Video-assisted thoracic surgery (VATS) lobectomy has been used in the treatment of lung cancer since the early 1990s. While there is evidence that lobectomy is better than wedge resection in most patients, there are nolarge prospective, randomized studies favoring video-assisted lobectomy over conventional lobectomy by thoracotomy.¹ However, there are several series that support the use of VATS lobectomy technique. These include some small (n 100) prospective, randomized studies that compare VATS with lobectomy by thoracotomy (Table 63-1). From these data, as well as data from several exclusively VATS series, it is clear that VATS lobectomy is technically feasible and safe and even may provide better quality-of-life outcomes in patients with resectable lung cancer. Despite these efforts, VATS lobectomies represent only approximately 5% of all lobectomies performed in the United States.²

Note: These early series suggest that the VATS and thoracotomy approaches have similar safety profiles and efficacy. There may be less pain with the VATS technique in the early postoperative period.

*Randomized, prospective study, but according to authors, rib spreading was used occasionally in removing the specimens.

Case-control study/retrospective.

Abbreviations: Thor is thoracotomy; NS is not significant; N/A is not applicable.

The VATS cancer operation is specifically defined as an anatomic lobectomy (or segmentectomy, when indicated) and consists of individual hilar ligation by means of three or four small incisions and no rib spreading. This anatomic lobectomy should leave the patient with results identical to a cancer resection by thoracotomy. That is, the surgeon resects the tumor with negative margins, performing individual vascular and bronchial ligation and division and a complete hilar lymph node dissection. Furthermore, mediastinal lymph node dissection or sampling is performed as appropriate. Certain aspects of the technique, most notably avoidance of rib spreading or the use of a rib retractor, are emphasized, with the goal of improving the patient's postoperative experience. Cosmetic aspects, such as smaller scars (largest incision is usually 5–8 cm), are also important. One variant, the video-assisted simultaneously stapled lobectomy, does not involve individual hilar ligation. In essence, it is a different operation and is not discussed in this chapter. Nevertheless, some surgeons have achieved excellent results with this technique.³

TECHNICAL AND ONCOLOGIC PRINCIPLES

Oncologically, this surgery is equivalent to a lobectomy by thoracotomy. The ultimate measure of success in cancer surgery is long-term survival. Proving that VATS lobectomy is comparable with conventional lobectomy would require a large prospective, randomized multicenter trial. It is unlikely that this will ever occur for lack of sufficient patient accrual. Many patients prefer the minimally invasive technique, and the lack of data of the highest order (i.e., large prospective, randomized series) does not matter to them. Today's patients are well informed, often using resources such as the Internet to choose the optimal technique or surgeon. The forthcoming Cancer and Leukemia Group B trial (CALGB 140501) on VATS lobectomy versus open lobectomy, sponsored by the National Cancer Institute, is a large prospective, nonrandomized trial and may garner support for VATS lobectomy as mainstream therapy for stage I non-small cell lung cancer (NSCLC).

SURVIVAL

In lieu of ideal prospective, randomized data, the existing data demonstrate comparable and sometimes better long-term survival rates with VATS lobectomy (Table 63-2). Stage I 5-year VATS survivals can range from 63% to 97%.^4–6 Although direct comparison is precluded, indirect comparison of these data with two series of patients undergoing lobectomy by thoracotomy demonstrates a trend for improved survival with VATS lobectomy. Mountain and colleagues reported 5-year survival in stage IA surgical patients of 61%.⁷ Martini and colleagues reported 5-year survival of 82% in stage IA surgical patients.⁸ Some hypothesize that the higher survival range observed with VATS is a result of the decreased presence of inflammatory mediators interleukin 6 and interleukin 8 in VATS patients compared with thoracotomy patients.^9–11 This theoretical decrease in postoperative inflammation may free the immune system to devote more effort to tumor cell surveillance and destruction.

