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Ann Thorac Surg 1997;63:1415-1421
© 1997 The Society of Thoracic Surgeons
University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School, University Thoracic Surgical Service, St. Peter's Medical Center, Robert Wood Johnson University Hospital, New Brunswick, New Jersey
Accepted for publication November 25, 1996.
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Abstract |
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Methods. Between September 1992 and August 1995, 100 consecutive video-assisted thoracic surgical simultaneously stapled lobectomies without rib spreading were performed.
Results. Forty-five male and 55 female patients had 24 right upper, 8 right middle, 29 right lower, 24 left upper, 15 left lower lobectomies for 66 adenocarcinomas, 20 squamous cell carcinomas, 4 large cell carcinomas, 8 benign lesions, and 2 metastatic lesions. Seventy-six patients had negative nodes. Nine patients had positive nodes. Every bronchoscopy was visually and cytologically negative. Forty-nine cervical mediastinoscopies were negative. Operating time for the series averaged 90.3 minutes. Hospitalization averaged 3.5 days for the entire group, but was 2.6 days for the last 20 patients. Lesions ranged from 1.5 to 8 cm, averaging 3.4 cm. There was no surgical mortality, no hemorrhage, no transfusion, and no urgent conversion to an open procedure. No bronchial fistula, vascular fistula, or bronchovascular fistula has occurred. Complications included 6 air leaks, 2 cerebrovascular accidents, 1 infected chest tube site, 2 cases of pneumonitis, and 1 subcutaneous emphysema.
Conclusions. Video-assisted thoracic surgical simultaneously stapled lobectomy without rib spreading is a safe operation that can be combined with lymph node sampling. At this early stage, therapeutic outcomes (survival) for resected neoplasms appear similar to results obtained from traditional open techniques.
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Introduction |
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The isolation-ligation technique for lobectomy has remained essentially unchanged for the past 56 years. It is not a new technique, because it was originally described in the early 1900s [1, 2]. Currently, it is accepted and advocated as the sole technique for lobectomy by most thoracic surgeons. Despite an absence of scientific evidence or documentation conferring any special advantages, the isolation-ligation technique continues to remain the usual method for lobectomy.
As technology continues to progress, techniques are evolving that could foster various, new methods for pulmonary resection. One of these techniques could be video-assisted thoracic surgical (VATS) simultaneously stapled (SS) lobectomy without rib spreading [VATS(n)SSL]. This method has been used successfully and safely for more than 4 years in 100 consecutive patients.
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Material and Methods |
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The technique for VATS(n)SSL has been described in detail in previous publications [3, 4]. Although it continues to be performed essentially as published, several minor modifications have been made. In addition to breaking the operating room table to spread the intercostal spaces, we also use an inflatable plastic bag to further expand the upper rib cage and to achieve more operating space between the ribs. The deflated bag is much easier to place in position than a sand bag or folded sheets, especially for obese patients (Fig 1
). Also, four incisions are now being made in a box or "gridiron" configuration (Fig 2). Care is taken to minimize pressure on the ribs with maximal use of the wider anterior interspaces. The visceral pleura, including that in the fissure, is appropriately opened, allowing observation of the hilar structures. The minor fissure in right upper lobe or right middle lobe resections is developed using the branches of the superior pulmonary vein as an anatomic guide. The division between the middle lobe veins and the upper lobe veins serves as a convenient landmark. Staple closures vary from 1.5 mm to 2.5 mm depending upon the size and thickness of the hilum. Usually, a staple closure of 1.5 mm is satisfactory for the thin hilum in small female patients and 2.5 mm for the thick hilum of large, muscular male patients. Tumors as large as 8 cm can be divided into thin sections within a plastic sleeve in the chest. Remaining in the plastic container, the divided lesions can be made to slide, as individual pieces, end to end between the anterior ribs where the intercostal spaces are the widest. This avoids the necessity to spread the ribs to remove large tumors. A single, soft, no. 20 silicone chest tube is inserted through a separate stab wound and is commonly removed after 24 hours.
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Results |
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). None of these benign or metastatic lesions could be completely removed by a lesser resection.
