University, Toyama, Japan
b Department of Respiratory Disease, Tomei-Atsugi Hospital, Atsugi, Japan
Accepted for publication May 2, 2003.
* Address reprint requests to Dr Doki, First Department of Surgery, Toyama Medical and Pharmaceutical University, 2630 Sugitani, Toyama, 930-0194 Japan
e-mail: ydoki{at}ms.toyama-mpu.ac.jp
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Abstract
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We report the case of a 53-year-old woman who underwent complete port-accessed middle lobectomy by a new technique that preserves all muscles, including the extracostal and intercostal muscles. The operation was performed by using only thoracovideoscopy, and the resected lobe was withdrawn in a pouch through a subxiphoid incision through the substernal route. This complete port-accessed lobectomy is a new technique and is thought to be less invasive than video-assisted lobectomy with minithoracotomy.
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Introduction
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A 53-year-old woman was referred to our institute with a pulmonary shadow in the middle lobe. Computed tomographic scan revealed a solid nodule 3 cm in diameter and a peripheral pneumonia-like opacity. Histopathologic and cytologic examination by bronchofiberscopy failed to establish the diagnosis. Bacteriologic study of bronchoalveolar lavage fluid and polymerase chain reaction analysis for tuberculosis and atypical mycobacteriosis were both negative. However, because malignancy could not be ruled out, a surgical biopsy was performed with the patient's informed consent.
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Technique
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The patient was placed in a half left lateral decubitus position under general anesthesia with a double-lumen endobronchial tube. The first thoracoport (10 mm in diameter) (U.S. Surgical, Norwalk, CT) for the videoscope was placed in the fifth intercostal space on the anterior axillary line. The second and third ports were inserted into the fourth and eighth intercostal spaces on the midaxillary line for introduction of surgical instruments. The middle lobe branches of the pulmonary vein, artery, bronchus, and interlobar pulmonary parenchyma were all stapled and divided with endoscopic devices. The resected middle lobe was caught in the disposable specimen pouch, which was introduced into the right pleural cavity through the substernal route from a subxiphoid 4-cm arched incision (Fig 1). The specimen was withdrawn, and frozen-section examination revealed that this tumor was an epithelial granuloma. Total blood loss was less than 100 mL, and the patient was sent to the recovery room in stable condition. The postoperative course was uneventful, and no analgesic except for epidural anesthesia (0.25% bupivacaine hydrochloride) was needed. The thoracostomy tube was removed on the second postoperative day, and the patient went home 3 days later. The maximum white blood cell count and C-reactive protein concentration were 8,300/µL and 3.7 mg/dL, respectively.
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Fig 1. (A) Lateral and (B) anterior views of the substernal route through a subxiphoid incision. This route enables lobectomy by the muscle-sparing method without thoracotomy. The solid line arrow represents the approach route; the dotted line arrow indicates the extracted route from right chest cavity.
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Fig 2. (Left) View of the postoperative wound (resected middle lobe; 8 x 15 cm). (Right) This specimen was easily extracted from the subxiphoid incision of a 4-cm arched shape.
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Comment
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Video-assisted thoracic surgery (VATS) has gained widespread acceptance in recent years. Its advantages are less invasiveness, better cosmesis, and supervision of the procedures by multiple surgeons [1, 2]. Gradually the indications for VATS have been expanded to include more complicated operations as techniques and instrumentation have evolved. In the last several years, lobectomy also has been performed by VATS with minithoracotomy in some centers [3]. Minithoracotomy preserves the major muscles, such as the latissimus dorsi and serratus anterior, which are ordinary divided during standard posterolateral thoracotomy. This facilitates postoperative recovery and permits better respiratory function in the early postoperative period. Until now, it has been impossible to avoid division of the intercostal muscles and rib spreading when the resected lobe was removed from the chest, and these maneuvers sometimes caused prolonged postoperative pain. Therefore, my colleagues and I developed complete port-accessed lobectomy with muscle sparing. The characteristic feature of our procedure is removal of the specimen through a subxiphoid incision [4] by the substernal route; this was initially developed by Ambrogi and associates [5] in 2000 for patients with bilateral metastatic lung cancer. These investigators used hand-assisted thoracic surgery to palpate and confirm the presence of tumor by using 1 hand. We adapted this route to serve as an extracting window, permitting lobectomy without thoracotomy. This approach can be used for either lung, and because the abdominal skin is more elastic than the thoracic skin, the resected lobe can be delivered through a small wound (Fig 2), further reducing postoperative pain. Moreover, this subxiphoid incision could be used to introduce surgical instrumentation to access to the pulmonary hilum and settle the chest drainage tube as a less painful placement. Our patient was discharged in 5 days and started housework on the day of discharge. Complete port-accessed lobectomy by the muscle-sparing method is our original technique and reduces the morbidity of thoracotomy.
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References
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- Gossot D., Validire P., Vaillancourt R., et al. Full thoracoscopic approach for surgical management of invasive pulmonary aspergillosis. Ann Thorac Surg 2002;73:240-244.[Abstract/Free Full Text]
- Watanabe S., Tsunezuka Y., Sato H., et al. Video-assisted thoracoscopic surgery (VATS) versus thoracotomy for spontaneous pneumothorax. J Jpn Assoc Chest Surg 1998;12:26-31.
- Daniels L.J., Balderson S.S., Onaitis M.W., et al. Thoracoscopic lobectomy: a safe and effective strategy for patients with stage I lung cancer. Ann Thorac Surg 2002;74:860-864.[Abstract/Free Full Text]
- Kido T., Hazama K., Inoue Y., et al. Resection of anterior mediastinal masses through an infrasternal approach. Ann Thorac Surg 1999;67:263-265.[Abstract/Free Full Text]
- Ambrogi V., Paci M., Pompeo E., et al. Transxiphoid video-assisted pulmonary metastasectomy: relevance of helical computed tomography for occult lesions. Ann Thorac Surg 2000;70:1847-1852.[Abstract/Free Full Text]
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Abstract
Introduction
