MINIMALLY INVASIVE THORACIC SURGERY PRINCIPLES AND PRACTICE OF THORACOSCOPIC TECHNIQUE MARCO SCARCI, PIERGIORGIO SOLLI, ALAN DL SIHOE
INDEX
ABCDEFGHIJKLMNOPQRSTUVWXZ
Note: Page numbers in bold or italic refer to tables or figures respectively.
A
Ablative therapy, 9
Absent/fused fissure, 67
Active drainage, 159, 160
Acute respiratory distress syndrome (ARDS), 23
Adhesions, 72
pleural, 67, 68
preoperative detection of, 67
Adson test, 101
Air-flow-pleural pressure, 160–2, 161–2
Air leakage
prolonged, 159, 160
VATS lobectomy and, 10–11
Airway bypass procedure, 81
American College of Surgeons Oncology Group Z0030 randomized clinical trial, 5
American Thoracic Society, 85
Analgesia, 10, 24
Anesthesia, 10
and fluid management, 23
general. See General anesthesia (GA)
and lung isolation. See Lung isolation
for medical thoracoscopy, 165
monitoring, 23–4
for robotic thoracic surgery, 25
for VATS pneumonectomy, 41–2
for VATS thymectomy, 89
for video-assisted thoracoscopic surgery, 25
Anterior mediastinal tumors, bilateral VATS approach for, 92, 92–3, 93, 94
Anterior mediastinum, robotic surgery in, 119
ectopic mediastinal parathyroid adenoma, 120, 120–1, 121
posterior mediastinal lesion resection, 121, 121, 122
thymic lesions, 119–20
Anterior segmental artery/vein, right upper lobe segmentectomy, 59, 59, 60, 61
Aortopulmonary window, 38
Apical segmental vein
left upper lobe segmentectomy, 61, 61, 62
right upper lobe segmentectomy, 57, 57–8, 58
ARDS. See Acute respiratory distress syndrome (ARDS)
Assisted VATS (a-VATS) lobectomy, 5
Azygos vein, 38, 38
B
BELIEVER HiFi study, 76
Benign lesions, 47
Bilateral VATS
approach for thymomas and anterior mediastinal tumors, 92, 92–3, 93
tumor characteristics for, 94
Biopsy
endobronchial ultrasound guided fine-needle aspiration, 123
lung, 74, 74
of pericardium, 95
Biportal VATS. See Two-port VATS
Bleeding, 68–9, 69
Bronchial anastomosis, 48, 48–9, 49
Bronchial blockers, 21–2, 22
double-lumen tube vs., 23
Bronchoscopic thermal vapor ablation (BTVA), 81
Bronchoscopy, 21, 23, 86. See also Electromagnetic navigation bronchoscopy (ENB)
Bronchus, 43, 43
transection of, 48, 48
BTVA. See Bronchoscopic thermal vapor ablation (BTVA)
C
Cancer and Leukemia Group B (CALGB), 5, 31
Cardiac tamponade, 95
Catamenial pneumothorax, 73
Cervicoaxillary canal, 102
Chest drainage systems. See Drainage systems
Chest wall reconstruction, 54–5
Chest wall resections
robotic lobectomy and, 125–6
VATS en bloc. See VATS en bloc chest wall resections
Chronic obstructive pulmonary disease (COPD), 75, 76, 78. See also Emphysema
pathway for lung volume reduction in, 77
Chylothorax, 70, 107
etiology of, 107
evaluation of, 107
mortality rate, 107
nonoperative management, 107, 108
operative management. See Operative management, of chylothorax
Clinical pathways, in MITS, 11, 27–9
feedback, 28
intraoperative factors, 28
postoperative care, 28
preoperative factors, 27
Collateral ventilation (CV), 76, 77–8
Complete VATS (c-VATS) lobectomy, 5, 7
Computed tomography (CT), 67, 71, 76, 85, 86, 86, 107
angiography, 101–2
of chest, 155, 155
for diaphragmatic function evaluation, 111
of thorax, 95
COPD. See Chronic obstructive pulmonary disease (COPD)
Costoclavicular space, anatomy of, 102, 102
Cough, 148
COX-2 inhibitor, 24
CT. See Computed tomography (CT)
c-VATS lobectomy. See Complete VATS (c-VATS) lobectomy
Cystic fibrosis, pneumothorax in, 73
D
Da Vinci Surgical System, 7, 119, 120, 123
Decortication, 86, 108
Deep sedation. See General anesthesia (GA)
Diaphragmatic dysfunction, 111–112, 112
Digital dissection, 86
Digital drainage, 11
Doppler catheter, 81–2
Dorsal segmental artery/vein
left lower lobe segmentectomy, 64–5, 65–6
right lower lobe segmentectomy, 60, 61
Double-lumen tube, 21, 21–2, 71
bronchial blocker vs., 23
Drainage systems, 167
active, 159, 160
electronic, 160
passive, 159
E
EASE. See Exhale airway stents for emphysema trial (EASE)
EBUS. See Endobronchial ultrasound (EBUS)
EBUS-FNA biopsy. See Endobronchial ultrasound guided fine-needle aspiration (EBUS-FNA) biopsy
EBUS-TBNA procedure, 149–50, 150
adequacy of, 151
complications of, 153
for diagnosis of sarcoidosis, 152
