Thoracoscopic Lobectomy

for Non–small Cell Lung

Cancer
a b,
Matthew A. Gaudet, MD , Thomas A. D’Amico, MD *

KEYWORDS
 Non–small cell lung cancer  VATS  Thoracoscopy  Lobectomy  Segmentectomy

KEY POINTS
 Video-assisted thoracoscopic lobectomy has developed into a safe and effective treat-
ment for lung cancer and is superior to lobectomy via thoracotomy in many regards.
 Development and further refinement of its technique has allowed thoracic surgeons to
perform a wide variety of complex procedures in a minimally invasive fashion.
 With future improvement in optics, energy devices, and anesthesia management, the thor-
acoscopic technique will continue to serve as the pillar for development of thoracic surgi-
cal interventions.

INTRODUCTION

Pulmonary resection as treatment for lung cancer has been performed for more
than 100 years. The first lobectomy for lung cancer was described in 1912, but
pneumonectomy remained the gold standard for many years thereafter. In the
1960s, lobectomy became widely accepted as an oncologically sufficient operation.
As technology advanced, thoracic surgeons took on the challenge of performing com-
plete oncologic resections for lung cancer with minimally invasive video-assisted thor-
acoscopic surgery (VATS) in the early 1990s.1 The VATS approach to pulmonary
resection has continued to evolve significantly over the last 25 years. In addition to pul-
monary resection, thoracic surgeons are using thoracoscopy to perform complex op-
erations on the airway, chest wall, mediastinum, esophagus, and even the certain
cardiac procedures. Although there are no multicenter, prospective, randomized,
controlled trials comparing pulmonary resection for lung cancer via thoracotomy

Dr T.A. D’Amico is a consultant for Scanlan Instruments. Dr M.A. Gaudet has nothing to
disclose.
a
Department of Cardiothoracic Surgery, Ochsner Medical Center, 1514 Jefferson Highway,
New Orleans, LA 70121, USA; b Section of General Thoracic Surgery, Duke University Medical
Center, DUMC Box 3496, Duke South, White Zone, Room 3589, Durham, NC 27710, USA
* Corresponding author.
E-mail address: [email protected]

Surg Oncol Clin N Am 25 (2016) 503–513

http://dx.doi.org/10.1016/j.soc.2016.02.005 surgonc.theclinics.com
1055-3207/16/$ – see front matter Ó 2016 Elsevier Inc. All rights reserved.
504 Gaudet & D’Amico

and VATS, the minimally invasive approach has produced excellent outcomes and
gained widespread acceptance.

Video-assisted Thoracoscopic Surgery Lobectomy as an Oncologic Procedure

Any operation intended to treat cancer should be undertaken with acceptable risk to
the patient while also not compromising complete resection and staging. Since the
introduction of the minimally invasive approach, many authors have evaluated VATS
lobectomy for its oncologic efficacy, safety, reproducibility, and outcomes when
compared with more conventional open techniques. In 1993, Walker and colleagues2
reported 158 cases of VATS lobectomy with 11% conversion rate, 1.8% mortality, and
3-year survival comparable to lobectomy with thoracotomy. As time went on and
experience with the technique grew, more surgeons began to investigate all aspects
VATS lung resection. Five years later, McKenna and colleagues3 reported the results
of 298 patients who underwent VATS lobectomy, with a 6% conversion rate and 0.3%
mortality. Port site tumor recurrence was reported in 1 case (0.3%). McKenna and col-
leagues4 followed this up with a review of 1100 patients who underwent VATS lobec-
tomy and reported a 2.5% conversion rate, 0.8% mortality, 0.57% local recurrence,
with a mean duration of hospital stay of 4.78 days. Onaitis and colleagues5 reported
500 VATS lobectomy cases with a 1.6% conversion rate, a 1% 30-day mortality,
and no operative mortality. The 2-year survival for stages 1 and 2 non–small cell
lung cancer was 85% and 77%, respectively. More recently, Berry and colleagues6
performed a retrospective review of nearly 1100 patients (610 VATS, 477 thoracotomy)
undergoing pulmonary resection for lung cancer and showed similar 5-year survival
between the 2 approaches. This was strengthened by a propensity-matched cohort
of 560 patients within this group showing no significant difference between thoracot-
omy and VATS.
Proponents of the open approach to pulmonary resection for non–small cell lung
cancer argue that the VATS approach limits the surgeon’s ability to adequately
perform complete and accurate staging of the mediastinum, a key component of
lung cancer staging and an important element of a sound oncologic operation. Medi-
astinal lymph node dissection during VATS lobectomy has shown to be equal to open
lobectomy by D’Amico and colleagues.7 In this National Comprehensive Cancer Net-
work’s database review, close to 400 patients undergoing VATS and open lobectomy
were reviewed and there was no difference in the number of N2 stations and mean
lymph nodes harvested. In 2 large metaanalyses, VATS lobectomy has been shown
to be safe with a conversion rate of 1% to 2% and oncologic outcomes equal to
open lobectomy.8,9
Many surgeons who had initially trained solely in open pulmonary resection have
taken these data and adapted their practices. Current thoracic surgery residents are
gaining extensive experience with a wide variety of thoracoscopic procedures
throughout their general and thoracic surgery training. Combined, these have led to
increase in the number of lobectomies performed via a VATS approach across the
world. In a recent review of the Society of Thoracic Surgeons General Thoracic Sur-
gery Database, 45% of lobectomies were performed with VATS techniques.10