Note: These series demonstrate excellent survival outcomes for stage I patients undergoing VATS lobectomy. Five-year survival for stage IA after thoracotomy and lobectomy has been reported to be between 61%⁴ and 82%.⁸

LOCOREGIONAL RECURRENCE

The reported locoregional recurrence rates for VATS lobectomy are comparable with the published standards for lobectomy (Table 63-3). In general, locoregional disease is estimated to recur in 5–10% of all patients.^1,8Port-site and incisional recurrence is extremely rare. Since the use of endoscopic bags for removing tumor became general practice, incisional or port-site recurrence has been reported to be in the low range of 0–0.57% of all cases.^2,12

Note: Locoregional occurrence has been reported between 0% and 6% in VATS lobectomy series with various follow-up times. For comparison, Ginsberg and colleagues (The Lung Cancer Study Group) reported an incidence of 6.4% for locoregional recurrence in thoracotomy patients.¹

LYMPH NODE DISSECTION

Lymph node dissection can be accomplished adequately in VATS lobectomy. In fact, several studies have shown that thoracotomy may provide only minimal, if any, advantage in exposing lymph nodes and stations.^13–15Sagawa and colleagues reported their experience with standard thoracotomy after VATS lobectomy. This group reported an average increased yield of 1.2 lymph nodes (2–3%) at follow-up thoracotomy, but without effect as to clinical stage in a single patient. Lymph node sampling was very efficient, with 40 nodes sampled on the right and 37 on the left using the VATS technique alone.¹⁵

INDICATIONS, PATIENT CHARACTERISTICS, AND PREOPERATIVE ASSESSMENT

The indications for VATS lobectomy are basically the same as those for conventional lobectomy, namely, non-small cell lung cancer, metastasectomy, and carcinoid tumors. The ideal and typical patient has stage I non-small cell lung cancer. Absolute contraindications to VATS lobectomy are the presence of T₃ or T₄ tumors, N₃ disease, or an inability to achieve single-lung ventilation. Relative contraindications include central hilar tumors, tumors that are visible on bronchoscopy or that necessitate a sleeve resection, bulky mediastinal or hilar lymphadenopathy, and a history of neoadjuvant chemotherapy or radiation. Incomplete or absent fissures rarely mandate conversion to thoracotomy. Furthermore, segmentectomy can be performed thoracoscopically. Older or more frail patients even may tolerate lobectomy better by VATS than by thoracotomy.¹⁶

The preoperative studies for VATS lobectomy are those typically performed for a lung cancer workup. These include chest radiograph, CT scan, bronchoscopy, pulmonary function studies, PET scan, and when necessary, other modalities for metastatic workup. In reviewing the CT scan, the surgeon should focus on whether there are any issues, such as bulky lymphadenopathy, that would render the hilar dissection more difficult with VATS.

SURGICAL TECHNIQUE

It is important to perform a safe and effective surgery without compromising any established oncologic principles. Conversion to an open technique should be viewed as a sign of good judgment, not failure. The adequacy of resection should not be jeopardized by the predilection for a VATS approach.

A thoracotomy tray with vascular clamps and chest retractors always should be available in the room. Spongestick and dental pledgets also should be ready and available on the field for tamponade of major bleeding sites while a thoracotomy is expeditiously and carefully performed.

Once preoperative evaluation has deemed the patient to be a candidate for VATS lobectomy, the patient is brought to the OR. The patient is anesthetized and intubated. Bronchoscopy is performed to rule out endobronchial lesions that would preclude a VATS approach. Mediastinoscopy is performed when indicated. Lung isolation is obtained with a double-lumen endotracheal tube or bronchial blocker. Good lung isolation is an absolute need throughout the entire case. Once the position of the tube is confirmed, the patient is placed in the lateral decubitus position. The endotracheal tube is reconfirmed via bronchoscopy to ensure that it has not migrated out of position. The ipsilateral lung is immediately collapsed to permit ample time for atelectasis to occur before entering the chest. Suction also may be applied through a suction catheter or bronchoscope to aid in collapse of the isolated lung.

Several different approaches have been described in the literature. Two to four ports plus a utility/access incision typically are required to perform a VATS lobectomy. We prefer to use three incisions: an inferior camera port, a posterior working port, and an anterior access/utility incision (Fig. 63-1). Avoidance of rib spreading is the key element in VATS lobectomy for preventing postoperative pain and trauma to the intercostal nerve bundles, which are responsible for the postthoracotomy pain syndrome.

