(Chest. 2005;128:2696-2701.)
© 2005
American College of Chest Physicians
Hybrid Surgical Approach of Video-Assisted Minithoracotomy for Lung Cancer*
Significance of Direct Visualization on Quality of Surgery
Morihito Okada, MD, PhD;
Toshihiko Sakamoto, MD, PhD;
Tsuyoshi Yuki, MD;
Takeshi Mimura, MD;
Kei Miyoshi, MD and
Noriaki Tsubota, MD, PhD
* From the Department of Thoracic Surgery, Hyogo Medical Center for Adults Akashi City, Hyogo, Japan.
Correspondence to: Morihito Okada, MD, PhD, Department of Thoracic Surgery, Hyogo Medical Center for Adults, Kitaohji-cho13–70, Akashi City 673-8558, Hyogo, Japan; e-mail: morihito1217jp{at}aol.com
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Abstract
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Study objectives: Controversy regarding the most suitable surgical approach for treating malignancies of the lung is a matter of continuous discussions. "Complete" video-assisted thoracic surgery (VATS) that is performed using only the vision of a monitor is generally limited to lung resections of minimal difficulty. With the great interest in minimally invasive techniques for treating various pathologies, we have widely applied an integrated surgical approach that combines muscle-sparing minithoracotomy (incision, 4 to 10 cm) and video assistance using mainly direct visualization of the lung resection, which we have called hybrid VATS. The aim of this study is to evaluate the usefulness of hybrid VATS.
Design: Retrospective single-center study.
Interventions: From January 1998 to October 2004, 405 of 678 lobectomies (60%) and 165 of 226 segmentectomies (73%) were performed for primary lung cancer using hybrid VATS.
Results: Bronchoplasty was performed in 93 of the 678 patients (14%) who underwent lobectomy and in 11 of the 226 patients (5%) who underwent segmentectomy. Hybrid VATS was utilized in 33% of sleeve lobectomy procedures and in 27% of sleeve segmentectomy procedures. The mean (± SD) surgical time using hybrid VATS was 164 ± 48 min for lobectomy and 158 ± 35 min for segmentectomy, and the mean blood loss was 166 ± 120 and 109 ± 80 mL, respectively. There was one operative mortality (0.2%) secondary to cardiogenic shock. Postoperative complications developed in 11% of patients with p-stage IA disease after undergoing hybrid VATS, in contrast to 19% of patients after undergoing open thoracotomy. The prognosis of patients treated by hybrid VATS was equivalent to that obtained with open thoracotomy.
Conclusions: Minithoracotomy combined with video support that is performed predominantly via direct visualization is a secure, integrated, minimally invasive approach to performing major resection for lung cancer, including atypical procedures such as bronchoplasty. This hybrid VATS can be an acceptable and satisfactory option whenever the performance of complete VATS is considered to be challenging.
Key Words: lung cancer • surgery • thoracotomy • video-assisted thoracic surgery
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Introduction
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In the last decade, thoracic surgeons have been forced somewhat to accept video-assisted thoracic surgery (VATS) as an innovation that can improve the overall quality of a patient’s life following surgery for lung cancer. Indeed, at present patients understand that VATS is less invasive than standard thoracotomy. The advantages of VATS are reduced pain, decreased production of various cytokines, and shorter hospital stay.12 In addition, several authors3456 have demonstrated that VATS can be performed safely without affecting survival, but many surgeons have questioned its safety, its adequacy as a cancer operation, and any benefit of VATS.78 Besides, two prospective randomized studies89 failed to conclusively prove the advantages of lobectomy performed by the VATS approach compared with that performed by standard thoracotomy.
At present, even the definition of VATS is being debated. Some medical communities have insisted that VATS must be defined as thoracic surgery that is performed completely by visualization through a television monitor, the so-called complete VATS, and that employing direct vision, even partially, should exclude a procedure from being defined as VATS.