linear, 150
and lung cancer, diagnosis and staging of, 150–1
for mediastinal lymphadenopathy diagnosis, 152
sensitivity of, 150
for suspected lymphoma investigation, 152–3
EBV therapy. See Endobronchial valve (EBV) therapy
EELV. See End-expiratory lung volume (EELV)
Electromagnetic navigation bronchoscopy (ENB), 11, 155
clinical applications of, 157–8
effectiveness of, 157
planning phase, 155, 155–6, 156
procedure set-up, 156, 156
registration phase, 156
target lesion, leading to, 156, 157
and tissue sampling, 156–7
Electronic drainage systems, 160
ELS. See Emphysematous lung sealant (ELS)
ELVR. See Endoscopic lung volume reduction (ELVR)
Emphysema, 75
bronchoscopic thermal vapor ablation, 81
emphysematous lung sealant technique, 81
endobronchial valve therapy for. See Endobronchial valve (EBV) therapy
exhale airway stents, 81–2
lung volume reduction coil, 79, 81
lung volume reduction surgery, 82
Emphysematous lung sealant (ELS), 81
Empyema
uniportal VATS for, 144
VATS for, 1
Empyema thoracis
diagnosis of, 86
management of, 86
mortality rate for, 85
principles of surgery, 85
stages of, 85, 85–6, 86
ENB. See Electromagnetic navigation bronchoscopy (ENB)
En bloc chest wall resection, VATS. See VATS en bloc chest wall resections
End-expiratory lung volume (EELV), 78
Endobronchial ultrasound (EBUS), 11, 149
cost-effectiveness of, 153
and EUS, 151
and investigation of isolated mediastinal lymphadenopathy, 152–3
linear probe, 149, 149, 150
radial probe, 149, 149
training and service provision, 153
with transbronchial needle aspiration. See EBUS-TBNA procedure
Endobronchial ultrasound guided fine-needle aspiration (EBUS-FNA) biopsy, 123
Endobronchial valve (EBV) therapy, 75–6
benefit of, 76
collateral ventilation, 77–8
complications associated with, 78–9
cost-effectiveness of, 79
feasibility of, 76
patient selection, 76, 77
physiological measures, 78
prognosis, 79, 80
safety profile, 78–9
surgical LVR vs., 79
Endometriosis, 73
Endoscopic lung volume reduction (ELVR), 75
Endoscopic ultrasound (EUS)
cost-effectiveness of, 153
EBUS and, 151
Enhanced recovery after surgery (ERAS), 24–5, 27
Equipment malfunction, 69
ERAS. See Enhanced recovery after surgery (ERAS)
EUROVENT study, 76
EUS. See Endoscopic ultrasound (EUS)
Exhale airway stents for emphysema trial (EASE), 81–2
Exudative stage, of empyema, 85, 85
F
FEV1. See Forced expiratory volume in one second (FEV1)
Fiberoptic bronchoscopy, 21, 23
Fibrinopurulent stage, of empyema, 85, 85–6
Fine-needle aspiration (FNA), 71
Fluid management, 23
Fluorescence imaging, 120
Fluoroscopy, 111
FNA. See Fine-needle aspiration (FNA)
Foley catheter, 28
Forced expiratory volume in one second (FEV1), 6, 75, 76, 123
Forced vital capacity (FVC), 6, 111–12
Fused fissure, 67
FVC. See Forced vital capacity (FVC)
G
Gabapentin, 10
General anesthesia (GA), 145
after-effects of, 10
for emphysematous lung sealant, 81
for nonintubated VATS, 146, 147
with single lung ventilation, 120
and spontaneous ventilation, 22
for thoracic surgery, 25
and three-port VATS approach, 96
for VATS pneumonectomy, 41
H
Haller index, 115
Healthcare information systems, 28–9
Health information technology (HIT), 29
Health-related quality of life (HRQOL), 1
Hilar structures, 3
HIT. See Health information technology (HIT)
HRQOL. See Health-related quality of life (HRQOL)
Hypercapnia, 147
Hypoxia, 147
I
Iatrogenic chylothorax, 107
IBV. See Intrabronchial valve (IBV)
ICG. See Indocyanine green (ICG)
Immunosurveillance, 6
Incisions
in segmentectomy, 57
in VATS en bloc chest wall resection, 54
in VATS pneumonectomy, 42
Indocyanine green (ICG), 120
Induction therapy, 125
Inferior pulmonary vein, 33–4
Interstitial lung disease (ILD)
uniportal VATS for, 143
VATS for, 74, 74
Intrabronchial valve (IBV), 75
Intraoperative complications
absent/fused fissure, 67, 67
bleeding, 68–9, 69
equipment malfunction, 69
during mediastinal lymphadenectomy, 70
pleural adhesions, diffuse/complete, 67, 68
pulmonary hilum, 67–8, 68
Intubated VATS, 148, 148
Invasive thymomas, VATS thymectomy for, 91, 91
Isolated mediastinal lymphadenopathy, investigation of, 152–3
J
Jacobaeus, Hans Christian, 3
K
Kerrison forceps, 103