By exchanging the camera and instruments and using the angles afforded by the three ports, all visualization and most dissection techniques practiced in open lobectomy procedures can be duplicated. Port placement may vary slightly to account for patient body habitus, location of the tumor, and surgeon preference. However, optimal port placement is important for successful resection. The camera port is created first, and it is usually placed at the seventh or eighth intercostal space. Whether to locate it in the anterior, middle, or posterior axillary line depends on multiple factors, including the level of the diaphragm, as determined by review of preoperative chest radiograph, the location of the pathology, and the side of the procedure (left versus right). Ideally, this port should provide views of the anterior and posterior hilum and should align with the major fissure. We use a 30-degree scope almost exclusively. It provides optimal views not afforded by a 0-degree scope, particularly during the difficult dissection around the superior hilum, and avoids "crowding" of the working instruments. Once the scope is inserted, we inspect the chest cavity and select the ideal position for the remaining two ports. The anterior port should be placed immediately over the hilum because this will be used as the access/utility port. Dissection of both the hilum and fissure will be performed through this port. The initial incision is limited to 1–2 cm in length. It is not fully extended (i.e., 5–8 cm in length) until the decision is made to proceed with VATS lobectomy. The port is usually created anterior to the latissimus dorsi muscle in the fourth intercostal space for an upper lobectomy and the fifth intercostal space for a lower lobectomy. The third port is usually sited in the fifth or sixth intercostal space, either inferior or posterior to the scapular tip. This port usually serves as the lung retraction port. Hemostasis is very important when creating the ports because bleeding from the port sites onto the camera and into the surgical field during the procedure is a nuisance and can prolong the operation significantly.

Once all the ports have been created, a more thorough exploration is performed. The pleural surface is inspected for implants. Adhesions may be encountered. These can be lysed and are not a contraindication to proceed with VATS lobectomy. Careful and complete adhesiolysis permits full mobility of the lung. Retraction of the lung is critical to completing the resection. For this reason, the inferior pulmonary ligament is always divided. The discovery of tumor invasion into the chest wall is a contraindication to VATS because it requires en bloc chest wall resection. Digital palpation of the tumor and lung is performed through the anterior access port not only to confirm the location and presence of the tumor but also to rule out additional unsuspected nodules or pathology not identified on preoperative studies. Before resection, the ipsilateral mediastinal lymph nodes are sampled, especially if mediastinoscopy was not performed earlier. If N₂ disease is discovered on frozen section, the VATS resection is aborted, and the patient is treated with neoadjuvant therapy. If a preoperative tissue diagnosis has not been determined, a wedge or core biopsy is performed initially, followed by lobectomy if frozen section reveals carcinoma.

A combination of conventional and endoscopic surgical instruments may be used for dissection. We have found the following conventional instruments to be particularly useful in accomplishing VATS lobectomy: ring forceps, right-angle clamps, Harkens clamps, Pearson scissors, long Allis clamps, Frazier clamps, biopsy forceps, and a red rubber catheter. Familiarity with the use of these instruments in open techniques translates to facility in their use during the VATS resection.

The order of division of the hilar structures is irrelevant in terms of oncologic outcome. Depending on the lobe, the order of division of the hilar structures differs and is described in detail below. Dissection of the hilar structures is fraught with danger, and one must have a comprehensive understanding of the anatomy and possible variations thereof, especially the pulmonary artery branches. Also, despite improved video technology, one must be aware of the limitations of performing three-dimensional dissections guided by a two-dimensional picture.

Hilar dissection is carried out through the anterior access incision, which is extended to approximately 5 cm when the decision to proceed with lobectomy is definite. Using a combination of sharp and blunt dissection, we divide the pleura. The lung is retracted away to aid the dissection. The hilar structures then are divided sequentially with an endovascular stapler. We complete the fissures with serial firings of an endoscopic stapler. The resected specimen then is placed in a heavy laparoscopic extraction sac to prevent tumor seeding of the port and is removed through the anterior access incision without spreading the ribs.

