[Totally endoscopic major pulmonary resection for stage I bronchial carcinoma: initial results]

Lung Cancer Treatment: From Tradition to Innovation

Lung cancer (LC) is the second most commonly diagnosed cancer and the primary cause of cancer death worldwide in 2020. LC treatment is associated with huge costs for patients and society; consequently, there is an increasing interest in the prevention, early detection with screening, and development of new treatments. Its surgical management accounts for at least 90% of the activity of thoracic surgery departments. Surgery is the treatment of choice for early-stage non-small cell LC. In this article, we discuss the state of the art of thoracic surgery for surgical management of LC. We start by describing the milestones of LC treatment, which are lobectomy and an adequate lymphadenectomy, and then we focus on the traditional and innovative minimally invasive surgical approaches available: video-assisted thoracoscopic surgery (VATS) and robotic-assisted thoracoscopic surgery (RATS). A brief overview of the innovation and future perspective in thoracic surgery will close this mini-review.

[Place of thoracoscopy in the treatment of chest diseases: report of 104 cases]

Introduction

La thoracoscopie est l'exploration endoscopique de la cavité pleurale, des organes avoisinants (diaphragme, péricarde, médiastin) et du poumon. Le but de ce travail se veut d'abord didactique; décrivant la thoracoscopie, ses techniques ainsi que sa place dans la prise en charge de la pathologie thoracique (indications et perspectives thérapeutiques) et informatif en rapportant l'expérience de notre équipe.

Méthodes

Il s'agit d'une étude rétrospective intéressant 104 thoracoscopies à visée diagnostique et/ou thérapeutique réalisées au service de chirurgie thoracique du Centre Hospitalier Universitaire Hassan II de Fès, sur une période de 04 ans (Août 2008-décembre 2012). Nous avons exclu de notre étude les cas ayant bénéficié d'une médiastinoscopie ainsi que les cas ayant bénéficié d'une thoracoscopie dans le cadre des traumatismes fermés du thorax ou des plaies thoraciques.

Résultats

L’ âge moyen des patients est de 47 ans, avec des extrêmes allant de 18 à 80 ans, et une légère prédominance masculine à 54%. La thoracoscopie est d'ordre pleural chez 86 patients, pulmonaire chez 10 patients et médiastinale chez 8 patients. La thoracoscopie avait une indication à visée diagnostique chez 87 cas et thérapeutique chez 52 patients (talcage dans 45 cas, décortication pleuropulmonaire dans 2 cas, résection de kystepleuro-péricardique dans 2 cas, cure de pneumothorax dans 2 cas et une fenêtre péricardique). L’évolution post opératoire etait marquée par une amélioration clinico-radiologique chez 40 malades, 11 ont présenté une amélioration clinique seule, 6 ont présenté une persistance ou une récidive de l’épanchement.

Conclusion

La thoracoscopie représente un réel gain en matière de diagnostic de certaines pathologies intra-thoraciques. Son intérêt thérapeutique limité doit être éventuellement étendu grâce à la chirurgie thoracique vidéo assistée, qui est une technique récente fiable avec une limitation de la durée d'hospitalisation et de la morbidité.

[Major pulmonary resections for lung cancer and thoracoscopic approach: some reflections on published data]

Video-assisted thoracic surgery has a renewed topicality in treating early stage non-small cell lung cancer. Numerous publications show the benefits of this surgical technique in comparison with conventional thoracotomy. However, some surgeons are still apprehensive for its validity in lung cancer. Few works were dedicated to the critical aspect of this new technique which generates silent controversy and is far from having the general approval of all surgical teams. A critical review of several papers disclosed some concerns related to this approach, notably the risk of intra-operative technical problems and the possibility of questionable results concerning cancer dissection and clearance. A randomized clinical trial is now mandatory to confirm the safety and usefulness of this technique.

Biportal complete video-assisted thoracoscopic lobectomy and systematic lymphadenectomy

The video-assisted thoracoscopic approach (VATS) for lobectomy of non-small-cell lung cancer (NSCLC) has not been standardized. Although three to four incisions are usually made, with the right surgical technique, the operation can be successfully carried out via only two incisions. This video demonstrates a case undergoing biportal complete VATS (biportal cVATS) right upper lobectomy and systematic lymphadenectomy. Here we describe our technique of biportal approach by using a combination of conventional and endoscopic instruments. As our experience gained, we consider the knacks of biportal cVATS lobectomy imply two radical changes of perspectives from the traditional triportal technique. One fundamental step is how to achieve satisfactory exposure in the case of single utility incision for multiple instruments to insert. Another technical tip that should be taken into account is how to introduce staplers conveniently without the third posterior port. Optimization of the whole procedures is critical for accomplishing anatomic hilar vascular, bronchial, and lymphatic dissection via two ports. In conclusion, biportal cVATS lobectomy for lung cancer is a safe and reliable procedure that can achieves good postoperative results without oncological compromise.

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.