Advertisement

Technique of Video-Assisted Thoracoscopic Chest Wall Resection

      Operative procedures used for cancerous chest wall invasion involve complete resection of the lung mass en bloc with adjacent segments of ribs, traditionally involving a potentially disfiguring resection, lengthy hospitalization, and a painful and protracted recovery period. As video-assisted thoracoscopic surgery experience has grown, the proportion of patients deemed suitable for this type of approach as opposed to the traditional thoracotomy for lung resection has increased. Although experience with this approach is still emerging, there is sufficient evidence demonstrating decreased morbidity and hospital stays with oncologic equivalency.
      • Paul S.
      • Altorki N.K.
      • Sheng S.
      • et al.
      Thoracoscopic lobectomy is associated with lower morbidity than open lobectomy: A propensity-matched analysis from the STS database.
      • Villamizar N.R.
      • Darrabie M.D.
      • Burfeind W.R.
      • et al.
      Thoracoscopic lobectomy is associated with lower morbidity compared with thoracotomy.
      • Yan T.D.
      • Black D.
      • Bannon P.G.
      • et al.
      Systematic review and meta-analysis of randomized and nonrandomized trials on safety and efficacy of video-assisted thoracic surgery lobectomy for early-stage non-small-cell lung cancer.
      As thoracoscopic resection for lung cancer evolved and became our predominant approach with the ability to perform an equivalent dissection to open procedures, we have naturally extended its indications to more complex situations. There have been few reports of thoracoscopic chest wall resection in an en bloc fashion, possibly because the perception that any benefit gained by avoiding rib spreading and the incision of other chest wall tissue would be eclipsed by perturbing the rib cage.
      • Demmy T.L.
      • Nwogu C.E.
      • Yendamuri S.
      Thoracoscopic chest wall resection: What is its role?.
      • Widmann M.D.
      • Caccavale R.J.
      • Bocage J.P.
      • et al.
      Video-assisted thoracic surgery resection of chest wall en bloc for lung carcinoma.
      For those interested in pursuing en bloc thoracoscopic resection, patients whose chest wall invasion lies near enough to an access incision favorable for lung resection and who require resection of 4 or fewer ribs are optimal candidates. The staging workup for all patients with chest wall invasion includes preoperative computed tomography scans in addition to positron emission tomography demonstrating no evidence of metastatic disease prior to being considered for chest wall resection. Moreover, preoperative imaging should demonstrate that the musculature and soft tissues superficial to the rib are uninvolved.
      Patients with larger tumors or with hilar lymph node involvement may not be suitable candidates for the hybrid approach secondary to limited mobility of the tumor and hilum. The nature of the tumor and chest wall involvement must also be such that if thoracoscopic isolation and division of the hilar lobar structures are required, they can be visualized adequately and mobilized sufficiently. In addition to these factors, other factors influencing patient selection include the use of prior radiation therapy, which may also limit hilar mobility, and the location of the chest wall involvement. Tumors requiring resection of the first rib are particularly challenging to manage thoracoscopically due to limited visualization at the apex of the thorax and difficulty of dissection near the thoracic outlet. In our experience, tumors involving the transverse processes are not attempted thoracoscopically. Finally, the area of chest wall involvement must not be in the immediate area where the incisions must be placed to allow for the appropriate angle for placement of instruments and staplers.
      • Berry M.F.
      • Onaitis M.W.
      • Tong B.C.
      • et al.
      Feasibility of hybrid thoracoscopic lobectomy and en-bloc chest wall resection.
      Although there is no consensus among surgeons regarding the size of chest wall defect necessitating reconstruction, the literature supports providing structural chest wall support for the loss of 2 or more ribs, for defects >5 cm in diameter, or for anticipated chest wall instability, which can lead to prolonged ventilator dependence.
      • Mansour K.A.
      • Thourani V.H.
      • Losken A.
      • et al.
      Chest wall resections and reconstruction: A 25-year experience.
      • Weyant M.J.
      • Bains M.S.
      • Venkatraman E.
      • et al.
      Results of chest wall resection and reconstruction with and without rigid prosthesis.
      In the case of apical or posterior rib resection, reconstruction may not be needed given that these areas are essentially covered with the scapula and the dense musculature of the back overlying them. However, when consecutive lateral or anterior ribs are resected, chest wall instability with paradoxical chest wall motion is likely to ensue. Patch repair in these cases will eliminate paradoxical motion and provide a physiologically sound repair.
      The following 3 tenets of the traditional open approach to chest wall resection must be maintained when performing this procedure thoracoscopically: (1) all involved tissues must be resected, leaving behind only healthy, viable tissue; (2) stability must be restored to the chest wall to avoid flail or scapular tip entrapment; and (3) the pleura must be sealed with healthy soft tissue to protect the viscera and blood vessels and prevent infection.
      • Skoracki R.J.
      • Chang D.W.
      Reconstruction of the chestwall and thorax.
      The steps under Operative Technique depict the resection of a right upper lobe tumor invading the chest wall.