Next, we perform a complete lymph node dissection for accurate staging. This includes levels 2, 4, 7, 8, and 9 on the right and levels 5, 6, 7, 8, and 9 on the left. Finally, we test the stump for pneumostasis under water to a pressure of at least 30–35 mm Hg. Hemostasis is checked. Electrocautery of the ports is used sparingly to avoid injury to the neurovascular bundle. A single 24F chest tube is left in the chest for postoperative drainage. The ports are closed, and the patient is repositioned supine on the OR table. A completion bronchoscopy is performed to check the staple line and for pulmonary toilet before extubating the patient in the OR.

The conduct of the operation for the different lobes is essentially the same and is described below with a few caveats based on experience.

Right Upper Lobectomy

For right upper lobectomies, we usually place the camera port in the seventh intercostal space along the anterior axillary line (Fig. 63-2A ). This placement provides good visualization of the anterior and superior hilum, the area of most hazardous dissection. The access port usually is located in the fourth intercostal space anteriorly, and caution is exercised to avoid injury of the long thoracic nerve and breast tissue in women. The posterior working/utility port is placed inferior or posterior to the scapula tip, which usually depends on the morphology of the chest. The orientation of this port should provide a right-angle configuration between instruments in the access and working ports. After initial exploration, the dissection is begun in the anterior hilum. The right upper lobe (and sometimes the middle lobe) is grasped gently with ring forceps and retracted posteriorly. This maneuver creates excellent exposure of the anterior hilum. The superior pulmonary vein is isolated first in the anterior hilum by dividing its pleural covering with a Harmonic scalpel, Pearson scissors, and/or endo-Kittners. The phrenic nerve is carefully dissected away from the hilum to prevent injury. The draining veins of the middle lobe must be identified as well to prevent unintentional division. An oiled 2–0 silk suture then is looped around the superior pulmonary vein (Fig. 63-2B ). The vein is divided with an endovascular stapler, usually introduced through the posterior port, which provides the best angle. After division of the superior pulmonary vein, the truncus anterior and its variable number of branches are exposed (Fig. 63-3). They are dissected free individually or as one trunk depending on their configuration and accessibility. They are then divided individually or as one trunk using an endovascular stapler. The "endoleader," a rubber catheter, can be used to safely guide the stapler through the tight space around the arterial branches.¹⁷ The arteries are best divided with the endovascular stapler introduced through the camera port, with the camera switched to viewing from the access port (Fig. 63-3, inset). A spongestick or dental pledget on a clamp always should be in the scrub technician's hand "at the ready" for tamponade of bleeding from malfunction of the stapler or avulsion of the hilar vessels. This single maneuver bides time for adequate control and conversion to an open thoracotomy, if needed. Once the arterial branches are divided, the next step is to dissect the interlobar main pulmonary artery at the confluence of the fissures. This dissection can be difficult with incomplete fissures. There are several alternatives to address this problem. One maneuver is to partially, but carefully, divide the fissure with a stapler or Harmonic scalpel. This provides better exposure of the interlobar pulmonary artery for dissection. The goal of exposing the interlobar pulmonary artery is to identify the space between the recurrent ascending arterial branch to the posterior segment of the upper lobe and the artery to the superior segment of the lower lobe. This space permits safe division of the recurrent ascending branch and completion of the posterior fissure. The most commonly used option for dealing with the incomplete fissure or for isolating the recurrent posterior segmental arterial branch is to approach it anteriorly and/or superiorly with the bird's-eye view provided by the 30-degree scope. Once all the arterial branches to the upper lobe are divided, the right upper lobe bronchus is dissected free by sweeping all nodal tissue on the bronchus toward the specimen side (Fig. 63-4). An endoscopic stapler, usually loaded with "thick tissue" staples, then is introduced through the camera port to divide the bronchus, leaving a short, intact stump. The fissure is completed with serial firings of the endoscopic stapler, if not already performed. The specimen lobe then is placed in a heavy laparoscopic extraction sac and is removed through the access incision without rib spreading.

