Video-Assisted Thoracic Surgery Lobectomy With Bronchoplasty for Lung Cancer: Initial Experience and Techniques

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.

The learning curve of video-assisted thoracoscopic sleeve lobectomy in a high-volume pulmonary center

Objectives

To evaluate the time course and caseload required to achieve proficiency by plotting the learning curve of video-assisted thoracoscopic sleeve lobectomy.

Methods

We reviewed 127 cases of video-assisted thoracoscopic sleeve lobectomy by a single surgeon at Shanghai Pulmonary Hospital to evaluate its learning curve using the cumulative sum (CUSUM) analysis. The changes of perioperative outcomes were assessed.

Results

The inflection points of the CUSUM curve were around case 30 and 90, according to which 3 phases were identified: Phase I, Phase II, and Phase III. Significant downtrends were observed regarding operative time (Phase I, 194 [173-233 minutes] vs Phase II, 172 [142-215 minutes] vs Phase III, 138 [117-164 minutes], P < .05, all), blood loss (Phase I, 200 [100-238 mL] vs Phase II, 100 [50-200 mL] vs Phase III, 50 [50-100 mL]; P < .05, all), drainage duration (Phase I [5.53 ± 1.11 days] vs Phase II [4.52 ± 1.38 days]; P < .05), and length of postoperative stays (Phase I [6.60 ± 1.13 days] vs Phase II [5.68 ± 1.47 days], P < .05). The rate of severe complications significantly decreased from Phase I to Phase II (P = .03).

Conclusions

Thirty cases should be accumulated to lay the technical foundation, and 90 cases were required to achieve proficiency. The focus should now shift to providing sufficient training opportunities for centers wanting to implement this technique.

Bronchial Sleeve Resection with Complete Pulmonary Preservation: A Single-Center Experience

Purpose

Bronchial sleeve resection with complete pulmonary preservation (BSRCPP) is a classic surgical method for the treatment of benign or low-grade bronchial tumors. For elderly patients and patients with poor cardiopulmonary function, BSRCPP is particularly advantageous because some of these patients may not tolerate lobectomy or pneumonectomy. We retrospectively reviewed the clinical data of 20 patients who underwent BSRCPP during the past 7 years. This report presents the experience with BSRCPP in our department.

Patients and Methods

We collected the data of 20 patients who underwent BSRCPP. Of these 20 patients, 17 underwent thoracotomy and 3 underwent video-assisted thoracoscopic surgery (VATS). The study cohort comprised 7 male and 13 female patients with an average age of 44 years (range, 4–71 years). All patients underwent a systematic preoperative examination to confirm the surgical indications and methods. Regular follow-up was conducted after the operation.

Results

All patients survived and remained clinically well. Two of the 20 patients (10%) were re-admitted to the hospital because of pulmonary air leakage, which was resolved after thoracic drainage. No patients developed tumor recurrence.

Conclusion

BSRCPP may be an effective treatment for selected patients with bronchial tumors. Notably, however, many technical key points require improvement, especially in VATS. Therefore, thoracoscopic minimally invasive treatment requires more practice and exploration.

A systematic review and meta-analysis of thoracoscopic versus thoracotomy sleeve lobectomy

Background

Operative safety and oncologic adequacy of thoracoscopic sleeve lobectomy remain controversial. As such, the purpose of this meta-analysis was to evaluate evidence comparing thoracoscopy and thoracotomy in sleeve lobectomy for centrally located non-small cell lung cancer (NSCLC).

Methods

Electronic searches of PubMed and Web of Science databases were undertaken from inception to March 2020. Comparative studies about thoracoscopic and thoracotomy sleeve lobectomy, with evaluation for perioperative outcomes and oncological results were identified. The following outcomes were measured in this meta-analysis: operating time, blood loss, numbers of lymph node, postoperative hospital stay, chest drainage time, postoperative complication rate, mortality, overall survival (OS). The standardized difference (SMD), relative risk (RR) and hazard ratio (HR) with 95% confidence intervals (CI) were pooled using Stata software.

Results

Six studies generating 281 thoracoscopy and 369 thoracotomy cases were finally included. There was no significant difference in intraoperative blood loss, number of resected lymph nodes, chest drainage time, postoperative complication rate and mortality between two groups. However, thoracoscopic sleeve lobectomy was associated with longer operation time (SMD 0.59, 95% CI: 0.14 to 1.03, P=0.010). And shorter postoperative hospital stays (SMD −0.24, 95% CI: −0.51 to 0.03, P=0.078) were observed in the thoracoscopy group with marginal significance. Furthermore, sleeve lobectomy via thoracoscopy could achieve comparable OS compared to that via thoracotomy (HR 0.69, 95% CI: 0.38 to 1.00; P<0.001). In addition, there were no evident publication bias in all observational outcomes.

Conclusions

Current evidence suggests that thoracoscopic sleeve lobectomy is a safe and efficient surgical procedure for centrally located NSCLC, with comparable perioperative outcomes and equivalent oncological results compared to thoracotomy sleeve lobectomy.

Video-assisted thoracoscopic surgery as the gold standard for lung cancer surgery

Surgical resection remains the only effective means of cure in the vast majority of patients with early-stage lung cancer. It can be performed via a traditional open approach (particularly thoracotomy) or a minimally invasive approach. VATS is 'keyhole' surgery in the chest, and was first used for lung cancer resection in the early 1990s. Since then, a large volume of evolving clinical evidence has confirmed that VATS lung cancer resection offered proven safety and feasibility, better patient-reported post-operative outcomes, less surgical trauma as quantified by objective outcome measures and equivalent or better survival than open surgery. This has firmly established VATS as the surgical approach of choice for early-stage lung cancer today. Although impressive new non-surgical lung cancer therapies have emerged in recent years, VATS is also being constantly rejuvenated by the development of 'next generation' VATS techniques, the refinement of VATS sublobar resection for selected patients, the utilization of bespoke post-operative recovery programmes for VATS and the synthesis of VATS into multi-modality lung cancer therapy. There is little doubt that VATS will remain as the gold standard for lung cancer surgery for the foreseeable future.

Comparison of video-assisted thoracoscopic surgery with thoracotomy in bronchial sleeve lobectomy for centrally located non-small cell lung cancer

OBJECTIVES

The aim of this study was to investigate the adequacy of bronchial sleeve lobectomy by video-assisted thoracoscopic surgery in perioperative outcomes and its oncological efficacy by comparing with thoracotomy in a balanced population.

METHODS

A total of 363 patients who received bronchial sleeve lobectomy for non-small cell lung cancer from January 2013 to December 2017 were included and placed in the thoracotomy (n = 251) and video-assisted thoracoscopic surgery (n = 112) groups. Statistical analyses were performed to compare patients' demographics, perioperative outcomes, and survival between the 2 groups.