Complete VATS offers the same approach for cancer surgery as that of open thoracotomy, in some cases, such as in standard lobectomy of low difficulty, results in more or less sacrificing the completeness of oncologic radicality, and therefore cannot be applied to all cancer operations, including segmentectomy and bronchoplasty. Until now, we have aggressively tried a minimally invasive approach that is reasonable as a lung cancer operation. Consequently, we have established an integrated surgical approach consisting of muscle-sparing minithoracotomy with television monitoring and direct visualization. Because this approach is somewhere between the two outlined approaches, we have called it hybrid VATS.
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Materials and Methods
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We began using hybrid VATS in January 1998, and, up to October 2004, 678 patients underwent lobectomy and 226 underwent segmentectomy for primary non-small cell carcinoma of the lung. Since, where feasible, we have always tried to perform minimally invasive surgery for any patients with lung cancer, we have not designed a fixed indication for performing VATS. Therefore, we flexibly extended the wound or converted to standard thoracotomy whenever we judged that it would be difficult to curatively and safely resect the lesions. The extent of the incision was decided by the surgeons according to their preferences. The common exclusion criteria were tumor size > 10 cm, extensive invasion of the chest wall identified by preoperative imaging findings, and repeat resection. Generally, cN2 disease, induction chemotherapy or radiation therapy, centrally located tumors, and lobar or hilar nodes adherent to pulmonary vessels were not necessarily contraindications to performing the hybrid VATS approach.
Operative Technique
Use of a headlamp is recommended. Under general anesthesia, double-lumen endotracheal intubation with selective contralateral lung ventilation is achieved. One access port for the insertion of a thoracoscope is normally placed with a 2-cm-long incision in the eighth or ninth intercostal space over the midaxillary line (Fig 1
, top left, A). An additional transverse skin incision 4 to 10 cm long for access thoracotomy is made over the midaxillary line in the fourth interspace for upper lobe and middle lobe tumors. Basically, no other port is built for access. The serratus anterior muscle is divided not transected, and no extracostal muscles or ribs are cut. The intercostal muscle of the fourth interspace is then incised, and the pleura is opened 2 to 3 cm wide using a thoracic opener (Fig 1, top right, B). Lower lobe tumors are accessed through the auscultatory triangle, for which a transverse incision is made below the tip of the scapula, and the chest is entered through the fifth intercostal space without cutting any ribs. More recently, the minithoracotomy has been opened to approximately 2 x 4 cm with a chest retractor or a silicon rubber instrument (Lap-Protector; Hakko; Nagano, Japan). It is important to note that the skin incision should be extended without hesitation if the surgeon during the procedure that the surgery would be too difficult to perform without such extension.
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Figure 1.. Top left, A: Skin incisions for one access port for a thoracoscope (circle) and for an access thoracotomy (solid line), which is made over the midaxillary line in the fourth interspace for upper or middle lobe tumors. Lower lobe tumors are approached through the auscultatory triangle in the fifth interspace (dotted line). An operative exposure about 2-cm-wide is made using a thoracic opener (top right, B), and dissection through direct vision is performed using an upside-down grip of 30-cm-long scissors, which the surgeon can maneuver at will by turning up the wrist (bottom left, C, and bottom right, D).