Left Upper Lobectomy

In our opinion, the left upper lobectomy is the most difficult to perform technically because of the variability in the arterial circulation, which can have up to three to eight branches. The order of division of the hilar structures is the same as with the right upper lobe—vein, artery, bronchus. The inferior camera port is placed more posteriorly to avoid obstruction of view by the heart (especially if enlarged) and the pericardial fat pad. In patients with marginal pulmonary function and a small tumor, a lingular-sparing left upper lobectomy, or lingulectomy, as appropriate, should be considered. Anatomically, the lingula can be considered the equivalent of the middle lobe on the left side. The order of hilar structure division is the same as for a right middle lobectomy (see below).

Right Middle Lobectomy

For right middle lobectomy, the camera port usually is placed in the seventh intercostal space along the midaxillary line. This position provides an excellent view of both the anterior hilum and the major fissure. The anterior access port usually is placed in the fourth intercostal space, whereas the working port generally is placed posterior to the scapular tip in the sixth or seventh intercostal space. The right middle lobe is retracted laterally, and the middle lobe veins (usually two branches) are dissected free and divided using the endovascular stapler. The middle lobe bronchus then is exposed. We divide the bronchus first because the bronchus is anterior to the artery. One must be careful not to injure the artery when dissecting around the bronchus. Next, we dissect out the arterial branches to the middle lobe. These are looped and divided with the endovascular stapler. The "endoleader" technique may be helpful in guiding the stapler around these branches.¹⁷ The fissure is completed, and the middle lobe is removed in a specimen sac through the access incision.

Right and Left Lower Lobectomy

The camera ports usually are placed in the eighth interspace to avoid crowding of the instruments. On the right, the camera port generally is positioned in the midaxillary line. On the left, in people with large hearts or "barrel chests," the port is placed more posteriorly to avoid obstruction of the view by the heart. The access port usually is placed anteriorly in the fifth intercostal space. The posterior working port usually is placed posterior to the scapular tip in the sixth or seventh intercostal space. We first divide the inferior pulmonary ligament and sample the level 9 lymph nodes. The lower lobe is retracted superiorly with a ring forceps through the posterior port, putting the ligament under tension. A long-tip electrocautery or ultrasonic scalpel divides the ligament through the access port. The level 9 lymph nodes are removed and sent for frozen section. Next, the interlobar main pulmonary artery is dissected free in the fissure. The basilar trunk and artery to the superior segment are identified, dissected, looped, and divided with the endovascular stapler. Next, the inferior pulmonary vein is dissected free, looped, and then divided with an endovascular stapler. Finally, the bronchus to the lower lobe is dissected and divided with an endoscopic stapler. As in the open technique, care must be observed on the right side to avoid impingement on the middle lobe bronchus. The fissure is completed, and the lobe is removed in a specimen sac through the access incision without any rib spreading.

POSTOPERATIVE ISSUES AND RESULTS

The elements of postoperative care are the same for VATS lobectomy as for conventional lobectomy. Typically, however, the postoperative course can be accelerated with regard to days of chest tube drainage and length of hospital stay (Table 63-4). The same complications occur with VATS lobectomy as with conventional thoracotomy but perhaps with decreased frequency. Morbidity in patients undergoing conventional lobectomy occurs in approximately 28–38% based on data reported from several large series.^18,19 Mortality for these same series ranges from 2% to 2.9%. The largest VATS series to date has reported morbidity and mortality rates of 15% and 0.8%, respectively.² The most common postoperative complications are atrial fibrillation and prolonged air leak.

Note: These VATS series demonstrate morbidity and mortality rates with some quality-of-life measures. In the largest series of patients undergoing lobectomy predominantly by thoracotomy, the morbidity ranges from 28% to 38%, and mortality ranges from 2% to 2.9%_.^18,19

The risk of fatal intraoperative hemorrhage merits special consideration because it may be a barrier to more surgeons using this technique. This risk is clearly related to experience and skill in the videoscopic dissection of the hilum. Regardless, of the perceived difficulty of this dissection, the risk of intraoperative hemorrhage is negligible based on reported series. The ability to control bleeding with a spongestick or other instrument gives the surgeon ample time to extend the incision and convert to a full thoracotomy.

