Video-Assisted Thoracoscopic Sleeve Lobectomy for Centrally Located Non-small Cell Lung Cancer: A Meta-analysis

Effect of preoperative three-dimensional modeling on uniportal video-assisted thoracoscopic bronchial sleeve resection and early postoperative outcomes

Background

The aim of this study was to evaluate the effects of preoperative three-dimensional (3D) modeling on the performance of uniportal video-assisted thoracoscopic bronchial sleeve resection and early postoperative outcomes.

Methods

A total of 10 patients (5 males, 5 females; mean age: 53.8±16.9 years; range, 18 to 75 years) who underwent uniportal video-assisted thoracoscopic bronchial sleeve resection with preoperative 3D modeling between April 2021 and November 2023 were retrospectively analyzed. Preoperative 3D modeling was prepared using computed tomography with an open-source 3D software program. Demographic, clinical, intraoperative, and postoperative data of the patients were recorded. Anatomical landmarks identified by preoperative 3D modeling were compared with intraoperative findings.

Results

The anatomical landmarks created with the 3D model were in 100% agreement with the intraoperative findings. The procedures performed were three left lower lobes, three right upper lobes, one middle lobe, one right lower lobe, and one parenchyma-sparing intermediate bronchial sleeve resection. Bronchial sleeve resection was completed using uniportal video-assisted thoracoscopic technique in 90% of patients, with only one patient requiring conversion to open thoracotomy. The mean resection time was 264.2±40.5 min, and the mean anastomosis time was 86.0±20.3 min. Anastomosis times decreased with increasing experience (p=0.008). Postoperative atelectasis was observed in two patients, and there was no mortality. The mean follow-up duration was 12.2±11.8 months.

Conclusion

Preoperative 3D modeling significantly contributed to the successful implementation of uniportal video-assisted thoracoscopic bronchial sleeve resection surgery. In the future, with advancements in simulation programs, patient-specific 3D modeling is expected to benefit the identification of anatomical landmarks for bronchial sleeve resections.

Right Lower Sleeve Lobectomy: Detailed Technique and Perioperative Patient Management

PURPOSE

This report reviews our experience with right lower sleeve lobectomy and describes our technique and approach to perioperative patient management.

METHODS

We retrospectively reviewed 11 patients who underwent right lower sleeve lobectomy for lung cancer. Surgical techniques and perioperative management were also investigated.

RESULTS

Bronchoplasty was performed using 4-0 absorbable monofilament sutures. The deepest portion was anastomosed using continuous sutures; interrupted sutures were used for the more superficial portions. The truncus intermedius and right middle lobe bronchus should be anastomosed in a natural position. Anastomosis patency was confirmed using intraoperative bronchoscopy. Separation of the right upper and middle lobes and pericardiotomy at the inferior edge of the superior pulmonary vein are useful for mobilizing the right middle lobe. Death during hospitalization and treatment-related death did not occur. One patient developed pneumonia, and another developed a bronchopleural fistula.

CONCLUSION

We reported our technique of right lower sleeve lobectomy and our approach to perioperative patient management. Sharing knowledge is essential to completing this rare surgery.

Anastomosis Complications after Bronchoplasty: Incidence, Risk Factors, and Treatment Options Reported by a Referral Cancer Center

BACKGROUND

Sleeve lobectomy with bronchoplasty is a safe surgical technique for the management of lung cancer and endobronchial localization of extrapulmonary cancers. However, anastomotic complications can occur, and treatment strategies are not standardized.

METHODS

Data from 280 patients subjected to bronchoplasty were retrospectively analyzed, focusing on surgical techniques, anastomotic complications, and their management. Multivariate analysis was performed, and Kaplan-Meier curves were used to determine survival.