Advantages of Video-assisted Thoracoscopic Surgery Lobectomy

In a propensity-matched analysis of a single-institution prospective database, Villami-
zar and colleagues11 evaluated 1079 patients undergoing VATS and open lobectomy
over a 10-year period. Compared with open lobectomy, VATS lobectomy patients
were shown to have fewer major complications, including atrial fibrillation, atelectasis,
prolonged air leak, pneumonia, and renal failure. Duration of chest tube and length of
 Thoracoscopic Lobectomy 505

hospitalization were shorter in the VATS lobectomy group. Similar findings were re-
ported by Paul and colleagues12 in a review of more than 6000 patients undergoing
lobectomy for non–small cell lung cancer from the Society of Thoracic Surgeons Data-
base. In an even larger review of data from the Society of Thoracic Surgeons data-
base, Boffa and colleagues13 confirmed that patients with stage I non–small cell
lung cancer undergoing resection fared better. In this study, patients who underwent
thoracotomy experienced significantly more pulmonary complications (21% vs 18%),
atrial arrhythmias (13% vs 10%), and were more likely to undergo transfusion (6% vs
4%) than those who were treated with VATS resection, although the mortality was
similar. Even when compared with a total muscle-sparing thoracotomy, 1 surgeon
found that duration of stay was less for patient who underwent VATS procedures.14
VATS lobectomy has also been shown to facilitate delivery of adjuvant treatment, an
important component of treatment for patients with advanced stage non–small cell
lung cancer. Peterson and colleagues15 reported a higher percentage of patients
receiving 75% or more of their planned adjuvant regimen without delayed or reduced
doses after undergoing VATS lobectomy compared with patients who had open lo-
bectomy (61% vs 40%; P 5 .03).
The cost of VATS lobectomy has been reviewed in a study of close to 4000 lung re-
sections16 and found to be less compared with open lobectomy ($20,316 vs $21,016;
P 5 .027). This study also found the risk of adverse events was significantly lower in
the VATS group (odds ratio, 1.22; P 5 .019). Recently, Farjah and colleagues17 even
showed that 90-day costs are lower with VATS lobectomy when compared with
open technique, explained by decrease in incidence of prolonged duration of stay
(>14 days) and less health care use after discharge.
There is also growing evidence to suggest that patient’s immune function is better
preserved after VATS compared with thoracotomy, as documented by the release of
proinflammatory and antiinflammatory cytokines, immunomodulatory cytokines,
circulating T cells (CD4), and natural killer cells, as well as lymphocyte function.18

Video-assisted Thoracoscopic Surgery Lobectomy: Impact on Other Pulmonary

Resections
As the technique has evolved and experience and comfort with VATS lobectomy has
grown, thoracic surgeons have used it in various subsets of patients with lung cancer
who in the past may not have been considered candidates for a curative resection or
would have required a thoracotomy. In patients with poor pulmonary function,
advanced age and small peripheral tumors who cannot tolerate a lobectomy or a tho-
racotomy, VATS sublobar resection (segmentectomy or wedge) can be an attractive
option. The lower risk profile of thoracoscopy has encouraged surgeons to investigate
its safety in patients who are at higher risk owing to preexisting conditions, including
chronic obstructive pulmonary disease. Linden and colleagues19 performed VATS
wedge resection in patients with a mean forced expiratory volume in 1 second of
26% and reported a 1% mortality rate. To decrease the risk of local recurrence after
VATS wedge resection, Santos and coworkers20 reported the use of brachytherapy
mesh placement over the stapled lung margin, which led to reduction of local recur-
rence from 18% to 2%. In patients with forced expiratory volume in 1 second of
less than 60%, Ceppa and coauthors10 reported a much lower incidence of pulmonary
complications (P 5 .023) in patients undergoing VATS lobectomy versus lobectomy
with thoracotomy.
Technical and oncologic principles of VATS lobectomy, namely individual ligation of
the supplying artery, vein, and bronchus, lymph node dissection, and resection of lung
parenchyma with surgical staplers have also been applied to performing minimally
506 Gaudet & D’Amico

