Video-assisted thoracoscopic lobectomy: the Edinburgh posterior approach

Vats lobectomy for lung cancer. What has been the evolution over the time?

Video assisted thoracic surgery (VATS) lobectomy is the treatment of choice for early-stage lung cancer. It is safe and effective compared to open surgery, as demonstrated by a large body of scientific evidence over the last few decades. VATS lobectomy's evolution was driven by the need to decrease post-operative pain by reducing the extent of surgical accesses, maintaining the same oncological efficacy of open lobectomy with less invasiveness. VATS lobectomy just turned 30 years old, evolving and changing significantly from its origins. The aim of this mini review is to retrace the history, starting from a multiport approach to a single port approach. At the end of this mini review, we will discuss the advanced and the future challenges of the technique that has revolutionized thoracic surgery.

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.

Uniportal video-assisted lobectomy through a posterior approach

We propose a technique of uniportal VATS lobectomy using a posterior approach. The main differences of our technique versus standard anterior uniportal VATS are the following: (I) the surgical incision is performed in the auscultatory triangle instead of in the posterior axillary line and (II) the surgeon is placed posteriorly to the patient rather than anteriorly. For thoracic surgeons who are familiar with posterolateral thoracotomy, our technique allows to replicate the same maneuvers performed in the open approach. This strategy was applied with success in 19 consecutive patients for anatomical resection of neoplastic (n=17) and benign (n=2) diseases.

[Troubleshooting Common Unexpected Situations during Thoracoscopic Anatomical Pulmonary Resection]

The history of modern thoracoscopic pulmonary surgery could date back to the 1990s, and the related surgical technique has been matured after 20 years' development. Meanwhile, large amount of clinical data has been collected. Minimally invasive thoracic surgery represented by the thoracoscopic approach has been universally accepted as the preferred choice for the surgical treatment of early-staged non-small cell lung cancer and pulmonary benign diseases, and for the diagnosis of pulmonary diseases. With the generalization of thoracoscopic anatomical pulmonary resection, some unexpected situations during clinical practice has been reported in literatures, with issues involving anatomical variation, pathological factors, and surgical techniques. However, the systemic summary of the unexpected situations during thoracoscopic anatomical pulmonary resection is lacking until now. The present review, therefore, aims to summarize accidental issues and troubleshooting these unexpected situations on the basis of our own clinical practice and literature reports.

The Role of VATS in Lung Cancer Surgery: Current Status and Prospects for Development

Since the introduction of anatomic lung resection by video-assisted thoracoscopic surgery (VATS) 20 years ago, VATS has experienced major advances in both equipment and technique, introducing a technical challenge in the surgical treatment of both benign and malignant lung disease. The demonstrated safety, decreased morbidity, and equivalent efficacy of this minimally invasive technique have led to the acceptance of VATS as a standard surgical modality for early-stage lung cancer and increasing application to more advanced disease. Formerly there was much debate about the feasibility of the technique in cancer surgery and proper lymph node handling. Although there is a lack of proper randomized studies, it is now generally accepted that the outcome of a VATS procedure is at least not inferior to a resection via a traditional thoracotomy.

VATS anatomic lung resections-the European experience

Video-assisted thoracoscopic surgery (VATS) has undergone significant evolution over several decades. Although endoscopic instruments continued to improve, it was not until 1992 that the first VATS lobectomy for lung cancer was performed. Despite significant seeding of such procedure in several thoracic units globally, the uptake was slow and frustrating. Many surgeons considered it complex and unsafe being skeptic about its oncological validity. The last decade has witnessed significant change of practice in many thoracic units with a new generation of VATS thoracic surgeons. Additionally the technique has been refined, standardized and proved its validity and superiority in lung cancer treatment.

Video-assisted thoracoscopic pneumonectomy: the anterior approach

BACKGROUND

Video-assisted thoracoscopic surgery (VATS) lobectomy is now a well-accepted way to perform a minimally invasive lobectomy. VATS lobectomy is different from the conventional surgery. Different incisions, instruments and camera positions have also been described in the past two decades. There are no fixed patterns in VATS lobectomy. We here describe our method for fissure-based VATS lobectomy using an anterior approach. The aim of this paper is to show our technique for VATS lobectomy and our experience and outcomes obtained.

METHODS

A 57-year-old man, who was admitted to the Affiliated Hospital of the Guangdong Medical College, had coughing up blood tinged sputum, right chest pain for one month. Thoracic CT imaging revealed a 22 mm × 22 mm × 20 mm, T1bN1M0 lesion in the right lower lobe. The patient for clinical stage II non-small cell lung cancer underwent VATS lobectomy by using an anterior approach on January 2013.

RESULTS

Total volume of chest tube drainage after operation was 450 mL, intraoperative blood loss was 80 mL, operation time was 105.8 min, chest tube duration was three days, length of postoperative hospital stay was eight days. Follow-up no recurrence and metastasis for six months.

CONCLUSIONS

The main advantages of the anterior approach in our experience are easy to deal with the absence or incomplete fissure by the "tunneling" approach. In addition, the mediastinal node packets are clearly seen, allowing thorough lymphadenectomy. Therefore, VATS lobectomy by the anterior approach is a safe, feasible procedure.

Video-assisted thoracic surgery versus open thoracotomy for non-small cell lung cancer: a meta-analysis of propensity score-matched patients

OBJECTIVES

This meta-analysis aimed to compare the perioperative outcomes of video-assisted thoracic surgery (VATS) with open thoracotomy for propensity score-matched patients with early-stage non-small cell lung cancer (NSCLC).

METHODS

Four relevant studies with propensity score-matched patients were identified from six electronic databases. Endpoints included perioperative mortality and morbidity, individual postoperative complications and duration of hospitalization.

RESULTS

Results indicate that all-cause perioperative mortality was similar between VATS and open thoracotomy. However, patients who underwent VATS were found to have significantly fewer overall complications, and significantly lower rates of prolonged air leak, pneumonia, atrial arrhythmias and renal failure. In addition, patients who underwent VATS had a significantly shorter length of hospitalization compared with those who underwent open thoracotomy.

CONCLUSIONS

In view of a paucity of high-level clinical evidence in the form of large, well-designed randomized controlled trials, propensity score matching may provide the highest level of evidence to compare VATS with open thoracotomy for patients with NSCLC. The present meta-analysis demonstrated superior perioperative outcomes for patients who underwent VATS, including overall complication rates and duration of hospitalization.