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Ann Thorac Surg 2006;82:e3-e4
© 2006 The Society of Thoracic Surgeons

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How to do it

Minimally Invasive Pneumonectomy

Department of Thoracic Surgery, Roswell Park Cancer Institute, State University of New York at Buffalo, Buffalo, New York

Accepted for publication April 19, 2006.

^_* Address correspondence to Dr Nwogu, Department of Thoracic Surgery, Roswell Park Cancer Institute, Elm and Carlton Streets, Buffalo, NY 14263 (Email: chumy.nwogu{at}roswellpark.org).

	Abstract

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Technical advances have resulted in the growing popularity and success of video-assisted thoracoscopic lobectomy for the treatment of nonsmall cell lung cancer. Several investigators have used similar techniques to safely perform pneumonectomies. Minimally invasive pneumonectomy may be indicated for patients who have centrally located malignant lesions and who are not candidates for sleeve resections. Adequate exposure of the proximal hilar vessels is mandatory. Short-term results are encouraging, but prospective long-term data are essential.

	Introduction

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As with several other minimally invasive oncologic operations, experience with video-assisted thoracic surgery (VATS) pulmonary lobectomies is growing [1–3]. However, the indications and expected benefits for VATS pneumonectomies are controversial [4–6]. The use of a thoracoscope to provide additional visualization permitted us to progressively decrease the size of the incisions we used for conventional (open) pneumonectomies. We herein report the technique we used for our first 7 consecutive cases of completely video-assisted pneumonectomies at a comprehensive cancer center.

	Technique

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The procedure followed VATS lobectomy techniques that were previously described [3]. Double lumen endobronchial intubation provided selective ventilation, and the patient was flexed in the lateral decubitus position to widen the intercostal spaces. Three 1.5-cm incisions yielded access to the pleural space. The first was made in the seventh or eighth intercostal space along the mid-axillary line. A flexible tip or 30-degree Visera video thoracoscope (Olympus, Melville, NY) helped guide the placement of an antero-inferior incision (at approximately the sixth intercostals space) in line with the major fissure to facilitate passage of the stapler across the pulmonary vessels. The third incision was placed directly over the pulmonary hilum with the visual aid of a 25-gauge "finder" needle testing the planned skin site. Once a VATS pneumonectomy was deemed feasible, this incision was extended to a length of 4 to 7 cm.

The soft tissues (not the ribs) were retracted at the access incision. Thorough hilar dissection was performed to ensure proximal control of the pulmonary artery. The pulmonary vessels were dissected with conventional instruments and divided with the Endo-GIA 2.0-mm or 2.5-mm roticulating staplers (US Surgical, Norwalk CT), whereas the proximal mainstem bronchus was divided with 4.8-mm staplers. The roticulation of the staplers facilitated the creation of short vascular and bronchial stumps.

A 5 x 8-inch (or 8 x 10-inch) Lapsac (Cook, Spencer IN) specimen sac retrieved the lung from the thoracic cavity. Three-point fixation of the sac facilitated insertion of the bulky specimen. The sac was delivered through the access incision by a firm rocking motion while suctioning its contents intermittently. An incision into the normal pulmonary parenchyma sometimes facilitated decompression of the lung specimen. Hilar and mediastinal lymphadenectomy or node sampling was performed.

Bronchial stump pneumo-stasis was confirmed, but coverage with a vascularized flap was not performed, although this is technically feasible.

Our institutional review board approved the procedure and then authorized the retrospective review of our results in July 2005. Patients gave individual consent for the operation. Twenty-five patients underwent pneumonectomy for bronchogenic carcinoma for a period of 20 months ending December 2004. A video-assisted pneumonectomy was attempted in 7 of these patients as an extension of the growing experience with VATS lobectomy and its observed clinical benefits [7].

Chest computed tomography and positron emission tomography provided staging information in all the patients. Mediastinoscopy was performed in all but one emergent open pneumonectomy case.

	Results

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Mediastinoscopy confirmed absence of mediastinal lymph node involvement in all the VATS pneumonectomy patients. The maximum dimension of the lesions resected by VATS ranged from 2.5 cm to 4.5 cm. The median number of mediastinal (and total) lymph nodes harvested in the VATS cases were 6 (19) versus 8.5 (23) in the open cases. There was 1 patient (14%) in the VATS group with N2 disease versus 4 patients (22%) in the open group.

Five VATS patients had either a central mass or bulky hilar adenopathy impinging on the main pulmonary artery, and 2 patients had main stem bronchial lesions involving the secondary carina. Intraoperatively they were deemed unsuitable for sleeve resections. One patient required conversion to a standard thoracotomy to facilitate a bronchoplastic procedure to achieve a negative proximal margin. Another patient with a negative intraoperative frozen section margin had involvement of the peribronchial tissue margin on final pathologic review and received adjuvant radiotherapy. Complications included atrial fibrillation in 2 patients, gastrointestinal ileus in 1, and pulmonary edema in 1. There was no perioperative mortality. However, 1 patient died 3 months later of radiation pneumonitis, and another died of liver metastases 3 months postoperatively, despite negative preoperative abdominal computed tomography and positron emission tomography. The other patients have no evidence of malignant disease at 21 months median follow-up.

