Invited Commentary

Abstract

Shah and colleagues [1Shah A.A. Worni M. Onaitis M.W. et al.Thoracoscopic left upper lobectomy in patients with internal mammary artery coronary bypass grafts.Ann Thorac Surg. 2014; 98: 1207-1213Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar] have written a provocative essay about managing the critically important, but vulnerable, internal mammary conduit during video-assisted thoracic surgery (VATS) lobectomy. This is an important issue as many patients survive revascularization of their smoking-related coronary atherosclerotic occlusive disease and now live long enough to develop lung cancer. Before addressing appropriateness, it is important to emphasize several themes. First, the authors used careful judgment and planning. They reviewed operative reports considering internal mammary artery (IMA) orientation, pleural opening, preparation (skeletonized or pedicle), sequencing, and conduit age. Catheterization or computed tomographic angiography showed relative branch coronary artery importance and its dependence on the IMA graft. Injury strategies were planned with collaborative cardiac teams. Intraoperative transesophageal echocardiography, cardiac anesthesiology, and detecting and managing perioperative cardiac events were important. During surgery, their high VATS reliability experience facilitated dealing with hostile pleural spaces. Initiating safe dissection planes between the lung hilum and pericardium remote from the graft and stapling lung to leave a remnant on the sternotomy or IMA were useful strategies. Both improved exposure and reduced parenchymal bleeding so tissue remnants could be observed or debrided appropriately. Supplemental thoracoscopic viewpoints may have helped. Finally, by VATS emulation of open vascular control methods they could perform safe conversions, if required. Currently, our specialty actively debates the merits of VATS for any lung cancer, not just these advanced cases. We generally trust master open thoracic surgeons to venture into more advanced frontiers by leveraging their aggregated skills and judgment. Perhaps it is time to extend the same provisional acceptance to our minimally invasive colleagues. On a personal note, I perform IMA cases such as these based on an advanced VATS practice that followed an earlier career emphasizing cardiac surgery. However, performing advanced cases like these without the aggregate experience or backup teams probably is unwise. Physically frail or advanced chronic obstructive pulmonary disease patients might be good cases to avoid thoracotomy; alternatively, those with good ventricular function tolerate thoracotomy if their grafts are protected. Importantly, not every successful VATS or robotic program exists within a cardiac center of excellence. Thus, a frank discussion of the above issues or contingency plans should be communicated with all parties. Should a frail patient chance an IMA injury at a high VATS reliability, noncardiac hospital, or go to a heart center for likely thoracotomy? Such questions remain imponderable until others have replicated these authors’ excellent but modest experience. Until then, we must disclose all reasonable options to patients including those of thoughtful surgeons who consider VATS approaches unproven or undesirable. Thoracoscopic Left Upper Lobectomy in Patients With Internal Mammary Artery Coronary Bypass GraftsThe Annals of Thoracic SurgeryVol. 98Issue 4PreviewThis study examined outcomes of a technique for performing thoracoscopic left upper lobectomy (LUL) in patients with a previous left internal mammary artery (LIMA) coronary artery bypass graft, where a small wedge of lung parenchyma adjacent to the graft is left to avoid injury. Full-Text PDF