Ann Thorac Surg 2008;85:S729-S732. doi:10.1016/j.athoracsur.2007.12.001
© 2008 The Society of Thoracic Surgeons
Supplement: The Minimally Invasive Thoracic Surgery Summit
Video-Assisted Thoracic Surgery Sleeve Lobectomy: A Case Series
Ali Mahtabifard, MD*,
Clark B. Fuller, MD,
Robert J. McKenna, Jr, MD
Department of Thoracic Surgery, Cedars-Sinai Medical Center, Los Angeles, California
* Address correspondence to Dr Mahtabifard, Cedars-Sinai Medical Center, 8635 W Third St, Ste 975W, Los Angeles, CA 90048 (Email: mahtabifarda{at}cshs.org).
Presented at the Minimally Invasive Thoracic Surgery Summit, New York, NY, June 8–9, 2007.
| Dr McKenna discloses that he has a financial relationship with Ethicon, Inc.
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Abstract
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Background: As thoracic surgery moves towards more minimally invasive procedures, such as video-assisted thoracic surgery (VATS) lobectomy, conversion from a VATS to open thoracotomy has been required for a sleeve resection. This article reports a large experience of VATS sleeve lobectomy.
Methods: We reviewed our thoracic surgery database of more than 1500 VATS lobectomies for VATS sleeve resections. Preoperative, operative, and perioperative outcome variables, including morbidity and mortality were examined.
Results: Identified were 13 patients (median age, 59 years; range, 16 to 82 years) who underwent VATS sleeve lobectomy. There were no conversions to thoracotomy. Diagnoses included non-small cell lung cancer in 8 patients, typical carcinoid in 4, and metastatic sarcoma in 1 patient. Median tumor size was 2.1 cm (range, 0 to 6.6 cm). Median data were operative time, 167 minutes (range, 90 to 300 minutes); blood loss, 250 mL (range, 75 to 800 mL); chest tube drainage, 692 mL (range, 459 to 1590 mL); and chest tube duration, 3 days (range, 2 to 6 days). Median intensive care unit stay was 0 days (range, 0 to 4 days), and median hospital stay was 3 days (range, 2 to 8 days). No complications occurred in 9 patients (69%). Morbidity in the remaining 4 patients included 1 patient each with atrial fibrillation, anastomotic stricture, reintubation, and bronchial tear requiring repair. There were no deaths at 30 days.
Conclusions: In experienced centers, VATS sleeve lobectomy is possible with acceptable morbidity and mortality as well as short length of stay.
Video-assisted thoracic surgery (VATS), for many reasons, is an appealing alternative to thoracotomy. In recent years, the momentum to perform minimally invasive pulmonary resections has grown in the field of general thoracic surgery. The worldwide experience with VATS lobectomy for early stage lung cancer is now sufficiently large enough to compare this procedure with open thoracotomy. Although no large randomized study has directly compared VATS lobectomy with conventional lobectomy by thoracotomy, the evidence in the literature is mounting in favor of VATS lobectomy. The literature shows that in the hands of experienced thoracoscopic surgeons, VATS lobectomy is a safe operation that offers patients at least comparable complication [1–3] and survival rates [1, 4–8] as with lobectomy by thoracotomy.
The VATS lobectomy has numerous advantages, including smaller incisions, decreased postoperative pain [9, 10], shorter length of stay, decreased chest tube output and duration [1, 11], decreased blood loss [11], better preservation of pulmonary function [12, 13], and earlier return to normal activities [2, 11]. These results are obtained without sacrificing the oncologic principles of thoracic surgery. In fact, there is evidence that VATS lobectomy may even offer reduced rates of complications and better survival [1–8].
The VATS lobectomy is not an easy operation, however, and even straightforward lobectomies require mature thoracoscopic skills. As such, until recently the need for any type of sleeve resection has been an absolute contraindication for VATS lobectomy and has forced conversion to thoracotomy. In fact, to date only one case of VATS sleeve lobectomy has been reported for a mucoepidermoid carcinoma of the left lower lobe [14].
