VATS Anatomic Lung Resections: The Hong Kong Experience

Abstract

We read with interest the article by Yim and colleagues (see page 13) describing their initial experience with video-assisted approaches to pulmonary lobectomy. They succinctly point to the current relevant questions regarding the utility, safety, and oncologic surgical feasibility of video-assisted lobectomy. Video-assisted thoracic surgical (VATS) lobectomy is not a procedure that should be attempted only by individuals who have considerable experience with open lobectomy and who also have taken the time to master the specific nuances of endoscopic thoracic surgery. Our thoracic surgical group devoted more than a year of laboratory animal study and had also performed over 200 thoracoscopic wedge resections before attempting our first anatomic lobectomy.1Landreneau RJ Mack MJ Hazelrigg SR et al.Video-assisted thoracic surgery: basic technical concepts and intercostal approach strategies.Ann Thorac Surg. 1992; 54: 800-807Abstract Full Text PDF PubMed Scopus (314) Google Scholar Our initial experience with VATS lobectomy was early in the evolution of VATS, and accordingly, our laboratory and clinical prelude to lobectomy was appropriate. Close contact with others exploring the possibilities of VATS lobectomy at that time allowed us to exchange ideas regarding the most effective and safest technical approaches to accomplish the procedure. Other surgeons have merited from our and other investigators' experiences with VATS lobectomy, and currently, we do not believe that the investment in time we required is necessary for thoracic surgeons who are actively involved in VATS. As more experience with the technique of VATS lobectomy accumulates, greater refinement and standardization in the technical details of the procedure can be anticipated. The relative merits of VATS lobectomy vs lobectomy accomplished through muscle sparing or standard posterolateral thoracotomy with regard to postoperative morbidity, length of hospital stay, and return to preoperative activity have been discussed by Yim et al and other investigators.3Kirby TJ Mack MJ Landreneau RJ et al.Initial Experience with video-assisted thoracoscopic lobectomy.Ann Thorac Surg. 1993; 56: 1248-1253Abstract Full Text PDF PubMed Scopus (148) Google Scholar, 4Lewis RJ The role of video-assisted thoracic surgery for carcinoma of the lung: wedge resection to lobectomy by simultaneous individual stapling.Ann Thorac Surg. 1993; 56: 762-768Abstract Full Text PDF PubMed Scopus (114) Google Scholar, 5Giudicelli R Thomas P Lonjon T et al.Comparative study of lobectomy through conventional thoracotomy and video-assisted thoracoscopy.Ann Thorac Surg. 1994; 58: 712-718Abstract Full Text PDF PubMed Scopus (184) Google Scholar, 6McKenna RJ Lobectomy by video-assisted thoracic surgery with mediastinal node sampling for lung cancer.J Thorac Cardiovasc Surg. 1994; 107: 879-882Abstract Full Text PubMed Google Scholar, 7Lewis RJ SIS lobectomy.J Thorac Cardiovas Surg. 1995; : 109Google Scholar, 8Kirby TJ Mack MJ Landreneau RJ et al.Lobectomy: VATS vs thoracotomy: a randomized study.J Thorac Cardiovasc Surg. 1995; 109: 997-1002Abstract Full Text Full Text PDF PubMed Scopus (395) Google Scholar Yim and colleagues also describe the anatomic and technical limitations preventing the use of VATS lobectomy at this time. Accordingly it does appear that lobectomy can be safely accomplished under total video-assisted guidance by experienced thoracic surgeons without compromise of patients' safety or of the primary oncologic principles important in the management of malignant intrathoracic lesions. Furthermore, postoperative morbidity appears to be reduced in most circumstances when well-trained individuals use the VATS lobectomy approach. We congratulate Yim et al for genuine and concise reporting of their experience with the VATS approach to pulmonary lobectomy. In accordance with their conclusions, we recommend the VATS lobectomy approach for small to moderate-sized tumors (less than 4 cm in diameter) confined to the lobe of the lung without evidence of endobronchial extension of the tumor. Of course, a careful intraoperative hilar and mediastinal nodal staging equivalent to that customarily performed during open lobectomy procedures should accompany VATS lobectomy when performed for carcinoma of the lung. VATS lobectomy is also a reasonable approach to benign pulmonary conditions requiring lobectomy (ie, localized bronchiectasis) when the hilar dissection is not compromised by intense inflammation or extensive adenopathy. There is no substitute for experience and mature surgical judgment when attempting VATS lobectomy for either benign or malignant pulmonary conditions, and accordingly, the surgeon should not hestitate to convert to an “open” thoracotomy approach if there is any question of compromising the safety or therapeutic goals of the proposed pulmonary resection.