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(Chest. 2003;123:619-622.)
© 2003 American College of Chest Physicians

Thoracoscopic Lobectomy for Lung Cancer With a Largely Fused Fissure*

Hiroaki Nomori, MD, PhD; Takashi Ohtsuka, MD; Hirotoshi Horio, MD; Tsuguo Naruke, PhD, FCCP and Keiichi Suemasu, PhD

* From the Department of Thoracic Surgery, Saiseikai Central Hospital, Tokyo, Japan.

Correspondence to: Hiroaki Nomori, MD, PhD, Department of Thoracic Surgery, Saiseikai Central Hospital, 1-4-17 Mita, Minato-ku, Tokyo 108-0073, Japan; e-mail: hnomori{at}qk9.so-net.ne.jp


   Abstract
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 Abstract
Introduction
 Materials and Methods
 Results
 Discussion
 References
 
Background: While isolating the pulmonary arterial branches within the fissure is a crucial step in lobectomy, a largely fused fissure usually hinders its achievement, making lobectomy with video-assisted thoracoscopic surgery (VATS) difficult to achieve. For VATS lobectomy in lung cancer patients with a largely fused fissure, we have conducted an unusual approach for each lobe, and the surgical results were compared between patients with and without a fused fissure.

Methods: Since1999, we have conducted VATS lobectomies in 77 patients. Of these, 10 had largely fused fissures that needed an unusual surgical approach for dividing the pulmonary arterial branches. The other 67 patients had separated fissures that allowed the isolation and division of the arterial branches within it. While the surgical approach used for the patients with largely fused fissures differed in each lobe, most often the lobar bronchus was divided before pulmonary arterial branches within the fissure were divided, with the fused fissure being divided last.

Results: There were no significant differences in age, lobectomy site, or tumor stage between the patients with fused fissures and those with separated fissures. The surgical data showed no significant differences between the two groups in operating time, blood loss, duration of chest tube drainage, and hospital stay after surgery. However, the patients with fused fissures required more staples to close the incision than did those with a separated fissure (mean number of staples, 7.7 vs 5.7; p < 0.001). There was no postoperative mortality or morbidity, including prolonged air leakage, in the patients with fused fissures.

Conclusion: Although the performance of VATS lobectomy for patients with largely fused fissures is more costly, it is feasible and safe. A largely fused fissure is not a limiting factor for the performance of VATS lobectomy.

Key Words: fused fissure • lobectomy • lung cancer • thoracoscopy


   Introduction
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 Abstract
 Introduction
Materials and Methods
 Results
 Discussion
 References
 
While video-assisted thoracoscopic surgery (VATS) is gaining popularity as a technique for performing lobectomies in patients with lung cancer,1 2 there are still several limiting factors for VATS lobectomy, such as advanced tumor stage, the presence of pleural adhesion, and a largely fused fissure.3 4 Of these, there is a general consensus that VATS lobectomy must not be conducted in patients with advanced lung cancer. However, some surgeons convert VATS lobectomy to a thoracotomy procedure for patients with largely fused fissures.4

Since August 1999, we have carried out VATS lobectomy with mediastinal lymph node dissection in 77 patients with clinical stage I lung cancer.5 During that time, we have completed VATS lobectomy successfully, even in patients with largely fused fissures, using an approach that differs from that in patients with a separated fissure. In this article, we present the approach of VATS lobectomy in patients with largely fused fissures that differs from that in patients with a separated fissure and compare the surgical results between the two groups.


   Materials and Methods
TOP
 Abstract
 Introduction
 Materials and Methods
Results
 Discussion
 References
 
Patients
Between August 1999 and March 2002, a total of 92 patients with clinical stage I lung cancer underwent VATS lobectomy with mediastinal lymph node dissection at our hospital. Fifteen of the patients underwent conversion to the open thoracotomy procedure during surgery due to advanced tumor stage (12 patients), bronchoplasty (1 patient), bleeding (1 patient), and pleural adhesion (1 patient). As a result, 77 patients (84%) successfully underwent VATS lobectomy and lymph node dissection. Of these patients, 10 patients had largely fused fissures, which made it difficult to approach the pulmonary arterial branches from outside of the fissure. Four patients had primary tumors in the right upper lobe (RUL), one had a primary tumor in the right middle lobe (RML), one had a primary tumor in the right lower lobe (RLL), two had primary tumors in the left upper lobe (LUL), and two had primary tumor in the left lower lobe (LLL). The characteristics of the 10 patients with largely fused fissures and the remaining 67 patients with separated fissures are shown in Table 1 . There were no significant differences in age, sex, the lobectomy site, tumor size, or pathologic tumor stage between the two groups.


