Ann Thorac Surg 2008;86:323-326. doi:10.1016/j.athoracsur.2008.01.091
© 2008 The Society of Thoracic Surgeons
How To Do It
Technical Tricks to Facilitate Totally Endoscopic Major Pulmonary Resections
Dominique Gossot, MD*
Thoracic Department, Institut Mutualiste Montsouris, Paris, France
Accepted for publication January 28, 2008.
* Address correspondence to Dr Gossot, Thoracic Department, Institut Mutualiste Montsouris, 42 Bd Jourdan, Paris, F-75014, France (Email: dominique.gossot{at}imm.fr).
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Abstract
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Lobectomies using video-assisted thoracoscopic surgery (VATS) are becoming more and more accepted since several recent studies have demonstrated their safety and efficacy for stage I lung cancer. However, "video-assisted thoracoscopic surgery lobectomy" usually means that a utility incision or a mini-thoracotomy is used for insertion of conventional instruments. We use a totally endoscopic approach in which only endoscopic instruments and video display are used. On the basis of our preliminary experience of 81 cases with this approach, we present some technical details that are important for a successful endoscopic procedure.
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Introduction
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Large series of video-assisted thoracoscopic surgery (VATS) lobectomies have recently been reported [1, 2]. The VATS technique means that a utility incision is used for insertion of conventional instruments. Few authors perform totally endoscopic major pulmonary resections, termed a "complete VATS" [3, 4] technique or "closed" technique [5], in which only video-display and endoscopic instrumentation are used. Apart from a retrospective comparative study [3], so far, it has not been demonstrated that this approach may be superior to the more commonly used video-assisted approach, but in some aspects it may be interesting. In this technique, there is no access incision, and the specimen is retrieved through one of the port sites that is enlarged at the end of the procedure. The main obstacles are the fissures that may be partly fused, the risk related to the dissection of large and fragile pulmonary vessels, and eventually the difficulty in completing a radical lymphadenectomy. This full endoscopic approach requires time, a thorough dissection, and use of the appropriate technology. In 2005, Demmy and colleagues [6] proposed troubleshooting guides for surgeons embarking on a VATS lobectomy program. Although most of their recommendations are relevant, they are mainly applicable to a video-assisted technique with an access incision. The aim of our article is to stress several technical details that we have found helpful in completing totally endoscopic lobectomies.
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Technique
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Enhancing Vision and Video-Imaging
During open surgery or VATS, the surgeon usually stands at the patient's back because the anatomical landmarks are more familiar that way. We have found that it is often preferable to stand at the patient's front [7] or to switch from behind to the front, according to the steps of the operation. For instance, it is usually more natural to divide the anterior part of the fissure from the front and its posterior part from behind. This means that at least two monitors should be used.
Because the procedure is long lasting, the endoscope tip may be soiled by blood drops that slide down along the trocar sheath. This annoying issue can be partly overcome by using a 12-mm trocar instead of a 10-mm trocar. Smoke aspiration is achieved by using a 3-mm suction device that is left in place throughout the procedure.
Maintaining optimal vision of the whole operative field with a single 0° optic is almost impossible. One of the main concerns with a direct viewing scope (0°) is the difficulty in controlling the instrument tip, which may be out of the field of vision (Fig 1). Formerly, to overcome this problem, we switched from a direct (0°) to an oblique viewing endoscope (30°) as vision became too tangential. However, these maneuvers were time consuming and tedious. Recently, we changed to a rigid scope with a deflectable tip (Olympus LTF; Olympus, Tokyo, Japan; Fig 2). Its angle of vision varies from 0° to 100°, and the flexibility is controlled by a lever located on the handle. Once chosen, the angulation can be locked. This allows the surgeon to have a bird's-eye view, making dissection more natural and safer. The endoscope tip houses a distal charge-coupled device connected to a high definition television standard camera (Exera II; Olympus) that provides dramatically sharp viewing, thus allowing for close-up vascular dissections.
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Fig 1. Example of the limitation of a direct viewing endoscope (0°) during the division of the fissure during thoracoscopic right upper lobectomy. (A) With a 0° scope, the tip of the endostapler is out of the vision field, (B) although it can be perfectly controlled with a deflectable scope.
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Fig 2. High definition deflectable tip thoracoscope allows performing the whole procedure with a single endoscope and avoids the problems related to tangential vision.
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Dedicated Instrumentation
To avoid conflicts with the instruments or the hands of the assistant, or both, we always use a mechanical telescope holder whose manipulation is easy and does not require locking, because its stability is ensured by a system of weight and counterweight (Olympus SH-1). It is placed at the back of the patient, at the level of the scapula tip, thus avoiding conflict with instrument shafts.
