Rib Spreading Research Articles

Terminology issues in thoracoscopic surgery.

Thoracoscopic surgery is being increasingly performed in the field of general thoracic surgery. Most of the thoracic surgical procedures, including pulmonary resection [1], esophagectomy [2], and surgical treatment of other thoracic disorders [3], that used to be performed by thoracotomy can now be performed by thoracoscopic surgery. Thoracoscopic surgery is still an evolving surgical technique, and its role in thoracic disorders is becoming increasingly important. However, it is also true that there is no rule for naming each type of specific modification of thoracoscopic procedures. Video-assisted thoracic surgery (VATS) lobectomy has been traditionally used as a term for lobectomy performed by thoracoscopy and video monitor guided surgery. Further, the term ‘VATS’ has been used as a generic name and prefix for all other minimally invasive surgical procedures in general thoracic surgery. However, whether the term ‘VATS’ appropriately describes thoracoscopic surgery and will be an adequate and adaptable term for naming future developments of new surgical technology has not been questioned. In the early era of minimally invasive surgery, the concept of video-assisted surgery was very new and was included as a main feature in the category of minimally invasive surgery. However, currently, video-assisted surgery is not a representative feature of minimally invasive surgery because video monitor guided surgery is now also being used in open thoracotomy. Some surgeons use a hybrid technique for thoracic diseases, with the surgery partially done by the thoracoscopic technique and partially by the open technique. Therefore, the concept of ‘video-assisted surgery’ is no longer a representative concept of minimally invasive surgery. The most important feature of minimally invasive surgery in the current era is endoscopic vision and the endoscopic surgical technique. Most of the benefits of minimally invasive surgery are due to the lesser degree of trauma to surgical entry sites and the preservation of skin, muscle, rib, and intercostal nerves. Further, ‘video-monitor assistance’ is one of the accompanying features of thoracoscopic surgery. Therefore, the concept of ‘endoscopic surgery’ should be included in the category of minimally invasive surgery. The second issue related to terminology is about the definition of thoracoscopic surgery because in clinical practice, thoracoscopy is used as an adjunctive procedure in open surgery. Lobectomy performed by relatively small thoracotomy with thoracoscopic assistance has also been described in reports as ‘thoracoscopic lobectomy.’ Although spreading of the ribs has been suggested as an important criterion in denoting thoracoscopic lobectomy, it cannot be a definitive criterion for thoracoscopic lobectomy because some surgeons prefer resecting a segment of the rib when removing a large mass and temporary rib spreading is relatively common in difficult situations including tumor removal. Furthermore, some surgeons prefer performing the whole procedure with the naked eye through a small utility thoracotomy without rib spreading. Should we call them all ‘thoracoscopic lobectomy’ or not? This is a difficult question to answer. Although it is difficult to formulate a new definition of thoracoscopic lobectomy, I think that we can suggest several features and requirements of thoracoscopic surgery. The first one is that the operation should be performed using thoracoscopic techniques. The surgeon should have the ability to perform monitor-guided operations; most of the techniques should be performed using endoscopic techniques rather than the open technique; and only a small thoracotomy wound should be made. The second requirement is that efforts to minimize chest wall damage should be made. Rib spreading or chest wall resection can be performed during thoracoscopic surgery for inevitable reasons; however, intentional spreading or cutting of the ribs, which can damage the ribs and the intercostal nerves, should be avoided. The last requirement is that all the operative methods to be performed during thoracotomy also be performed in thoracoscopic surgery. Incomplete minimally invasive surgery is not a true minimally invasive surgery. For example, mediastinal lymph node dissection should be performed completely as in thoracotomy. If this is not possible technically, conversion to open surgery can be justified rather than performing incomplete surgery. Decades have passed since the beginning of thoracoscopic lobectomy, and this procedure has become one of the main surgical treatment options for many kinds of thoracic diseases. However, the unclear terminology and definitions for the procedure have been an obstacle for the education, communication, and outcome evaluation of thoracoscopic lobectomy. Better definitions and clearer terminology will be helpful for the future advancement of thoracoscopic surgery and for obtaining better outcomes for our patients.