RESULTS

A total of 116 thoracotomy cases were matched with 72 video-assisted thoracoscopic surgery cases by propensity score. Compared with thoracotomy, patients in the video-assisted thoracoscopic surgery group after matching had less intraoperative blood loss (P < .01) and length of postoperative hospital stay (P < .01), duration of chest tube drainage (P < .01), and intensive care unit stay (P = .03) despite comparable operative time, complication rate, and 30- to 90-day mortality rate. The overall survival and recurrence-free survival were similar in patients who received sleeve lobectomy by thoracotomy and video-assisted thoracoscopic surgery (log-rank, P = .24 and .20, respectively) at 3 years. Although advanced TNM stage was independently associated with worse overall survival and recurrence-free survival in multivariable analysis, older age was only predictive for worse overall survival (hazard ratio, 1.04; 95% confidence interval, 1.01-1.07; P = .02). Body mass index was also found be a predictive factor (overall survival: hazard ratio, 0.93; 95% confidence interval, 0.86-0.99, P = .03; recurrence-free survival: hazard ratio, 0.93; 95% confidence interval, 0.87-0.99, P = .02).

CONCLUSIONS

With appropriate patient selection and continued experience, video-assisted thoracoscopic surgery appears to be safe in the short-term perioperative period and does not appear to comprise oncologic outcomes in performing sleeve lobectomy.

Short-term and mid-term survival in bronchial sleeve resection by robotic system versus thoracotomy for centrally located lung cancer

OBJECTIVES

The aim of this study was to compare the short-term and mid-term results of patients with centrally located lung cancer who underwent bronchial sleeve resection by robotic system or thoracotomy.

METHODS

From September 2014 to September 2015, 103 patients, including 17 robotic and 86 open cases, were included in our study. All the clinicopathological data, operative details and follow-up information were investigated.

RESULTS

There were no intraoperative deaths. The mean console time was 113.59 min. The operative time for robotic surgery (155.06 ± 44.75 min), even in our initial cases, was comparable to that for thoracotomy (150.30 ± 47.84 min, P = 0.71). The 30-day mortality rate in the robotic and thoracotomy groups was 1 (6%) patient and 2 (2%) patients, respectively, with no significant difference (P = 0.43). A total of 4 (24%) patients in the robotic group and 22 (26%) patients in the thoracotomy group experienced postoperative complications (P = 0.86). In multivariable analysis, tumour size and postoperative radiotherapy were significant predictors of relapse-free survival, whereas only the intensive care unit stay was a significant predictor of overall survival. There was no significant difference in relapse-free survival (log-rank P = 0.16) and overall survival (log-rank P = 0.59) between the 2 groups.

CONCLUSIONS

Robotic surgery for bronchial sleeve resection is safe and feasible and has similar oncological outcomes compared with open procedures. But long-term survival still needs to be investigated.

Da Vinci Xi robot decreases the number of thoracotomy cases in pulmonary resection

Background

Minimally invasive pulmonary resection has been shown to provide superior outcomes compared to open thoracotomy. We sought to determine if adding a robot to a general thoracic surgery practice would decrease the total number of open thoracotomy cases.

Methods

We performed a retrospective analysis of prospectively collected data from the Society of Thoracic Surgeons (STS) database from 2012-2017. We grouped patients before and after the date of first robot usage with the vascular stapler in pulmonary resections. We analyzed the number of patients who underwent either an elective thoracotomy or were converted to thoracotomy from a planned minimally invasive approach.

Results

There were 389 patients who underwent pulmonary resection between the two time periods. There were 220 patients (56.6%) from 2012-2015 prior to the first use of the robot with vascular stapler and 169 patients (43.4%) from 2016-2017 after the addition of the robot. During the pre-robot time period, 194 of 220 cases (88.2%) were performed with video-assisted thoracoscopic surgery (VATS) while during the post-robot time period, 118 of 169 cases (69.8%) were performed with the robot. A significantly higher number of patients (41 total, 19%) required a thoracotomy in the pre-robot time period compared to the post-robot time period (8 total, 5%, P<0.001). Multivariate analysis showed that adding a robot to the general thoracic surgery program could decrease up to 75% the odds of having thoracotomy [odds ratio=0.25 (95% CI 0.12-0.55, P<0.001)].

Conclusions

The adoption of a robot with a vascular stapler may decrease the number of patients who require a thoracotomy. Potential explanations include an improved ability to perform complex minimally invasive pulmonary resections.

Application of the "continuous suture dividing and equal suture tightening" method in video-assisted thoracoscopic surgery sleeve lobectomy

Background

The primary focus of video-assisted thoracoscopic surgery (VATS) sleeve lobectomy is bronchial anastomosis. Both interrupted suture and continuous suture cannot overcome entanglement of the suture threads. The present study used the "continuous suture dividing and equal suture tightening" method in VATS sleeve lobectomy for bronchial anastomosis and discussed the feasibility of this approach.

Methods

A total of 17 patients underwent VATS sleeve lobectomy with bronchial anastomosis using the "continuous suture dividing and equal suture tightening" method. Four incisions were utilized in the operation as follows: (I) the pulmonary arteries and veins were cut-off using an endoscopic linear stapler. Systematic hilar and mediastinal lymph node dissection was performed; (II) the surgeon used a surgical knife for incision into the thoracic cavity and to cut the lung lobe and main bronchi. Intraoperative pathological analysis revealed negative bronchial margins; (III) the "continuous suture dividing and equal suture tightening" method was performed for anastomosis; (IV) the integrity of the anastomosis was assessed by intraoperative bronchoscopy. Computed tomography (CT), three-dimensional (3D) reconstruction and bronchoscopy assessed the anastomosis 1-week postoperatively. A follow-up was conducted using a 3-month bronchoscopy, and CT scans monitored the recurrence and stenosis of the anastomosis.

Results

The method was successfully completed for VATS sleeve lobectomy with bronchial anastomosis in 17 cases. Although various histological profiles were observed, the 1-week postoperative CT and bronchoscopy showed adequate healing of the anastomotic stoma as well as the absence of postoperative mortality and bronchial pleural fistula. All patients were alive and followed up for 31-49 months postoperatively; local recurrence and anastomotic stenosis were not detected.

Conclusions

The continuous suture dividing and equal suture tightening method is convenient, feasible, and safe for bronchial anastomosis in VATS sleeve lobectomy. It can effectively avoid the entanglement of the suture threads, thereby enabling the widespread adoption of VATS sleeve lobectomy.

