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a Thoracic Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York
b Peter MacCallum Cancer Centre and St. Vincent’s Hospital, Melbourne, Australia
* Address correspondence to Dr Flores, Thoracic Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, 1275 York Ave, Rm C-879, New York, NY 10021 (Email: floresr{at}mskcc.org).
Presented at the Minimally Invasive Thoracic Surgery Summit, New York, NY, June 8–9, 2007.
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Abstract |
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Introduction |
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The definition of VATS lobectomy is ambiguous as well. The technique varies in the number of incisions from 2 to 5, length of utility incisions from 4 to 10 cm in size, degree of rib-spreading, if any, and individual hilar ligation vs tourniquet lobectomy. In addition, when VATS lobectomy is compared with open thoracotomy, one must take into account the type of open approach: standard posterolateral thoracotomy, complete muscle-sparing thoracotomy, thoracotomy sparing only the serratus muscle, anterolateral thoracotomy, and sternotomy. Therefore, both open and VATS techniques must be explicitly defined in order to draw any meaningful conclusions from published studies.
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Methods |
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In addition, all patients with clinical stage I lung cancer who had lobectomy by VATS at Memorial Sloan-Kettering Cancer Center were identified. Our standard VATS approach uses a 4-cm utility incision, an anterior 2-cm port for the camera, a posterior 2-cm port, no rib-spreading, individual ligation of hilar structures, and a mediastinal lymph node dissection or sampling. Our robotic technique uses the da Vinci Surgical System (Intuitive Surgical, Sunnyvale, CA) with the same three incisions and with the same camera and working ports.
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Results |
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Randomized Controlled Trials
Few RCTs exist in this area (Table 1). Of the three published trials comparing open with VATS lobectomies, two examine clinical outcomes and one investigates biochemical markers [1–5]. The first well-known RCT was published by Kirby and colleagues [3]. They randomized 61 patients with clinical stage I non-small cell lung cancer (NSCLC) to undergo lobectomy by VATS (31 patients) or muscle-sparing thoracotomy (30 patients). The VATS were performed without rib-spreading. One patient in the open group and 2 patients in the VATS group had benign disease and were excluded from analysis. In addition, 3 patients in the VATS group required conversion to thoracotomy and were also excluded from the analysis, leaving 30 in the open group and 25 in the VATS group. There were few differences between the groups. The incidence of postoperative complications was less in the VATS group (6% vs 16%). No significant differences were noted in operating time, blood loss, duration of chest tube placement, length of hospital stay, or incidence of disabling postthoracotomy pain (2 in the open vs 1 in the VATS group).
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A study comparing acute phase responses randomized 22 patients to VATS and 19 patients to open lobectomy [5]. They used a nonrib-spreading technique, and all patients had mediastinoscopy preoperatively. Blood samples were taken before and at various times in the first week after the operation. Both procedures increased acute-phase response markers, but VATS was associated with lower rises in C-reactive protein (CRP) and interleukin 6.
The final RCT was performed comparing complete VATS (c-VATS) with assisted VATS (a-VATS) [6]. The authors randomized 18 patients with clinical stage I lung cancer to a nonrib-spreading approach (c-VATS) and 16 patients to a minithoracotomy approach with rib-spreading (a-VATS). The authors found significantly shorter length of stay (11 vs 15 days), longer operating room times, less blood loss, and lower serum markers (CRP, white blood cells) in the c-VATS group.
Case–Control Studies
A number of case–control studies with different primary end points have been performed on VATS major lung resections (Table 2). Two studies have investigated the effects of VATS lobectomies in high-risk patients [7, 8]. A Japanese case–control study done with patients aged 80 years or older with 17 VATS cases and 15 open controls showed no significant difference in survival or complications with trends favoring the VATS group [7].
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A number of other case–control series examining pain, changes in pulmonary function tests, nocturnal hypoxemia, and various markers of inflammation have been performed and are summarized in Table 2 [10–14]. They generally favored VATS approaches, but the selection of controls was problematic. For example, in one study of cytokines before and after operation, the control group comprised patients with T2 tumors and the VATS patients had T1 tumors [10].
Case Series
Numerous case series have been published, many of which have been updated to reflect the ongoing experience of the authors, follow-up of patients, and modifications in technique. A review of the English-language series with more than 100 patients is in Table 3.