The "cut-in patch-out" technique for Pancoast tumor resections results in postoperative pain reduction: a case control study

BackgroundSince 2001 we have utilized a novel surgical approach for Pancoast tumors in which lobectomy and mediastinal lymph node dissection are performed directly though the chest wall defect. The defect is then patched at the completion of the procedure ("cut-in patch-out") thereby avoiding a separate thoracotomy with rib spreading. We undertook a study to compare outcomes of this novel "cut-in patch-out" technique with traditional thoracotomy for patients with Pancoast tumors.MethodsWe retrospectively identified 41 patients undergoing surgical resection of Pancoast tumors requiring en-bloc removal of at least 3 ribs at our institution from 1999 to 2012. Surgery was accomplished by either a "cut-in patch-out" technique (n = 25) or traditional posterolateral thoracotomy and separate chest wall resection (n = 16). Multiple variables including patient demographics, neoadjuvant therapy, extent of resection, and pathology were analyzed with respect to outcomes from morbidity, narcotic use, and oncologic perspectives.ResultsBaseline demographics, neoadjuvant therapy, and perioperative factors including extent of surgery, complete resections (R0), nodal status and lymph node number, morbidity, and mortality were similar between the two groups. The mean duration of out-patient narcotic use was significantly lower in the "cut-in patch-out" group compared to the thoracotomy group (80.6 days ± 62.4 vs. 158.2 days ± 119.2, p < 0.01). Using multivariate regression analysis, the traditional thoracotomy technique (OR 7.72; p = 0.01) was independently associated with prolonged oral narcotic requirements (>100 days). Additionally, five year survival for the "cut-in patch-out" group was 48% versus the traditional group at 12.5% (p = 0.04).ConclusionsCompared with a traditional thoracotomy and separate chest wall resection approach for P-NSCLC, a "cut-in patch-out" technique offers an alternative approach that appears to have at least oncologic equivalence while decreasing pain. We have more recently adapted this technique to select patients with pulmonary neoplasms involving chest wall invasion and believe further investigation is warranted.Electronic supplementary materialThe online version of this article (doi:10.1186/s13019-014-0163-z) contains supplementary material, which is available to authorized users.

Evolving from conventional video-assisted thoracoscopic lobectomy to uniportal: the story behind the evolution.

When I started my training in thoracic surgery in 1999, I realized that the post-operative period for patients were very painful and hard because the incision we used to operate was very large, about 15 cm with rib spreading. So very often I thought of ways on how to improve this post operational period of our sick patients. In short, what could we do to reduce this pain and facilitate a better quality of life?

67IN - What is the Place of Less Invasive Surgery in Lung Cancer?

ABSTRACT The dissemination of screening programs makes it possible to diagnose more early stage lung cancers than in the past. Screen-detected cancers are generally 400 days), some of which may be overdiagnosed. Most stage Ia cancers are not associated with lymph node infiltration, and a recent publication has identified factors predicting lymph node involvement: in the absence of such factors, radical lymphadenectomy may not be necessary, and for screen-detected stage Ia cancers, standard lobectomy plus radical lymphadenectomy may be overtreatment .For such cases it is important to reduce the invasiveness and extent of surgery, and also to explore and validate non-surgical treatments. The traditional open surgical approach (thoracotomy with rib spreading) to lobectomy and segmentectomy is being superseded by minimally invasive video-assisted thoracic surgery (VATS) even in non-academic centres. However, robotic surgery has fewer technical difficulties with shorter surgeon learning time than VATS: the magnified three-dimensional view, greater precision of instrument movements, hand tremor filtration and improved ergonomics overcome the limitations of VATS favouring its use even for more advanced cases. Sublobar resections are considered adequate procedures for patients at high risk of surgical complications (with commodities or age over 75 years), may also be adequate in patients with good performance status and peripheral lung cancer Disclosure: The author has declared no conflicts of interest.