As our experience with VATS lobectomy has grown (currently greater than 1500 cases), our list of relative contraindications has simultaneously diminished. In an effort to offer the advantages afforded by VATS lobectomy to patients who would otherwise require a thoracotomy, we have performed VATS sleeve lobectomy and no longer view the need for a sleeve resection or bronchoplasty as an absolute indication for thoracotomy. This article presents our current experience with VATS sleeve lobectomy.
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Material and Methods
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We reviewed our thoracic surgery database of more than 1500 VATS lobectomies for sleeve resections. The office charts and hospital records were reviewed. Preoperative, operative, and postoperative variables were recorded.
Operative Procedure
We have previously reported the technical details of the various lobectomies and will forego that discussion here by directing the reader to the appropriate references [15–17]. The main difference in the conduct of the operation between VATS lobectomy and VATS sleeve lobectomy is the need for a bronchial anastomosis. With gentle manipulation, all aspects of the lung and therefore all lesions can be directly palpated through the utility incision. Trocars are not used except for the camera port. The entire operation is then performed with conventional long instruments that are available in any operating room and are familiar to the thoracic surgeon.
If present, adhesions are taken down with the long electrocautery, and the entire lung is fully mobilized. Next, dissection of the hilar structures is begun, with visualization solely on the monitor. The clarity and magnification that is afforded by modern day optics provides a comprehensive view of all hilar structures. The pulmonary vein and artery are individually identified, dissected, isolated, and stapled (Ethicon, Cincinnati, OH). Articulation of the stapler is unnecessary because proper placement of the incisions at the outset provides optimal angles.
The bronchus is addressed last; the inferior pulmonary ligament is incised to allow for further mobilization of the lung to decrease any tension on the anastomosis. The bronchus is identified and dissected. Next, a 15-blade scalpel on a long handle through the utility incision is used to transect the bronchus proximal and distal to the tumor. The fissure is then completed, and once the lobe is completely disconnected, it is placed in a Lap Sac (Cook Urological, Spencer, IN) and brought out through the utility incision.
Although the fissure is usually completed after the vessels and the bronchus are transected, one should not hesitate to complete the fissure earlier if this maneuver provides better access to the vessels or the bronchus. A largely fused fissure is not a contraindication to VATS lobectomy and, in fact, should not alter the conduct of the operation in any way.
Stay sutures can now be placed in the bronchus, and the two ends of the bronchus are then brought together using interrupted 3-0 Vicryl suture (Ethicon). The posterior row is completed first, followed by the anterior row (Fig 1). A complete mediastinal lymph node dissection is then done thoracoscopically, which is outlined in prior publications [15–17]. The chest is then irrigated, and the anastomosis is checked for an air leak under water. Two 28F chest tubes are placed and the incisions are closed. Postoperative bronchoscopy is then performed to clear the airways of blood and secretions before extubation.
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Fig 1. The construction of the anastomosis between the intermediate bronchus and the main stem bronchus. This is performed with a standard needle holder through the utility incision as the surgeon looks at the monitor.
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Results
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Preoperative Characteristics
Between June 2002 and July 2007, 13 VATS sleeve lobectomies were performed. Table 1
summarizes patient characteristics. There were 5 men and 8 women, with a median age of 59 years (range, 16 to 82 years). Preoperative mediastinoscopy had been performed in 7 patients and was negative for local metastasis in all cases. Preoperative pulmonary function tests are listed in Table 1. No patient had received neoadjuvant treatment, and 1 had a prior thoracotomy.
Operative Characteristics
Table 2
summarizes intraoperative variables. The most common type of resection was right upper lobe sleeve resection (n = 7), followed by right middle lobe and superior segment of right lower lobe sleeve resection (n = 3) with reimplantation of the distal bronchus intermedius into the basilar segments of the right lower lobe. The median tumor size was 2.3 cm (range, 1.1 to 6.6 cm), median estimated blood loss was 250 mL (range, 75 to 800), and median operative time was 174 minutes (range, 90 to 300 minutes). There were no conversions to thoracotomy, and no blood transfusions were necessary.