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). Bilobectomies were performed in 3 patients with carcinoma and 1 patient with a large granuloma. Each of these lesions involved the minor fissure. Early in our experience, postoperative bronchoscopy was performed to inspect the residual bronchial stump. These averaged 4 to 5 mm. Operating times ranged from 40 to 150 minutes, averaging 90.9 minutes. For the last 20 lobectomies, the average time was 82.4 minutes. No patient in the entire series received a transfusion. Blood loss usually was estimated to be less than 100 mL. Malignant tumors ranged from 1.5 to 8.0 cm, with a median size of 3.4 cm (Table 1). Primary tumor sizes were 1.5 cm (10 patients), 2 cm (9 patients), 2.5 cm (4 patients), 3 cm (26 patients), 3.5 cm (8 patients), 4 cm (14 patients), 4.5 cm (4 patients), 5 cm (11 patients), 6 cm (2 patients), and 8 cms (2 patients). Average tumor size increased to 4.4 cm for the last 20 patients. Hospitalization varied from 1 to 6 days with a median of 3.5 days. The last 20 patients had a median stay of 2.6 days. There has been no surgical mortality. Complications included air leaks in 6 patients, mild subcutaneous emphysema in 1 patient, cerebrovascular accident occurring 3 days and 6 months after hospital discharge in 2 hypertensive patients, a superficial inflammation of a chest tube site in 1 patient, and two postoperative pneumonias. All of these patients made a complete recovery. No neoplasms developed at a port site in this series.
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The 90 patients who had a primary lung carcinoma resected by VATS(n)SSL were staged preoperatively; 43 had stage I and 47 had stage II lesions. Postoperative staging was 40 stage I, 45 stage II, 2 stage IIIa, and 3 stage IV. All neoplasms were staged according to the International Staging System [5].
Follow-up has ranged from 13 to 51 months with an average of 26.5 months. Nine patients have died, 3 of causes unrelated to carcinoma: renal failure (2 months), cerebrovascular accident (5 months), and myocardial ischemia (7 months).
Currently, 6 patients have died of their carcinoma. Survival after curative resection for this group of patients ranged from 6 to 18 months, averaging 13.2 months. Four died of brain metastases and 2 of liver metastases. Five patients had adenocarcinoma and 1 squamous cell carcinoma, which occurred in 3 right lower and 3 left upper lobes. N1 nodes were positive in 2 of these patients, and neoplastic cells were identified in the vascular system of the resected lobe in 4 patients. Five patients had stage II and 1 patient stage I disease postoperatively (Table 2).
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Comment |
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In 1940, Blades and Kent [11] reintroduced isolation-ligation at the Annual Meeting of The American Association for Thoracic Surgery, hoping to reduce the then very high incidence of bronchopleural fistula. They presented only 10 patients, and 6 or 60% of them had bronchopleural fistulas. Nevertheless, thoracic surgeons found the technique to be very appealing and attractive, probably because of the intricate and meticulous anatomic dissection of tissue planes that was required. Unfortunately, cancer does not respect anatomic tissue planes. Possibly because of this regrettable characteristic, the overall 5-year survival for surgically resected carcinoma of the lung has remained at only 40% [12].
Simultaneously stapled lobectomy is recommended for patients with a pliable, noninfected bronchus and a lesion away from the hilum. All hilar lobar structures are stapled simultaneously in their normal anatomic configuration without distortion or strangulation. The patients operated on and the surgical techniques used for VATS(n)SSL are substantially different from the historic mass ligation lobectomies described in the literature [13–15].
Initially, when we began to do our first VATS lobectomies, in August, 1991, we used the traditional isolation-ligation technique. It soon became apparent to us that it was awkward, cumbersome, and, at times, even dangerous for VATS. Attempts to copy or transfer conventional methods to new technologies sometimes cause problems and can diminish safe and beneficial outcomes. Over the years, surgeons have introduced different techniques for lobectomy [16, 17]. Although each of these various techniques allows for a successful resection, most have remained unnoticed and currently are not being performed or even evaluated. Some of these neglected methods could have certain advantages when used with new, evolving technology.
Video-assisted thoracic surgical SS lobectomy without rib spreading is not a "large wedge resection" because it permits the complete removal of the entire lobe. As noted, postoperative bronchoscopies have confirmed residual bronchial stumps of 4 to 5 mm. Usually a true and acceptable lobectomy is measured not so much by the length of the residual vessels but rather by the length of the remaining bronchial stump. Simultaneously stapled lobectomy, as we perform it, includes a careful and accurate evaluation of each ipsilateral nodal station. In this series, nodes were resected from 87 patients excluding nodes contained within the operative specimen. They were not resected in the remaining 13 patients. Eight of these patients had benign disease. Of the 5 other patients, 2 had T2 lesions and 2 had lesions less than 2 cm. All 4 patients are living and well without evidence of neoplastic disease. The fifth patient died of a cerebrovascular accident at 6 months without evidence of carcinoma. Despite careful dissection of each nodal station, in these 5 patients, nodes were absent or too minute for biopsy, even with magnification. Notably, there is recent evidence that lymph node exploration or lymphadenectomy may not always be necessary for lesions smaller than 2 cm [7, 18].
