Video-assisted thoracoscopic lobectomy using a standardized three-port anterior approach - The Copenhagen experience.

Abstract

Video-Assisted Thoracoscopic Surgery (VATS) lobectomy is now well established and performed all around the world. Formerly there was much debate about the feasibility of the technique in cancer surgery and proper lymph node handling. Although there is a lack of proper randomized studies, it is now generally accepted that the outcome of a VATS procedure is at least not inferior to a resection via a traditional thoracotomy. Several papers have concluded that there is no significant difference in survival rates and that there might even be a better outcome by VATS (1-3). A VATS lobectomy and even more a VATS anatomical segmentectomy is a challenging and technically demanding procedure to perform; and yet there is still no consensus about the basic principles in the technique. Different techniques have been described including the simultaneously stapled lobectomy (4), a VATS assisted operation with some rib spreading (5) and a true VATS lobectomy defined by no rib spreading along with anatomical hilar dissection and only monitor based vision rather than looking through the utility incision. The procedure is performed with up to 5 incisions and is even reported with a uniportal approach (6). Different lobe specific approaches have been reported (7) and a wide variation in instruments and camera positions is seen. At our institution we have a large experience with about 1,000 cases performed by a standardised three-port anterior approach with sequential division of the hilar structures, proper lymph node handling, no rib spreading and vision relying on the monitor only. This allows us to perform VATS lobectomies in the majority of the cases even if there are significant difficulties (8). We find that our standardized three-port anterior approach facilitates the VATS lobectomy, and it is our experience from visiting surgeons that our technique can easily be adapted by many surgeons, especially those who are used to an open anterior approach. The major advantages of the standardized anterior approach are: ❖ The mini-thoracotomy is placed directly over the hilum and the major pulmonary vessels. Easy to clamp the major vessels in case of major bleeding ❖ No need of changing the surgeons’ position or the place of the incision if a conversion is required ❖ The first structures to be transected are the major vessels ❖ The same approach to all lobes makes it easy to reproduce and learn ❖ The lung tissue only pushed backwards gently with peanuts and never grasped with forceps and therefore not torn apart ❖ Easy to teach as the surgeon and the assisting surgeon stand on the same side and use the same monitor. They do not work opposite to each other and therefore maybe against one and another. This facilitates a fluid learning process Indications for VATS lobectomy VATS lobectomy is commonly performed for selected peripherally located T1 or T2 tumours and usually reserved for patient where complications are not expected. We think that the advantages of a minimally invasive approach would also benefit cases that are more advanced and therefore the question in our daily clinically practice is: Are there any contraindications to perform the planned lobectomy as a VATS procedure? At present we find the following contraindications: ❖ T3 or T4 tumours. ❖ Tumours larger than 6 cm. ❖ Tumours visible in the bronchus by bronchoscopy within 2 cm of the origin of the lobe to be resected and where a possible Sleeve resection might be needed. ❖ Centrally placed tumours in the hilum and adherent to vessels. This means that patients with former Tuberculosis, previous cardiothoracic surgery and patients who have received preoperative chemo-radiotherapy are still considered as candidates for a VATS lobectomy. All our patients have a preoperative examination with lung function testing, PET/CT, bronchoscopy and EBUS/mediastinoscopy for preoperative staging (unless it is a peripheral placed T1 tumour on PET). With growing experience, we perform VATS lobectomy in the majority of the cases at our institution, even if they do present with co-morbidity. In the last few years, between 70% and 80% of all cancer lobectomies in our institution were performed by VATS and we now perform well over 200 VATS lobectomies and quite a few anatomical VATS segmentectomies each year (17 in 2011) with a very low conversion rate (2% in 2011).