Postoperative Characteristics
Table 3
lists the postoperative characteristics, including histology and final pathologic stage of the tumors. The median intensive care unit stay was 0 days (range, 0 to 4 days). Median chest tube drainage was 690 mL (range, 459 to 1351 mL), and median chest tube duration was 3 days (range, 2 to 6 days). Most patients were discharged on the day of chest tube removal, resulting in a median length of stay of 3 days (range, 2 to 8 days).
The histology of the various tumors and their pathologic stage is listed in Table 3 with the most common type being typical carcinoid (n = 4). All were lung primaries but one.
Hospital Course, Morbidity, and Death
The various operative complications are listed in Table 4. There were no intraoperative or postoperative deaths. Nine of the 13 patients had no complications at all. Two of the 9 patients stayed in the intensive care unit for 1 day each. Other complications are as listed. One of the two major complications included a patient who experienced edema and stricture in the left main stem bronchus to left upper lobe anastomotic site and required airway stenting on postoperative day 8. She was discharged on the day of the stenting. The other patient had an anastomotic dehiscence that was clinically evident in the recovery room. The patient had no intraoperative air leak when a water test was performed, but he coughed intensely while awaking from the anesthetic and a large air leak developed. Immediate return to the operating room showed a dehiscence in the posterior membranous portion of the airway that was repaired using interrupted 3-0 Vicryl suture. He went on to do well and was discharged on postoperative day 5.
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Comment
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Since the first VATS lobectomy performed in the early 1990s, many authors worldwide have published reports confirming its safety and advantages. As a result, VATS lobectomy continues to gain popularity among thoracic surgeons for the multiple advantages that it affords patients requiring major thoracic surgery. The advantages of VATS vs thoracotomy for lobectomy are multiple and continue to be well documented in the literature. These include a smaller incision, less pain, reduced chest tube output, decreased blood loss, decreased length of stay, earlier return to activities, and improved quality of life. Furthermore, these advantages are afforded without oncologic compromise and with comparable survival rates [1–13].
Sleeve lobectomy, when required, has been absolute indication for conversion to thoracotomy until recently. Even in experienced centers with considerable experience with VATS lobectomy, the need for a sleeve resection has precluded the minimally invasive approach. To date, one case report of VATS sleeve lobectomy has been published from a group in Italy [14]. As our own experience has grown with VATS lobectomy, our list of absolute and relative contraindications to VATS has shrunk. In an effort to apply all the advantages of minimally invasive procedures to patients who need sleeve resections, we have performed 13 VATS sleeve lobectomies in the past 5 years.
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References
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- Nomori H, Ohtsuka T, Horio H, Naruke T, Suemasu K. Difference in the impairment of vital capacity and 6-minute walking after a lobectomy performed by thoracoscopic surgery, an anterior limited thoracotomy, an antero-axillary thoracotomy, and a posterolateral thoracotomy Surg Today 2003;33:7-12.[Medline]
- Nakata M, Saeki H, Yokoyama N, Kurita A, Takiyama W, Takashima S. Pulmonary function after lobectomy: video-assisted thoracic surgery versus thoracotomy Ann Thorac Surg 2000;70:938-941.[Abstract/Free Full Text]
- Santambrogio L, Cioffi U, De Simone M, Rosso L, Ferrero S, Giunta A. Video-assisted sleeve lobectomy for mucoepidermoid carcinoma of the left lower lobar bronchus: a case report Chest 2002;121:635-636.[Medline]
- Lewis RJ, Caccavale RJ. Video-assisted thoracic surgical non-rib spreading simultaneously stapled lobectomy (VATS(n)SSL) Sem Thorac Cardiovasc Surg 1998;10:332.[Medline]
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Abstract
Introduction
