Thoracoscopic sleeve resection-the better approach?

Abstract

In the past, thoracoscopic sleeve resection has been reserved for the most adventurous and capable minimal invasive thoracic surgeons. However, with improvements in thoracoscopic competency, greater exchange of knowledge and technical know-how, and advances in equipment, increasing number of centers are able to perform sleeve resections thoracoscopically. Jianxing He’s team from China, a group known for their innovation and thoracoscopic excellence, has recently published their experience of bronchial sleeve resections (1). Among the 49 patients, 20 (41%) received the bronchial sleeve lobectomy thoracoscopically, with one patient requiring half-carinal reconstruction in combination with right upper sleeve lobectomy. A 3-port VATS technique was used, with the utility thoracotomy placed anteriorly, and the camera port inferiorly. In just under half of their initial cases, a modified interrupted suture anastomosis technique of closing the membranous posterior wall of the bronchus with continuous 4-O polypropylene followed by alternating figure-of-eight and mattress with 4-O single-strand absorbable suture for the cartilaginous anterior wall was used. For the subsequent remaining cases, a continuous suture technique was used for both the posterior and anterior bronchial walls. Neither covering nor buttressing techniques were needed for the anastomoses, and no postoperative anastomotic leakage was detected. With no perioperative mortality and excellent immediate results, this study seem to further support the relative safety and efficacy of thoracoscopic sleeve resection in experienced thoracoscopic surgery centers. In addition, the study has highlighted the evolution in thoracoscopic bronchial anastomotic technique from the traditional emphasis on the security of interrupted suturing (2), to the increasing use of the more convenient continuous suturing techniques over recent years (1,3,4). Evidently, continuous suturing techniques will result in less suture tangling and may be quicker, while proponents of interrupted suturing have emphasized the potential advantages of less anastomotic site ischemia and security of their technique. It seems impossible to have a meaningful comparison of clinical outcomes between the different anastomotic approaches for thoracoscopic sleeve lobectomy because of the relatively low case numbers, patient heterogeneity and the wide variations in technique within each anastomotic approach, for example, suture size and type used, or stitch spacing, just to mention a few. In thoracic surgery, perhaps more so in thoracoscopic surgery, it is often the technique which the surgeon has been trained and is most comfortable with which produces the best results. The bronchial anastomotic technique chosen should be the one most familiar to the surgeon.