RESULTS

Ninety percent of 280 surgeries were for lung cancer. Anastomotic complications occurred in 6.42% of patients: late stenosis in 3.92% and broncho-pleural fistula in 1.78%. The median survival was 65.90 months (95% CI = 41.76-90.97), with no difference (p = 0.375) for patients with (51.28 months) or without (71.03 months) anastomotic complications. Mortality at 30 days was higher with anastomotic complications (16.7% vs. 3%, p = 0.014). Multivariable analysis confirmed pathological stage (N+) as a risk factor for anastomotic complications (p = 0.016). Our mortality (3.93%) and morbidity rate (41.78%) corresponded to recent series results.

CONCLUSIONS

In our experience, surgery is preferred to avoid life-threatening complications in bronchopleural fistulas. Bronchoscopic balloon dilatation is preferred for benign strictures. The nodal stage is related to complications (p = 0.0014), reflecting the aggressiveness of surgery, which requires extended radical lymphadenectomy.

Ultrasound-guided serratus anterior plane block to prevent neurocognitive impairment in elderly patients after thoracoscopic lobectomy: protocol for a single-centre, double-blind, randomised controlled trial

INTRODUCTION

Postoperative neurocognitive dysfunction (PND), including postoperative delirium (POD), is a common complication in elderly patients after major surgeries, often leading to poor postoperative recovery. Although the pathological mechanism underlying PND is still unclear, postoperative pain is strongly associated with the development of PND. The ultrasound-guided serratus anterior plane block (SAPB) has been reported to relieve postoperative pain in thoracic surgery. Therefore, this prospective trial hypothesises that SAPB may reduce the incidence of PND in the elderly undergoing thoracoscopic lobectomy.

METHODS AND ANALYSIS

This study is designed as a single-centre, double-blind, randomised controlled clinical trial. A total of 256 elderly patients scheduled to undergo thoracoscopic lobectomy at Shanghai Pulmonary Hospital will be randomly assigned to general anaesthesia group or SAPB group. The primary outcome is the incidence of PND 7 days postoperatively or before discharge from hospital. The secondary outcomes include the occurrence of POD, the postoperative pain scores, Quality of Recovery at 1-2 days postoperatively and incidence of PND at 3 months postoperatively. The levels of fasting blood glucose in peripheral blood will be examined before and 1-2 days postoperatively.

ETHICS AND DISSEMINATION

The trial has been approved by the Clinical Research Ethics Committee of Shanghai Pulmonary Hospital (identifier: K20-290). All participants will be required to provide written informed consent before any protocol-specific procedures. Findings will be disseminated in a peer-reviewed journal and in national and/or international meetings to guide future practice.

TRIAL REGISTRATION NUMBER

ChiCTR2100052633.

Effect of erector spinae plane block with different doses of dexmedetomidine as adjuvant for ropivacaine on the postoperative quality of recovery after video-assisted thoracoscopic lobectomy surgery: a randomized controlled trial

BACKGROUND

Erector spinae plane block (ESPB) improves postoperative analgesia and significantly enhances the quality of recovery (QoR) after video-assisted thoracoscopic lobectomy surgery (VATLS). However, it is not known whether the use of dexmedetomidine (Dex) as an adjunct for ropivacaine to ESPB affects the QoR after VATLS. The purpose of this study was to explore the effects of different Dex dosages as an adjunct for ropivacaine in combination with ultrasound-guided ESPB on the quality of postoperative recovery in patients with VATLS.

METHODS

In this single-center, double-blind, randomized study, 120 patients between the ages of 18 and 65 who were scheduled for VATLS from december 2021 and october 2022 in our hospital under general anesthesia were randomly divided into three groups: ultrasound-guided ESPB with 30 mL of 0.5% ropivacaine (Group R), ultrasound-guided ESPB 0.5% ropivacaine plus 0.5 µg/kg Dex (Group RD1), and ultrasound-guided ESPB 0.5% ropivacaine plus 1.0 µg/kg Dex (Group RD2), ultrasound-guided ESPB was administrated at the T5 vertebral level before surgery. The primary outcome was the QoR-15 score 24 h after the surgery. The secondary outcomes included the QoR-15 scores at 12 h, 48 h, and 72 h after the operation, visual analogue scale (VAS) scores at 8 h, 12 h, 24 h, and 48 h after surgery, cumulative flurbiprofen consumption, postoperative nausea and vomiting (PONV), postoperative bradycardia, and hypotension.

