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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.
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.
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.
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.
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.
The steps under Operative Technique depict the resection of a right upper lobe tumor invading the chest wall.
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.
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
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.
Thoracoscopic lobectomy is associated with lower morbidity than open lobectomy: A propensity-matched analysis from the STS database.