L
LAM. See Lymphangioleiomyomatosis (LAM)
Left lower lobe, dorsal segmentectomy, 64–5, 65–6
Left lower VATS lobectomy, 34–5
Left main bronchus (LMB), 40, 40, 41
Left main pulmonary artery (LMPA), 38, 39
Left paratracheal lymph nodes, dissection of, 38–9, 39
Left-sided double-lumen tube, 21, 21–2
Left upper lobe, uniportal VATS segmentectomy
apical segmentectomy, 61, 61, 62
lingulectomy, 63–4, 64, 65
posterior segmentectomy, 62, 62, 63
trisegmentectomy, 62–3, 63, 64
Left upper VATS lobectomy, 34
Lewis, Ralph, 3
Linear probe EBUS, 149, 149, 150
with TBNA, 150
LLV. See Lower lobe vein (LLV)
LMB. See Left main bronchus (LMB)
LMPA. See Left main pulmonary artery (LMPA)
Lobectomy
robotic. See Robotic lobectomy
VATS. See VATS lobectomy
Lower lobe vein (LLV), 140
Lung biopsy, for interstitial lung disease, 74, 74
Lung cancer
diagnosis and staging of, 150–1
lobectomy for. See VATS lobectomy
patients, questionnaires to assess QoL in, 5–6
thoracic surgery approaches for, 8
Lung collapse, 147, 147
Lung isolation, 21, 89
bronchial blocker, 21–2, 22, 23
double-lumen tube placement, 21, 21–2
Lung movements, 148
Lung volume reduction coil, 79, 81
Lung volume reduction surgery (LVRS), 2, 75, 82
Lymphadenectomy, 140
Lymphangioleiomyomatosis (LAM), 107
Lymph node dissection, 37
mediastinal. See Mediastinal lymph node dissection (MLND)
single-port VATS, 140
Lymph nodes
dissection. See Lymph node dissection
paratracheal, 38–9, 39
subcarinal, 38, 38, 40, 40, 41
M
Magnetic mini-mover procedure (3MP), 116
Magnetic resonance imaging (MRI), 111, 112
Mediastinal lymphadenopathy, diagnosis of, 152
Mediastinal lymph node dissection (MLND), 37
complications during, 70
robotic lobectomy for, 123–4
by VATS. See VATS mediastinal lymph node dissection
Mediastinoscopy, 123
Mediastinum, 119
anterior, robotic surgery in, 119–22
re-staging of, 151–2
Medical thoracoscopy (MT), 163
anesthesia for, 165
and chest drainage, 167
complications of, 167–8, 168
documentation, 167
equipment for, 163, 164
inspection, 166
patient positioning, 166
pleural sampling in, 166, 167
and pneumothorax, 166
preprocedure evaluation, 164–5
talc insufflation at, 167
video-assisted thoracoscopic surgery vs., 163, 163
Medium lobe vein (MLV), 140
MG. See Myasthenia gravis (MG)
Mild bleeding, 68
Minimally invasive thoracic surgery (MITS). See also Video-assisted thoracic surgery (VATS)
benefits of, 1
clinical pathways in, 11, 27–9
defined, 1
evidence for, 1–2
evolution of, 7
future use of, 2
goals, 28
historical overview of, 3
program, 17–19
MLND. See Mediastinal lymph node dissection (MLND)
MLV. See Medium lobe vein (MLV)
Morbidity, VATS pneumonectomy, 43
Mortality rate
for chylothorax, 107
for empyema thoracis, 85
for VATS pneumonectomy, 43, 44
3MP. See Magnetic mini-mover procedure (3MP)
MRI. See Magnetic resonance imaging (MRI)
MT. See Medical thoracoscopy (MT)
Multi-port VATS, 7, 8, 9
Myasthenia gravis (MG), 119–20
uniportal VATS for, 90–1
Mycobacterium tuberculosis, inspection of, 152
N
Nasogastric tube placement, 28
National Emphysema Treatment Trial (NETT), 2, 75
National Health Service, 17
Natural killer (NK) cells, 6
Natural orifice surgery, 9
Natural orifice transluminal endoscopic surgery (NOTES), 95, 99
Near-infrared (NIR) imaging, 120
Needlescopic VATS (nVATS), 8, 9, 95, 129–31, 130, 131
instruments for, 134
intraoperative view during, 131, 131
pericardial window, 96, 97, 98
perioperative care, 133
step-wise training, 133–4
troubleshooting, 134
Nerve compression, 101
NETT. See National Emphysema Treatment Trial (NETT)
NIR imaging. See Near-infrared (NIR) imaging
NK cells. See Natural killer (NK) cells
Nonintubated VATS
advantages of, 145, 145
awake technique, 146
contraindications to, 146, 146
conversion to intubated VATS, 148
general anesthesia for, 146, 147
intraoperative complications, 147–8
patient selection for, 145–6
preparation for, 146
regional anesthesia techniques, 146–7
sedation usage, 146
types of, 145
Non-small cell lung carcinoma (NSCLC), 53
Non-thymomatous myasthenia gravis, VATS thymectomy for, 89, 90, 90–1
NOTES. See Natural orifice transluminal endoscopic surgery (NOTES)
NSCLC. See Non-small cell lung carcinoma (NSCLC)