Fundamentals of Standard Sleeve Resection

Standard sleeve resection refers to the circumferential removal of a segment of the main bronchus in continuity with a lobectomy in order to avoid pneumonectomy. By doing so, surgery can be carried out in patients with compromised pulmonary function while also benefiting those with more normal function. It is most often indicated for malignant tumors located at the origin of the right upper lobe bronchus. Operative mortality is low and in the range of 2% to 3%, and quality of life and long-term survival are better than what is observed after pneumonectomy.

Uniportal video-assisted thoracoscopic surgery (VATS) sleeve resections for non-small cell lung cancer patients: an observational prospective study and technique analysis

Bronchus sleeve resection for operative treatment of non-small cell lung cancer (NSCLC) is a gold standard in modern thoracic surgery in cases of centrally located tumors or hilär lymph node metastases. Advanced instruments and growing surgical experience allowed surgeons to reduce the required incisions (from 3-port to uniportal) and to resect larger and more centrally located malignancies minimal invasively. It is a logical and expected advance in thoracic surgery that video-assisted thoracoscopic surgery (VATS) would be ultimately used also for complex bronchial resections. We therefore present in this study our early clinical results and technique of uniportal sleeve resections for patients with centrally located NSCLC or carcinoids. In the period 2015-2017, n:40 patients with NSCLC were found eligible for uniportal VATS sleeve resection in our institution. In two cases a thoracotomy conversion because of severe hilar scar tissue was necessary. In 38 cases a uniportal VATS sleeve resection could be completed. We believe that uniportal sleeve resections are the logical evolution of VATS allowing patients with locally advanced malignancies to have quicker recovery and reduced perioperative pain.

Are There Contraindications for Uniportal Video-Assisted Thoracic Surgery?

Allowing oneself to indulge in illusory superiority when it comes to uniportal video-assisted thoracic surgery (VATS) can harm patients and the specialty. It is important for every VATS surgeon to remain vigilant. One must be clear about the absolute and relative contraindications for VATS: those conditions that should deter from even attempting a uniportal approach. Once the operation is started, one must also bear in mind those situations that should prompt one to convert. Only by first safeguarding patients in this way can the aspiring uniportal VATS surgeon go on to safely master the approach and explore its benefits.

Video-assisted thoracoscopic surgery bronchial sleeve lobectomy

A sleeve lobectomy (SL) is considered a valid option instead of a pneumonectomy in patients affected by central non-small cell lung cancer (NSCLC). In the last few years, the improvement of video-assisted thoracoscopic surgery (VATS) has allowed experienced surgeons to carry out this challenging operation by a minimally invasive approach. A full pre-operative assessment enclosing a flexible fiber-optic bronchoscopy evaluation and a multidisciplinary team discussion of the clinical case must be accomplished. There is no strictly an indication for the number of thoracoscopic ports: VATS SL is reported from 1 to 3-4 incisions. A significant variability in the technique of the anastomosis is documented and depends on the personal use and ability of the surgeon. However the operational principles are the same of an open SL: free bronchial margins at the frozen section examination, tension-free anastomosis, avoid luminal disparity and en-bloc resection. Due to the extent of the tumour, VATS SL can be associated to other complex resections like arterioplasty, or double sleeve (bronchial and artery) mainly on the left side. A patient underwent a VATS SL must be enrolled in an enhanced recovery pathway (ERP): physiological rehabilitation is a key point to achieve good outcomes and avoid complications.

Single-port right upper lobe sleeve lobectomy for a typical carcinoid tumour

Pulmonary carcinoid tumours are well-differentiated neuroendocrine tumours with indolent behaviour; complete resection offers long-term survival. When centrally located, these tumours can be treated with lung-sparing procedures. We present a case of a centrally located typical carcinoid tumour treated with a minimally invasive, right upper lobe sleeve lobectomy using a single port.

Initial experience of single-port video-assisted thoracoscopic surgery sleeve lobectomy and systematic mediastinal lymphadenectomy for non-small-cell lung cancer

BACKGROUND

In this study, we evaluate the feasibility and safety of single-port video-assisted thoracoscopic surgery (VATS) sleeve lobectomy (SL) and systematic mediastinal lymphadenectomy and summarize our surgical experience.

METHODS

From October 2014 to December 2015, eight cases of single-port VATS SL [seven male patients and one female patient, median age 56.0 (range, 38-63) years] were performed by a single group of surgeons in Fujian Medical University Fujian Union Hospital. The median tumor size was 2.7 cm. Types of resection included four right upper, one right lower, and three left upper sleeve lobectomies. Systematic mediastinal lymphadenectomy was performed in all patients. A modified anastomosis technique developed by the author (Chen's technique) was applied for bronchial anastomosis. Postoperative outcome and short-term follow-up data were recorded and analyzed.

RESULTS

All eight operations were completed uneventfully with no conversion to thoracotomy or reoperation required. No perioperative death was observed. Major results (medians or percentages) were as follows: operative duration, 234.5 [185-345] min; bronchial anastomosis duration, 38.0 [30-43] min; blood loss, 65.0 [50-200] mL; number of lymph node dissected, 22.5 [18-37]. The postoperative complication rate was 37.5% (three of eight cases, including two pulmonary infections and one atrial fibrillation). All patients recovered and were discharged uneventfully with symptomatic therapy. Pathology showed squamous cell carcinoma in seven patients and adenocarcinoma in one patient; two patients were in TNM stage IB, three in stage IIA, one in stage IIB, and two in stage IIIA. The mean follow-up was 7.5 [2-15] months. There were no tumor recurrences or bronchial anastomotic complications.

CONCLUSIONS

Single-port VATS SL and mediastinal lymphadenectomy are safe and feasible. Improvements in operating procedures can help facilitate single-port VATS. The application of Chen's technique in bronchial anastomosis is easy and reliable and shows a satisfactory short-term clinical outcome.

Robotic-assisted thoracoscopic sleeve lobectomy for locally advanced lung cancer

BACKGROUND

The Da Vinci robotic system has been used to enhance the surgeon's visualization and agility in lung cancer surgery, and thus facilitate refined dissection, knot tying and suturing. However, only a few case reports exist on performing a sleeve lobectomy with a robotic-assisted thoracoscopic surgery (RATS) technique. Here we describe our early experience performing RATS sleeve lobectomies. To our knowledge, this is the first study reporting a series of RATS sleeve lobectomies.

METHODS

The six consecutive NSCLC patients who underwent a RATS sleeve lobectomy between November 2013 and July 2015 at the National Taiwan University Hospital were enrolled in this study. The lobectomies were all performed by the same surgeon using a three-arm robotic system with an additional utility incision made for assistance and specimen retrieval.

