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

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