The 2 patients in the series with N2 disease had freely mobile, normal appearing nodes that contained microscopic foci of malignancy. Because there can be a potential 10% 5-year survival, on occasion, we will perform resection in patients with small, mobile, single station, intracapsular N2 nodes, which could not be detected preoperatively but could be diagnosed only during VATS exploration of the nodal stations. Although VATS is a less burdensome procedure, and each of these patients has made a rapid, uneventful recovery, only time will determine if such a small potential salvage can justify a VATS lobectomy when minimal N2 disease is present.
Elderly patients with carcinoma of the lung often present with compromised pulmonary and cardiac function. Usually, most will require postoperative monitoring and intensive care. In this series, 16 patients were more than 75 years old, and of these, 5 were in their 80s. The mean length of stay for these 16 patients was 3.5 days. Our anesthesiologists maintain that reduced dosages of anesthetic agents can be administered to patients undergoing VATS operations. The lighter level of anesthesia that seems to be appropriate and satisfactory for this type of operation could contribute to the earlier and more vigorous recovery frequently observed. Also, postoperative pain seems to be diminished because our patients usually require only nonnarcotic analgesics from 1 to 5 days. Infrequently, a young patient may be given a single, intramuscular injection of 50 mg of meperidine hydrochloride in the recovery room. Video-assisted thoracotomy is being demonstrated to be less traumatic and burdensome for the patient than the traditional open thoracotomy [19–22]. No VATS lobectomy patient has been given an epidural block or local infiltration of analgesics into the wound.
Many of our patients having open conventional resections still require 24 to 48 hours of intensive services. However, the intensive care unit, with its intensive services and monitoring, is no longer used for the SS lobectomy patients [6]. From the recovery room, they are transferred to a surgical floor and receive routine nursing care. Arterial lines and telemetry are not used. Moreover, postoperative medical consultations have been reduced, because many complications that occurred in the past, eg, arrythmias, hypoxia, and atelectasis, in patients with co-morbid problems undergoing a traditional open thoracotomy have not materialized when VATS(n)SSL has been performed. Early hospital discharge, usually on the second or third postoperative day, has become routine for VATS patients, whereas most of our patients undergoing an open, traditional, procedure will average 5 to 7 days of hospitalization and usually require a 6- to 8-week period of recovery before returning to their preoperative levels of physical activity [23]. Often patients undergoing VATS are satisfactorily recovered and physically active within 7 to 10 days [22]. Six of these patients had prior, formal thoracotomies, some with muscle-sparing incisions, for pulmonary resections, and, subsequently, each has had a contralateral VATS pulmonary resection. All patients were in agreement that there was decreased pain, earlier recovery, and better general well being with VATS. In our experience, the bone-sparing incision of VATS has more advantages for the patient than the muscle-sparing incision [24]. We have found that most patients have been reluctant to undergo a second thoracotomy, but, up to the present time, none has objected to a second VATS procedure.
Four separate incisions in the configuration of a box or "gridiron" have markedly increased access to the intrathoracic structures. The option of changing the position of the scope to either the anterior or posterior port allows a more thorough dissection and exploration of the entire mediastinum. These four separate port sites provide alternative and appropriate approaches to the various intrathoracic organs and structures. Also, the surgeon and the assistant have the ability to work more skillfully and more efficiently using two hands.
In the past, adhesions were a frequent indication for conversion to an open procedure. Because VATS magnifies and facilitates access to all areas of the thorax including the apex and costophrenic angles, dense, diffuse adhesions usually can be lysed satisfactorily. In this series, no VATS operation was converted to an open procedure because of adhesions, hemorrhage, or unfavorable intrathoracic anatomy. The need for an open technique was anticipated preoperatively in 2 patients because of a thick, muscular chest wall. After a careful VATS exploration to confirm resectability, these patients underwent an open procedure. The right upper lobe continues to be the most difficult to resect because of the frequent absence of a minor fissure. As experience was acquired, this became much less of a problem because the minor fissure can now be anatomically developed using the pulmonary veins as landmarks. In 4 patients who needed a bilobectomy (right upper and middle lobes) because the lesion crossed the minor fissure and involved both lobes, SS lobectomy proved to be an adequate and appropriate technique. Usually, the other lobes did not present any particular technical problems.
