Ann Thorac Surg 2007;84:196
© 2007 The Society of Thoracic Surgeons
Original Articles: General Thoracic
Invited commentary
Todd L. Demmy, MD
Department of Thoracic Surgery, Roswell Park Cancer Institute, Elm & Carlton Sts, Buffalo, NY 14263
(Email: todd.demmy{at}roswellpark.org).
The article by Nakanishi [1] describes one center’s initial experience with the expansion of minimally invasive therapy into another complex thoracic operation (ie, bronchial sleeve resection). Slightly more than a decade ago, many considered thoracoscopic lobectomy a bit farfetched, much less video-assisted thoracic surgery bronchoplasty. Today some will ponder using the technique in this article for carefully selected patients with favorable anatomic characteristics.
The combination of surgeon experience and improved instrumentation has made thoracoscopic lobectomy the preferred approach in several centers including more than 85% of such resections in this commenter’s institution. Endoscopic staplers and high-resolution thoracoscopes now permit the exposure and safety enjoyed by surgeons who prefer open thoracotomy. In fact, these same instruments facilitate operating through a large wound by enhancing lighting, enabling viewing (particularly for second assistants), and dividing tissue in tight spaces. Ultimately, some surgeons "cross the threshold" by choosing thoracoscopy as a routine exposure method in their practice (armed with a countermove for most exposure challenges). Afterward they attempt other complex, yet less frequent operations in due course. As cited in reference 12 of the accompanying article, another busy thoracoscopic dominant center performed three sleeve lobectomies, which now totals 11 such resections using an interrupted suturing technique (R. L. McKenna, personal communication, e-mail, April 2007).
Despite good imaging, thoracoscopic expansion is hampered by instrument limitations, time needed for learning curve investment, and a concentration of suitable cases. Regarding the latter, if sleeve lobectomy was practiced as commonly as aortic valve replacement (AVR), then we probably would have seen these reports sooner. I use AVR as a comparison because it is a complex operation requiring highly reliable deep suture control. Although also performed using similar nearby access incisions, minimally invasive AVR was reported more than a decade ago.
Given the pervasive, less invasive trends in medicine, questioning whether our specialty should condone another complex thoracoscopic operation now seems less interesting than sorting out when individual surgeons are ready for this transition. Unfortunately, uncommon procedures will not generate publications demonstrating safety or equivalent outcomes quickly enough to validate the forays of early adopters. Perhaps surgeons could be credentialed for such operations by demonstrating thoracoscopic mastery of related advanced procedures. We need to consider how to best compile, organize, and disseminate the technical maneuvers required for our profession’s future. Enabling technology like robotic instruments, expanded mentoring programs, and web-based troubleshooting forums are all potential mechanisms to achieve these ends.
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References
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- Nakanishi K. Video-assisted thoracic surgery lobectomy with bronchoplasty for lung cancer: initial experience and techniques Ann Thorac Surg 2007;84:191-196.[Abstract/Free Full Text]
Related Article
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Video-Assisted Thoracic Surgery Lobectomy With Bronchoplasty for Lung Cancer: Initial Experience and Techniques
- Kozo Nakanishi
Ann. Thorac. Surg. 2007 84: 191-195.
[Abstract]
[Full Text]
[PDF]
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