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Two recent case series have been published from different centers in Japan [16, 17]. Iwasaki and colleagues [16] published their experience with 140 procedures (100 lobes, 40 segments). Their technique did not involve rib-spreading, and their indications were clinical stage I disease with peripheral tumors sized less than 3 cm. They reported a 5-year survival of 77.3% for the VATS patients, with 80.9% for stage I and 70.3% for stage II tumors.
The other Japanese case series involved 106 patients; of whom 95 had a VATS procedure and the other 11 were converted to thoracotomy (10% conversion rate) [17]. Their main indication was clinical stage I. Tumor size was not a criterion. Their technique involved the use of a minithoracotomy and rib-spreading. They reported a 3-year survival of 93%, but only included the 82 patients for whom they had follow-up data for more than 6 months.
Yim and colleagues [20] from Hong Kong published their series of 266 patients with tumors sized less than 5 cm for whom they attempted VATS resections. They converted to thoracotomy 19% of the time and completed 214 VATS major lung resections. A rib-spreader was used. They reported a 22% incidence of nonfatal complications, one postoperative death, and 93% of patients alive at 2 years.
In the largest series of VATS major lung resections, McKenna and colleagues [21] reported their experience of 1100 patients for whom they performed 1072 procedures with a conversion rate of 2.5%. There were no intraoperative deaths, and their mortality rate was only 0.8%. The complication rate was 15.3%, with the most common complications being prolonged air leak and atrial fibrillation. Extrapolation of the Kaplan-Meier survival curves for their study shows 5-year survivals of about 80% for stage I cancer and 60% for stage II cancer. The incidence of port site recurrence was 0.6%.
Finally, two independent series using forms of simultaneous stapling have been published [22, 23]. This technique involves no rib-spreading and uses variations on stapling the bronchus and vascular structures together without formal dissection. Lewis and colleagues [22] reported a complication rate of 11.2% and 3-year survival of 83%. Of note, almost half of the patients were stage II. Gharagozloo and colleagues [23] reported 179 patients with a 5-year survival of 83%. They performed 29 right upper and middle bilobectomies (16%) in the series. This high number was performed as a conscious decision after some early recurrences in the N1 nodes between upper and middle lobes.
From 2002 to 2007, we have performed approximately 400 VATS lobectomies at our institution without any perioperative deaths, and analyses of the data are ongoing.
Robotic Lobectomy
Robotic surgical technique varies not only by technical details but also by type of robotic equipment used. The most commonly used robotic system is the da Vinci Surgical System, which requires that the surgeon operate on a console separate from the operative field. The surgeon controls 3 arms (2 dissecting arms and a camera port). Other techniques involve voice-controlled robots, such as the Automated Endoscopic System for Optimal Positioning (AESOP) robotic system and Zeus (both from Computer Motion Inc, Goleta, CA), which respond to surgical voice commands to maneuver the camera; the remainder of the procedure is performed using VATS techniques. In contrast to the da Vinci system, AESOP and Zeus require the surgeon be physically present at the operative field.
Our experience with robotic lobectomy was published in 2006 [24]. The technique, which uses 3 ports, is described in detail using the da Vinci Surgical System. There were a total of 30 robotic-assisted lobectomy cases. All 5 lobes were resected by this technique. There were no perioperative deaths, but median operative time was 218 minutes.
We have also used the AESOP system on several occasions. This method differs from our standard VATS technique only by having the robot run the camera instead of an assistant. We consider this technique a VATS lobectomy rather than a robotic lobectomy.
Another relatively large series from Italy describes a 4-port technique using the da Vinci Surgical System in 23 patients. Most were lower lobectomies; only one middle lobectomy and one right upper lobectomy were performed. One patient died postoperatively of pulmonary embolism [25].
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Comment |
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Because the published evidence is thin, no definite recommendations can be made. The reality of the situation is that many surgeons are performing the procedure and many patients are requesting it. The data support that VATS lobectomy can be done safely and that the survival of early-stage patients is equivalent to thoracotomy. Data on the postoperative course are mixed, but seem to suggest that VATS patients have less pain and shorter hospital stays.