RESULTS

Five patients were diagnosed with squamous cell carcinoma, while the sixth was diagnosed with a carcinoid tumor. The mean operation time was 436.7 [255-745] minutes. The mean postoperative intensive care unit (ICU) stay and hospital stay were 3.7 [1-11] and 11.3 [3-26] days, respectively. Two (33.3%; 2/6) morbidities were noted, including one pneumonia and one anastomosis stricture. There were no cases of mortality or of conversion to thoracotomy.

CONCLUSIONS

Our experience performing a RATS sleeve lobectomy in the six patients demonstrated the feasibility of RATS in complex lung cancer surgeries. The three-dimensional vision and articulated joint instruments made robotic-assisted bronchial anastomosis easier under the endoscopic setting. Our experience suggests that RATS offers specific advantages with regard to accuracy and safety when performing sleeve lobectomies.

VATS right upper lobe bronchial sleeve resection

BACKGROUND

The aim of this study is to discuss video-assisted thoracic surgery (VATS) sleeve bronchial lobectomy when handling the locally advanced central lung cancer (involving the trachea and/or main bronchus).

METHODS

A 2.5 cm × 1.0 cm mass was found in the right upper lobe. Bronchoscopy demonstrated the tumor obstructing the right upper lobe bronchus and involved the right main bronchus and bronchus intermedius. Interrupted sutures were chosen for bronchial anastomosis. Bronchial membrane was sutured first, and then circumference end-to-end anastomoses were carried out using 3-0 absorbable sutures.

RESULTS

There were no complications and the patient was discharged 8 days postoperatively.

CONCLUSIONS

The third intercostal space of the anterior axillary line was suggested for right upper lobe bronchial sleeve resection. This incision can reduce the distance and angle between the anastomosis to the incision, and facilitate anastomosis. This approach can also prevent operator from fatigue for keeping one posture for a long time. Clearance of the mediastinal lymph nodes before cutting the bronchus was helpful for exposing the right main bronchus, the upper lobe bronchus and bronchus intermedius satisfied. And this option would avoid pulling bronchial anastomosis during mediastinal lymph nodes clearance. Interrupted suture was safe and effective for VATS bronchial anastomosis.

Thoracoscopic tracheal reconstruction without surgical field intubation

A cross‐filed endotracheal intubation is usually applied to maintain single lung ventilation during both open and thoracoscopic tracheal resection and reconstruction. Herein, we report a case of thoracoscopic tracheal resection and reconstruction with interrupted ventilation via transoral endotracheal intubation in a patient with thoracic tracheal adenocarcinoma. Tracheal anastomosis was accomplished using a running suture with a 3‐0 Prolene stitch.

Complete video-assisted thoracoscopic surgery (VATS) bronchial sleeve lobectomy

BACKGROUND

To explore the effectiveness of video-assisted thoracoscopic surgery (VATS) bronchial sleeve resection and reconstruction.

METHODS

The clinical data of patients who had received VATS bronchial sleeve lobectomy in our center from January 2008 to February 2015 were retrospectively analyzed.

RESULTS

Totally 118 patients (105 men and 13 women) received the VATS bronchial sleeve lobectomy. The procedures included sleeve resection of right upper lobe (n=59), right middle lobe (n=7), right lower lobe (n=8), left upper lobe (n=34), and left lower lobe (n=10). The lesions were confirmed to be squamous cell carcinoma (n=68), adenocarcinoma (n=16), mucoepidermoid carcinoma (n=8), adenosquamous carcinoma (n=7), large cell carcinoma (n=1), carcinoids (n=5), and others (n=13; including small cell carcinoma, pleomorphic carcinoma, and inflammatory myofibroblastic tumor). Operations lasted 118-223 min [mean ± standard deviations (SD): 124.00±31.75 min]. The length of removed bronchus was 1.50-2.00 cm (mean ± SD: 1.75±0.26 cm). The duration of bronchial anastomosis (from the first puncture to the completion of knotting) was 15-42 min (mean ± SD: 30.20±7.97 min). The number of dissected lymph node stations (at least three mediastinal lymph node stations, including station 7) was 5-9 stations (mean ± SD: 6.50±1.18 min). The number of dissected lymph nodes was 10-46 (mean ± SD: 26.00±10.48). The intraoperative blood loss was 20-400 mL (mean ± SD: 71.00±43.95 mL), and no blood transfusion was performed. All patients were observed in intensive care unit (ICU) for 1 day. Postoperative drainage was performed for 3-8 days (mean ± SD: 5.00±1.49 days). Postoperative hospital stay was 3-8 days (mean ± SD: 5.10±2.07 days).

CONCLUSIONS

VATS bronchial sleeve resection and reconstruction is a safe and feasible technique.

Video-assisted thoracic surgery right upper lobe bronchial sleeve resection

BACKGROUND

Video-assisted thoracic surgery (VATS) is a new technology for nearly 30 years in the field of thoracic surgery most watched. However, there are still some controversy concerning the technical difficulties, operation duration, the extent of lymph node dissection and perioperative complications for VATS sleeve bronchial lobectomy when handling the locally advanced central lung cancer (involving the trachea and/or main bronchus).

METHODS

A 66 years old man was admitted for coughing for 2 months. He had smoked for 30 years, 20 packs a day. Chest computed tomography (CT) revealed a 2.5 cm × 4.5 cm mass in the right upper lobe. Bronchoscopy demonstrated the tumor obstructing the right upper lobe bronchus and involved the right main bronchus and bronchus intermedius. Pathology was squamous cell carcinoma. His pulmonary function result was forced expiratory volume in 1 second (FEV1): 1.91 L (64.7% predicted), forced vital capacity (FVC): 4.36 L. He received general anesthesia with double-lumen endotracheal intubation and left lung ventilation. Left lateral decubitus position was chosen. The first 1.5 cm incision was selected in the eighth intercostal space in the midaxillary line, and was used for the camera. A 4 cm long incision was made in the 3rd intercostal space in the preaxillary line. A third 1.5 cm incision was performed in the 9th intercostal space in the postaxillary line for assistant. Pulmonary ligament and the entire right hilum were mobilized. Pulmonary vein is the most forward hilar structure, sometimes immediately prior pulmonary trunk. The right upper lobe vein was transected with a vascular stapler. Truncus and posterior ascending pulmonary artery were then divided and transected with a vascular stapler. Major and minor fissures were stapled by 60 mm green linear stapler. Following clearance of the mediastinal lymph nodes of level 7, 4R and 2R, the bronchial sleeve resection and reconstruction began. The distal right main bronchus and bronchus intermedius were fully mobilized to ensure adequate surgical exposure. Traction sutures were routinely placed on the lateral walls and to reduce tension. Interrupted sutures were chosen for bronchial anastomosis. Bronchial membrane was sutured first, and then circumference end-to-end anastomoses were carried out using 3-0 absorbable sutures.

