Video-Assisted Lobectomy: General Considerations

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CHAPTER 6 Video-Assisted Lobectomy

General Considerations

Robert J. McKenna, Jr.

Introduction

A lobectomy performed as video-assisted thoracic surgery (VATS) should be a standard, anatomic resection, just as a lobectomy performed through a thoracotomy.

Criteria

Indications and contraindications for a VATS-type lobectomy are given in Table 6-1. Most lobectomies can be performed by VATS. We perform more than 90% of our lobectomies by VATS. The ribs are not spread. Larger tumors (5 to 8 cm) can be resected through a 5- to 6-cm incision if the rib is shingled posteriorly. Because tumors larger than 8 cm in diameter take up so much space in the chest, it is difficult to manipulate the lobe to perform the dissection, and these large tumors require a thoracotomy.

Table 6-1 Indications and Contraindications for Video-Assisted Lobectomy

Indications Relative Contraindications Contraindications
Stage 1 lung cancer Tumor 5-8 cm in diameter Tumors >8 cm in diameter
Tumor <6 cm Preoperative irradiation Mediastinal invasion
Benign disease (e.g., bronchiectasis) Preoperative chemotherapy Surgeon discomfort
  Sleeve resections  
  Chest wall invasion  

Relative contraindications are factors that may make the procedure difficult or unsafe. Dissection of abnormal nodes adherent to the vessels, preoperative chemotherapy, and preoperative radiation therapy may mandate a thoracotomy. However, we have performed 18 bronchial sleeve resections, and we usually can perform lobectomies1 and full node dissections after neoadjuvant chemotherapy for stage III lung cancers.2,3

Absolute contraindications are factors that make a VATS-type resection almost impossible. If the tumor is too large, it cannot fit through the small incision used in VATS. Tumors attached to the chest wall, including Pancoast tumors, require a thoracotomy and rib resection. Combined chemotherapy and radiation therapy usually make enough scar tissue around the vessels that a thoracotomy is needed to complete the nodes dissection and to safely dissect around vessels.

Video-Assisted Lobectomy

♦ Usually work from anterior to posterior.
♦ To ensure safety, identify the vessels. Expose the vessels to ensure they are not accidentally transected or injured and to position the stapler for safe and anatomic resections.
♦ It is safest to dissect on named structures. Paradoxically, staying closer to the pulmonary vessels and bronchi greatly reduces the chances of inadvertent injury.
♦ The fissures are completed with staples to reduce air leaks. Dissection is not performed in the fissure to expose the vessels.

Postoperative Care After Video-Assisted Thoracic surgery

♦ Postoperative care is streamlined after VATS.4 No routine laboratory tests or radiographs are used. Laboratory tests are performed if there are arrhythmias, fevers, or other specific indications.
♦ The chest drainage system is attached to an intravenous line pole so that the patients can more easily ambulate and get to the bathroom and to prevent the drainage system from falling over. The drainage system is not placed on suction because randomized studies have shown prolonged air leaks when suction is applied.5 Suction is applied to the drainage system for patients with increased postoperative drainage, such as extensive adhesions that were lysed or significant subcutaneous emphysema.
♦ Chest radiographs are needed for patients with dyspnea, hypoxia, or significant subcutaneous emphysema and for fever workup. Chest radiographs are not performed after removal of chest tubes, unless the patients develop significant dyspnea, hypoxia, or subcutaneous emphysema.

Advantages of Video-Assisted Lobectomy

♦ Although there are no large multi-institutional, randomized trials comparing VATS and thoracotomy for lobectomy, the mounting data show many advantages for the VATS approach.
♦ After VATS, patients have a shorter hospital stay,2,3 possibly less morbidity and mortality,2,3,6 less pain,6 better pulmonary function,7,8 and less cost. Frail patients tolerate it better,9 and patients recover faster.10
♦ Because patients recover faster after VATS than after a thoracotomy, they have a better chance of receiving full doses of their adjuvant chemotherapy.11,12

Learning About Video-Assisted Lobectomy

♦ Attend a VATS-type lobectomy course, usually more than once. The initial course can help you understand the basic approach. During additional courses, more subtle details of the procedure that were missed during an introductory course may become clear.
♦ Read book chapters and atlases.
♦ Study videos.
♦ Consult with a new associate who has experience with the procedure.
♦ Transition gradually from a posterolateral incision to a muscle-sparing incision to VATS. With the muscle-sparing incision, you move to the front of the patient. The incision is in the location of the utility incision (incision 3) for a video-assisted lobectomy. It starts at the edge of the latissimus muscle and extends anteriorly. The latissimus is not mobilized or cut. A few fibers of the serratus are separated. The intercostal muscles are cut from the internal mammary vessels to the spine. Dissect the hilum of the lung anteriorly to posteriorly, as for a VATS-type lobectomy. Do some of the dissection while looking at a monitor. As you make the transition from open surgery to VATS, make the incision smaller, and do not spread the ribs.

References

1 Mahtabifard A, Fuller CB, McKenna RJ Jr: VATS sleeve lobectomy, Ann Thorac Surg (in press)

2 McKenna R.J.Jr, Houck W., Fuller C.B. Video-assisted thoracic surgery lobectomy: experience with 1100 cases. Ann Thorac Surg. 2006;81:421-426.

3 Onaitis M.W., Petersen R.P., Balderson S.S., et al. Thoracoscopic lobectomy is a safe and versatile procedure: experience with 500 consecutive patients. Ann Surg. 2006;244:420-425.

4 McKenna RJ Jr, Mahtabifard A, Fuller CB: Fast tracking after VATS pulmonary resection, Ann Thorac Surg (in press)

5 Cerfolio R.J., Bass C., Katholi C. Prospective randomized trial compares suction versus water seal for air leaks. Ann Thorac Surg. 2001;71:1613-1617.

6 Whitson B.A., Groth S.S., Duval S.J., et al. Surgery for early-stage non-small cell lung cancer: A systemic Review of the video-assisted thoracoscopic surgery versus thoracotomy approaches to lobectomy. Ann Thorac Surg. 2008;86:2008-2018.

7 Nomori H., Ohtsuka T., Horio H., et al. Difference in the impairment of vital capacity and 6-minute walking after a lobectomy performed by thoracoscopic surgery, an anterior limited thoracotomy, an antero-axillary thoracotomy, and a posterolateral thoracotomy. Surg Today. 2003;33:7-12.

8 Nakata M., Saeki H., Yokoyama N., et al. Pulmonary function after lobectomy: video-assisted thoracic surgery versus thoracotomy. Ann Thorac Surg. 2000;70:938-941.

9 Demmy T.L., Curtis J.J. Minimally invasive lobectomy directed toward frail and high-risk patients: a case-control study. Ann Thorac Surg. 1999;68:194-200.

10 Demmy T.L., Plante A.J., Nwogu C.E., et al. Discharge independence with minimally invasive lobectomy. Am J Surg. 2004;188:698-702.

11 Nakajima J., Takamoto S., Kohno T., Ohtsuka T. Costs of videothoracoscopic surgery versus open resection for patients with lung carcinoma. Cancer. 2000;89(Suppl):2497-2501.

12 Petersen R.P., Pham D., Burfeind W.R., et al. Thoracoscopic lobectomy facilitates the delivery of chemotherapy after resection for lung cancer. Ann Thorac Surg. 2007;83:1245-1249. discussion 1250

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