	Comment

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Numerous advances in surgical techniques and video instrumentation have enabled minimally invasive pneumonectomy. The clinical characteristics and outcomes of our patients are similar to those reported in the literature [4–6].

The indications for this procedure are quite narrow. Primary lesions or associated lymphadenopathy abutting a significant length of the main pulmonary artery necessitate a pneumonectomy for complete oncological resection. The VATS can accomplish this in some cases in which sleeve vascular resections are not feasible. At present, complicated vascular reconstructions are probably safer using traditional, open incisions. Involvement of mainstem bronchi or secondary carinae in configurations that preclude sleeve resections may also suit VATS pneumonectomy. Selected patients with synchronous ipsilateral upper and lower lobe malignancies or isolated tumors extending into multiple lobes are also appropriate candidates.

Lesions with extensive chest wall or mediastinal invasion are probably unsuitable for minimally invasive pneumonectomy; however endoscopic rib cutters (Sofamor Danek, Medtronic Corp, Minneapolis, MN) allow limited en bloc resections. A safe resection mandates full visualization and control of the proximal hilar vessels. Lesions larger than 5 cm may be difficult to extract through a small incision without significant rib spreading, although tumors have a wide range of compressibility. Thus the value of VATS pneumonectomy in such cases is unclear and requires careful judgment before undertaking. We routinely inspect the thoracic cavity with a thoracoscope before all pneumonectomies, and we consider a VATS pneumonectomy in patients with lesions 5 cm in diameter or less with adequate exposure of the hilar vessels for safe vascular stapling. Decompression of blood and air from the surrounding pulmonary parenchyma when the specimen is placed in the retrieval bag facilitates extraction through the modest access incision. The incisions in our patients were between 4 and 7 cm.

Complete mediastinal lymphadenectomy can be accomplished in a minimally invasive fashion, although this remains controversial [8]. We found no difference in the number of N1, N2, or total lymph nodes harvested between the VATS and open pneumonectomy groups.

As long as oncologic principles are maintained, VATS pneumonectomy represents an advancement that surgeons have a responsibility to explore if it offers frail patients the opportunity for surgical cure. In addition, the faster recovery may allow more patients to start adjuvant chemotherapy in a more timely fashion. However, the expected decrease in morbidity is worthwhile only if there is no compromise to the curative potential in patients who can tolerate thoracotomy.

Patients with anatomic characteristics that would allow minimally invasive pneumonectomies are uncommon. However, it is feasible to perform such resections using current VATS techniques. Short-term results are encouraging, but prospective long-term outcome data are required to properly assess the role of minimally invasive pneumonectomy in the contemporary care of lung cancer patients.

	References

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1. Demmy TL, Curtis JJ. Minimally invasive lobectomy directed toward frail and high-risk patientsa case-control study. Ann Thorac Surg 1999;68:194.[Abstract/Free Full Text]
2. Walker WS, Codispoti M, Soon SY, et al. Long-term outcomes following VATS lobectomy for non-small cell bronchogenic carcinoma Eur J Cardiothorac Surg 2003;23:397.[Abstract/Free Full Text]
3. Demmy TL, James TA, Swanson SJ, et al. Troubleshooting video-assisted thoracic surgery lobectomy Ann Thorac Surg 2005;79:1744.[Abstract/Free Full Text]
4. Conlan AA, Sandor A. Total thoracoscopic pneumonectomyindications and technical considerations. J Thorac Cardiovasc Surg 2003;126:2083.[Free Full Text]
5. Craig SR, Walker WS. Initial experience of video assisted thoracoscopic pneumonectomy Thorax 1995;50:392.[Abstract/Free Full Text]
6. Roviaro G, Varoli F, Vergani C, et al. Techniques of pneumonectomyvideo-assisted thoracic surgery pneumonectomy. Chest Surg Clin N Am 1999;9:419.[Medline]
7. Demmy TL, Plante AJ, Nwogu CE, et al. Discharge independence with minimally invasive lobectomy Am J Surg 2004;188:698.[Medline]
8. Sagawa M, Sato M, Sakurada A, et al. A prospective trial of systematic nodal dissection for lung cancer by video-assisted thoracic surgerycan it be perfect?. Ann Thorac Surg 2002;73:900.[Abstract/Free Full Text]

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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): Chumy E. Nwogu Todd L. Demmy Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Nwogu, C. E. Articles by Demmy, T. L. Search for Related Content PubMed PubMed Citation Articles by Nwogu, C. E. Articles by Demmy, T. L. Related Collections Lung - cancer