RESULTS

There were no complications and the patient was discharged 8 days postoperatively.

CONCLUSIONS

The 3rd intercostal space of the anterior axillary line was suggested for right upper lobe bronchial sleeve resection. This incision can reduce the distance and angle between the anastomosis to the incision, providing convenient conditions for easy anastomosis. And avoid the operator fatigue for keeping the posture for a long time. Clearance of the mediastinal lymph nodes before cutting the bronchus was helpful for satisfied explosion of the right main bronchus, the upper lobe bronchus and bronchus intermedius. And this would avoid pulling bronchial anastomosis for mediastinal lymph nodes clearance. Interrupted suture was safe and effective for VATS bronchial anastomosis.

Surgical treatment for pulmonary tuberculosis: is video-assisted thoracic surgery "better" than thoracotomy?

OBJECTIVE

To compare video-assisted thoracoscopic surgery (VATS) lobectomy and conventional open lobectomy in patients with pulmonary tuberculosis (TB) who require surgery.

METHODS

Forty patients with pulmonary TB who required lobectomy were randomized to receive either VATS or open lobectomy. Patient demographic, pulmonary function, operative, and postoperative data were compared between the groups.

RESULTS

There were 20 patients who received VATS lobectomy (median age 31.5 years, range 19-67 years) and 20 that received open lobectomy (median age 33.5 years, range 16-60 years). The two groups were similar with respect to gender, age and pulmonary function (all, P>0.05). Lobectomy was completed by VATS in 19 of 20 patients (95%), and by thoracoscope-assisted mini-incision lobectomy in 1 patient. The median intraoperative blood loss was 345 mL (range, 100-800 mL), and the median duration of pleural cavity closed drainage was 5 days (range, 3-7 days). All open lobectomies were completed successfully, and the median intraoperative blood loss was 445 mL (range, 150-950 mL) and the median duration of pleural cavity closed drainage was 5 days (range, 3-9 days). No statistically significant differences were found between the groups with respect to operation completion rates, type of lung resection, intraoperative blood loss, closed pleural drainage duration and volume of postoperative chest drainage. The operation time, number of postoperative complications, postoperative pain index at 24 hours after surgery and postoperative hospital stay were all significantly less in the VATS group. With a median follow-up duration of 14 months (range, 8-18 months) no positive sputum examination results were found in either group.

CONCLUSIONS

VATS lobectomy is an effective and minimally invasive method for treating patients with pulmonary TB.

Sleeve lobectomy by video-assisted thoracic surgery versus thoracotomy for non-small cell lung cancer

BACKGROUND

Both video-assisted thoracic surgery (VATS) and thoracotomy are used for sleeve lobectomy for patients with non-small cell lung cancer (NSCLC). This retrospective study aimed to assess the safety and efficacy of VATS sleeve lobectomy for NSCLC patients.

METHODS

Between May 2009 and May 2013, 51 sleeve lobectomies (10 by VATS and 41 by thoracotomy) were performed for patients with NSCLC. Operative characteristics and postoperative course were compared between two groups.

RESULTS

Patient demographics were similar between the two groups. Thoracotomy patients had larger tumors compared with VATS patients (p = 0.02). VATS patients had a longer operating time (p < 0.001) but a shorter length of postoperative hospital stay (p = 0.009). The two groups did not differ in pathologic stage, histologic results, blood loss, ICU stay, amount of chest drainage, duration of chest drainage, numbers and distributions of dissected lymph nodes and the occurrence of complications. There were no perioperative deaths in the VATS group, whereas there was one death (2.4 %) in the thoracotomy group. There were no conversions to thoracotomy in the VATS group. The overall median survival between the two groups was similar (3.2 years VATS versus 3.2 years thoracotomy, log-rank p = 0.58).

CONCLUSIONS

VATS sleeve lobectomy for the treatment of NSCLC is technically feasible and safe and is associated with comparable complication rates and survival compared with thoracotomy approach, but it deserves further investigation in large series.

INITIAL EXPERIENCE OF THORACOSCOPIC LOBECTOMY PERFORMANCE WITH BRONCHOPLASTY

The article presents an initial Russian experience of video-thoracoscopic bronchoplastic lobectomies performed in 2 clinical cases of centric lung tumors. The upper bronchoplastic lobectomies with right lymphodissection were carried out on two patients in 2012. Complications weren’t observed in intraoperative and postoperative periods. There wasn’t relapse during two years after operation. Thus, the authors came to conclusion that thoracoscopic bronchoplastic lobectomies turned out to be safe and effective interventions in individual patients with centric tumor location, which wasn’t extended outside mouth of the lobar bronchus. The choice of candidates for thoracoscopic bronchoplasty was made using video-bronchoscopy, angio-computer tomography of the thorax and PET. This allowed avoiding an invasive staging and excluded patients with substantial extra-bronchial lesions.

Initial experience of thoracoscopic lobectomy with partial removal of the superior vena cava for lung cancers

OBJECTIVES

The objectives of this study were to report the surgical techniques and clinical outcome of thoracoscopic lobectomy with partial removal of the superior vena cava for lung carcinomas.

METHODS

Between January 2010 and November 2013, 1132 patients with lung cancer underwent radical surgery by thoracoscopy; 5 (0.4%) underwent thoracoscopic lobectomy with partial removal of the superior vena cava. Perioperative variables and postoperative outcomes of these cases were analysed to evaluate the technical feasibility and safety of this operation.

RESULTS

For all cases, a right upper lobectomy was performed. The average time of surgery was 260 min (range, 170-380, 260±90 min).The intraoperative blood loss averaged 160 ml (range, 50-300, 160±90 ml). The median postoperative hospital stay was 11 days (interquartile range, 7-15 days). Postoperatively, tracheal extubation was achieved in the recovery room without further need for mechanical ventilation. In 1 case, the patient experienced postoperative superior vena cava thrombosis; he recovered after administration of anticoagulation drugs. None of the patients developed active blood leakage postoperatively. Perioperative mortality was not observed.

CONCLUSION

Thoracoscopic lobectomy with partial removal of the superior vena cava can be considered a feasible and safe operation for selected patients with lung cancer.

Technical difficulties and extending the indications for VATS lobectomy

BACKGROUND

Data on advantages of video-assisted thoracoscopic surgery (VATS) lobectomies has been accumulated during the last 10 years then number of thoracoscopic anatomic pulmonary resections rapidly increased. But still there is no agreement about limitations of the method. The most popular "technical contraindications" for VATS anatomic pulmonary resections are: dense pleural adhesions, incompleteness of interlobar fissure, previous chemo- or/and radiotherapy, perivascular or/and peribronchial fibrosis, tumor larger than 5 cm, chest wall involvement, centrally located tumor, severe comorbidity, advanced age, severe COPD and emphysema. Extending of indications for the VATS anatomic pulmonary resection and its influence on the immediate outcomes was investigated.