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Through the minithoracotomy, the surgeon can directly observe the hilum of the diseased lobe, and can dissect the bronchi and vessels using standard surgical instrumentation. We prefer 30-cm-long scissors (model 101-8098-30; Mayo-Harrington; Stille, Sweden) with a backhand grip, holding them upside-down, for sharp dissection (Fig 1, bottom left, C, bottom right, D) and forceps covered with a nonconducting material. As well, lengthy needle holders and forceps are usually used for suturing with synthetic material (Vicryl and PDS-II; ETHICON; Tokyo, Japan), and, especially, long, curved dissecting forceps are our favorite instruments for individually ligating the vessels. Also, coaxial endosurgical instruments may be employed to assist the retraction of the parenchyma during the dissection. Television monitor guidance is variably utilized during the procedure when dissecting an area out of direct view such as the mediastinal lymph nodes, the lower lung ligament, and adhesions. The lower access port established primarily for a thoracoscope is usually used to subsequently introduce the stapler (Endocutter; Ethicon Endo-Surgery Inc; Cincinnati, OH) for pulmonary vascular or bronchial closure, while the stapler can be inserted directly through the thoracotomy if the angle is more appropriate. In general, we use a stapler to completely cut and close the lobar bronchi in the case of standard lobectomy, although we prefer to suture bronchi manually during the course of the segmentectomy. When the intersegmental plane is being cut during segmentectomy or the fissure is absent or incomplete even during lobectomy, direct vision in hybrid VATS is extremely significant. In these cases, the three-dimensional understanding of pulmonary anatomy is crucial to avoid ambiguous procedures. The segmental plane can be stapled, which makes the adjacent remaining portion severely distorted and restricted from full expansion, and therefore we commonly use electrocautery or a combination.1011 Using a commercially available fibrin sealant (Bolheal; Chemo-Sero Therapeutic Institute; Kumamoto, Japan) that is composed of fibrinogen and thrombin and an absorbable polyglycolic acid felt (Neoveil; Japan Medical Planning Co; Kyoto, Japan), the raw surface of the remaining lung allows minimum or no air leakage following the procedure. The affected lung tissue is wrapped in a surgical bag whenever there is a fear of increased risk of cancer dissemination due to the difficulty of removing it through the small wound. Routinely, the chest is drained using a single chest tube under a water seal, which is put through the incision that was initially established for a thoracoscope.
Institutional review board approval was obtained for collecting the data in a secure database and for reporting them. Staging was determined according to the international TNM staging system.12 Survival was calculated by the Kaplan-Meier method, and differences in survival were determined by the log-rank analysis. Zero time was the date of pulmonary resection, and the terminal event was death attributable to cancer, noncancer, or unknown causes.
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Results
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The number and distribution of surgical approaches performed according to hybrid VATS or standard thoracotomy are shown in Figure 2
. From January 1998, 405 of the 678 patients (60%) who underwent lobectomy and 165 of the 226 patients (73%) who underwent segmentectomy were operated on using hybrid VATS. The distribution of patients by clinical and pathologic stage in the lobectomy and segmentectomy group is demonstrated in Table 1
. Among the 405 patients who underwent hybrid VATS lobectomy, 177 (44%) had c-stage IA disease, 163 (40%) had c-stage IB disease, 32 (8%) had c-stage II disease, and 33 (8%) had c-stage III disease. In contrast, 15%, 33%, 27%, and 25% of the patients, respectively, who needed open thoracotomy for lobectomy had c-stage IA, IB, II, and III disease. Of the patients who underwent hybrid VATS segmentectomy, 92% were clinically staged as having IA disease.
Since less removal of the lung parenchyma can be beneficial to patients, we have always employed pulmonary-saving procedures even for the treatment of malignant lesions.101314 Further analysis revealed that bronchoplasty was performed in 93 of the 678 patients (14%) who underwent lobectomy and in 11 of the 226 patients (5%) who underwent segmentectomy (Fig 2). Hybrid VATS was employed in 33% of sleeve lobectomies and in 27% of sleeve segmentectomies. Over the years, hybrid VATS has been applied more frequently. When analysis is restricted to the last 2 years, hybrid VATS was found to have been utilized in 70% of lobectomies and in 83% of segmentectomies. The mean (± SD) total time of surgery using hybrid VATS was 164 ± 48 min for lobectomy and 158 ± 35 min for segmentectomy, while that using standard thoracotomy was 163 ± 32 min for lobectomy and 147 ± 38 min for segmentectomy. During lobectomy and segmentectomy performed through hybrid VATS, the estimated mean intraoperative blood loss was 166 ± 120 mL and 109 ± 80 mL, respectively. With the standard thoracotomy procedure, the mean blood loss was 187 ± 122 mL for lobectomy and 119 ± 86 mL for segmentectomy. There was one operative death (0.2%) from cardiogenic shock among the 570 patients who underwent hybrid VATS. Postoperative complications developed in 28 of the 255 patients (11%) with p-stage IA disease who underwent hybrid VATS, and in 47 of the 254 patients (19%) with p-stage IA disease who underwent open thoracotomy. Atrial fibrillation was the most common morbidity following surgery by either approach.