Nuss technique, 116–17, 117
nVATS. See Needlescopic VATS (nVATS)
O
One-lung ventilation, 22–3, 23, 96
Open lobectomy, VATS lobectomy vs., 41
Open pneumonectomy, VATS pneumonectomy vs., 44
Open thoracotomy, VATS vs., 1
Operative management, of chylothorax, 107–8, 108
decortication, 108
pleurodesis, 108, 108–9, 109
thoracic duct ligation, laparoscopic approach, 110
thoracic duct ligation, minimally invasive VATS/robotic, 109, 109–10
Operative techniques, of VATS pneumonectomy
bronchus, 43, 43
closure, 43
incisions in, 42
overview of, 42, 42
patient positioning, 42
thoracoscopic exploration, 42
Organization stage, of empyema, 86, 86
P
PA. See Pulmonary artery (PA)
Paget–Schroetter syndrome, 104
Pain, 101
neuropathic, pharmacotherapy annd, 10
VATS lobectomy and, 4, 5
PAL. See Prolonged air leak (PAL)
Paraaortic lymph nodes, dissection of, 38, 39
Paraesthesia, 101
Parapneumonic effusion, 85
diagnosis of, 86
management of, 86
Paratracheal lymph nodes, 38
left, 38–9, 39
Passive drainage, 159
Patient-controlled analgesia (PCA), 24
PCA. See Patient-controlled analgesia (PCA)
Pectus excavatum, 115, 115–16
chest X-ray of, 116
etiopathogenesis, 115
medical care, 116
Nuss technique for, 116–17, 117
PEEP. See Positive end-expiratory pressure (PEEP)
Pericardial effusion (PE)
causes of, 95
prognosis of, 95
Pericardial window
subxiphoid, 95–6
uniportal VATS, 143–4
VATS. See VATS pericardial window
PET. See Positron emission tomography (PET)
PET-CT scan. See Positron emission tomography-computed tomography (PET-CT) scan
Pharmacotherapy, 10
Physiotherapy, 10, 102
Pleural adhesions, diffuse/complete, 67, 68
Pleural effusion, 85–6, 107, 144
Pleural pressure, 160–2, 161–2
Pleurodesis, 107, 108, 108–9, 109
Pleuroscopy, 163
equipment and personnel, 163–4, 164, 165
historical overview of, 163
medical. See Medical thoracoscopy (MT)
Plication, of diaphragm, 112, 113
Pneumonectomy, VATS. See VATS pneumonectomy
Pneumothorax, 78
catamenial, 73
in cystic fibrosis, 73
medical thoracoscopy and, 166
principles of, 71–2
spontaneous, 22, 71
VATS for, 1–2, 71–3, 72, 73. See also VATS pneumonectomy
Polymeric lung volume reduction, 81
Port placements, for VATS lobectomy, 37, 37
Positive end-expiratory pressure (PEEP), 22, 23
Positron emission tomography (PET), 71
Positron emission tomography–computed tomography (PET-CT) scan, 123
Posterior segmental artery/vein
left upper lobe segmentectomy, 62, 62, 63
right upper lobe segmentectomy, 58, 58–9
Prolonged air leak (PAL), 159, 160
Protective lung ventilation, 22–3, 23
Pulmonary artery (PA), 31–2
dissection of, 42, 43
Pulmonary function, 27
Pulmonary hilum, 67–8, 68
Pulmonary veins (PVs), 42
Q
QoL. See Quality of Life (QoL)
Quality Assessment of Diagnostic Accuracy Studies (QUADAS) tool, 152
Quality of Life (QoL), 5–6, 75, 78
Questionnaires, to assess lung cancer patients, 5–6
R
Radial probe EBUS, 149, 149
RATS. See Robot-assisted thoracic surgery (RATS)
Re-expansion, of collapsed lung, 147
RENEW trial, 79
Rib spreading, 1
during thoracotomy, 5
VATS lobectomy and, 5
Right lower lobe, dorsal segmentectomy, 60, 61
Right lower VATS lobectomy
operative steps, 33–4
patient positioning, 33
ports position, 33
Right middle VATS lobectomy
operative steps, 32–3
patient positioning, 32
port position, 32
Right-sided double-lumen tube, 21, 21–2
Right upper lobe, uniportal VATS segmentectomy
anterior segmentectomy, 59, 59, 60, 61
apical segmentectomy, 57, 57–8, 58
posterior segmentectomy, 58, 58–9
Right upper VATS lobectomy
needlescopic, intraoperative view during, 131, 131
operative steps, 31–2
patient positioning, 31
port position, 31
two-port VATS, 132–3
Robot-assisted thoracic surgery (RATS), 7–8, 25
nVATS vs., 8
Robotic lobectomy, 123
and chest wall resection, 125–6
docking for, 123
evaluation of candidates for, 123
and induction therapy, 125
intraoperative complications, 126, 126
left lower, 125
patient positioning/port placement, 123–4, 124
preparation for, 123
results reported in series of, 127
right lower, 125
right middle, 124–5
right upper, 124
sleeve/bronchoplastic technique, 126
wedge resection, 124
Robotic surgery, in anterior mediastinum, 119