Exposure of the hilum or fissure, or both, may require a number of grasping forceps or retractors (ie, 5-mm ports, or even 10-mm ports) that can be a cause of postoperative pain and discomfort. We have partly overcome this concern by using 3-mm grasping forceps (Fig 3), thus reducing parietal trauma to a minimum.
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Fig 3. Opening the fissure during a thoracoscopic middle lobectomy using 3-mm grasping forceps for better exposure. (ML = middle lobe; RLL = right lower lobe; RUL = right upper lobe.)
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Laparoscopic conventional straight instruments are useful for some steps of the dissection. However, getting "round the corner" is necessary when dissecting large and fragile vessels, such as the pulmonary vein or branches of the pulmonary arteries. Dissection must be as smooth as possible, which means that no traction and no force must be exerted on the vessel. We use a deflectable dissector and grasping forceps (Endoflex; Surgical Innovations, Leeds, United Kingdom; Fig 4). For example, clamping the bronchus or the parenchyma to determine an intersegmental plane is achieved with a dedicated endoscopic 5-mm clamp (Storz, Tuttlingen, Germany; Fig 5).
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Fig 4. Control of the lobar bronchus during a thoracoscopic right upper lobectomy using deflectable grasping forceps to help pass around the bronchus. (RLL = right lower lobe; RUL = right upper lobe.)
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Fig 5. Clamping the parenchyma to determine the intersegmental plane is achieved with a dedicated endoscopic 5-mm clamp (in this case, during a thoracoscopic lingulectomy for carcinoid tumor).
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Guiding and Manipulating Endostaplers
The lack of manual manipulation of lung tissue and instruments may make accurate positioning of staplers difficult, even with articulated ones. It is of utmost importance to load the fissure or the bronchus or the vessels without friction. Two tricks may be used: (1) passing a tape around the vessel so that it can be lifted up, thus helping passing the endostapler smoothly, (2) using a chest tube or a 16-French suction tube [8] (Gentle-Flow, Kendall). Its base is secured to the anvil by simple pressure. This can be done inside or outside the chest. Its distal end is passed around the structure to be divided and pulled out trough the trocar tube. The stapler tip is thus guided around the tissue to be stapled (Fig 6).
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Fig 6. Facilitating the passage of the endostapler for fissure division during a thoracoscopic left basilar segmentectomy using a thin suction catheter as a guide. The fine tip is first passed behind the vessel and pulled out to attract its basis connected to the stapler jaw. (LLL = left lower lobe; LUL = left upper lobe.)
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Hemostasis and Control of Small Vessels
Whenever possible, clips should be avoided because they may slip or conflict with staples. However medium diameter vessels, such as some of the segmental pulmonary branches, are too small for an endostapler and too large to be coagulated with electrocautery or ultrasounds. When clips are used they are always doubled or even tripled. For all other minor vessels, we use ultrasonic shears (EndoSurg; Olympus, Tokyo, Japan). These are also used for dividing the thin external part of the fissure [9] (Fig 7). We had no complication or postoperative air leak, as already stated by authors who have used ultrasonic shears for pulmonary biopsies [10].
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Fig 7. Initiating fissure division using ultrasonic shears during a thoracoscopic left lower lobectomy. (LLL = left lower lobe; LUL = left upper lobe.)
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Lymphadenectomy is done only with the ultrasonic dissector and clips are almost never used. Appropriate use of this technology is necessary to avoid accidental application of the active part of the blade to a vessel, a nerve, or the trachea. A suction device is activated all along the dissection time for immediate evacuation of smoke and mist.
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Results
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We have performed 81 attempts at endoscopic lobectomies and segmentectomies. The indication was benign lesion in 33 patients, metastasis in 27, and stage I lung cancer in 21. There were eight conversions to thoracotomy (10%). Six of these occurred with a benign lesion, because these patients most frequently had inflammation, adherent lymph nodes, or tight pleural adhesions. The causes of conversion were pleural adhesions (2 patients), fused fissure (2 patients), dense inflammation or lymph nodes, or a combination of both (4 patients). None of the conversions occurred because of hemorrhage. In 73 patients who had a totally endoscopic procedure, 68 were lobectomies (right upper lobe, 18; middle lobe, 11; right lower lobe, 16; left upper lobe, 11; left lower lobe, 12) and 5 segmentectomies (right lower lobe superior segment, 3; left lower lobe basilar segment, 1; lingula, 1). The average time for completing resection was 205 minutes (range, 90 to 288 minutes). The average blood loss was 70 cc (range, 0 to 400 cc). For patients operated on for stage I lung carcinoma, the average number of collected lymph nodes was 20 (range, 5 to 31).