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  		Table 1.. Patient Characteristics*

 
VATS Lobectomy Procedure
Our usual VATS lobectomy technique has been reported previously.5 Briefly, it was performed with each patient in the lateral decubitus position, with the arm elevated and secured on a padded armboard. A skin incision about 5 to 6 cm long was made, generally on the midaxillary line. The chest was generally entered through the fourth intercostal space, which was opened to a width of about 2 cm using a thoracic opener. Three further access ports were created. The operators usually divided the pulmonary vessels and bronchus under direct vision via the minithoracotomy site, aided by an assistant via the other ports, and using the TV monitor for guidance. The pulmonary vein is usually divided with an endoscopic stapler. The pulmonary arterial branches within a fissure are approached from outside the fissure and are usually divided with ligation. For the mediastinal lymph node dissection, the thoracic opener was removed, and the operating surgeon dissected the lymph nodes under television monitor guidance.

Our procedures for VATS lobectomy in patients with largely fused fissures are the follows.

Right Upper Lobectomy
The superior pulmonary vein is divided by a stapler. The pulmonary artery, which is located just beneath the divided pulmonary vein, is dissected to the central side to expose the truncus superior artery of the RUL. Dividing the truncus superior artery exposes the RUL bronchus, which in turn is divided by a stapler. Just inferior to the divided bronchus lies the ascending artery of the RUL, which then is divided. The lung is then retracted backward to expose the descending limb of the pulmonary artery. The pulmonary artery is dissected along its route to the peripheral side into the fused fissure to expose the RML and RLL arteries. The fused fissure is divided from the anterior to the posterior side with staplers, thus completing the right upper lobectomy.

If the ascending artery of the RUL is seen nearby the anterior side of the fused fissure, it is divided before dividing the RUL bronchus. Then the fused fissure is divided, thus exposing the RUL bronchus. The division of the RUL bronchus completes the lobectomy.

Right Middle Lobectomy
The pulmonary vein of the RML is divided. The RML bronchus, located just beneath the divided RML vein, is divided by a stapler. This is followed by the division of the RML artery, which lies just posterior to the divided bronchus. The fissure then is divided by staplers, thus completing the lobectomy.

Right Lower Lobectomy
The pulmonary vein of the RLL is divided. The RLL is retracted superiorly to expose the reverse side of the RLL bronchus. The RLL bronchus is divided by a stapler, thus exposing the RLL pulmonary artery. After turning the RLL to the normal position, the posterior side of the fused fissure is divided with staplers. This allows for the identification of both the RML and RLL pulmonary artery from outside the fissure, which is a view that is more familiar to surgeons than that from the reverse side. The RLL pulmonary arterial branches then are divided. Finally, the remaining anterior side of the fused fissure is divided with staplers, thus completing the lobectomy.

Left Upper Lobectomy
The pulmonary vein of the LUL is divided, exposing both the LUL bronchus and the truncus superior pulmonary artery. The truncus superior pulmonary artery then is divided, and the LUL is retracted inferiorly to expose the LUL bronchus. After dissecting the LUL bronchus from the pulmonary artery, it is divided with a stapler, exposing the lingular arterial branches of the LUL and the arterial branches of the LLL. Before dividing the lingular arterial branches, the LUL is turned to its normal position and the posterior side of the fused fissure is divided, because this allows the surgeons to see both the pulmonary artery of the LLL and the lingular branches of the LUL from outside of the fissure, which is a view that is more familiar to surgeons than that from the reverse side. After the division of the lingular arterial branches, the remaining anterior side of the fused fissure is divided, thus completing the lobectomy.

Left Lower Lobectomy
The approach for a left lower lobectomy differs from that for a right lower lobectomy, because of the differences in the directions of the pulmonary artery. The pulmonary vein is divided first, with the lung being retracted forward to expose the posterior side of the pulmonary arterial branches to the LLL. The superior segmental artery of the LLL is exposed and divided, and the posterior side of the fused fissure is then divided with staplers, allowing the exposure of the pulmonary artery to the basal segment of the LLL and the lingual arterial branches of the LUL. After dividing the basal artery, the remaining anterior side of the fused fissure is divided. Finally, the LLL bronchus is divided, thus completing the lobectomy.


   Results
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 Abstract
 Introduction
 Materials and Methods
 Results
Discussion
 References
 
There was no accidental bleeding in any of the patients with fused fissures or in those with separated fissures. An 82-year-old male patient in the group with separated fissures died of postoperative pneumonia 23 days after undergoing surgery. Other than this patient, there were no deaths or postoperative complications, such as atelectasis, pneumonia, arrhythmia, or postoperative prolonged air leakage, in either group.

