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Surgical approaches employed in the management of patients with lung cancer are still evolving. Conventional approaches, including posterolateral thoracotomy and muscle-sparing thoracotomy, remain the standard for the majority of patients with resectable lung cancer. Minimally invasive procedures, however, may be employed in selected patients with early-stage lung cancer, to minimize operative morbidity without sacrificing oncologic efficacy.
Minimally invasive procedures utilizing operative telescopes and video technology may be described as thoracoscopic procedures or video-assisted thoracic surgery (VATS). For clarity, the terms “VATS” or “thoracoscopic” refer to totally thoracoscopic approaches, where visualization is dependent on video monitors, and rib spreading is avoided. Thoracoscopic lobectomy is defined as the anatomic resection of an entire lobe of the lung, using a videoscope and an access incision, without the use of a mechanical retractor and without rib spreading.
To be considered a viable alternative to conventional lobectomy, thoracoscopic lobectomy must be applied with the same oncologic principles: individual vessel ligation, complete anatomic resection with negative margins, complete hilar lymph node dissection, and appropriate management of the mediastinal lymph nodes. The advantages of minimally invasive resection include decreased postoperative pain, shorter chest tube duration, shorter length of stay, preserved pulmonary function, and superior cosmetic result when compared with lobectomy via open thoracotomy.
The indications for thoracoscopic lobectomy are similar to those for lobectomy using the open approach: patients with known or suspected lung cancer (clinical stage I) that appears amenable to complete resection by lobectomy. Preoperative staging and patient selection for thoracoscopic lobectomy should be conducted as for conventional thoracotomy. Tumor size may preclude the option of thoracoscopic lobectomy in some patients, as some large specimens may not be amenable to removal without rib spreading; however, no absolute size criteria are used.
Absolute contraindications to thoracoscopic lobectomy include the inability to achieve complete resection with lobectomy, T3 or T4 tumors, N2 or N3 disease, and inability to achieve single-lung ventilation. Relative contraindications include tumors that are visible at bronchoscopy, the presence of hilar lymphadenopathy that would complicate vascular dissection (benign or malignant), prior thoracic irradiation, and the use induction therapy. Prior thoracic surgery, incomplete or absent fissures, and benign mediastinal adenopathy should not be considered contraindications.
Strategy for thoracoscopic lobectomy
After bronchoscopy and mediastinoscopy (when indicated), single-lung anesthesia is established using a dual lumen endotracheal tube or bronchial blocker. The patient is positioned in full lateral decubitus position with slight flexion of the table at the level of the hip, which provides splaying of the ribs to improve thoracoscopic access and exposure. Before sterile preparation and draping, the chest is marked for the placement of thoracoscopic incisions.
The most significant difference between thoracoscopic lobectomy and conventional lobectomy is the strategy of performing dissection beginning anteriorly and continuing posteriorly. Whereas most surgeons perform open lobectomy by dissecting within the fissure to gain access to the arterial branches, thoracoscopic lobectomy is performed entirely within the hilum, and the fissure is not completed until all hilar structures are divided.
Most surgeons use 3 or 4 incisions, although lobectomy can usually be accomplished using only 2 incisions. The first incision, a 10 mm port-access used predominantly for the thoracoscope, is placed in the 7th or 8th intercostal space in the mid-axillary line. The second incision, an anterior access incision (4.5–6.0 cm) for dissection and specimen retrieval, is placed in the 5th or 6th intercostal space, just inferior to the breast and pectoralis major. The location of this incision, where the intercostal spaces are the widest, is chosen to provide access for hilar dissection and is usually not dependent on whether the planned procedure is an upper or lower lobectomy. Additional incisions may be employed, either in the axilla or posteriorly, to improve visualization or to provide retraction (Fig 1).
After the placement of the second incision, the surgeon performs thoracoscopic exploration, which includes confirmation of the location of the tumor, exclusion of the presence of pleural metastases, and division of the pulmonary ligament. If a malignant diagnosis has not been achieved preoperatively, thoracoscopic wedge resection is performed using an automatic stapling device, and the specimen is removed in a protective bag. After frozen section confirms a malignant diagnosis, thoracoscopic lobectomy may then be completed. Mediastinal lymph node dissection may be performed at this point or may be deferred until the lobectomy is completed.