Minimally invasive epicardial left ventricular lead placement in a case of massive pleural adhesion

BackgroundIn cases of intravenous placement failure of the left ventricular (LV) lead for cardiac resynchronisation therapy (CRT) and obliteration of the left pleural space, the alternative approach of transthoracic placement by video-assisted thoracoscopic surgery (VATS) is difficult and not commonly practiced.MethodsHere, we present a simple technique for transthoracic introduction of an epicardial LV lead using a wound retractor (ALEXIS®) in a patient with heart failure. This wound retractor enables atraumatic tissue retraction without rib spreading, an optimal direct view in the pleural space for surgical pleurolysis and a high degree of safety for the patient.ResultsNo perioperative complications occurred. The tube drainage was removed on the second postoperative day, and the patient was discharged on the third postoperative day.ConclusionsThe decided advantage of this new method is the lack of any need for rib spreading using a mechanical retractor. Especially in patients with a history of open-heart surgery (including internal mammary artery bypass grafting and/or revascularisation of the left lateral wall) or known pleural adhesions (e.g., pleuritis or lung operations), the described technique provides a rapid and save access with minimal surgical effort and greater safety.

A Specific Instrument to Facilitate Thoracoscopic Ligation

The rigid wall of the thoracic cavity provides an ideal cavity for minimally invasive surgery without the need for the cumbersome CO2 insufflation that is essential to perform laparoscopic surgery. And by that, the novel ligation technique facilitating minithoracotomy, which we published before, is possible to be transferred to the video-assisted thoracoscopic surgery (VATS). We attempt to modify the structure of the conventional right angle forceps and its usage so as to accommodate VATS. The unique shape of this instrument facilitates its passage through a trocar or a true VATS intercostal access instead of a rib spreading minithoracotomy. Its clinical performance renders that it a cheaper and better alternative to commercially available products. This new device has the potential to make a substantial contribution to the manual ligation practice of VATS.

Minimally invasive mitral valve repair: the Liverpool Heart and Chest Hospital Technique-tips for safely negotiating the learning curve.

Minimally invasive mitral valve surgery (MIMVS) is technically challenging with a learning curve of 75-125 cases, and aspects of the procedure such as a 4 cm incision, no rib spreading, endoaortic balloon occlusion and a totally thoracoscopic technique increase the level of difficulty (1). Undoubtedly, one year of fellowship training in a high volume centre with plenty of operative exposure is important, but starting a new programme can still be daunting especially in the era of surgeon-specific data reporting. Selection of appropriate patients is probably the most important variable; choice of less complex repairs in patients with a normal body mass index (BMI) and no aortic valve incompetence is helpful. Thereafter, avoiding aspects of the technique that increase the level of difficulty becomes important. This video demonstrates a simple and reproducible technique that provides a safe platform that can be built upon as one’s experience increases. It is a good starting point for surgeons wishing to introduce this into their practice and safely negotiate the learning curve.

Technique for delivering large tumors in video-assisted thoracoscopic lobectomy

The optimal technique for delivering large tumors during video-assisted thoracoscopic lobectomy remains uncertain. In 258 patients receiving video-assisted thoracoscopic lobectomy for lung cancer, techniques for delivering the resected lobe included complete video-assisted thoracoscopic lobectomy without rib spreading (n = 206, 80%), resection of a short rib segment (n = 9, 3%), brief rib spreading (n = 12, 5%), and conversion to a minithoracotomy (n = 21, 8%). In 10 (4%) patients, a novel anterior rib cutting technique was used: one rib at the utility port was cut near its anterior end to widen the intercostal space without forcible rib spreading for lobe delivery. There was no mortality or major morbidity using the anterior rib cutting technique, and it delivered tumors of a larger mean diameter than complete video-assisted thoracoscopic lobectomy (5.4 ± 3.4 vs. 2.3 ± 1.4 cm, p = 0.017) whilst yielding a similar mean operation time and blood loss to the other non-complete video-assisted thoracoscopic lobectomy techniques. The anterior rib cutting technique gave similar postoperative patient pain scores and analgesic use to complete video-assisted thoracoscopic lobectomy, and shorter mean hospital stay than the other non-complete video-assisted thoracoscopic lobectomy techniques (5.6 ± 2.8 vs. 10.0 ± 7.1 days, p = 0.003). In video-assisted thoracoscopic lobectomy, the anterior rib cutting technique is a safe and feasible procedure for delivering large tumors, causing no more pain than complete video-assisted thoracoscopic lobectomy, and allowing faster recovery than other non-complete video-assisted thoracoscopic lobectomy techniques.