ectopic mediastinal parathyroid adenoma, 120, 120–1, 121
posterior mediastinal lesion resection, 121, 121, 122
thymic lesions, 119–20
Roos technique, 102, 103
S
Sarcoidosis, diagnosis of, 152
SBRT. See Stereotactic body radiation therapy (SBRT)
Scalene triangle, anatomy of, 102, 102
SCAT. See Suction-compressing angiorrhaphy technique (SCAT)
Segmentectomy, 10, 57
incision placement, 57
indications, 57
left lower lobe dorsal, uniportal VATS, 64–5, 65–6
left upper lobe, uniportal VATS. See Left upper lobe, uniportal VATS segmentectomy
patient positioning, 57
right lower lobe dorsal, uniportal VATS, 60, 61
right upper lobe, uniportal VATS. See Reft upper lobe, uniportal VATS segmentectomy
uniportal VATS, 140, 141
SGRQ. See St George's Respiratory Questionnaire (SGRQ)
Single-port VATS. See Uniportal VATS
6-minute walk test (6MWT), 76, 78
Sleeve lobectomy
robotic, 126
VTAS. See VATS sleeve lobectomy
Sniff test, 111
Solitary pulmonary nodule (SPN), 71, 72
SPN. See Solitary pulmonary nodule (SPN)
Spontaneous pneumothorax, 22, 71
primary, uniportal VATS for treatment of, 143
VATS for, 72, 72–3, 73
Stereotactic body radiation therapy (SBRT), 9
Stereotactic radiosurgery, 9, 157
St George's Respiratory Questionnaire (SGRQ), 76, 79
Subcarinal lymph nodes, dissection of, 38, 38, 40, 40, 41
Sublobar resection, VATS lobectomy and, 9–10
Subxiphoid pericardial window (SXP), 95–6
Suction-compressing angiorrhaphy technique (SCAT), 69, 69
Superior vena cava (SVC), 38, 38
Supraclavicular approach, TOS surgery, 102
Surgical lung volume reduction (LVR), 75, 76
EBV therapy vs., 79
videothoracoscopic approach, 102–4, 103, 104
SVC. See Superior vena cava (SVC)
SXP. See Subxiphoid pericardial window (SXP)
Sympathectomy, uniportal VATS and, 143
T
Talc insufflation, at medical thoracoscopy, 167
TEMLA. See Transcervical extended mediastinal lymphadenectomy (TEMLA)
Thoracic duct
embolization of, 107
ligation, minimally invasive VATS/robotic, 109, 109–10
location of, 109
Thoracic epidural analgesia, 24
Thoracic outlet syndrome (TOS)
anatomical considerations, 102, 102
causes of, 101, 101
clinical aspects of, 101
diagnosis of, 101–2
historical perspective, 101
posterior approach, 102
supraclavicular approach, 102
surgical indications in, 102
transaxillary approach, 102, 103
Thoracoscopic adhesiolysis, 67
Thoracoscopic lobectomy. See VATS lobectomy
Thoracoscopy. See Pleuroscopy
Thoracotomy, 1, 3
conversion rate from VATS pneumonectomy to, 43, 44
posterior technique, 102
rib-spreading during, 5
sleeve lobectomy by, 47. See also VATS sleeve lobectomy
VATS and, similarity between, 6
Three-port strategy
for needlescopic VATS, 129–31, 130
VATS lobectomy, 7, 8, 9
VATS pericardial window, 96
Thymectomy. See VATS thymectomy
Thymomas
bilateral VATS approach for, 92, 92–3, 93, 94
VATS thymectomy for, 89, 91, 91
T1N0 NSCLC randomized trial, 10
Transbronchial needle aspiration (TBNA), EBUS with. See EBUS-TBNA procedure
Transcervical extended mediastinal lymphadenectomy (TEMLA), 152
Transesophageal echocardiography, 24
Transthoracic needle aspiration (TTNA), 155
Two-port VATS, 8, 9, 131–2
instruments for, 134
perioperative care, 133
port strategy for, 132
right upper lobectomy, intraoperative view during, 132–3
step-wise training, 133–4
troubleshooting, 134
U
Ultrasound, 86, 111. See also Endobronchial ultrasound (EBUS); Endoscopic ultrasound (EUS)
Uniportal VATS, 8–9, 9, 11, 95, 137
complex resections, 141–2
instruments, 137–8
for interstitial lung disease, 143
for intrathoracic conditions, 144
left lower lobe dorsal segmentectomy, 64–5, 65–6
left upper lobe segmentectomy. See Left upper lobe, uniportal VATS segmentectomy
lower lobectomy, 138, 139
lymphadenectomy, 140
material used in, 137
middle lobectomy, 140
for myasthenia gravis, 90–1
pericardial window, 143–4
pericardial window approach, 97–9, 98
for plication of diaphragm, 112
pneumonectomies, 141
positioning during, 137–8
for primary spontaneous pneumothorax treatment, 143
principles of, 143
right lower lobe dorsal segmentectomy, 60, 61
right upper lobe segmentectomy. See Right upper lobe, uniportal VATS segmentectomy
segmentectomy, 140, 141
and sympathectomy, 143