METHODS

Ninety two consecutive cases of VATS anatomic pulmonary resection performed by the single surgeon from January 2012 till December 2013 at the Federal University Hospital #122 in Saint Petersburg, Russia were retrospectively analyzed. Forty three males and 49 females at the age from 21 to 87 years old (mean age 59±7.2). The most of the cases were comprised by lung cancer of I-III stage together with bronchiectasis and tuberculomas. Conversion rate was 3.2% mostly due to perivascular calcification and/or fibrosis. There were no cases of 30-days mortality and readmission. All those patients retrospectively divided into two groups: with standard and extended indications for the VATS lobectomy. Inclusion in "extended" group was made if patients had one or more technical challenges among following: size of the lesion 5 cm and more; strong pleural adhesions and/or "bad fissure"; adjacent structures involvement; hilar or mediastinal lymph nodes enlargement or involvement; centrally located tumors; previous chemo- or chemoradiotherapy or previous thoracic surgery.

RESULTS

According to these criteria, 45 standard (S) and 47 extended (E) patients were pair-matched with no statistically significant differences between the groups in common patients' characteristics. Postoperative comparison of "standard" and "expanded" groups revealed some differences in average operation time (152 vs. 189 min), in number of resected mediastinal lymph nodes (10.2 vs. 13.1), and in the mean time before removal of the chest tube (3.9 vs. 5.2 days). But the blood loss, morbidity and the length of hospital stay were almost the same in the two groups.

CONCLUSIONS

Extension of indications to VATS lobectomy does not compromise the short-term results. Incompleteness of interlobar fissures, pleural adhesions, preoperative chemotherapy, big size of lesion, and some cases of centrally located tumors are not supposed to be the contraindications for VATS lobectomy. Peribronchial and perivascular lymph node calcification may complicate and even preclude lobectomy by VATS.

Advances in the use of video-assisted thoracoscopic lobectomy in lung cancer: sleeve bronchoplasty and arterioplasty

SUMMARY 

This article focuses on the technical strategies for performing sleeve bronchoplasty and pulmonary arterioplasty as advances in the application of video-assisted thoracoscopic surgery (VATS) as lobectomy with bronchovascular reconstruction is a favorable alternative to pneumonectomy in terms of the pulmonary function. When performing VATS sleeve bronchoplasty or arterioplasty, several technical issues should be discussed, including how to reduce the anastomotic tension of the airway, perform bronchial anastomosis, and clamp the pulmonary artery and select the type of vascular clamp. The traction device technique and continuous suture technique are thought to help surgeons perform VATS sleeve bronchoplasty, while cross-clamping of the pulmonary artery using thoracoscopic instruments aids in carrying out VATS arterioplasty.

Video-assisted thoracoscopic surgery sleeve lobectomy with bronchoplasty

BACKGROUND

We review our experiences with video-assisted thoracoscopic surgery (VATS) sleeve lobectomy with bronchoplasty for NSCLC. The safety, effectiveness, indications, and operation precautions of this approach were examined.

METHODS

From September 2011 to September 2012, 11 patients underwent VATS sleeve lobectomy with bronchoplasty in our hospital (right upper lobe = 8, left lower lobe = 2, left upper lobe = 1). The operation consisted of VATS anatomic sleeve lobectomy with bronchoplasty combined with systematic lymph node dissection. Three incisions were made. Bronchial anastomosis was combined with simple continuous suture anastomosis of the membranous part of the bronchus and simple interrupted suture anastomosis of the cartilaginous part of the bronchus.

RESULTS

All procedures went uneventfully. Median operative time was 178 min; median bronchial anastomosis time was 42 min; median blood loss was 180 ml. There was no case of conversion to thoracotomy. Pathological examination showed 10 squamous cell carcinomas and 1 adenocarcinoma. All patients recovered well, except one who suffered minor complications. Median postoperative chest tube drainage duration was 6.8 days, and median hospital stay was 8.9 days. All patients were followed up for 2-13 months without recurrence.

CONCLUSIONS

Video-assisted thoracoscopic surgery sleeve lobectomy with bronchoplasty is a safe and effective surgical approach in the treatment of non-small cell lung cancer. The operating incision placed at the 4th intercostal space on the anterior axillary line is convenient for anastomosis our experience shows that anastomosis combining simple continuous suture of the membranous part of bronchus and simple interrupted suture anastomosis of the cartilaginous part of the bronchus is fast and secure. Moreover, preserving the azygos vein does not affect the anastomosis.

Thoracoscopic half carina resection and bronchial sleeve resection for central lung cancer

BACKGROUND

The objectives of this study were to report the surgical techniques and clinical outcome of thoracoscopic half carina resection and thoracoscopic bronchial sleeve resection for central lung cancer.

METHODS

Between January 2011 and November 2012, 675 patients with lung cancer underwent radical surgery by thoracoscopy, and 49 (7.3%) underwent bronchial sleeve resection. Among 49 patients, 20 (41%) received thoracoscopic bronchial sleeve lobectomy. Perioperative variables and postoperative outcomes of these cases were analyzed to evaluate the technical feasibility and safety of this operation.

RESULTS

In one patient, right upper lung sleeve resection was combined with half-carinal resection and reconstruction. In another, right medial lung sleeve resection was combined with lower right dorsal segment resection. The average time of surgery was 239 ± 51 minutes (range = 142-330 minutes), and the average time of airway reconstruction was 44 ± 17 minutes (range = 22-75 minutes). The intraoperative blood loss averaged 207 ± 96 mL (range = 80-550 mL). The median postoperative hospital stay was 10 days (interquartile range = 8-12 days). Postoperatively, extubation was achieved in the recovery room without further need for mechanical ventilation. None of the patients developed anastomotic leak. Perioperative mortality was not observed.

CONCLUSION

Thoracoscopic bronchial sleeve resection can be considered a feasible and safe operation for selected patients with central lung cancer. The complicated anastomosis technique of half carina resection was feasible.

Left lower sleeve lobectomy by uniportal video-assisted thoracoscopic approach

Endobronchial tumours requiring sleeve resection have been usually considered a contraindication for video-assisted thoracoscopic surgery (VATS). However, with new technical advances and the experience gained in VATS, sleeve lobectomy has been performed by thoracoscopy in experienced VATS centres. Right-sided sleeve anastomoses are easier to perform by VATS than left-sided ones because of the presence of the pulmonary artery and aortic arch on the left side. Most surgeons use a 3 to 4 incision VATS technique for sleeve anastomosis but the surgery can be performed by using only one incision. This is the first report of a left-sided sleeve lobectomy by uniportal approach.