invasive anatomic segmentectomy. Schuchert and colleagues21 reported on 225

cases of anatomic segmentectomy performed by VATS or thoracotomy. Length of
stay (5 vs 7 days; P<.001) and pulmonary complications (15.4% vs 29.8%;
P 5 .012) were improved significantly in patients undergoing VATS segmentectomy.
Similar outcomes have been reported by multiple other authors with acceptable sur-
vival and local recurrence rates.
Berry and colleagues22 reported on a hybrid technique of VATS lobectomy with en
bloc chest wall resection without rib spreading or scapula retraction. In this series, the
technique of VATS lobectomy was used to achieve lung resection, which was followed
by a small counterincision to remove the involved ribs en bloc. They reported a shorter
length of stay (P 5 .03) in 12 patients with this hybrid approach compared with 93 pa-
tients who had a thoracotomy.
Further advanced VATS techniques such as bronchoplasty and sleeve resections
have also been reported over the last 5 years (Fig. 1). Agasthian23 reported a case
series of 21 patients, 9 of whom had simple bronchoplasty; 8 patients had sleeve lo-
bectomy and 4 patients had extended bronchial resection. All patients underwent
hand-sewn closure of the bronchus with interrupted sutures. One patient developed
bronchopleural fistula. There was no operative mortality and no local recurrence
was reported at 6 months. Yu and colleagues24 reported on 9 cases from China under-
going VATS lobectomy and sleeve resection without any major intraoperative or post-
operative complications.

Video-assisted Thoracoscopic Surgery Lobectomy: Development of Uniportal Video-

assisted Thoracoscopic Surgery
Over the years, VATS lobectomy has evolved and various modifications with 2 to 4 in-
cisions have been reported by various leading surgeons across the world. Similar to
single incision laparoscopic surgery, thoracic surgeons have evolved and VATS lobec-
tomy has been modified into a single incision access with no rib spreading or multiple
ports within the same intercostal space (Fig. 2). Wedge resections to complex pulmo-
nary resections have been reported. Over a 10-year period, Rocco and colleagues25
performed more than 600 uniportal VATS cases. The majority of these cases were
for pleural disorders and wedge resections for pulmonary nodules. The authors re-
ported excellent outcomes without any major intraoperative complications.
Gonzalez-Rivas and associates26 reported their first 100 cases over a 2-year period

Fig. 1. Bronchoplastic closure after thoracoscopic lobectomy.

 Thoracoscopic Lobectomy 507

Fig. 2. Traditional 2-port (A) and modified Uniportal (B) approaches. ICS, intercostal space.

with impressive results. The majority (96%) of lobectomies were accomplished with
the uniportal technique, with no operative mortality. Mean chest tube duration and
length of stay were 2 and 3 days, respectively. An average of 14.5 lymph nodes
were harvested per resection with 154 minutes of mean operative time. Tam and col-
leagues27 reported similar results in 38 uniportal VATS lobectomy. Six patients
required thoracotomy. In all, 97% of patients did not require intravenous analgesia
and mean time to return to full normal activities was 7 days. Gonzalez-Rivas and col-
leagues28 have also reported uniportal right pneumonectomy without any major com-
plications. McElnay and colleagues29 showed no difference in median morphine use
or visual analog pain score in the first 24 hours postoperatively, or in patient-
controlled analgesia duration, chest drain duration, or overall length of stay in 15 uni-
portal VATS lobectomies compared with the standard multiport technique.