Data related to intraoperative and postoperative factors are summarized in Table 2 . There were no significant differences in operating time, intraoperative blood loss, or duration of chest tube drainage. The mean (± SD) length of hospital stay after surgery was 7.3 ± 1.1 days in the group with separated fissures, except for the one patient who died, and 6.7 ± 1.0 days in the group with fused fissures, with the intergroup difference being nonsignificant. The mean number of staplers used was 7.7 ± 1.2 in the group with fused fissures, which was significantly more than the 5.7 ± 1.1 in the group with separated fissures (p < 0.001).


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  		Table 2.. Operative and Postoperative Data*

 

   Discussion
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
References
 
While some surgeons recommend a thoracotomy procedure for patients with a largely fused fissure,4 we have conducted VATS lobectomies in such patients and have compared the results with those for patients with separated fissures. We found no significant difference in operating time, intraoperative blood loss, duration of chest tube drainage, or hospital stay after surgery between the two groups. There was no accidental bleeding during VATS surgery, postoperative mortality or morbidity (including prolonged pulmonary air leakage) in the group with fused fissures. On the basis of our finding, we now consider that a largely fused fissure is not a limiting factor for VATS lobectomy.

In this series, the only difference between the patients with fused fissures and those with separated fissures was that the former group needed significantly more staplers than did the latter group. This was, of course, because more staples were required to divide the largely fused fissure. Because one staple cartridge costs approximately $200 in Japan, the mean cost for patients with fused fissures was $400 higher than that for patients with separated fissures. However, there was no postoperative air leakage in the patients with fused fissures, enabling the removal of the chest tube 1 day after surgery in all patients. The hospital stay also was not prolonged, thus reducing the overall medical costs. Besides, the cost would be similar even if the VATS was converted to open thoracotomy, because the same numbers of staples should be used to divide a fused fissure.

The procedure for thoracoscopic lobectomy varies in each institution. In 1998, Yim et al2 reported the results of a questionnaire survey involving 33 thoracic surgeons from different parts of the world on their thoracoscopic lobectomy procedure. According to the report, just 10 thoracic surgeons (30%) never used a retractor, while 18 (55%) always or occasionally use a retractor. The article also showed that the skin incision ranged from 4 to 10 cm in length. Our procedure uses a skin incision 6 cm in length and uses a retractor during lobectomy but not during mediastinal lymph node dissection, which is the average for worldwide thoracoscopic lobectomy procedures.

We have reported previously that the only advantage of our VATS lobectomy over the anterior limited thoracotomy procedure was a decreased degree of pain within 2 weeks after surgery.5 However, we have been actively conducting VATS lobectomies in patients with clinical stage I lung cancer, because decreased pain is important even during the short period after surgery to improve the patient’s activities of daily living and accelerate their return to work. Therefore, we usually conduct VATS lobectomies even for patients with largely fused fissures. However, we would like to stress that if some technical difficulty arises during a VATS lobectomy using the present technique for patients with largely fused fissures, a limited open thoracotomy would be preferable from the standpoint of safety.


   Footnotes
 
Abbreviations: LLL = left lower lobe; LUL = left upper lobe; RLL = right lower lobe; RML = right middle lobe; RUL = right upper lobe; VATS = video-assisted thoracoscopic surgery

Received for publication April 8, 2002. Accepted for publication August 16, 2002.


   References
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 References
 

  1. Mack, MJ, Scruggs, GR, Kelly, KM, et al (1997) Video-assisted thoracic surgery: has technology found its place? Ann Thorac Surg 64,211-215[Abstract/Free Full Text]
  2. Yim, APC, Landreneau, RJ, Izzat, MB, et al Is video-assisted thoracoscopic lobectomy a unified approach? Ann Thorac Surg 1998;66,1155-1158[Abstract/Free Full Text]
  3. Yim, APC, Liu, HP, Izzat, MB, et al Thoracoscopic major lung resection: an Asian perspective. Semin Thorac Cardiovasc Surg 1998;10,326-331[Medline]
  4. Kirby, TJ, Priest, BP Video-assisted thoracoscopic lobectomy and video thoracoscopic lobectomy and pneumonectomy. Brown, WT eds. Atlas of video-assisted thoracic surgery. 1994,221-226 WB Saunders Philadelphia, PA.
  5. Nomori, H, Horio, H, Naruke, T, et al What is the advantage of a thoracoscopic lobectomy over a limited thoracotomy procedure for lung cancer surgery? Ann Thorac Surg 2001;72,879-884[Abstract/Free Full Text]



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