upper lobectomy, 138–40, 139–40
V
VATS. See Video-assisted thoracic surgery (VATS)
VATS decortication, 86
VATS en bloc chest wall resections, 53–5
incision placement, 54
outcomes of, 55
patient positioning, 53
patient selection, 53
planned area of, 54, 54
technical challenges associated with, 53
VATS lobectomy, 3–4, 31–5
and air leakage, 10–11
clinical research, 12–13
contraindications, 31
defined, 5
description of, 31
indications, 31
left lower, 34–5
left upper, 34
and levels of NK cells, 6
open lobectomy vs., 41
perioperative care, 10
port placements for, 37, 37
and postoperative pain, 4
and Quality of Life, 5–6
renaissance of, 4–5
right lower. See Right lower VATS lobectomy
right middle. See Right middle VATS lobectomy
right upper. See Right upper VATS lobectomy
single-direction, 67
sleeve. See VATS sleeve lobectomy
studies, quality of, 5–6
and sublobar resection, 9–10
surgical approaches for, 5
thoracotomy and, similarity between, 6
three-port strategy, 7
VATS mediastinal lymph node dissection, 37
left, 38–9, 39–40
right, 38
VATS pericardial window, 96
approaches, 95
case studies, 96, 97
indications, 95
natural orifice transluminal endoscopic surgery, 99
needlescopic, 96, 97, 98
patient selection, 95
preoperative planning, 95
uniportal approach, 97–9, 98
VATS plication, of diaphragm, 112, 113
VATS pneumonectomy
anesthesia for, 41–2
benefits of, 41
complications after, 43
contraindications to, 41
conversion rate to thoracotomy, 43, 44
defined, 41
mortality rate, 43, 44
open pneumonectomy vs., 44
operative techniques of. See Operative techniques, of VATS pneumonectomy
outcomes of, 44
patient selection for, 41
postoperative analgesia for, 42
preoperative evaluation for patients, 41
uniportal, 141
VATS sleeve lobectomy, 47–50, 68, 68
benefits of, 49
clinical outcomes, 49–50
complications, 49
patient characteristics, 47
patient positioning, 47
postoperative care, 49
technical considerations, 47–9, 48–9
technique of, 47
VATS thymectomy
classifications of, 89
clinical indications for, 89
for invasive thymomas, 91, 91
for non-thymomatous myasthenia gravis, 89, 90, 90–1
patient positioning for, 89, 89
right, port and instrument placements for, 89, 90
surgical technique, 89, 89–90, 90
for thymomas, 89, 91, 91
Ventilation
protective lung, 22–3, 23
spontaneous, 22
Video-assisted thoracic surgery (VATS), 17
advantages of, 71
advent of, 129
anesthetic techniques, 21–5
bilateral. See Bilateral VATS
for empyema, 1
evolution of, 8, 8–9, 9, 11–13, 129
for interstitial lung disease, 74, 74
intraoperative complications and conversions, 67–70
lobectomy. See VATS lobectomy
LVRS through, 2
medical thoracoscopy vs., 163, 163
needlescopic, 8, 9
nonintubated. See Nonintubated VATS
open thoracotomy vs., 1
overview of, 3
for pneumothorax, 1–2, 71–3, 72, 73
for solitary pulmonary nodule, 71, 72
for spontaneous pneumothorax, 71–3, 72, 73
two-port, 8, 9
uniportal. See Uniportal VATS
Videothoracoscopy, 102–4, 103, 104
W
Wedge resection, 124
X
Xiphoid process, 95
Z
Zephyr valve, 75
×
Chapter Notes

Save Clear

The rationale for minimally invasive thoracic surgeryChapter 1

Arthur Kostron,
Eric Lim
 
INTRODUCTION
Surgery as a speciality has originated from a spirit of innovation and improvement, an innate driving force within us that strives to better outcomes and lower morbidity. What we consider to be standard practice today would have started its journey from impossible, advocated by ‘irresponsible rogue surgeons’ to development, refinement and acceptance. Along the way, some procedures will be proven not to be of any benefit (e.g. no improved survival with extrapleural pneumonectomy for mesothelioma), others have demonstrable improvement in outcomes (e.g. pleurodesis to reduce recurrent pneumothoraces) but most will be accepted as standard practice without question (e.g. surgery for early stage lung cancer).
One of the main reasons surgeons and patients seek minimally invasive options for procedures that can otherwise be done safely using conventional open surgery is the allure that the same benefit can be achieved with less ‘trauma’ resulting in reduced pain, quicker recovery and better cosmetic appearance.