      Operative Technique

      Figure thumbnail gr1
      Figure 1Computed tomography image of the chest demonstrating a right upper lobe tumor with chest wall involvement.
      Figure thumbnail gr2
      Figure 2The patient is placed in the lateral decubitus position with the table break maximally flexed at the patient's hip level. Reverse Trendelenburg is used to tilt the table so that the patient's lateral chest wall is parallel to the floor. The chest is then prepped and draped in the standard fashion.
      Figure thumbnail gr3
      Figure 3Single-lung ventilation is established. The first of 2 port incisions is placed in the 8th intercostal space just anterior to the axillary line if the tumor invades the chest wall posteriorly and just posterior to the axillary line if the tumor invades the chest wall anteriorly. A 30° rotating thoracoscope is then inserted into the chest, and thoracoscopic exploration is undertaken. Any visualized adhesions can be partially taken down with a combination of sharp and blunt dissection.
      A more anterior working port incision is made in the 5th or 6th intercostal space. Specifically, the location of the working port incision is chosen based on the location of the tumor to allow for optimal visualization as well as the width of the interspace. The lung is more completely mobilized under thoracoscopic vision. At this point, mediastinal sampling or mediastinal lymph node dissection is undertaken. The lung is mobilized up to the point where the mass invades the chest wall. The lung and pleural space is carefully inspected for the presence of unexpected metastatic disease.
      Figure thumbnail gr4
      Figure 4After mobilization and inspection, a lobectomy is undertaken of that portion of the lung that is involved with tumor. The superior pulmonary vein is dissected from the overlying pleura via the access incision. The perivascular tissue is placed on tension by forceps and standard scissors are used to cut and dissect the tissue to expose the superior and inferior aspects of the vein. A curved clamp is passed behind the superior pulmonary vein after clear identification of the middle lobe vein. A ring forceps is placed through this port and is used to retract the upper lobe posteriorly. A 2.5-mm vascular linear cutting stapling device is placed through the posterior port, is passed behind the superior pulmonary vein, and is fired.
      Figure thumbnail gr5
      Figure 5Once the pulmonary vein has been divided, the truncus arteriosus is easily visualized. Dissection is performed by placing tension on the perivascular tissue with a forceps and incising the tissue with a scissors until the entire arterial branch can be seen from its origin from the main pulmonary artery. Dissection of the 10R lymph nodes may need to be performed to facilitate arterial visualization and dissection. Once the entire artery is visualized, a curved clamp is passed behind the artery and brought through the anterior incision. The vascular stapler is passed through the posterior access port to transect the vessel. RML, right middle lobe; RUL, right upper lobe; RULA, right upper lobe artery; RULV, right upper lobe vein.
      Figure thumbnail gr6
      Figure 6Transection of the truncus artery branch exposes the right upper lobe bronchus. Scissors are used to incise the peribronchial tissue sharply. Blunt dissection with a closed scissors is then used to develop a plane between the interlobar pulmonary artery and the bronchus. Once the interlobar artery is safely pushed away from the bronchus and the inferior and superior aspects of the right upper lobe bronchus are clearly visualized, a curved clamp is passed behind the bronchus. A 4.8-mm linear cutting stapler is placed through the posterior port and the right upper lobe bronchus is transected. This exposes the recurrent branch of the pulmonary artery, which is transected in the same fashion through the posterior port. RML, right middle lobe; RUL, right upper lobe.
      Figure thumbnail gr7
      Figure 7Once all the structures to the upper lobe have been divided, the fissure is then assessed. A retractor placed through the posterior port is used to retract the middle and lower lobes inferiorly and a retractor through the anterior incision retracts the upper lobe superiorly. Once the fissure is exposed with a long curved ring forceps, a universal 4.8-mm stapler is placed through the anterior incision to complete both minor and major fissures. RML, right middle lobe; RUL, right upper lobe; RULA, right upper lobe artery; RULV, right upper lobe vein.
      Figure thumbnail gr8
      Figure 8Circumferential pleural incision is then undertaken with electrocautery at the desired area of chest wall resection.
      Figure thumbnail gr9
      Figure 9Careful inspection of the area of chest wall involvement is then performed to determine the extent of chest wall resection required to obtain adequate margins. A 22-gauge needle is used to mark externally where the mass is observed internally. The thoracoscope is used to assist in creating a limited counterincision centered in the intercostal space directly over the area where the mass is visualized to limit the size of the incision and division of muscles, as well as to obviate the need for rib spreading. This allows for more precision when proceeding with the chest wall resection, subsequently minimizing the extent of the chest wall resection.
      Figure thumbnail gr10
      Figure 10Dissection is then continued up to the chest wall. At this point, further development of those ribs above and below where the tumor is centered is undertaken. The ribs are exposed from the most superior border to the furthest inferior border and circumferentially to facilitate resection. The ribs are first transected anteriorly with a rib cutter and then posteriorly to create adequate margins. The ribs both above and below the site of chest wall tumor invasion are handled in this way and taken with the en bloc resection. The intercostal tissues are divided off the inferior aspect of the caudad most rib using electrocautery. The tissues on the superior aspect of the cephalad-most rib are taken in a similar fashion. The soft tissues at the anterior and posterior extents of the excision are also divided with electrocautery, taking care to obtain hemostasis of the intercostal vessels.
      The specimen is then removed as an en bloc chest wall resection via the counterincision without any rib spreading or scapular mobilization. The specimen is then sent to the pathology department for a frozen section to ensure negative margins.
      The chest is irrigated and aspirated dry to ensure that there are no sites of active bleeding. Gore-Tex reconstruction of the newly created defect is then undertaken using a 2-mm-thickness Gore-Tex patch of the appropriate size. This patch is anchored in place circumferentially around the defect using the adjacent ribs or by drilling through the adjacent ribs with interrupted nonabsorbable sutures.
      The chest is again copiously irrigated with warm bacitracin-containing normal saline and aspirated dry. A single chest tube is placed through the axillary port incision and positioned deep to the chest wall reconstruction. The chest tube is then secured to the chest wall with nylon sutures. A Jackson-Pratt drain is placed through the anterior port incision and positioned above the mesh and inferior to the chest wall fascia. The Jackson-Pratt drain is secured to the chest wall with a nylon suture. The chest wall fascia is closed with a running 3-0 Vicryl suture. The subcutaneous tissue is closed with a running 2-0 Vicryl suture. The skin is closed with a running 3-0 Vicryl suture in a subcuticular fashion. Sterile dressings are placed over all incision sites.