Total Muscle-Sparing Uniportal Video-Assisted Thoracoscopic Surgery Lobectomy

Conventional video-assisted thoracoscopic lobectomy uses multiple incisions, including an access incision and several port incisions. This series aims to evaluate the technical feasibility and early results of uniportal video-assisted thoracoscopic surgery (UVATS) lobectomy using a small, total muscle-sparing incision. We performed the first UVATS lobectomy in June 2009, and 38 major resections were attempted using this approach until September 2011. A single, small, muscle-sparing incision was made without rib spreading. True anatomic hilar dissection, individual vascular and bronchial ligation, and mediastinal lymph node dissection were performed under thoracoscopic visualization on a monitor. Thirty-two patients (84%) had malignant diseases, and 6 patients (16%) had benign diseases. Of the primary lung cancers, 85% were in stage I. Of the 38 attempted major resections, 32 UVATS lobectomies were successfully completed and 6 were converted to open thoracotomy. The early outcomes of successful UVATS lobectomy were analyzed (32 patients); 97% had no postoperative complications. There were no deaths. Mean pain score was 0.4 on postoperative day 1 and decreased to 0 by 1 week. Ninety-seven percent of patients received only oral analgesia postoperatively. Eight percent of patients experienced mild intercostal neuralgia not requiring treatment. No patients complained of shoulder dysfunction. The median duration of returning to full normal activities was 7 postoperative days. Total muscle-sparing UVATS lobectomy is technically feasible with low morbidity and mortality rates. Patients had minimal postoperative pain and narcotic use; and good functional outcomes with no shoulder dysfunction and early return to full normal activities.

Single-port video-assisted thoracoscopic lobectomy with pulmonary artery reconstruction

Despite the advances in video-assisted thoracoscopic surgery (VATS), vascular reconstruction of the pulmonary artery (PA) is still infrequently performed by thoracic surgeons because of the technical difficulties and the increased operative risk during thoracoscopy. The few published reports have been performed by using 3-4 incisions. We present the first report of a pulmonary artery reconstruction procedure performed by a single-incision VATS technique. A 73-year old male patient was operated on by the thoracoscopic approach through a single 4-cm incision with no rib spreading. The postoperative recovery was uneventful.

Intrathoracic Migration of a Silicone Breast Implant After Video-Assisted Thoracoscopic Surgery

A 71-year-old woman with a history of bilateral mastectomies with reconstruction (Fig 1) for ductal carcinoma in situ 22 years previously presented with an incidental finding of a right middle lobe nodule. She underwent video-assisted thoracoscopic right middle lobectomy with use of a camera port, an instrument port, and a 1.5-cm access incision in the axilla with no rib spreading. The pathologic appearance was consistent with a carcinoid tumor.

Bilateral apical vertebral derotation technique by vertebral column manipulation compared with vertebral coplanar alignment technique in the correction of lenke type 1 idiopathic scoliosis

BackgroundWidely used rod rotation and translation techniques for idiopathic scoliosis (IS) are effective in correcting spinal coronal deformity. Bilateral apical vertebral derotation technique by vertebral column manipulation (VCM) and vertebral coplanar alignment (VCA) technique are two strategies for three-dimensional (3D) correction for IS. The purpose of this study is to compare the post-surgical results and technical features of the bilateral apical vertebral derotation technique by VCM against the VCA technique in patients with Lenke type 1 IS.MethodsForty-eight patients with Lenke type 1 IS were enrolled in the present prospective clinical assay. They were divided into groups A (bilateral apical vertebral derotation technique by VCM, n=24) and B (VCA technique, n=24). Radiographic parameters measured before and after surgery included the Cobb angle, thoracic kyphosis, and apical vertebral rotation. Scoliosis Research Society (SRS)-22 scores were evaluated during the final follow-up. The differences in the demographics, surgical details, and radiographic measurements between the two groups were determined using a T test. The Mann–Whitney U test was used to evaluate the differences in the SRS-22 scores. A value of P<0.05 was considered statistically significant.ResultsIn the coronal plane, a significant difference was found in the correction rate of the major curve (group A: 84.8%, group B: 78.4%; P=0.045) and in the Cincinnati Correction Index between two groups (group A: 2.21, group B: 1.98; P=0.047). In the sagittal plane, no difference was found in the postoperative thoracic kyphosis between the two groups (P=0.328). In the transverse plane, no difference was found between the two groups in the correction rates of the rotation angle sagittal (P=0.298), rib hump (P=0.934), apical vertebral body-to-rib ratio (P=0.988), or apical rib spread difference (P=0.184). Patients underwent follow up for an average of 21.9 and 22.2 months in groups A and B, respectively. Results obtained at the final follow-up indicated no significant loss of correction. No differences were found in the SRS-22 scores between the two groups. No aortic or neurological complications were observed.ConclusionsThe 3D deformity of the spine was effectively corrected using the bilateral apical vertebral derotation technique by VCM and the VCA technique, and encouraging post-surgical results were obtained for patients with Lenke type 1 IS. The two techniques were effective in allowing 3D correctional force that was applied in different ways.