In a median follow-up period of 63 months (range, 2 to 145 months), the overall survival curves of patients with p-stage IA disease who were stratified by the surgical approach are shown in Figure 3 . The prognosis of patients who were operated on using hybrid VATS was as good as that of those who underwent open thoracotomy, whether it was lobectomy or segmentectomy. In addition, the overall survival curves of patients with p-stage IB to III disease who underwent lobectomy showed that performing surgery with hybrid VATS did not affect prognosis even in patients with advanced disease compared with standard thoracotomy (Fig 4
). These data suggested that there should be wide application of the hybrid VATS approach for lung cancer surgery.
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Figure 4.. Overall survival curves of patients with pathologic stage IB disease (top, A), stage II disease (middle, B), and stage III disease (bottom, C) who underwent lobectomy stratified by the surgical approach.
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Discussion
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Complete VATS can now be used safely in lobectomy for resecting selected lung lesions, as we know from accumulated experience. Since we have been confronted relatively frequently with the need to perform atypical surgical procedures for the treatment of lung cancer, such as bronchoplasty, reconstruction of the pulmonary artery, and segmentectomy,10111314 we have tried to find a new minimally invasive surgical approach for various types of resections.
Recently, Szwerc and colleagues15 reported their experience with minithoracotomy combined with mechanically stapled bronchial and vascular ligation for lung resection. We agree with their principles regarding the surgical approach. In practice, however, there are some differences between their technique and ours. For example, video assistance is mandatory for our procedure, and we often utilize manual ligation and suturing of the bronchi and vessels in the hilum. Bronchoplasty by hybrid VATS is typical of the latter.
In 2003, Gharagozloo and colleagues16 reported their experience with complete VATS in 179 patients with clinical stage I disease. They admitted that the most significant reason why their VATS approach resulted in many cases of right upper and middle bilobectomies was a technical problem, leading to unnecessary removal of potentially healthy tissue. Kirby and associates9 reported that in their randomized trial 11% of all patients enrolled in the study were converted from VATS to thoracotomy due to incomplete fissures, although McKenna and coworkers17 reported no conversions to thoracotomy because of fused fissures. We consider access minithoracotomy important because one can look through the incision under direct vision and divide the fissure if it were largely fused or had severe adhesions. Additionally, this hybrid approach may decrease the incidence of superfluous stapling, thereby leading to full expansion of the preserved lobe. In particular, when the tumor is located closer to a fissure or in cases of patients with lung emphysema, the three-dimensional view of the anatomy given by this hybrid integrated approach can be very useful.
The key to effective and successful maneuvering within the thoracic cavity is an optimal port placement as well as a 30° video thoracoscope. In addition, we have preferred the use of an upside-down backhand grip on 30-cm-long scissors for incisive dissection, and on a long needle holder for bronchoplasty and angioplasty (R. Belsey, MD; Frenchay Hospital; Bristol, UK; and F.G. Pearson, MD; Toronto General Hospital; Toronto, ON, Canada; personal communication, 1974) to facilitate deep maneuvering in many instances in which the location of the lesion and the surgical circumstance make procedures by standard instruments difficult or impossible to perform. Dr. Pearson emphasized the importance of the sharp angle between the scissors and the surgeon’s wrist for greater control. The handling of the scissors had been developed before VATS was introduced, and we consider it suitable for maneuvering through an access opening in the era of VATS. In our series, survival of the patient after undergoing hybrid VATS was comparable to or better than that after undergoing open thoracotomy. The result suggests that lung cancer surgery can be completed by hybrid VATS without compromising the patients’ prognosis.