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Comment
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Thoracoscopic lobectomies and segmentectomies are technically demanding. There are two key points for a successful operation: (1) having a high-quality video system, (2) using the appropriate instrumentation to have perfect exposure and perform sharp dissection. As mentioned by Kondo and Adachi [7], the thoracoscope can be used in this technique as it used in microscopic surgery, because the surgeon takes profit of the close-up view on dissected elements, especially with the use of high definition camera systems. A full thoracoscopic technique may look more difficult than a video-assisted technique during which a utility incision is sometimes used for insertion of conventional instruments and even direct visualization of the operative field. However, we find some advantages to a pure endoscopic approach in that it allows for high accuracy, step-by-step meticulous hemostasis, and may result in a bloodless field, as demonstrated by Shigemura and colleagues [3]. Using a deflectable endoscope and deflectable instruments gives more degrees of freedom, thus overcoming one of the main limitations of VATS, whereas the trocars are more or less fixed in the chest wall, limiting the field of action of the instruments. One of the questions raised by this approach is: Why make a retrieval incision at the end of the procedure rather than an access incision at the beginning? The answer is twofold: (1) the site of the access incision is usually chosen for a dedicated step, such as hilar dissection or fissure division, so that there are some steps of the procedures where the incision location is not suitable; and (2) the retrieval incision is minimal, it can be located anywhere (eg, in the axilla, it never requires a rib spreader and it is used for a very short time, thus resulting in minimal trauma).
Because it is rarely possible to limit the number of ports to three (in our experience, four to five ports are needed), it is crucial that the operative field is not burdened with the hands of a camera man. This is the reason we always perform thoracoscopy in a solo-surgery manner with a scope holder. In addition, this allows for a stable image and to free the hands of the potential camera man. The development of dedicated and sophisticated instrumentation seems a prerequisite for the growth of this technique.
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Acknowledgments
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Part of the equipment (deflectable thoracoscope) used for evaluation was provided free of charge by Olympus. No funding was given and the authors have no financial support from the company. All other items mentioned in this article were purchased by our institution on the basis of the market.
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References
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- McKenna R, Houck W, Fuller C. Video-assisted thoracic surgery lobectomy: experience with 1100 cases Ann Thorac Surg 2006;81:421-426.[Abstract/Free Full Text]
- Onaitis M, Petersen R, Balderson S, Toloza E, Burfeind W, Harpole D, D'Amico T. Thoracoscopic lobectomy is a safe and versatile procedure: experience with 500 consecutive patients Ann Surg 2006;244:420-425.[Medline]
- Shigemura N, Akashi A, Funaki S, et al. Long-term outcomes after a variety of video-assisted thoracoscopic lobectomy approaches for clinical stage 1A lung cancer: a multi-institutional study J Thorac Cardiovasc Surg 2006;132:507-512.[Abstract/Free Full Text]
- Shiraishi T, Shirakusa T, Miyoshi T, Hiratsuka M, Yamamoto S, Iwasaki A. A completely thoracoscopic lobectomy/segmentectomy for primary lung cancer: technique, feasibility and advantages Thorac Cardiovasc Surg 2006;54:202-207.[Medline]
- Oda M, Ishikawa N, Tsunezuka Y, et al. Closed three-port anatomic lobectomy with systematic nodal dissection for lung cancer Surg Endosc 2007;21:1464-1465.[Medline]
- Demmy T, James T, Swanson S, McKenna R, D'Amico T. Troubleshooting video-assisted thoracic surgery lobectomy Ann Thorac Surg 2005;79:1744-1753.[Abstract/Free Full Text]
- Kondo K, Adachi H. Minimally invasive surgery for lung cancer using thoracoscope as a "microscopic surgery" for the safety endoscopic surgery Kyobu Geka 2006;59:703-709.[Medline]
- Ito N, Suda T, Inoue T, et al. Use of a soft silicone tube guide for an automatic suture device in video-assisted lung lobectomy J Thorac Cardiovasc Surg 2005;130:931-932.[Free Full Text]
- Tanaka K, Hagiwara M, Kondo Y, et al. Usefulness of ultrasonically activated scalpel for pulmonary resection in video-assisted thoracoscopic surgery Kyobu Geka 2006;59:1171-1175.[Medline]
- Molnar T, Benko I, Szanto Z, Laszlo T, Horvath O. Lung biopsy using harmonic scalpel: a randomised single institute study Eur J Cardiothor Surg 2006;28:604-606.
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Abstract
Introduction