Video-assisted Thoracoscopic Surgery Lobectomy: Development of Robotic Assisted

Video-assisted Thoracoscopic Surgery
Advancement in robotic technology has generated interest among thoracic surgeons
to its suitability for VATS pulmonary resections and other thoracic operations. It has
been proposed that 3-dimensional optics and the articulation provided by robotic in-
struments may allow for increased use of a minimally invasive approach for pulmonary
resection. The learning curve for robotic prostatectomy has been shown to be the
same among laparoscopic trained fellows and experienced open surgeons who are
not familiar with minimally invasive skills.30 This has lead thoracic surgeons to wonder
if this experience can be replicated in thoracic surgery. Can surgeons not trained in
VATS lobectomy perform robot-assisted VATS resection? More recently, the dual
console systems, infrared technology for better anatomic visualization and tissue
perfusion as well as improved simulation and training have made surgeons experi-
enced in VATS lobectomy techniques interested in including robotics in their practice.
Louie and colleagues31,32 compared directly robotic and thoracoscopic pulmonary
resection in a case-control analysis of anatomic robotic and VATS lung resections:
46 robotic resections (40 lobectomies, 5 segmentectomies, 1 conversion to VATS
included in this group for intention-to-treat analysis) were compared with 34 VATS
508 Gaudet & D’Amico

resections (27 lobectomies, 7 segmentectomies). Length of stay, major and minor

postoperative morbidity, and operative times were comparable. In a multiinstitutional
retrospective cohort study of 325 patients who underwent robotic lobectomy,30 me-
dian chest tube duration and length of stay was 3 and 5 days, respectively. Major peri-
operative complications were seen in 3.7% of patients and surgical mortality was
0.3%. The estimated 5-year survival was 80%. Implementation of robotic surgery pro-
grams carry a high capital cost and require expensive maintenance protocols. In a
recent study, Nasir and colleagues33 evaluated 862 robotic lung resections. The
30-day mortality was 0.25% and major morbidity was seen in 9.6% of patients. The
authors estimated a profit of $4750 per patient after factoring in the operative and hos-
pital cost. Median length of stay in this study was 2 days.

Video-assisted Thoracoscopic Surgery Lobectomy: Development of Awake

Thoracoscopy
Traditionally, intubation with a double-lumen tube or use of an endobronchial blocker
and single lung ventilation has been considered mandatory for thoracoscopic surgery
to obtain optimal visualization. This is tolerated well in most cases, but adverse effects
of general anesthesia and airway trauma from double-lumen tube placement are inev-
itable. Many thoracic surgery patients have preexisting comorbid conditions and car-
diopulmonary compromise, which makes general anesthesia much more precarious.
These issues have led some thoracic surgeons to explore the concepts of awake or
nonintubated thoracoscopy. Pleuroscopy with drainage of effusion and pleural biopsy
with local anesthesia has been performed routinely with flexible scopes in an outpa-
tient setting for many years, mostly by pulmonologists. Anesthesia for a more complex
thoracoscopic intervention, termed ‘awake VATS’ includes a regional block with or
without conscious sedation. This consists of one of the following: local anesthesia,
intercostal nerve blocks, paravertebral blocks, and thoracic epidural anesthesia. In
this setup, open pneumothorax after trocar insertion leads to gradual collapse of
the nondependent lung and leads to spontaneous 1-lung ventilation.34
In a small, randomized trial performed by Pompeo and colleagues,35 43 patients
with spontaneous pneumothorax underwent VATS bullectomy and pleurodesis under
a thoracic epidural anesthesia. Their results showed safety and efficacy of this tech-
nique of VATS along with shorter hospital stay and reduced cost. The same group
has also reported 19 cases of empyema treated with awake VATS decortication.36
Three patients developed mild hypercapnia that resolved with time and 4 patients
required general anesthesia because thick pleural peel required a nonemergent thora-
cotomy. Chen and colleagues37 reported their single institution experience of doing
awake VATS in 285 cases. Of these, 137 were VATS lobectomy, 132 were VATS
wedge resection, and 16 were VATS segmentectomy. Conversion to general anes-
thesia was required in 4.9% of cases and 1 patient required thoracotomy for bleeding.
There was no operative mortality. Anesthesia consisted of thoracic epidural, sedation
and temporary intrathoracic vagal blockade for inhibition of cough reflex.