The location of these incisions is chosen so that they do not compete with each other, yet still provides adequate visualization of the hilum. Of note, the stapling device may be placed through either incision to provide the best angle to some of the hilar structures. Instrumentation for thoracoscopic lobectomy is critical to successful completion of the procedure. The thoracoscope should be a 30-degree angled scope, to optimize the ability to achieve panoramic visualization during dissection and to minimize competition with the operative instruments. A spectrum of surgical instruments may be employed for dissection, including conventional instruments and dedicated thoracoscopic or laparoscopic instruments. It is especially beneficial to use long, curved instruments for retraction and dissection, as it will minimize the tendency for instruments to compete or collide with each other. Thoracoscopic (linear) mechanical staplers, such as the EndoGIA (U.S. Surgical, Norwalk, CT), are employed for control of the vessels (2.0 or 2.5 mm staples), bronchus (3.5 or 4.8 mm staples) and fissure (Fig 2).
Hilar dissection is performed through the access incision, to achieve visualization and mobilization of the hilar structures. For any anatomic thoracoscopic lobectomy, hilar dissection is begun with mobilization of the pulmonary vein. For upper lobectomy, the lung is reflected posteriorly and inferiorly to facilitate dissection. For lower lobectomy, the lung is retracted superiorly. Moving the thoracoscope to the anterior incision may improve visualization of the superior hilum and facilitate placement of the linear stapler for upper lobectomy.
The risk of intraoperative hemorrhage is minimized with careful hilar dissection, which is facilitated by the visual clarity and magnification available with the video thoracoscope. Unexpected bleeding from a major branch of the pulmonary artery or pulmonary vein may occur, however. In most cases, the source of the bleeding is easily identifiable and tamponade is possible, allowing conversion to thoracotomy if necessary. To minimize the risk of vascular injury, surgeons have employed a variety of techniques to isolate the pulmonary arterial and venous branches, including ligatures to retract the vessels and catheters to guide the stapling devices. These techniques may be helpful in difficult cases, but are not required for the majority of patients.
All lobectomy specimens are removed using a protective specimen bag, to prevent implantation of tumor cells in the incision. The lobectomy specimen and hilum are each inspected to ascertain that anatomic lobectomy has been performed. After retrieval, the hemithorax is irrigated with warm saline, and the bronchial stump is inspected. If an air leak is encountered, repeat stapling or endoscopic suturing may be performed.
Left upper lobectomy
With the thoracoscope in the mid-axillary incision, the horizontal and oblique fissures are inspected and the presence of the tumor in the left upper lobe is confirmed. The lung is retracted posteriorly, and the superior pulmonary vein is identified and mobilized. The left superior pulmonary vein is then encircled using a curved clamp; dissection behind the superior pulmonary vein allows identification of the pulmonary artery (Fig 3). The stapling device is then applied, and the superior pulmonary vein is divided, exposing the pulmonary artery.
The apical and anterior branches of the left pulmonary artery are then mobilized, a maneuver that is facilitated by the dissection of the hilar node at the anterior aspect of the upper lobe bronchus. These branches are then stapled and divided. If not included within the apical-anterior trunk, a posterior artery may now be visualized, stapled and divided (Fig 4).
The left upper lobe bronchus is now visualized and may be stapled and divided. Alternatively, when the bronchus appears more anterior that the apical and anterior arterial branches, management of the bronchus may be completed first (Fig 5).
Subsequently, the lingular branches are stapled. Finally, the fissures are completed and the specimen is retrieved (Fig 6).
Right upper lobectomy
Right upper lobectomy is slightly more difficult than left upper lobectomy, because both the horizontal and oblique fissures must be managed. With the thoracoscope in the mid-axillary incision, the horizontal and oblique fissures are inspected and the presence of the tumor in the right upper lobe is confirmed. After division of the pulmonary ligament, it is helpful to continue the dissection posteriorly by dividing the posterior pleural reflection to the level of the azygos vein, exposing the bifurcation of the upper lobe bronchus and intermediate bronchus (Fig 7).