RESULTS

The QoR-15 scores were higher in group RD2 than the R and RD1 groups on postoperative day 1 (P < 0.05), in addition, no significant difference was found in the QoR-15 scores between groups R and RD1 on postoperative day 1. The VAS scores were significantly lower in group RD2 than in groups RD1 and group R 12-24 h after surgery (P < 0.05). No significant differences were observed in the QoR-15 and VAS scores at 48 and 72 h after surgery between the three groups. The cumulative flurbiprofen consumption was markedly reduced during the 72 h after surgery in the RD2 group (P < 0.05). The incidence of postoperative nausea and vomiting was lower in the RD2 group (P < 0.05).

CONCLUSIONS

The combination of 1 µg/kg dexmedetomidine as an adjunct with 0.5% ropivacaine 30 ml for erector spinae plane block significantly improved the postoperative quality of recovery and provided better postoperative analgesia on postoperative day 1 in patients undergoing Video-assisted thoracoscopic lobectomy surgery. However, dexmedetomidine (1 µg/kg) as an adjunct for ropivacaine combined with erector spinae plane block did not enhance the postoperative quality of recovery at 48 and 72 h postoperatively.

TRIAL REGISTRY NUMBER

The number of this clinical trial registry is ChiCTR2100053230, date of registration: 16/11/ 2021).

VATS sleeve resections

Sleeve resections in central tumors is a surgical method preferred over pneumonectomy owing to its parenchymasparing features. With the increasing surgical experience and developing technology in recent years, sleeve resections can be performed using the video-assisted thoracoscopic surgery method. However, these resections are technically challenging and require significant experience. In this review, we discuss sleeve resections with video-assisted thoracoscopic surgery in the light of the literature.

Overview of indications for pulmonary sleeve resection

Pulmonary sleeve resection is a complex lung resection and reconstruction surgery mostly performed in patients with centrally located locally invasive lung cancers which often penetrate into central airways and vasculature. This approach was initially used for patients unable to tolerate pneumonectomies, while it is currently also being preferred in patients whose tumors are anatomically suited. Today, thoracic sleeve resections include a wide range of procedures ranging from bronchial and tracheal sleeve resections to carinal sleeve pneumonectomies. In this review, we discuss indications for various types of sleeve resection in the light of current literature.

Video-assisted thoracoscopic versus open sleeve lobectomy for non-small cell lung cancer: A systematic review and meta-analysis from six comparative studies

BACKGROUND

Lung sleeve resection is indicated for centrally located lung tumors, especially for patients who cannot tolerate pneumonectomy. With video-assisted thoracoscopic surgery (VATS) being increasingly implemented for a wide variety of thoracic pathologies, this study aims to compare the intraoperative, postoperative, and long-term outcomes of VATS and open bronchial sleeve lobectomy for non-small cell lung cancer (NSCLC).

METHODS

The MEDLINE (via PubMed), Cochrane Library, and Scopus databases were searched. Original clinical studies, comparing VATS and open sleeve lobectomy for NSCLC were included. Evidence was synthesized as odds ratios for categorical and weighted mean difference (WMD) for continuous variables.