Initial experience with video-assisted thoracoscopic bronchoplasty

OBJECTIVES

Bronchial-origin involvement by endobronchial tumours or direct invasion by tumour or metastatic lymph nodes is a relative contraindication for video-assisted thoracoscopic (VATS) lobectomy. However, selected cases can be resected by VATS bronchoplasty.

METHODS

Between 2006 and 2009, 21 of 231 (9.1%) VATS lobectomy cases underwent VATS bronchoplasty. Cases with endobronchial involvement and limited non-bulky invasion of bronchus by tumour or metastatic nodes without major vascular invasion were selected for bronchoplasty by preoperative bronchosocpy and CT scan thorax. Patients underwent a simple/wedge bronchoplasty (bronchus divided at origin and closed flush or transversely), sleeve bronchoplasty or others (bronchoplasty combined with other extended resections). All bronchoplasties were done totally endoscopically by directly watching a TV monitor. Bronchial margins were all subjected to intraoperative pathological analysis. Anastomosis was done with interrupted sutures. Integrity of anastomosis was checked by intraoperative bronchoscopy. The follow-up was done by 6-monthly CT scans and bronchoscopy.

RESULTS

Eleven patients were females. Mean age was 64.9 years (range, 47-83 years). Indications were endobronchial tumours in 3, direct invasion in 6 and metastatic nodes in 12. In 4 cases, invasion was detected at the time of surgery. Mean hospital stay was 5.2 days (range, 3-8 days). Mean duration of surgery was 287 min (range, 135-540 min). Nine had simple/wedge bronchoplasty, 8, sleeve bronchoplasty and 4, extended bronchoplasties. Histology was non-small-cell carcinoma (NSCLC) in 19, carcinoid in 1 and colonic metastasis in 1. In the NSCLC, 5 patients were in stage IB, 5 in stage IIA, 2 in stage IIB and 7 were in IIIA. All bronchial margins were negative for malignancy. The mean follow-up was 26.2 months (range, 6-32 months). There was no operative mortality, but 1 patient developed bronchopleural fistula. To date, there have been no local tumour recurrences.

CONCLUSIONS

Selected endobronchial and non bulky tumours with limited invasion at bronchial origin can be resected by VATS bronchoplasty.

Complex thoracoscopic pulmonary resections for the treatment of lung cancer-a review

Minimally invasive surgery is increasingly being used in cancer resections. Benefits attributed to minimally invasive surgery include improved functional and oncological outcomes. In keeping with this trend, thoracoscopic lung resections are gaining acceptance amongst thoracic oncologic surgeons. As surgeons become more comfortable with these approaches, more complex resections are being performed through these techniques. This review article summarizes the current state of the art with respect to complex thoracoscopic resections.

VATS lobectomy: surgical evolution from conventional VATS to uniportal approach

There is no standardized technique for the VATS lobectomy, though most centres use 2 ports and add a utility incision. However, the procedure can be performed by eliminating the two small ports and using only the utility incision with similar outcomes. Since 2010, when the uniportal approach was introduced for major pulmonary resection, the technique has been spreading worldwide. The single-port technique provides a direct view to the target tissue. The conventional triple port triangulation creates a new optical plane with genesis of dihedral or torsional angle that is not favorable with standard two-dimension monitors. The parallel instrumentation achieved during single-port approach mimics inside the maneuvers performed during open surgery. Furthermore, it represents the less invasive approach possible, and avoiding the use of trocar, we minimize the compression of the intercostal nerve. Further development of new technologies like sealing devices for all vessels and fissure, robotic arms that open inside the thorax, and wireless cameras will facilitate the uniportal approach to become the standard surgical procedure for pulmonary resection in most thoracic departments.

Initial experience of video-assisted thoracic surgery left upper sleeve lobectomy for lung cancer: Case report and literature review

Video-assisted thoracic surgery (VATS) sleeve lobectomy continues to represent a great challenge to thoracic surgeons. Herein we report what we believe to be the first case of thoracoscopic left upper sleeve lobectomy for lung cancer. A 61-year-old male patient with centrally located lung cancer of the left upper lobe was successfully treated by this minimally invasive technique. Based on the success of the operation, we believe that VATS left upper sleeve lobectomy is also feasible, however, surgical approaches and procedures still require further improvement.

Unanticipated troubles in video-assisted thoracic surgery: a proposal for the classification of troubleshooting

INTRODUCTION

Most thoracic surgeons encounter atypical cases or unexpected situations that usually lead them to convert minimally invasive surgery to open thoracotomy. But are there other options besides open surgery? The purpose of this study was to suggest a video-assisted thoracic surgery (VATS) classification system and present tips for the application of VATS to atypical cases or unexpected situations. We have categorized VATS procedures for atypical cases or unexpected situations into two groups: the modification of techniques/instruments and the creation of additional access incisions.

METHODS

We retrospectively reviewed VATS with optional additional techniques. We used direct visualization or monitoring as the situation demanded, switching back and forth between the monitor and direct vision.

RESULTS

Of the 33 cases we reviewed, 27 patients had malignant lung disease and 6 had benign lung disease. All patients underwent lobectomies including one or more of the following: bronchoplasty (n = 12), control of the main pulmonary artery (n = 9), total adhesiotomy (n = 7), combined resection with the diaphragm (n = 3), and separation of totally fused fissures (n = 2). The mean length of the skin incision was 8 cm, the mean total operating time was 208 min, and the mean blood loss was 173 mL No operative or hospital deaths occurred.

CONCLUSIONS

Veteran surgeons can instinctively deal with intraoperative variance, but we frequently see inexperienced surgeons panic and change the course of their procedures. A VATS classification system may have educational benefits for newer surgeons. We believe that the creation of a categorized coping plan will help inexperienced surgeons deal with unanticipated problems.

Bronchoplasty with continuous sutures for non-small-cell lung cancer

Bronchoplasty is sometimes performed in patients with compromised lung function to preserve functional lung parenchyma. Although the bronchial anastomosis was generally performed with interrupted sutures, we applied it with continuous sutures by using monofilament absorbable material in two patients with non-small-cell lung cancers to obtain a good operative view and shorten the operating time. These patients recovered uneventfully with good healing of the bronchial anastomosis. Bronchial anastomosis with continuous sutures is considered a useful technique.

