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New Technology

Microthoracoscopic One-Port Method for Lung Cancer

Division of General Thoracic Surgery, Department of Surgery, Tokai University School of Medicine, Isehara, Kanagawa, Japan

Accepted for publication September 30, 2008.

^_* Address correspondence to Dr Iwazaki, Division of General Thoracic Surgery, Department of Surgery, Tokai University School of Medicine, Isehara, Kanagawa, 2591193, Japan (Email: iwasaki{at}is.icc.u-tokai.ac.jp).

	Abstract

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Purpose: We investigated whether the one-window method for thoracoscopic operations is possible as an operation for early-stage lung cancer.

Description: The subjects were the 40 patients in whom ND2 lymph node dissection was performed among those with a preoperative diagnosis of stage IA (T1 N0 M0) lung cancer who underwent thoracoscopic operations in our hospital during the 2-year period from January 2001 to December 2002. With the patient in the lateral position, a Thoraco Holder (Fuji Systems Corp, Tokyo, Japan) was inserted between the fourth and fifth intercostal space on the anterior axillary line. The surgeon used it as a port for performing the surgical maneuvers. An access needle was placed in the auscultatory triangle in the fifth intercostal space, and a 3-mm thoracoscope was used. Pulmonary lobectomy and mediastinal dissection were performed in the same manner as the standard thoracoscopic two-windows method.

Evaluation: The one-window technique was successful in 38 patients, and conversion to the two-windows method occurred in the other 2. Mean operation time was 2 hours 18 minutes. A mean number of 16.5 lymph nodes were removed, and mean blood loss was 22 mL. All 40 patients are alive and free of recurrence at 5 or more years since the operation.

Conclusions: As a result of mastering the operation and developing improved instruments, pulmonary lobectomies can now be performed by the one-window method. This method is the least invasive method of pulmonary cancer surgery available at the present time.

	Technology

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In January 1991 we introduced thoracoscopic surgical techniques into the field of thoracic surgery. In July 1993 we devised an operation by the two-windows method in which ports are created at a mere two sites in the thoracic wall. We began with benign diseases, and we expanded its application to malignant tumors and devised the thoracoscopic two-windows method for primary lung cancer [1].

In February 2001 we went on to develop the even less invasive one-window method (Fig 1), in which all of the maneuvers are performed through a single port. In this method, a 3-mm-diameter thoracoscope is inserted first. After confirming the absence of any adhesions in the pleural cavity, a 2-cm operating port is created, and all of the surgical maneuvers are done through this port. As a result, we think this method is the least invasive surgical procedure for lung cancer currently available. This study was performed according to the principles of the Helsinki Declaration. The Institutional Review Board of Tokai University School of Medicine approved this study and waived the need for patient consent.

View larger version (110K): [in this window] [in a new window]   Fig 1. Thoracoscopic one-window and puncture method.

	Technique

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Operations were performed after obtaining sufficient informed consent from every patient. All operations were performed under general anesthesia during one-lung ventilation with a Univent (Fuji Systems Corp, Tokyo, Japan) [2]. The patients were in the lateral position during the procedure, which made it possible to switch to standard thoracotomy (posterolateral thoracotomy) at any time.

First, an access needle (Ethicon Endosurgery, Cincinnati, OH) was inserted between the fourth and fifth intercostal space on the anterior axillary line. The pleural cavity was examined with a 3-mm, 45° scope (Karl-Storz, Tuttlingen, Germany) to determine adhesion status. Next, an access needle was inserted near the auscultatory triangle in the fifth intercostal space. From this port the assistant secured the intraoperative field of view with the scope. Then, an approximately 2-cm working port was created on the anterior axillary line between in the fourth and fifth intercostal space, and a Thoraco Holder (Fuji Systems Corp) was inserted [3]. Fine blood vessels were double ligated with 3-0 silk sutures. An automatic stapler (ENDO GIA multifire 30-2.8; Covidien, Norwalk, CT) was used to deal with many of the blood vessels, and an Endobag (Covidien) was used to remove the lobe from the pleural cavity.

Mediastinal lymph node dissection was performed immediately after the lobectomy. After confirmation that there were no air leaks or bleeding before closing the chest, a chest tube was inserted through the surgical wound on the surgeon's side, and the operation was concluded.