 
DEFINING MINIMALLY INVASIVE SURGERY
Minimally invasive surgery usually refers to a procedure undertaken through a smaller skin incision(s). Often this involves the use of specialised (thoracoscopic) cameras and equipment designed to facilitate operating within the body whilst taking up as little space as possible.
While most of us are caught up in the allure of ‘minimal invasion’, we often fail to realise if the operation is to be equally effective, the procedure performed is the same and therefore the degree of ‘invasion’ is comparable (apart from that saved by incision length).
There are other benefits apart from incision length alone. Rib spreading is widely thought to contribute to post-operative intercostal nerve pain and therefore no rib spreading is an accepted definition for what constitutes a ‘minimally invasive’ (or VATS) lobectomy. Additional distinguishing factors include looking solely at the television screen and not into the wound whilst operating. These definitions may have originated from requirements of clinical trials1 but are often used to segregate surgeons who claim to be undertaking a minimally invasive procedure simply by shortening the length of the usual incision for ‘open’ surgery.
Less consideration has been given to determine if any of the strict definitions improves patient outcome by defining a procedure using a smaller access. For example, would an open operation undertaken without rib spreading (as used in countries such as Japan) though a short incision yield similar benefits in terms of better pain control and quicker recovery?
 
EVIDENCE FOR MINIMALLY INVASIVE THORACIC SURGERY
There are several randomized and non-randomized trials comparing video-assisted thoracic surgery (VATS) to conventional open resection of lung cancer summarized in a systematic review and meta-analysis was performed.2 2641 patients from 2 randomized and 19 non-randomized trials were included and postoperative outcomes such as prolonged air leak, arrhythmia, pneumonia and surgical mortality were found to be comparable between the groups. Oncological results seem to be equal for local recurrence; however, lower systemic recurrence rates and a reduced 5-year mortality were reported. The reason might be selection bias, on the other hand it has been suggested that due to a better physical performance status more patients were eligible to complete adjuvant therapy;3 however, a recent retrospective study comparing both modalities in patients with clinical stage I lung cancer and unsuspected lymph node metastasis found no difference in the application of adjuvant chemotherapy or number of patients completing all cycles.4
A meta-analysis of 7 retrospective studies suggested that VATS should be the preferred technique for lung resection in patients with limited pulmonary function as VATS was associated with significantly reducing the overall pulmonary complications, mainly the incidence of pneumonia and thus leading to a shorter stay in intensive care and overall length of stay5 with similar benefits compared to those with normal pulmonary function.6
Important patient related outcomes, like postoperative pain and affection on the health-related quality of life (HRQOL) unfortunately are seldom addressed in studies and therefore conclusive data on these relevant issues is missing. HRQOL has just been reported in two trials comparing the two modalities for the resection of lung cancer; these have lately been summarized by a systematic review7 that concluded that VATS may have a better HRQOL compared to thoracotomy; however, they admitted a high risk of selection bias.
Literature is scarce for the comparison of VATS to open thoracotomy in other indications. A systematic review of pulmonary metastasectomy consisting of 7 controlled, non-randomized trials comparing VATS to open resection concluded that the current lack of high quality data makes it impossible to favour one of the two approaches.8
For empyema surgery, one relatively large retrospective study comparing 289 patients undergoing VATS with 94 patients after open decortication and it was suggested, that VATS had less operating time, postoperative air leak, atelectasis, need for re-intubation, ventilator dependency, transfusion, sepsis, hospitalisation, and 30-day mortality; however, the groups were not matched well and a clear selection bias was present.9
For the treatment of pneumothorax, open treatment still seems to have the lowest recurrence rate (1% vs 4%).10 However, VATS is widely 2recommended,11 due to better overall tolerability, reduced length of hospitalisation, fewer analgetic requirements and perhaps less perioperative pulmonary dysfunction.12
For lung volume reduction surgery (LVRS) in end-stage emphysema, the National Emphysema Treatment Trial, the largest randomized controlled trial in this field, allowed both, VATS and median sternotomy, and of the 580 patients randomly assigned to surgical treatment, 30% underwent LVRS through VATS.13 A subgroup analysis comparing VATS to median sternotomy showed comparable complication rates, equal surgical mortality and equal functional status at 12 and 24 months; however, patients undergoing VATS had a shorter time of hospitalisation, lower cost of operation, better independent living by 30 days after surgery (81% versus 71%) and less overall cost in the 6 months after surgery.14 Therefore, VATS has been suggested to be the preferred approach for LVRS.15
 
FUTURE OF MINIMALLY INVASIVE SURGERY
Within the standard three port VATS there continues to be modifications for the procedure. Some enthusiasts argue that it is rib spreading rather than the number of ports used and so are less concerned by the number of incisions;16 others continue to develop less incisions and undertake lung resections through a single incision.17 In parallel, advances continue to be made in robotic surgery.18
Currently, we function in an environment that lacks high quality comparative data from clinical trials, and in this circumstance, the patient should be given the opportunity to decide on the benefits and risks of traditional versus minimally invasive surgery. Whilst waiting for the generation of evidence, our current practice may or may not be influenced and in return is a function of the different capabilities of individual surgeons and patient preference for the ‘right’ procedure.