RESULTS

Our analysis included six studies with non-overlapping populations reporting on 655 patients undergoing bronchial sleeve lobectomy for NSCLC (229 VATS and 426 open). VATS sleeve lobectomy was associated with significantly longer operative time ((WMD): 45.85 min, 95% confidence interval (CI): 12.06 to 79.65, p  =  0.01) but less intraoperative blood loss ((WMD): -34.57 mL, 95%CI: -58.35 to -10.78, p < 0.001). No significant difference was found between VATS and open bronchial sleeve lobectomy in margin-negative resection rate, number of lymph nodes resected, postoperative outcomes (drainage duration, length of hospital stay, 30-day mortality), postoperative complications (pneumonia, bronchopleural fistula/empyema, prolonged air leakage, chylothorax, pulmonary embolism, and arrhythmia), and long-term outcomes (overall survival, recurrence-free survival).

CONCLUSIONS

The limitation of our study arises mainly due to the heterogeneity of the included studies. Nevertheless, VATS bronchial sleeve lung resection constitutes a feasible and safe alternative to the open sleeve lung resection surgery for the management of centrally located lung tumors.

A Cohort Study on the Comparison of Complications, Short-Term Efficacy, and Quality of Life between Thoracoscopic Surgery and Traditional Surgery in the Treatment of Rib Fractures

Objective

A case-control study was conducted, to assess the complications, short-term effectiveness, and quality of life of video-assisted thoracoscopic surgery with conventional surgery in the treatment of rib fractures.

Methods

From February 2018 to April 2021, 100 patients with rib fractures who required surgical treatment at the hospital were selected. Patients were randomly divided into control and study groups. The study group received thoracoscopy-assisted rib internal fixation, and the control group received traditional open reduction and internal fixation for rib fractures. The treatment effect, postoperative complication rate, surgery-related indicators, stress response, blood gas indicators, VAS (visual analog scale) pain score, and SF-36 quality of life score were compared between the two groups.

Results

The total effective rate of the study group was higher than that of the control group, and the difference was statistically significant (P < 0.05). The postoperative complications in the study group were significantly lower than those in the control group (χ²-5.317; P < 0.05), but there was no significant difference in hospitalization costs between the two groups (P > 0.05). The operation time, intraoperative blood loss, incision length, drainage tube placement time, postoperative activity time, and hospital stay in the study group were significantly lower than those in the control group. The SF-36 score and VAS score in the study group were higher than those in the control group (P < 0.05). Compared with the two groups after the operation, the levels of PaO2, SaO2, and PaO2/FiO2 in the study group were significantly higher than those in the control group (P < 0.05). Before surgery, there was no significant difference in stress response indicators such as cortisol, blood sugar, and C-reactive protein between the two groups (P > 0.05), but there was no significant difference in stress response indicators after surgery (P > 0.05). Cortisol, blood sugar, C-reactive protein, and other indicators were increased in both groups, but compared with the control group, the study group had decreased postoperative cortisol, blood sugar, C-reactive protein, and other stress response indicators (P < 0.05).

Conclusion

There is a significant difference between thoracoscopic surgery and traditional surgery in the treatment of rib fractures. The probability of postoperative complications of thoracoscopic surgery is lower, and the operation time, intraoperative blood loss, and incision length are better. The pain of patients before and after the operation is significantly reduced, the quality of life is improved greatly, and the stress response is weak.

Complete Video-Assisted Thoracoscopic Surgery and Traditional Open Surgery for Elderly Patients With NSCLC

Objective:

To observe the efficacy of complete video-assisted thoracoscopic surgery (CVATS) and traditional open surgery (TOS) in the treatment of elderly patients with non-small cell lung cancer (NSCLC) and their influence on cardiopulmonary function.

Methods

A total of 120 elderly patients with primary NSCLC who were treated surgically in our hospital from January 2018 to January 2021 were selected and divided into the study group and the control group according to the different surgical procedures, 60 patients in each group. CVATS was used in the observation group and TOS in the control group. The surgical indexes and cardiopulmonary function indexes were observed and compared between the two groups. The serum C-reactive protein (CRP) level and visual analog scale's (VAS) score of the patients at different time points were detected. The incidence of postoperative complications was compared between the two groups.