The right lung is retracted posteriorly, and the superior pulmonary vein is identified and mobilized, to identify the division between the middle lobe and upper lobe venous branches. The upper lobe branches are encircled using a curved clamp; dissection behind the superior pulmonary vein allows identification of the pulmonary artery. The stapling device is then applied and the vein is divided, exposing the pulmonary artery (Fig 8).
The pulmonary artery is mobilized, and the apical anterior trunk (truncus anterior) may then be stapled and divided (Fig 9).
The right bronchus is now exposed, and the upper lobe bronchus may be stapled and divided (Fig. 10). Subsequently, the posterior ascending arterial branch is stapled. Finally, the fissures are completed and the specimen retrieved (Fig. 11).
Right middle lobectomy
With the thoracoscope in the mid-axillary incision, the horizontal and oblique fissures are inspected and the presence of the tumor in the middle lobe is confirmed. The lung is retracted posteriorly, and the superior pulmonary vein is identified and mobilized, to identify the division between the middle lobe and upper lobe venous branches.
The middle lobe vein is encircled and stapled, exposing the middle lobe bronchus and artery. Retraction of the middle lobe superiorly and posteriorly optimizes exposure of the bronchus (Fig 12).
At this point, the bronchus is encircled and stapled, further exposing the middle lobe artery. The middle lobe artery is then stapled and divided as well, allowing completion of the fissures (Fig 13).
Lower lobectomy (right or left)
The strategy for lower lobectomy is similar on the right and left sides. With the thoracoscope in the mid-axillary incision, the presence of the tumor in the lower lobe is confirmed. The lung is retracted anteriorly, and the posterior pleural reflection is incised. The lung is then retracted superiorly and posteriorly, to incise the pleura overlying the inferior pulmonary vein, which may then be encircled and stapled, after ascertaining that the superior segment branch is included in the dissection. Further superior retraction of the lower lobe improves exposure of the bronchus, at the bifurcation of the lower lobe bronchus and the middle lobe bronchus (right lung) or lingular bronchus (left lung) (Fig 14).
Dissection of the bronchus with development of the plane between the bronchus and artery is performed with visualization of the artery. The lower lobe bronchus is then encircled and stapled, exposing the lower lobe arterial trunk, which is then stapled and divided. Finally, the fissure is completed and the specimen retrieved (Fig 15).
The safety and efficacy of thoracoscopic lobectomy for patients with early-stage lung cancer has been established.
Although there are no prospective, randomized series that compare thoracoscopic lobectomy to conventional approaches, a sufficient number of series have been published, both single-institution and multi-institution experiences, to conclude that thoracoscopic lobectomy is a reasonable strategy for patients with clinical stage I lung cancer.
Daniels and colleagues reported the results of thoracoscopic lobectomy in 110 consecutive patients.
The 30-day mortality was 3.6%, with no intraoperative deaths. The conversion rate was 1.8%, and none were emergent. The median chest tube duration was 3 days and median length of stay was 3 days. The Cancer and Leukemia group B (CALGB) reported on the results of a multi-institutional series of 97 patients who underwent thoracoscopic lobectomy.
In this series, the mortality was 2%, the operative time was 130 minutes, and the median length of stay was 3 days. Numerous other series have been published. In summary, thoracoscopic lobectomy has been demonstrated to be equivalent in terms of safety and oncologic efficacy, as measured by complete resection rate, operative time, extent of lymph node dissection, operative mortality, and short-term survival, when compared with published results for thoracotomy and lobectomy.
Minimally invasive approaches to lung cancer treatment have been demonstrated to be safe and effective for patients with early-stage lung cancer. Thoracoscopic lobectomy is designed to achieve the same oncologic result as conventional lobectomy: complete hilar dissection and individual vessel control. The recognized advantages of thoracoscopic anatomic resection include less short-term postoperative pain, shorter hospital stay, and preserved pulmonary function. Although there are no prospective randomized studies comparing the thoracoscopic approach to conventional thoracotomy, there is no data from published series to suggest any difference in oncologic efficacy.