THE DUKE APPROACH

Single-lung ventilation is required and may be achieved with a dual lumen endotra-
cheal tube or a bronchial blocker. The patient is placed in the lateral decubitus posi-
tion. Most thoracoscopic lobectomies may be performed via 2 or three incisions, and
the overwhelming majority in our experience has been performed with only 2.
In general, the port positions are the same whether an upper, lower, or middle lo-
bectomy is performed. The first port, placed in the seventh or eighth intercostal space
 Thoracoscopic Lobectomy 509

in the posterior axillary line, is used predominantly for camera placement and, ulti-
mately, chest tube placement. The second port is placed in the fifth intercostal space
anteriorly, where the intercostal space is the widest (Fig. 3).
Instrumentation is critically important when performing thoracoscopic surgery,
including the use a 30 videoscope and long, curved instruments to allow for ease
of retraction and dissection. High-definition video equipment improves visualization
for difficult dissections. Linear staplers are used to control and divide lung paren-
chyma, vessels, and bronchus.
Most of the hilar dissection may be performed bluntly, with either a dissecting instru-
ment (Figs. 4 and 5) or a thoracoscopic suction device, which also keeps the field dry
during dissection, although some surgeons prefer sharp dissection or dissection with
an energy device. In most cases, the fissure is completed at the conclusion of the
dissection with the stapling device and the specimen is removed using a protective
bag. Mediastinal lymphadenectomy is subsequently performed, although this may
be done before hilar dissection at the surgeon’s discretion.
In addition to the dissection strategy, which varies according to the which lobe is
being resected, the surgeon should have a planned strategy for conversion if bleeding
is encountered or if there is failure to progress with the dissection thoracoscopically.
Most of the bleeding encountered can be controlled with direct pressure using a
sponge stick, and that conversion need not be performed emergently.

Right Upper Lobectomy

Once the right chest has been entered, the lung is retracted medially and dissection
along the posterior pleura is carried at the level of the bronchial bifurcation, which fa-
cilitates bronchial dissection later from the anterior approach. In some patients, bron-
chial division can be performed at this point. The lung is then reflected posterior and
dissection is performed to identify the bifurcation of the upper and middle lobe veins.
Once the upper lobe vein has been clearly identified, it is circumferentially dissected
free and divided with the linear stapler. This reveals the underlying pulmonary artery.
In a similar fashion, the pulmonary arteries to the upper lobe are mobilized and divided,
beginning with the truncus anterior. The last structure to be dissected is usually the
bronchus; however, occasionally the bronchus is divided before dissection of the pos-
terior ascending artery. After dividing the bronchus, the fissures are developed and
divided using stapling devices and the specimen is extracted from the chest in a pro-
tective bag.

Fig. 3. Location of port placement for traditional approach.

510 Gaudet & D’Amico

Fig. 4. Isolation of truncal artery during thoracoscopic left upper lobectomy.

Left Upper Lobectomy

Thoracoscopic left upper lobectomy is performed in a similar fashion to that on the
right. Posterior dissection is undertaken first to divide the pleural reflection and to
identify the posterior artery; as with the right upper lobe, this posterior dissection
greatly facilitates the completion from the anterior approach. With the lung retracted
posteriorly, dissection is used to identify both pulmonary veins (to ascertain that a
common pulmonary vein is not present). The superior pulmonary vein is then encircled
and divided, revealing the underlying pulmonary artery and upper lobe bronchus.
Dissection of the lymph nodes between the cephalad aspect of the bronchus and
the arterial trunk (to the anterior and apical segments) will facilitate the arterial dissec-
tion. The branches of the anterior trunk can now be individually exposed and divided,
followed by division of the posterior and lingular branches. Bronchial dissection and
division is now easily accomplished, and finally, the major fissure is divided with the
stapling device.

Left and Right Lower Lobectomy

There are 2 basic strategies for lower lobectomy, both of which begin with division of
the inferior pulmonary ligament, followed by dissection and division of the inferior pul-
monary vein. The preferred method does not involve dissection within the fissure
(which is stapled last, as with upper lobectomy). After dividing the vein, attention is

Fig. 5. Isolation of superior pulmonary vein during thoracoscopic left upper lobectomy.
 Thoracoscopic Lobectomy 511

directed to the bronchus by retracting the lobe cranially, a perspective not obtained
via thoracotomy. A plane is created between the bronchus and the artery by dissecting
close to the bronchus, which is then divided. For right lower lobectomy, this dissection
is begun at the bifurcation with the middle lobe bronchus, which must be preserved.
The arterial trunk is then encircled and divided, although it is sometimes easier to
divide the branches to the superior and basilar segments individually. Ultimately,
the fissure is divided and the specimen removed.

SUMMARY

Over the last 20 years, VATS lobectomy has developed into a safe and effective treat-
ment for lung cancer and is superior to lobectomy with thoracotomy in many regards.
Development and further refinement of its technique has allowed thoracic surgeons to
perform a wide variety of complex procedures in a minimally invasive fashion. With
future improvement in optics, energy devices and anesthesia management, the thor-
acoscopic technique will continue to serve as the pillar for development of newer
thoracic surgical interventions.

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