Video-assisted thoracic surgery for lung cancer

Video-assisted thoracic surgery (VATS) lobectomy is currently accepted as an appropriate procedure for selected patients with early-stage non-small-cell lung cancer (NSCLC). Evidence has demonstrated that VATS lobectomy is not only a safe and feasible technique, it provides better functional recovery and oncological efficacy similar to that achieved with conventional thoracotomy. However, there are still ongoing issues concerning VATS in terms of terminology, oncological efficacy, functional recovery, benefit of screening detected lung cancer, and its role in limited resection. As the number of VATS procedures are increasing and VATS is becoming a dominant procedural choice, it would be wise to collect evidence and come to a consensus to justify the expansion of surgical indications for VATS.

U-clip for airway reconstruction: an experimental study of the feasibility of a robot-assisted endoscopic procedure

BACKGROUND

The U-clip anastomotic device was developed to facilitate interrupted anastomoses without the need to tie sutures. Recently, this technology has been expanded into various fields of surgery. However, in the field of airway reconstruction, there have been no previous reports of this technology being used. The present study examined the technical feasibility of performing safe and efficient robot-assisted endoscopic airway reconstruction using nitinol U-clips in rabbits.

METHODS

A total of six tracheal anastomoses with S60 U-clips were performed using the da Vinci Surgical System. Anastomosis time and complications were recorded. The effectiveness of anastomoses was evaluated by postoperative observation of rabbits for 8 weeks and measurement of anastomotic strictures and pathological findings.

RESULTS

All procedures were completed safely. Mean procedure time was 14 ± 1.8 min (mean ± SD). There were no perioperative complications; however, all animals died between postoperative days 14-27, and anastomotic stricture was the likely cause of death. All anastomoses had severe strictures; the mean stricture rate was measured as being 51.1 ± 33.3 (%).

CONCLUSIONS

Although the technical feasibility of robot-assisted endoscopic airway reconstruction using U-clips has been demonstrated in rabbits, the safety of this technique has not been evaluated. Our data suggest that U-clips are not a feasible approach for airway reconstruction surgery because of the occurrence of severe postoperative anastomotic stricture.

Main bronchial sleeve resection and bronchoplasty without removing lung parenchyma

We applied main bronchial sleeve resections without removing lung parenchyma and bronchoplasty in two patients with metastatic lung cancer and squamous cell carcinoma in situ. Main bronchial sleeve resection without removing lung parenchyma is generally considered technically difficult, as the remaining lung prevents the surgeon from obtaining good operative views; this means that the bronchial anastomosis must be performed in the deep, narrow space of the thorax. However, the two patients showed excellent results. Postoperative bronchoscopy ensured patency of the bronchial lumen in both patients. We believe that the surgeon can obtain a good operative view by resecting Botallo's ligament or by traction of the trachea and main pulmonary artery in cases involving lesions such as polypoid tumors toward the internal lumen of the bronchus, leading to successful results.

Long-term outcome of hybrid surgical approach of video-assisted minithoracotomy sleeve lobectomy for non-small-cell lung cancer

BACKGROUND

The aim of this study was to evaluate the technical feasibility and safety of a hybrid surgical approach of video-assisted minithoracotomy (hybrid VATS) sleeve lobectomy for non-small-cell lung cancer (NSCLC), using success rate as the primary end point.

METHODS

Between February 1996 and December 2006, patients with bronchogenic tumors were prospectively registered to undergo hybrid VATS sleeve resection in a single institution. Hybrid VATS involved performing the main procedures via rib spreading and minithoracotomy using a monitor and direct vision. A successful procedure was defined as a patient who had a sleeve lobectomy via hybrid VATS without conversion to thoracotomy and without significant perioperative morbidity or mortality.

RESULTS

A total of 148 patients (108 men and 40 women; median age = 58 years) who underwent hybrid VATS sleeve lobectomy for NSCLC were identified in our database. The median duration of the successfully completed procedures was 190 min (range = 145-305 min). The median length of time of chest tube in place was 3 days (range = 1-12 days). Hybrid VATS sleeve lobectomy was performed successfully in 134 of 148 patients for a success rate of 90.5%. The median follow-up period was 65.1 months (range = 34.5-154.8 months). The overall 5-year disease-free survival and overall survival of all patients were 36.7% (95% CI = 27.9-45.5%) and 54.2% (95% CI = 44.8-63.6%), respectively.

CONCLUSION

Hybrid VATS sleeve lobectomy is feasible for selected patients with NSCLC in specialized centers.

Video-assisted surgery for lung cancer. State of the art and personal experience

This paper reviews the role of videothoracoscopy in lung cancer, highlighting its utility in definitive staging, diagnosis, and treatment. We show exploratory videothoracoscopy to be the perfect technique for last-minute staging, looking for tumor invasion, especially parietal T3 and vascular T4 (due to videopericardioscopy), management of solitary pulmonary nodules, and the possibility of radical treatment with video-assisted thoracoscopic lobectomy. We perform an overview of the literature and analyze our experience of 1,381 patients with lung cancer. In 1,277 of them, the final decision on resectability was made by exploratory videothoracoscopy, including 91 by videopericardioscopy (only 30 were considered non-resectable on videopericardioscopy). Solitary pulmonary nodules were diagnosed in 382 cases (190 were cancer), and we performed 260 major lung resections by video-assisted thoracoscopic surgery (22 pneumonectomies, 238 lobectomies/bilobectomies).

Is thoracoscopic pneumonectomy safe?

BACKGROUND

While thoracoscopic surgical lobectomy is an established operation, the safety of thoracoscopic pneumonectomy (TP) is uncertain.

METHODS

From January 1, 2002, to September 30, 2008 at a comprehensive cancer center, 70 patients underwent pneumonectomy. Three patients were excluded for emergent operations. Thoracoscopic pneumonectomy was completed successfully in 24 patients and attempted in 8 others (25% conversion rate). Analysis was done on an intention-to-treat basis.

RESULTS

By 2008, 75% of pneumonectomy cases were planned as TP while there were no conversions to thoracotomy. There was no difference in median blood loss between patients undergoing TP versus thoracotomy (325 vs 300 mL, p = 0.52), but operations were longer (286 vs 228 minutes, p < 0.01). Median intensive care unit stay was 2 days in both groups and median hospital stay was 5.0 days in the TP group versus 6.0 days in the thoracotomy group (p = 0.28). Major complications were similar between groups. The TP reoperations were for bleeding (2), bronchopleural fistula (2), empyema (1), and chylothorax (1). The only TP death occurred in an 83-year-old patient from respiratory failure. Neither the use of adjuvant therapy nor the time between surgery and commencement of adjuvant therapy was different between groups. Conversions alone compared with patients undergoing thoracotomy were associated with a moderate increase in blood loss and intensive care unit stay, but not in any major complications.

CONCLUSIONS

Thoracoscopic pneumonectomy can be done safely. The availability of this option is important especially in an era of multimodality therapy as more debilitated patients present for surgical therapy.