      Discussion

      Postoperatively, when the remaining lung expands without evidence of an air leak, the chest tube can be removed, and the patient can be discharged home assuming there are no other complications. In such cases, patients are often able to be discharged home within a similar time frame as traditional thoracoscopic lobe resection patients, that is, within the 3rd to 4th postoperative day. Generally, patients make a rapid, complete recovery and return to full physical activity without restrictions in 2 weeks' time. Patients are often discharged home with the Jackson-Pratt drain in place and return for follow-up approximately 2 weeks after discharge. If there are no signs of infection and minimal drainage from the drain, it can be removed at their follow-up visit.
      Although many surgeons believe that rib removal trumps incisional pain, substantial evidence exists that the use of fewer chest tubes and protection of each nerve transected during thoracotomy make incremental improvements in pain.
      • Cerfolio R.J.
      • Bryant A.S.
      • Maniscalco L.M.
      A nondivided intercostal muscle flap further reduces pain of thoracotomy: A prospective randomized trial.
      Moreover, avoiding rib spreading to the chest wall reduces aggregate thoracic nociceptive stimuli and the incidence of postoperative chronic pain, with better preservation of pulmonary function in comparison with those patients undergoing thoracotomy. As an additional benefit, these patients need not be placed on lifting restrictions at discharge, facilitating earlier return to independence and preoperative activity levels and faster overall recovery.
      Finally, we use a Gore-Tex patch to restore chest wall rigidity. However, the choice of prosthetic material is dependent on the size, nature, and location of the resulting defect as well as surgeon preference. Generally, prosthetic material offers the desirable properties of rigidity to eliminate paradoxical chest movement, malleability to allow contouring to the chest wall during surgical reconstruction, and radiolucency to allow for radiographic follow-up. Providing adequate stabilization of the chest wall is a key component to reducing ventilator dependence, hospital stay, and postoperative complications.
      The video-assisted thoracoscopic surgery approach permits controlled, accurate, and complete dissection and resection of lung and chest wall structures while maintaining the tenets of performing chest wall resection without the concomitant morbidity associated with the major chest wall trauma involved with traditional thoracotomy and rib resection techniques. A retrospective review of all patients undergoing lobectomy for non-small-cell lung cancer with en bloc chest wall resection between January 2000 and July 2010 at our institution demonstrates comparable morbidity and mortality with shortened hospital stays in comparable patient populations
      • Berry M.F.
      • Onaitis M.W.
      • Tong B.C.
      • et al.
      Feasibility of hybrid thoracoscopic lobectomy and en-bloc chest wall resection.
      (Table 1).
      Table 1Comparison of Preoperative Characteristics, Tumor and Resection Details, and Outcomes for Patients Receiving Open versus VATS En Bloc Chest Wall Resections
      Thoracotomy (n = 93)VATS (n = 12)P Value
      Demographics
       Mean age (range)60 (31-85)58.5 (41-84)0.8
       Previous thoracic surgery12 (13%)3 (25%)0.4
       Mean FEV1 (percent predicted)68 + 1769 + 180.6
       Mean DLCO (percent predicted)66 + 1969 + 180.6
       Induction chemotherapy52 (56%)4 (33%)0.2
       Induction radiation51 (55%)3 (25%)0.07
       Mean pack-year smoking history47 + 2552 + 280.5
      Comorbidities
       Hypertension34 (36%)5 (4%)0.8
       Coronary artery disease15 (16%)3 (25%)0.4
       Chronic obstructive pulmonary disease22 (24%)5 (42%)0.3
       Diabetes mellitus5 (5%)1 (8%)0.5
       Cerebrovascular disease5 (5%)0 (0%)1
       Peripheral vascular disease4 (4%)0 (0%)1
       Congestive heart failure1 (1%)0 (0%)1
      Tumor/resection details
       Mean tumor size5.4 + 2.55.6 + 2.60.8
       Mean ribs resected3.3 + 0.93.1 + 0.90.4
       Superior sulcus location34 (37%)2 (17%)0.2
       pStage 264 (69%)12 (100%)
       pStage 327 (29%)0 (0%)
       pStage 42 (2%)0 (0%)
      Outcomes
       30-d mortality3 (3.2%)0 (0%)1
       30-d morbidity55 (59%)5 (42%)0.4
       Mean hospital stay (range)6 (2-124)5.5 (3-15)0.03
       Postoperative bronchoscopy23 (25%)3 (25%)1
       Atrial arrhythmia24 (26%)1 (8%)0.3
       Pneumonia19 (20%)1 (8%)0.45
       Postoperative transfusion16 (17%)2 (17%)1
       Chest tube longer than 5 d19 (20%)2 (17%)1
      Abbreviations: DLCO, carbon monoxide diffusing capacity; FEV1, forced expiratory volume in 1 second; VATS, video-assisted thoracoscopic surgery; pStage, pathologic stage.
      Given that experience and oncologic principles appear preserved in experienced surgeons conducting more common thoracoscopic procedures, it is reasonable to expand minimally invasive approaches to less common complex operations such as localized chest wall malignancies—particularly for high-risk and frail patients that would likely experience poorer outcomes from more morbid procedures. Therefore, as experience grows with these complex thoracoscopic procedures, the patients and conditions treated will be broadened with subsequent improved outcomes.