Results

The perioperative indexes such as operation time were significantly different between the two groups (p < 0.05), but the number of lymph node dissection was not significantly different (p > 0.05). The serum CRP level and VAS score of the observation group were significantly lower than those of the control group on the 1st, 3rd, and 7th postoperative days (p < 0.05). There were significant differences in cardiopulmonary function between the two groups on the 7th postoperative day (p < 0.05). The incidence of adverse reactions in the observation group was significantly lower than that in the control group (p > 0.05).

Conclusion

CVATS is effective in the treatment of NSCLC. Compared with TOS therapy, CVATS has less damage to cardiopulmonary function and fewer complications, which is conducive to the rehabilitation of elderly patients. It is a safe and reliable scheme for the treatment of elderly patients with NSCLC.

An External-Validated Algorithm to Predict Postoperative Pneumonia Among Elderly Patients With Lung Cancer After Video-Assisted Thoracoscopic Surgery

The aim of the study was to develop an algorithm to predict postoperative pneumonia among elderly patients with lung cancer after video-assisted thoracoscopic surgery. We analyzed 3,009 patients from the Thoracic Perioperative Database for Geriatrics in our hospital and finally enrolled 1,585 elderly patients (age≧65 years) with lung cancer treated with video-assisted thoracoscopic surgery. The included patients were randomly divided into a training group (n = 793) and a validation group (n = 792). Patients in the training group were used to develop the algorithm after screening up to 30 potential risk factors, and patients in the validation group were used to internally validate the algorithm. External validation of the algorithm was achieved in the external validation dataset after enrolling 165 elderly patients with lung cancer treated with video-assisted thoracoscopic surgery from two hospitals in China. Of all included patients, 9.15% (145/1,585) of patients suffered from postoperative pneumonia in the Thoracic Perioperative Database for Geriatrics, and 10.30% (17/165) of patients had postoperative pneumonia in the external validation dataset. The algorithm consisted of seven variables, including sex, smoking, history of chronic obstructive pulmonary disease (COPD), surgery duration, leukocyte count, intraoperative injection of colloid, and intraoperative injection of hormone. The C-index from the receiver operating characteristic curve (AUROC) was 0.70 in the training group, 0.67 in the internal validation group, and 0.71 in the external validation dataset, and the corresponding calibration slopes were 0.88 (95% confident interval [CI]: 0.37–1.39), 0.90 (95% CI: 0.46–1.34), and 1.03 (95% CI: 0.24–1.83), respectively. The actual probabilities of postoperative pneumonia were 5.14% (53/1031) in the low-risk group, 15.07% (71/471) in the medium-risk group, and 25.30% (21/83) in the high-risk group (p < 0.001). The algorithm can be a useful prognostic tool to predict the risk of developing postoperative pneumonia among elderly patients with lung cancer after video-assisted thoracoscopic surgery.

Comparison of Sleeve Lobectomy for Lung Cancer Using Mini-Thoracotomy and an Optimized Robot-Assisted Technique