Current advances in radiology, especially with the introduction of helical high-resolution CT scanning for the diagnosis of lung cancer have resulted in an increased detection of small lung tumors.1819 The treatment for small-sized, deep-seated lesions that have not been pathologically diagnosed as malignancies preoperatively, which are encountered more frequently, can make the procedure a trial of the surgeon’s skill. Without confirming the malignancy, thoughtlessly adopting lobectomy to ensure complete removal of a potential underlying malignancy must be avoided regardless of the surgical access that can be chosen. It is very unusual for lobectomy to be required for a benign tumor. When a benign nodule is completely excised, what is the rationale for resecting the remaining lobe? This is a difficult issue even when performing open thoracotomy. In this regard, Kirby20 indicated that one of the major drawbacks of complete VATS lobectomy for an undiagnosed disease was that the surgeon would lose his/her ability to accurately assess intrathoracic pathology and to decide on the most appropriate resection. We should realize again that the primary target of minimally invasive surgery is the preservation of the pulmonary parenchyma, and that the second target is to reduce trauma by selection of the surgical approach. In our experience, segmentectomy has allowed the optimal resection of suspicious lesions with a deep location with safe surgical margins using hybrid VATS, although the application of a complete VATS lobectomy must not be an option in any case. The three-dimensional view provided by hybrid VATS enables us to observe the appropriate margins, otherwise diseased lung tissue could be left or a larger volume of healthy tissue could be removed. Indeed, we wonder whether there are any patients among those who have undergone complete VATS who would have undergone an exclusively different procedure had open thoracotomy been performed. For instance, the adequacy of an intraoperative assessment of the diseased bronchus has to be questioned in cases in which the only visualization of the operative field is through a television monitor, and thus we fear that VATS pneumonectomy would normally be performed when bronchoplasty instead would help to protect any part of the lung parenchyma that has no disease.
It is desirable that the trauma caused by the surgical approach is minimal regardless of the visualization of the operative field. Whether a direct view or visualization through a television monitor is used is, in essence, only a peripheral issue. Thoracic surgeons will have to balance the benefits of complete VATS with its disadvantages; for example, an ill-advised lobectomy for an undiagnosed disease. After long consideration, our attempts to reach an integrated harmony for performing such surgery have led us to the introduction of hybrid VATS. The most important aspect of cancer surgery must be its radicality, that is, to cure the disease. One should keep in mind that the surgical access should be changed very flexibly whenever curative resection is hard to perform for any reason, including the operative skills of the surgeon. For instance, in hybrid VATS, extending the incision from 5 to 8 cm and enlarging the access thoracotomy provides a quite different view of the surgical field and facilitates our maneuvers.
What is the advantage of performing VATS for the treatment of a lung malignancy only with visualization through a television monitor? Would some advantages thereby accrue to the patient or the surgeon? The hybrid VATS approach is useful regarding education for residents in the sense that it allows a direct view of the surgical field and visualization of the field through a television monitor. Although we should acknowledge the nature of a retrospective study, we think that this accentuates the merits and can conclusively lessen some drawbacks of complete VATS access.
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Footnotes
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Abbreviation: VATS = video-assisted thoracic surgery
Received for publication March 1, 2005.
Accepted for publication April 22, 2005.
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References
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- Nagahiro, I, Andou, A, Aoe, M, et al (2001) Pulmonary function, postoperative pain, and serum cytokine level after lobectomy: a comparison of VATS and conventional procedure. Ann Thorac Surg 72,362-365[Abstract/Free Full Text]
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Abstract
Introduction