      References

        • Paul S.
        • Altorki N.K.
        • Sheng S.
        • et al.
        Thoracoscopic lobectomy is associated with lower morbidity than open lobectomy: A propensity-matched analysis from the STS database.
        J Thorac Cardiovasc Surg. 2010; 139: 366-378
        • Villamizar N.R.
        • Darrabie M.D.
        • Burfeind W.R.
        • et al.
        Thoracoscopic lobectomy is associated with lower morbidity compared with thoracotomy.
        J Thorac Cardiovasc Surg. 2009; 138: 419-425
        • Yan T.D.
        • Black D.
        • Bannon P.G.
        • et al.
        Systematic review and meta-analysis of randomized and nonrandomized trials on safety and efficacy of video-assisted thoracic surgery lobectomy for early-stage non-small-cell lung cancer.
        J Clin Oncol. 2009; 27: 2553-2562
        • Demmy T.L.
        • Nwogu C.E.
        • Yendamuri S.
        Thoracoscopic chest wall resection: What is its role?.
        Ann Thorac Surg. 2010; 89: S2142-S2145
        • Widmann M.D.
        • Caccavale R.J.
        • Bocage J.P.
        • et al.
        Video-assisted thoracic surgery resection of chest wall en bloc for lung carcinoma.
        Ann Thorac Surg. 2000; 70: 2138-2140
        • Berry M.F.
        • Onaitis M.W.
        • Tong B.C.
        • et al.
        Feasibility of hybrid thoracoscopic lobectomy and en-bloc chest wall resection.
        Eur J Cardiothorac Surg. 2012; 41: 888-892
        • Mansour K.A.
        • Thourani V.H.
        • Losken A.
        • et al.
        Chest wall resections and reconstruction: A 25-year experience.
        Ann Thorac Surg. 2002; 73: 1720-1726
        • Weyant M.J.
        • Bains M.S.
        • Venkatraman E.
        • et al.
        Results of chest wall resection and reconstruction with and without rigid prosthesis.
        Ann Thorac Surg. 2006; 81: 279-285
        • Skoracki R.J.
        • Chang D.W.
        Reconstruction of the chestwall and thorax.
        J Surg Oncol. 2006; 94: 455-465
        • Cerfolio R.J.
        • Bryant A.S.
        • Maniscalco L.M.
        A nondivided intercostal muscle flap further reduces pain of thoracotomy: A prospective randomized trial.
        Ann Thorac Surg. 2008; 85: 1901-1906