Differences in indications, technique, and extents of lymph node dissection make comparing across studies difficult. If one can perform the same operation in terms of anatomic dissection and lymph node removal as done through thoracotomy, then it would seem reasonable to offer a VATS lobectomy. The therapeutic role of lymph node dissection will remain unanswered in thoracotomy patients for the time being until the survival results of the recently completely American College of Surgeons Oncology Group (ACOSOG) Z0030 study, comparing mediastinal lymph node dissection with sampling, have matured [30]. However, our own experience as well as that of other centers indicates that a mediastinal node dissection can be similarly performed by VATS as in open thoracotomy [4].
Few studies, however, have been performed specifically to assess the adequacy of lymph node dissection in VATS lobectomy. Sagawa and colleagues [31] conducted an interesting study by performing a VATS lobectomy and mediastinal lymph node dissection with rib-spreading, followed by a conversion to thoracotomy at the same operation to assess the residual lymphatic tissue that remained unresected. In 29 patients, the mass of lymphatic tissue missed by VATS lobectomy was less than 3% of the amount resected, which they judged to be an adequate result. In a more conventional retrospective analysis, Watanabe and colleagues [29] compared 191 VATS lobectomy patients with 159 thoracotomy patients. They demonstrated that the number of nodes dissected was similar in both groups. Shiraishi and colleagues [27] also noted in their small case–control study that the number of mediastinal lymph nodes dissected was similar in VATS and open groups.
Our practice has been to offer VATS lobectomy without rib-spreading to patients with clinical stage I cancers with peripheral tumors sized less than 3 cm in diameter. Relative contraindications include the use of preoperative chemotherapy or radiotherapy. Lobectomy remains the standard of care for all early lung cancers. As such, the use of simultaneous stapling techniques is probably not warranted, particularly in light of the increased number of bilobectomies performed by one center due to the inadequacy of their N1 lymph node removals [22]. It would seem that this is not the same operation as an open lobectomy.
Robotic lobectomy proponents underscore greater technical ease owing to the advantages of three-dimensional optics, a stable camera platform, the elimination of tremor, and instrumentation that provides motion with 7 degrees of freedom. The disadvantages include the lack of tactile feedback, the requirement of another surgeon experienced in VATS to provide retraction at the operating table, and increased nursing support. In addition, the robotic arms must be continuously removed to allow stapling of structures during the venous, arterial, bronchial, and fissural phases of the procedure.
Several questions need to be addressed with regard to robotic-assisted lobectomy compared with VATS lobectomy:
The current data suggest that robotic-assisted VATS resection is feasible but unlikely to be universally adopted unless significant technologic advancements are made that make it more suitable for lobectomy. At this point, a robotic-assisted procedure appears to have no clearcut advantages for the patient compared with VATS [24].
Further study is needed in several areas in minimally invasive thoracic surgery. A large multicenter randomized trial comparing open lobectomy with VATS lobectomy would be ideal; however, the myriad of techniques used by different surgeons would make the standardization of the VATS arm difficult. Quality of life studies with validated instruments need to be performed to ascertain the impact of VATS. Another interesting avenue of investigation that has been embarked on but requires further study is the use of VATS in higher-risk groups to see if they tolerate resection better. Also, with the recent shift in clinical practice to adjuvant chemotherapy for more and more of our patients, there may be some additional benefit to VATS lobectomy if patients are better able to tolerate chemotherapy postoperatively [2].
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This article has been cited by other articles:
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  R. M. Flores, B. J. Park, J. Dycoco, A. Aronova, Y. Hirth, N. P. Rizk, M. Bains, R. J. Downey, and V. W. Rusch Lobectomy by video-assisted thoracic surgery (VATS) versus thoracotomy for lung cancer J. Thorac. Cardiovasc. Surg., July 1, 2009; 138(1): 11 - 18. [Abstract] [Full Text] [PDF]
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 S. C. Tomaszek, S. D. Cassivi, K. R. Shen, M. S. Allen, F. C. Nichols III, C. Deschamps, and D. A. Wigle Clinical Outcomes of Video-Assisted Thoracoscopic Lobectomy Mayo Clin. Proc., June 1, 2009; 84(6): 509 - 513. [Abstract] [Full Text] [PDF]
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 F. Gharagozloo, M. Margolis, and B. Tempesta Robot-Assisted Thoracoscopic Lobectomy for Early-Stage Lung Cancer Ann. Thorac. Surg., June 1, 2008; 85(6): 1880 - 1886. [Abstract] [Full Text] [PDF]
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