Commentary on “Total Videothoracoscopic Lobectomy Versus Open Thoracotomy for Early-Stage Non–Small-Cell Lung Cancer”

Abstract

Ironically, thoracoscopy was first introduced by an internist, Jacobaeus, in 1910. His two cannulae technique was briefly mentioned in Munich Journal and was definitively described in 1922 at Royal Society of Medicine meeting in London.1,2 Enthusiasm for operative thoracoscopy declined in 1945, as streptomycin became an effective agent in preventing many of complications of tuberculosis. The idea for a more humane approach to thoracic surgery predates current generation of surgeons. It has been suggested that Edward Churchill, MD, expressed his concerns regarding issues of patient comfort; however, he did not have to present-day facilities. The introduction of video technology into clinical arena has enabled us to explore alternative approaches to anatomic lung resections. Coincidentally, development of endoscopic stapling devices has facilitated practical application of minimally invasive thoracic surgery. In mid-1990s, we read about Hong Kong, Scottish, and American experiences with video-assisted thoracoscopic surgery (VATS).3-5 However, in all cases, procedures involved an access incision of 4-8 cm, defining a hybrid (video/ open) approach to anatomic lung surgery. Although there was some evidence of decreased analgesia requirements and shorter length of stay following VATS, binocular vision and manual lesion palpation were lost. More recently, Lewis and colleagues have published a modification of VATS that is safe with low morbidity.6 Their philosophy deviates from conventional thinking that the identical operation must be performed using a VATS approach as that accomplished through a standard thoracotomy.5 Lewis et al use VATS, without rib spreading, in combination with simultaneous stapling of hilar structures (VNSSL). They emphasize that this technique does not represent a large wedge-resection, since an entire lobe can be removed. Luketich et al, in this edition, retrospectively compare VATS to open thoracotomy.7 Their technique of resection is endoscopic equivalent of a conventional open lobectomy where hilar structures are individually isolated and divided. In contrast to Lewis’s approach, Luketich’s specimen is removed through a small anterior incision (4-6 cm). Lewis’s lesion is divided within receptacle to avoid a large counter incision for retrieval. Luketich reports not only a shorter hospital stay, but also less time with a chest tube in place. As physicians, our priority has always been patient comfort and safety. With