Video-assisted vs open mediastinal lymphadenectomy for Stage I non-small-cell lung cancer: results of a prospective randomized trial†

Since the introduction of video-assisted lobectomy for non-small-cell lung cancer (NSCLC) into clinical practice, it has been discussed controversially whether mediastinal lymphadenectomy can be performed as effectively as an open procedure via thoracotomy. Therefore, we address this issue in a prospective randomized trial conducted in our institution. In total, 66 patients with completely staged clinical Stage I NSCLC were included and randomized either into a video-assisted group (n = 34) or into the conventional lobectomy group (n = 32). The video-assisted thoracoscopic (VATS) lobectomy was performed by using a 4- to 5-cm utility incision in the fourth or fifth intercostal space and two additional 10-mm ports without rib spreading. The conventional lobectomy was done via an anterolateral thoracotomy. Lymph nodes were classified according to the International Association for the Study of Lung Cancer classification; for right-sided tumours, lymph nodes number 2R, 4R, 7, 8, 9, 10, 11 and 12 were dissected, and for left-sided tumours, lymph nodes number 5, 6, 7, 8, 9, 10, 11 and 12. For the subsequent analyses, lymph nodes were grouped into different zones consisting of Zone 1 (2R and 4R), Zone 2 (7), Zone 3 (8R and 9R), Zone 4 (10R, 11 R and 12R), Zone 5 (4 L), Zone 6 (5 and 6), Zone 7 (8L and 9L) and Zone 8 (10 L, 11 L and 12L). Both groups were comparable with respect to different clinical pathological parameters (age, tumour size and comorbidity). In the video-assisted group, 2 patients were excluded due to conversion to an open thoracotomy. The number of mediastinal lymph nodes removed was as follows: VATS (right side) 24.0 lymph nodes/patient, open right-sided 25.2 lymph nodes/patient, VATS (left side) 25.1 lymph nodes/patient and open left-sided 21.1 lymph nodes/patient. With respect to the zones mentioned above, we found the following results: VATS vs open (mean number of lymph nodes/patient): Zone 1: 9 vs 8.5; Zone 2: 6.3 vs 5.6; Zone 3: 2.4 vs 3.2; Zone 4: 6.5 vs 6.9; Zone 5: 0 vs 0.5; Zone 6: 3.2 vs 3.7; Zone 7: 4.6 vs 3.2 and Zone 8: 10.5 vs 8.9. There were no statistically significant differences between the procedures, either with respect to the overall number of lymph nodes or with respect to the number of lymph nodes in each zone. Mediastinal lymph node dissection can be performed as effectively by the video-assisted approach as by the open thoracotomy approach. Furthermore, the video-assisted approach allows a better visualization of different lymph node zones.