Ultimately, the future use and technique of minimally invasive surgery will depend on generating evidence from clinical trials. Otherwise the movement will continue to be introduced in an ad hoc and patchy manner, limited to centres and surgeons with an interest in this field. Robust data needs to be generated to support claims of improvement in patient care or acceptability and balanced against potential risks and cost. Until cost-effectiveness data is available, it would be more difficult to secure fair reimbursement and national procedure tariffs.
REFERENCES
  1. Swanson SJ, Herndon JE 2nd, D'Amico TA, et al. Video-assisted thoracic surgery lobectomy: report of CALGB 39802 – a prospective, multi-institution feasibility study. J Clin Oncol 2007;25:4993–4997.
  1. Yan TD, Black D, Bannon PG, McCaughan BC. Systematic review and meta-analysis of randomized and nonrandomized trials on safety and efficacy of video-assisted thoracic surgery lobectomy for early-stage non-small-cell lung cancer. J Clin Oncol 2009;27:2553–2562.
  1. Teh E, Abah U, Church D, et al. What is the extent of the advantage of video-assisted thoracoscopic surgical resection over thoracotomy in terms of delivery of adjuvant chemotherapy following non-small-cell lung cancer resection? Interac Cardiovasc Thorac Surg 2014;19:656–660.
  1. Licht P, Schytte T, Jakobsen E. Adjuvant chemotherapy compliance is not superior after thoracoscopic lobectomy. AnnThorac Surg 2014;98:411–416.
  1. Oparka J, Yan T, Dunning J. Does video-assisted thoracic surgery provide a safe alternative to conventional techniques in patients with limited pulmonary function who are otherwise suitable for lung resection? Interactive Cardiovasc Thorac Surg 201317:159–162.
  1. Ceppa DP, Kosinski AS, Berry MF, et al. Thoracoscopic lobectomy has increasing benefit in patients with poor pulmonary function: a society of thoracic surgeon's database analysis. Ann Surg 2012;256:487–493.
  1. Gazala S, Pelletier JS, Storie D, et al. A systematic review and meta-analysis to assess patient-reported outcomes after lung cancer surgery. Scientific World Journal 2013;2013:789625.
  1. Greenwood A, West D. Is a thoracotomy rather than thoracoscopic resection associated with improved survival after pulmonary metastasectomy? Interac Cardiovas Thorac Surg 2013;17:720–724.
  1. Tong BC, Hanna J, Toloza EM, et al. Outcomes of video-assisted thoracoscopic decortication. Ann Thorac Surg 2010;89:220–225.
  1. Barker A, Maratos EC, Edmonds L, Lim E. Recurrence rates of video-assisted thoracoscopic versus open surgery in the prevention of recurrent pneumothoraces: a systematic review of randomised and non-randomised trials. Lancet 2007;370:329–335.
  1. MacDuff A, Arnold A, Harvey J. Management of spontaneous pneumothorax: British Thoracic Society pleural disease guideline 2010. Thorax 2010;65:ii18–31.
  1. Vohra HA, Adamson L, Weeden DF. Does video-assisted thoracoscopic pleurectomy result in better outcomes than open pleurectomy for primary spontaneous pneumothorax? Interact Cardiovasc Thorac Surg 2008;7:673–677.
  1. Fishman A, Martinz F, Naunheim K, et al. A randomized trail comparing lung volume reduction surgery with medical therapy for severe emphysema. N Engl J Med 2003;348:2059–2073.
  1. McKenna R, Benditt J, DeCamp M, et al. Safety and efficacy of median sternotomy versus video-assisted thoracic surgery for lung volume reduction surgery. J Thorac Cardiovasc Surg 2004;127:1350–1360.
  1. Huang W, Wand WR, Deng B, et al. Several clinical interests regarding lung volume reduction surgery for sever emphysema: meta-analysis and systematic review of randomized controlled trials. J Cardiothorac Surg 2011;6:148–156.
  1. McKenna RJ Jr, Houck W, Fuller CB. Video-assisted thoracic surgery lobectomy: experience with 1,100 cases. Ann Thorac Surg 2006;81:421–425.
  1. Gonzalez-Rivas D, Fieira E, Delgado M, et al. Uniportal video-assisted thoracoscopic sleeve lobectomy and other complex resections. J Thorac Dis 2014;6:S674–681.
  1. Nasir BS, Bryant AS, Minnich DJ, Wei B, Cerfolio RJ. Performing robotic lobectomy and segmentectomy: cost, profitability, and outcomes. Ann Thorac Surg 2014;98:203–208.
FURTHER READING
  1. Handy JR. Minimally invasive lung surgery and postoperative quality of life. Thorac Surg Clin 2012;22:487–495.
  1. Moisiuc FV, Colt HG. Thoracoscopy: origins revisited. Respiration 2007;74:344–355.