	Clinical Experience

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No incisions except for the single working Thoraco Holder were necessary in 38 patients and the one-window method was possible. Because of the interlobar formation in the 2 patients with complete failure of lobation, a switch was made to the two-windows method. Some pleural adhesions were found in 3 patients, but dissection by the thoracoscopic technique was possible, and no conversions were made to the thoracoscopic two-windows method or to standard thoracotomy because of pleural adhesions.

The mean duration of time required for the operation was 2 hours 18 minutes (range, 56 minutes to 2 hours 59 minutes) A mean of 16.5 lymph nodes (range, 12 to 28) were removed by mediastinal lymph node dissection. The postoperative histopathologic examinations resulted in a diagnosis of N0 in 35 patients, N1 in 1, and N2 in 4. The mean volume of blood loss was 22 mL (range, 5 to 62 mL). A mean number of 2.4 ENDO GIA 30-2.8 staples was used. No additional suturing was necessary in any patient. The failure of lobations were dealt with by using an ENDO GIA Universal 45-3.5 (Covidien) or an ETS 45-3.5, and a mean of 0.86 cartridges were needed.

Pulmonary function was evaluated by measuring forced expiratory volume (FEV), FEV in 1 second, (FEV₁), and forced expiratory volume % in one second (FEV1.0%) before and 1 month postoperatively. The preoperative results were FEV, 2.81 ± 0.68 L; FEV₁ 3.46 ± 0.6 L; and FEV1.0%, 82.2% ± 26.5%. The evaluation of pulmonary function 1 month postoperatively yielded FEV, 2.59 ± 0.5 L; FEV₁, 2.65 ± 0.8 L; and FEV1.0%, 78.2% ± 6.7%. All patients received epidural anesthesia for pain management during the first 2 days postoperatively, but no analgesics were required subsequently. The thoracotomy tube was removed 2 days after the operation in 38 patients, but an air fistula was present in the other 2 patients 5 days or more postoperatively.

	Comment

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Pulmonary lobectomy for lung cancer was performed by video-assisted thoracoscopic surgery (VATS) for the first time in 1993 [4–6]. The thoracoscopic surgery designed to reduce invasion of the thoracic wall was a revolutionary method [4, 6], and Lewis [5] particularly emphasized the low invasiveness of the thoracic wall. In Japan, thoracoscopic lobectomy for lung cancer was introduced at various institutions in 1993, and 14 years have passed since then. With the exception of our institution, all of the operations require 3 or more skin incisions for access to the pleural space. Many surgeons soon supported thoracoscopic operations for lobectomy, but even now there is controversy regarding the performance of mediastinal lymph node dissection thoracoscopically.

The first systematic mediastinal lymph node dissection was performed thoracoscopically in 1994 [7]. At that time, we developed the two-windows method and performed mediastinal lymph node dissection with the conventional surgical instruments that we used during standard thoracotomy. We showed that dissection equivalent to that performed during standard thoracotomy was possible [8].

As of the year 2000, the two-windows method that we developed caused the least surgical invasion among the operations available for lung cancer. Because postoperative pain has a major effect on the speed of the patient's return to a normal life in society and on the degree of limitation of activities of daily living, performing the thoracoscopic operation adequately while minimizing the thoracotomy procedure was the direction that should be aimed for in lung cancer surgery.

We initially made skin incisions just large enough to insert a single hand into the pleural cavity and performed operations with thoracoscopic insertion ports at 2 sites. In the beginning we performed the operations by making a 6-cm incision on the surgeon's side and a 3-cm incision on the assistant's side. We then reduced the size of both incisions even further, and as we acquired proficiency in performing the operation, devised a method that used 2 Thoraco Holders in the fourth intercostal space centered on the subscapular angle; that is, the two-windows method [1, 2]. With the two-windows method, not only are there just 2 small surgical scars visible on the skin and little invasion of the respiratory muscles, but it is possible to perform mediastinal lymph node dissection equivalent to that performed during the standard thoracotomy operation [8].