Objective: To evaluate the clinical significance of an optimized approach to improve surgical field visualization and simplify anastomosis techniques using robotic-assisted sleeve lobectomy for lung or bronchial carcinoma. Method: A total of 26 consecutive patients who underwent sleeve lobectomy between January 2017 and April 2020 were enrolled in the study. The cohort included 11 cases of robotic-assisted surgery (RAS group) and 15 cases of mini-thoracotomy (MT group). RAS was performed via an exclusive optimized approach utilizing the "3 to 4-6 to 8/9" four-port technique. Retrieved demographical and clinical data included operation time, anastomosis time, blood loss, chest drainage time and volume, postoperative pain scores, complications, white blood cell (WBC) levels, and duration of hospital stay and follow-up. Results: No cases of perioperative death were recorded. Compared to MT group, the RAS group had a similar anastomosis time (30.82  ±  6.08 vs 33.20  ±  7.73 min, respectively, p > 0.05) and shorter operation time (189.73  ±  36.41 vs 225.33  ±  38.19 min, respectively, p < 0.05). The RAS group had lower pain scores (4.23  ±  0.26 vs 4.91  ±  0.51, p < 0.05), lower levels of WBC (p < 0.05), and no anastomotic complications postoperatively. The RAS and MT groups demonstrated a successful bronchus reconstruction with low risk of angulation (1/11 vs 1/15, p > 0.05) and satisfactory disease-free survival (eight cases, 72.73% and 12 cases, 80%, respectively). Conclusion: The optimized approach to RA sleeve lobectomy is convenient and efficient and provides satisfactory clinical outcomes. Further study with a large sample size and evaluation of long-term survival are warranted. Key points: (i) we present a novel, convenient, and efficient approach for robotic-assisted sleeve lobectomy, ie, "3 to 4-6 to 8/9" four-port technique. The optimized approach for RA sleeve lobectomy is convenient and efficient and provides satisfactory clinical outcomes; (ii) details for the "3 to 4-6 to 8/9" four-port method: the assistant port was located at the fourth intercostal space. The 1-cm camera port was inserted at the sixth intercostal space in the posterior axillary line. The 0.5-cm da Vinci ports of the instrument arms were placed at the third intercostal space in the anterior axillary line and the eighth or ninth intercostal space in the posterior axillary line. The patient cart was inserted from the back of the patient's head and shoulders at 75° to the longitudinal line.

Video-assisted thoracic surgery sleeve resection and bronchoplasty using 3D imaging system: its safety and efficacy

Background

Video-assisted thoracic surgery sleeve resection with bronchial anastomosis or bronchoplasty is a technically demanding procedure. Three-dimensional endoscopic surgery has been reported to be helpful in decreasing operation time and improving spatial perception with less surgical errors, but there have been rare reports about relatively difficult thoracoscopic procedures utilizing 3D thoracoscope. We performed this study to evaluate early clinical outcomes of thoracoscopic sleeve resection and bronchoplasty utilizing 3D thoracoscope.

Methods

Data from a total of 36 patients who underwent thoracoscopic sleeve lobectomy or bronchoplasty at our institution from December 2015 to October 2017 were retrospectively reviewed. Three-port approach with one utility incision was used with a 10 mm, 30° three-dimensional thoracoscope. Twenty-three patients (81%) were male, and mean age was 65.9 ± 9.4 years. Fourteen patients (38.9%) underwent sleeve resection with bronchial anastomosis, 22 (61.1%) underwent wedge or simple bronchoplasty, and one patient received concomitant PA procedure. Bronchial anastomosis sites were not covered with viable tissue flaps.

Results

There was no (0%) suture needle injury from spatial misperception during bronchoplasty or sleeve anastomosis. There was no (0%) operative mortality. The pathologic report revealed squamous cell carcinoma (63.9%), adenocarcinoma (19.4%), carcinoid (6.9%), adenosquamous carcinoma (3.4%), and sarcomatoid carcinoma (2.8%). One (2.8%) late mortality was due to systemic recurrence of sarcomatoid carcinoma. There was no (0.0%) anastomotic failure. The mean number of dissected lymph nodes were 27.4 ± 13.2, and mean operation time was 216.8 ± 60.0 min. Median postoperative 24-h drain amount was 315 mL. Median chest tube days and hospital days were 4 and 6, respectively. Two patients (5.6%) had complications greater than Clavien-Dindo grade II—one case of ARDS, and the other case of a delayed bronchopleural fistula.

Conclusions

Thoracoscopic sleeve resection and bronchoplasty utilizing HD 3D thoracoscope is a safe and effective procedure with excellent early clinical outcomes. Further investigation for long-term outcomes will be needed.