In this series, all preoperative bronchoscopies were visually and cytologically negative. Even though a short bronchial stump can be accomplished satisfactorily with a SS lobectomy, if tumor is visualized through the bronchoscope preoperatively, then an open isolation-ligation resection would be our procedure of choice. Every cervical mediastinoscopy in this series was negative for neoplastic lymph nodes because any patient with a positive biopsy was excluded from a major resection by our criteria. Usually, when the computed tomographic scan does not reveal nodes larger than 1 cm and a cervical mediastinoscopy has not been performed, the mediastinum will be evaluated for nodal abnormalities during the VATS exploration. Each nodal station can be carefully dissected. Incision of the pleura and blunt dissection permits identification of the lobar bronchus and pulmonary vessels. Any lymph nodes present in the fissure or around the bronchus can be resected before stapling and resection. Although nodal involvement with cancer currently remains the main prognostic determinant for carcinoma of the lung, other tumor markers resulting from various genetic aberrations are being investigated as possible earlier and more definitive predictors of survival [25].
Ninety patients had primary carcinoma of the lung resected by lobectomy, and in every case, the bronchial margin was free of neoplasm. Of the 6 patients who have died of metastases, 4 demonstrated vascular spread within the resected lobe and 2 had positive N1 nodes. These are unfavorable prognostic signs. In the entire series, no patient had neoplastic involvement of any port or an isolated recurrence involving only the operated side.
Three patients with neoplasm have died of other causes. Presently, 81 patients are alive, but 6 have manifested recurrent neoplastic disease. After examination of their resected lobes, 3 of these patients were placed in stage IV because of multiple microscopic intraparenchymal lesions interpreted as probable metastases. We were persuaded to place these patients in stage IV because of several recent publications supporting this categorization [6, 7, 26]. Two of the other patients with recurrence had postoperative stage II disease and 1 other had stage IIIa disease. Two of these 3 patients had positive N1 nodes resected at operation; all 3 demonstrated neoplastic cells within blood vessels in the resected pulmonary tissue. Their prognoses were considered to be poor. In this early experience, survival and recurrence for carcinoma appear to be similar whether we perform an SS lobectomy or a traditional isolation-ligation lobectomy. More time will be needed to determine the validity of this impression. The stage and biologic characteristics of the tumor both seem to be very important determinants for prolonged survival.
In this series, as in other series, VATS inferred an advantage for decreased acute and chronic pain, shortened length of stay, decreased period of recovery, reduced costs, and improved patient satisfaction when compared with the open thoracotomy [19–22]. Possibly, the same survival outcomes can be attained with VATS(n)SSL but without the adverse effects of the traditional, open thoracotomy. As our follow-up approaches 5 years, more definitive comparisons will be made.
Video-assisted thoracic surgical SS lobectomy without rib spreading has become our standard procedure for resection with few exceptions. A large central lesion, fibrotic hilum, or chest wall invasion will still require an open thoracotomy. As expertise is developed, larger lesions can be successfully resected. In these first 90 patients with primary carcinoma, lesions averaged 3.4 cm, whereas, in the last 20 patients, tumor size averaged 4.4 cm. Video-assisted thoracic surgical SS lobectomy without rib spreading has been a reliable and consistent operation for both benign and malignant diseases.
If VATS(n)SSL is to be performed safely, efficiently and expeditiously, then a team approach, similar to cardiac surgery, must be instituted. A surgeon with advanced training, necessary inherent skills, and temperament must lead a team dedicated to advancing the quality and comprehensiveness of VATS resections. Surgeons performing occasional VATS procedures with operating room personnel inexperienced with these techniques will probably have less than optimal results, frequent complications, and higher costs, not to mention increased stress and frustration. Cardiac surgeons demonstrated years ago that dedicated surgical and operating room teams working in a cardiac center with a sufficient volume of cases to ensure the frequent performance of cardiac operations are essential for consistent success. This same philosophy and standards should be applied to VATS if efficient and successful progress is to be made.
At our institution, comparison of costs have found savings for patients having a SS lobectomy [27]. Because there is an associated early return to work after SS lobectomy, it is anticipated that a reduction in disability expenditures will be achieved. Further experience will be necessary to confirm these findings, but they are similar to those currently reported in the literature [19].
Initially, some members of our group strongly opposed VATS SS lobectomy and remained staunch supporters of the traditional open isolation-ligation techniques. Currently, every surgeon in the group is a strong advocate of VATS(n)SSL. Presently, comparison of our results attained with VATS(n)SSL with those published extensively for the open thoracotomy seems to suggest similar outcomes for malignant resections. However, a longer follow-up will be needed to support these impressions.
Video-assisted thoracic surgery requires a different temperament, different philosophy, and different surgical skills from those required of surgeons in the past. Some surgeons with enormous experience and advanced skills for conventional, open surgery may elect, for various reasons, not to make the transition to VATS. Because of significant benefits, without demonstrable serious deficiencies, VATS(n)SSL should be further studied and evaluated as a possible addition to our armamentarium for lobectomy.
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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References |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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