ONCOLOGIC OUTCOMES

Through the many single- and multi-institution series, it has been established that VATS lobectomy can be performed safely. The 3-, 4-, and 5-year survivals for some of the published series in Table 63-2 and the locoregional recurrence data in Table 63-3 demonstrate that this surgery can be performed with good oncologic outcome. The published morbidity and mortality rates are also comparable to or better than those of lobectomy by thoracotomy. Other significant factors, such as those that fall under the expansive category of quality of life, ultimately may validate VATS lobectomy.

Quality of Life

VATS lobectomy may give patients improved quality of life as compared with open lobectomy. Quality of life is measured in terms of psychological and physical effects. Factors that affect patient perception include postoperative morbidity, mortality, pain, independence, and overall oncologic outcome, to name a few.

The quality-of-life variable that argues favorably for VATS lobectomy over lobectomy by thoracotomy is the tolerable postoperative course associated with VATS. Avoiding rib spreading theoretically reduces pain. Evidence that VATS causes less pain and is associated with lower analgesia requirements during the early and late postoperative periods has been published^20–23 (see Table 63-1). This may be related to lack of rib spreading and earlier removal of the chest tube after VATS lobectomy. Patients are often discharged earlier on postoperative days 2 through 4 and may achieve earlier independence. Demmy and colleagues compared VATS with thoracotomy to determine discharge independence and found that a significantly higher percentage of case-control thoracotomy patients were discharged to nursing facilities, whereas approximately 95% of VATS patients, despite shorter hospital stays, were discharged to home with or without nursing assistance.¹⁶

Currently, there are several large series that support chemotherapy in early-stage lung cancer patients with stage IB and greater disease.^24,25 However, receiving chemotherapy postoperatively can be fraught with delays and complication. In fact, a recent trial reported that as few as 45% of patients receive full-dose chemotherapy on schedule.²⁶ The practice of administering chemotherapy in early-stage lung cancer patients has raised a new question—whether minimally invasive (VATS lobectomy) procedures can expedite the chemotherapy course. A quicker recovery from surgery may mean a higher likelihood of completing a full course on schedule. This may translate into improved survival data. The optimal time for chemotherapy is probably in the very early postoperative period, while the tumor burden is lowest, even given the limitations of wound healing.

SUMMARY

Once mastered, VATS lobectomy can be performed safely with excellent perioperative and oncologic results. The frequency with which this operation is performed remains low. A large prospective series, such as the CALGB 140501, is necessary to gain widespread acceptance and increase use of this technique.

CASE HISTORY

A 66-year-old woman with a significant remote smoking history was found to have a left upper lobe mass on routine preoperative workup for elective orthopedic surgery (Fig. 63-5). A CT/PET scan further delineated the mass with a standardized uptake value of 5.1 (Fig. 63-6). Brain imaging was negative, and pulmonary function tests were excellent. The patient underwent cervical mediastinoscopy, thoracoscopy, and a needle biopsy, which confirmed the diagnosis of non-small cell lung cancer. The surgeons then proceeded with video-assisted left upper lobectomy and mediastinal lymph node dissection. Her postoperative course was unremarkable, and she was discharged on postoperative day 3. Final pathology results revealed a stage IB lung adenocarcinoma. Postoperative chemotherapy was recommended and begun 3 weeks after surgery. The patient tolerated the full course of chemotherapy on schedule. The patient is now 6 months out of surgery without any evidence of recurrence or change in lifestyle.

EDITOR'S COMMENT

Our approach is quite similar to Dr. Swanson's except that we generally perform the VATS lobectomy completely thoracoscopically. That is, we use port access and an operating thoracoscope throughout. This allows a complete lobectomy with truly minimal access incision. The lobe is then placed in a sterile bag and removed through an incision that is just large enough to allow its removal. This has resulted in excellent cosmesis as well as very good functional outcomes. The duration of CT drainage is the sole determinant of discharge.

–MJK

REFERENCES