Acupuncture against chronic postsurgical pain in non-small cell lung cancer patients: A protocol of randomized controlled trial

INTRODUCTION

Video-assisted thoracoscopic lobectomy is the prior recommended treatment for non-small cell lung cancer (NSCLC), with the advantages of small trauma, less postoperative pain, and quick recovery. However, a large number of patients may suffer chronic postsurgical pain (CPSP), which makes the patients unwilling to practice pulmonary exercises, and it would directly affect patient's cough, sputum expectoration, and mobility. Opioids could greatly improve the quality of postoperative analgesia and the quality of life after surgery, but it is accompanied with obvious side effects. A number of clinical studies have proved that acupuncture could improve postoperative pain and reduce opioid use. In this study, we try to conduct a randomized controlled study to evaluate the efficacy and safety of plum-blossom needle acupuncture combined with Tramadol in improving CPSP after lobectomy in NSCLC patients.

METHODS

Patients will be randomly divided into treatment group (acupuncture plus Tramadol) and control group (sham acupuncture plus Tramadol) with a random number table in 1:1 ratio. The patients, outcome assessor, and statistician will be blinded. The outcomes are changes of numerical rating scale, Karnofsky performance score, brief pain inventory, blood routine, liver and kidney function. The data will be analyzed by SPSS 22.0.

CONCLUSIONS

The results will help to evaluate the efficacy and safety of plum-blossom needle acupuncture in improving CPSP after lobectomy in NSCLC patients.

Video-Assisted Thoracic Surgery Lobectomy

Video-assisted thoracoscopic surgery (VATS) has been established as the surgical approach of choice for lobectomy in patients with early-stage non-small cell lung cancer (NSCLC). Patients with clinical stage I NSCLC with no lymph node metastasis are considered candidates for VATS lobectomy. To rule out the presence of metastasis to lymph nodes or distant organs, patients should undergo meticulous clinical staging. Assessing patients' functional status is required to ensure that there are no medical contraindications, such as impaired pulmonary function or cardiac comorbidities. Although various combinations of the number, size, and location of ports are available, finding the best method of port placement for each surgeon is fundamental to maximize the efficiency of the surgical procedure. When conducting VATS lobectomy, it is always necessary to comply with the following oncological principles: (1) the vessels and bronchus of the target lobe should be individually divided, (2) systematic lymph node dissection is mandatory, and (3) touching the lymph node itself and rupturing the capsule of the lymph node should be minimized. Most surgeons conduct the procedure in the following sequence: (1) dissection along the hilar structure, (2) fissure division, (3) perivascular and peribronchial dissection, (4) individual division of the vessels and bronchus, (5) specimen retrieval, and (6) mediastinal lymph node dissection. Surgeons should obtain experience in enhancing the exposure of the dissection target and facilitating dissection. This review article provides the basic principles of the surgical techniques and practical maneuvers for performing VATS lobectomy easily, safely, and efficiently.

The Role of Surgery in Lung Cancer Treatment: Present Indications and Future Perspectives-State of the Art

Non-small cell lung cancers (NSCLC) are different today, due to the increased use of screening programs and of innovative systemic therapies, leading to the diagnosis of earlier and pre-invasive tumors, and of more advanced and controlled metastatic tumors. Surgery for NSCLC remains the cornerstone treatment when it can be performed. The role of surgery and surgeons has also evolved because surgeons not only perform the initial curative lung cancer resection but they also accompany and follow-up patients from pre-operative rehabilitation, to treatment for recurrences. Surgery is personalized, according to cancer characteristics, including cancer extensions, from pre-invasive and local tumors to locally advanced, metastatic disease, or residual disease after medical treatment, anticipating recurrences, and patients' characteristics. Surgical management is constantly evolving to offer the best oncologic resection adapted to each NSCLC stage. Today, NSCLC can be considered as a chronic disease and surgery is a valuable tool for the diagnosis and treatment of recurrences, and in palliative conditions to relieve dyspnea and improve patients' comfort.