Uniportal Video-Assisted Thoracoscopic Lobectomy: Two Years of Experience

A video-assisted thoracoscopic approach to lobectomy varies among surgeons. Typically, 3 to 4 incisions are made. Our approach has evolved from a 3-port to a 2-port approach to a single 4- to 5-cm incision with no rib spreading. We report results with single-incision video-assisted thoracic major pulmonary resections during our first 2 years of experience. In June 2010, we began performing video-assisted thoracoscopic lobectomies through a uniportal approach (no rib spreading). By July 12, 2012, 102 patients had undergone this single-incision approach. Of 102 attempted major resections, 97 were successfully completed with a single incision (operations in 3 patients were converted to open surgery and 2 patients needed 1 additional incision). Five uniportal pneumonectomies were not included in the study. We have analyzed early outcomes of successful uniportal lobectomies (92 patients studied). Right upper lobectomy was the most frequent resection (28 cases). Mean surgical time was 154.1 ± 46 minutes (range, 60-310 minutes), mean number of lymph nodes was 14.5 ± 7 (range, 5-38 nodes), and mean number of explored nodal stations was 4.6 ± 1.2 (range, 3-8 stations). The mean tumor size was 2.8 ± 1.5 cm (0-6.5 cm). The median duration of time a chest tube was in place was 2 days and the median length of hospital stay was 3 days. There were complications in 14 patients; no postoperative 30-day mortality was reported. Single-incision video-assisted thoracoscopic anatomic resection is a feasible and safe procedure with good perioperative results, especially when performed by surgeons experienced with the double-port technique and anterior thoracotomy.

Single-port video-assisted thoracoscopic anatomic segmentectomy and right upper lobectomy

Video-assisted thoracoscopic surgery (VATS) segmentectomies are usually more complex procedures than lobectomies. With the gained experience in the field of thoracoscopic surgery, many thoracic surgery departments have progressively adopted this technique to preserve lung parenchyma, especially in cases of metastasis or benign conditions. The majority of surgeons use three incisions but the procedure can be performed by only one port. We report the first anatomic segmentectomy performed by uniportal VATS with no rib spreading.

Video-assisted thoracic surgery pneumonectomy: the first case report in Poland.

Minimally invasive video-assisted thoracic surgery (VATS) lobectomy has proved to be equal and in some aspects superior to open lobectomy in T1 and T2 lung cancers. Indications for VATS pneumonectomy however are still not clearly defined and strictly limited. The minimally invasive VATS pneumonectomy can be undertaken in patients with centrally located tumors without extended invasion of the large pulmonary vessels, chest wall, pericardium, mediastinal structures or proximal part of the main bronchus and when sleeve resection is not feasible (T2). We present a case of a patient who underwent left VATS pneumonectomy due to left lung cancer. Based on the preoperative examinations any kind of less extensive resection than pneumonectomy was excluded. Our VATS technique consisted of three incisions: two ports and a 5-6 cm long utility incision without any kind of rib spreading. The whole of the procedure was controlled on the monitor via a thoracoscope and the technique of resection was described in detail. Total surgery time was 130 min and blood loss was 150 ml. The chest tube was removed on the 2nd post-operative day and the patient was discharged home on the 8th postoperative day. The final histopathological examination confirmed squamous cell lung cancer (T2aN0M0 stage IB). In the authors’ opinion VATS pneumonectomy should be performed only in centers with extensive experience in minimally invasive VATS lobectomy. Despite limited indications for VATS pneumonectomy, if the patients fulfill the VATS pneumonectomy inclusion criteria they may gain from all the advantages of minimally invasive techniques.

Video-atlas of thoracoscopic formal lung resections emulating traditional open techniques - Editor's comments.

The following video compilation by Dr Demmy is a valuable atlas of thoracoscopic lobectomy, both for thoracic trainees, for whom this approach will become increasingly routine, and for senior surgeons wishing to expand and evolve their surgical repertoire for lung cancer surgery. The videos, with excellent clarity and appropriate narrative, sequentially take the viewer through five individual lobectomies, which are accompanied by a helpful side bar that demonstrates the correct placement of the thoracoscope and other instruments at every stage. Surgeons who are currently using a standard thoracotomy will recognise the exposures and patient positioning. Those used to performing some VATS procedures will be familiar with the triangulation technique used in these videos with 2 ports and an additional access incision. Two decades after its first description, lung resection by video-assisted thoracoscopic surgery (VATS) has not only answered the initial criticisms questioning its alignment with the principles of surgical oncology (1), but has survived through to reach for the higher ground with a growing evidence base for its superiority over its more invasive counterpart of a larger and rib spreading conventional thoracotomy in the management of early-stage non-small cell lung cancer. Advantages of less pain, less blood loss, less frequent post-operative complications, shorter hospital stay, earlier post-operative recovery, better post-operative lung function and an earlier facilitation for the timely delivery of adjuvant therapy when necessary, are increasingly reported in the literature (2-5). The thoroughness of mediastinal lymph nodes sampling is not compromised by thoracoscopy. More importantly, the medium and long-term survival following VATS lobectomy is not only comparable (6-9), but may even be superior to that following open thoracotomy (10). These comparisons have been made with the standard postero-lateral thoracotomy, which entails significant muscle division and rib-spreading. Some surgeons are limiting this by moving towards a more anterior incision, while others are embracing a hybrid approach through a limited thoracotomy with thoracoscopic assistance. Evidence that VATS lobectomy causes less inhibition of underlying immune function when compared to lung resection via a thoracotomy (11), would further support a survival advantage with the less invasive approach and adds impetus to embracing this technology on a larger scale than is prevalent amongst thoracic surgeons. This has largely resulted from a shortage of experienced surgical mentors and less from any continued scepticism of VATS lobectomy as a legitimate surgical technique that respects oncological principles. Dr Demmy’s video atlas is a welcome addition to the limited resources in this field and should serve to stimulate a greater uptake of thorasoscopic lung resections.