Because the two-windows method enables identification of the tracheal bifurcation directly below, it is easy to observe the status of the dissection, and the procedure is safe, with little risk of bleeding. It is also superior in every respect to the standard thoracotomy method as an operation for stage IA lung cancer in terms of blood loss, operation time, postoperative pain, and length of hospital stay; it is also more economical [3, 4].

The one-window technique is an even better method. There are no differences from the two-windows method in terms of operation time, blood loss, and number of staplers used, but the results obtained have shown that the one-port method is superior from the standpoint of postoperative pain and pulmonary function. The skin incision is approximately 2 cm long, and the operation can be performed through just the single port. However, because of the need to remove the resected lung from the body and the need to use automatic anastomosis devices, it is impossible to make the skin incision any smaller at the present time.

For patients with poor pulmonary function, elderly patients, and patients with complications, and even in the patients in whom the performance an operation for stage IA lung cancer is impossible by the conventional method, the thoracoscopic one-window method is less invasive, and we think the indications can be extended.

We used the Univent for differential lung ventilation intraoperatively in every case. The tube is particularly useful in thoracoscopic procedures. If the Univent is used, the lobe to be resected can be selectively maintained in an atelectatic state, and the operation is possible while the other lobes are ventilated, even in patients with poor pulmonary function [2]. Moreover, by continuously aspirating the inside of the blocker, complete pulmonary collapse can be achieved intraoperatively. Incomplete lung collapse creates a major impediment to surgical maneuvers during thoracoscopic procedures and prolongs blood loss and operation time [9, 10]. Collaboration with the anesthesiologist plays a major role in whether the operation is successful [11–13]. The thoracoscopic one-port method is a superior method that is capable of application to a wide variety of intrathoracic diseases, and we think that in the future it should be regarded as one of the choices of surgical methods.

	Disclosures and Freedom of Investigation

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The authors had full control of the design of this study, methods used, outcome measurements, analysis of data, and production of the written report.

	Footnotes

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^Disclaimer The Society of Thoracic Surgeons, the Southern Thoracic Surgical Association, and The Annals of Thoracic Surgery neither endorse nor discourage use of the new technology described in this article.

	References

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1. Iwasaki M, Nishiumi N, Maitani F, Kaga K, Ogawa J, Inoue H. Thoracoscopic surgery for lung cancer using the two small skin incisional method J Cardiovasc Surg 1996;37:79-81.[Medline]
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4. Kirby JT, Mack JM, Landreneau JR, et al. Initial experience with video-assisted thoracoscopic lobectomy Ann Thorac Surg 1993;56:1248-1253.[Medline]
5. Lewis JR. The role of videoassisted thoracic surgery for carcinoma of the lung: wedge resection to lobectomy by simultaneous individual stapling Ann Thorac Surg 1993;56:762-768.[Abstract/Free Full Text]
6. McKenna JR. Lobectomy by video-assisted thoracic surgery with mediastinal node sampling for lung cancer J Thorac Cardiovasc Surg 1994;107:879-882.[Abstract/Free Full Text]
7. Lewis RJ, Caccavale RJ. Video-assisted thoracic surgical non-rib spreading simultaneously stapled lobectomy Semin Thorac Cardiovasc Surg 1998;10:332.[Medline]
8. McKenna Jr RJ. VATS lobectomy with mediastinal lymph node sampling or dissection Chest Surg Clin North Am 1995;4:223.
9. Leschber G, Holinka G, Linder A. Video-assisted mediastinoscopic lymphadenectomy (VAMLA)--a method for systematic mediastinal lymph node dissection Eur J Cardiothorac Surg 2003;24:192-195.[Abstract/Free Full Text]
10. Iwasaki M, Kaga K, NIshiumi N, Maitani F, Inoue H. Experience with the two-windows method for mediastinal lymph node dissection in lung cancer Ann Thorac Surg 1998;65:800-802.[Abstract/Free Full Text]
11. Nomori H, Horio H, Naruke T, et al. What is the advantage of thoracoscopic lobectomy over a limited thoracotomy procedure for lung cancer surgery? Ann Thorac Surg 2001;72:879-884.[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): Hiroshi Inoue Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Iwazaki, M. Articles by Inoue, H. Search for Related Content PubMed PubMed Citation Articles by Iwazaki, M. Articles by Inoue, H. Related Collections Lung - cancer