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

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).

Single-incision video-assisted thoracoscopic right pneumonectomy

The most common approach for Video-assisted thoracoscopic (VATS) lobectomy is undertaken with three or four incisions, including a utility incision of about 3-5 cm. However, major pulmonary resections are amenable by using only a single utility incision. This video shows the technical procedure of a right pneumonectomy by single-incision approach with no rib spreading. A 52-year-old woman was proposed for single-incision VATS resection of a 5-cm right lower lobe adenocarcinoma. A 4-cm incision was made in the fifth intercostal space. We placed a 30-degree, high-definition, 10-mm thoracoscope in the posterior anterior part of the incision. Digital palpation confirmed that the tumor involved the fissure and the posterior portion of the upper lobe, which indicated the need for right pneumonectomy. We inserted the instruments through the anterior part of the utility incision to start the detachment of the right upper lobe by using a harmonic scalpel. The first step was dissecting the inferior pulmonary vein. The hilar structures were exposed by using harmonic scalpel and a long dissector (Fig. 1A). The upper and middle-lobe pulmonary veins were dissected and transected, allowing visualization of truncus anterior, which was then stapled. The inferior pulmonary vein and the intermediate truncus artery were divided, allowing optimal exposure to the main bronchus, which was stapled. The lung was removed in a protective bag by adding 1 cm to the incision, and a systematic lymph node dissection was performed. A single chest tube was placed in the posterior part of the utility incision. Total surgery time was 210 min. The chest tube was removed on postoperative day 2 (Fig. 1B), and the patient was discharged home on day 4 with no complications. Single-port VATS pneumonectomy for selected cases is a feasible procedure, especially when performed from a center with previous experience in double-port VATS approach. Recent advances in surgical and video-assisted techniques have allowed minimally invasive pneumonectomy to be undertaken safely. VATS pneumonectomy is not a new procedure and in fact was initially reported 15 years ago and was felt to result in less postoperative pain and a faster return to normal activities [1]. Despite this, there have been only a few case reports or series published of VATS pneumonectomies [2, 3].

Video-assisted thoracoscopic lobectomy for lung cancer

Video-assisted thoracoscopic surgery (VATS) provides a new approach for treating early-stage lung cancer. VATS lobectomy has significant perioperative advantages such having as a lower rate of morbidity and being less immunosuppressive than open lobectomy, and it also provides a shorter recovery time, less postoperative pain, and faster resumption of a normal lifestyle. However, a clear definition of VATS lobectomy is lacking in the current literature. The generally accepted method of VATS lobectomy is from three to four incisions in number of port, 4.0 to 8.0 cm in utility length, and without rib spreading. However, there is still much debate on the role of VATS in lobectomy for the treatment of lung cancer. Concerns regarding safety, the extent of mediastinal lymph node dissection, and long-term survival have made some surgeons apprehensive of its validity for lung cancer. Nevertheless, recent data have shown that VATS lobectomy appears to have equivalent oncological results compared with open lobectomy for patients with early stage non-small cell lung cancer. With growing experience with VATS and development of thoracoscopic instrument, VATS can be beneficial to patients with early stage of lung cancer.