Video-assisted Lobectomy Research Articles

Developing a robotic program in thoracic surgery at Cape Cod Hospital.

This study aimed to elucidate the stepwise progression of robotic skills required, the natural progression from thoracoscopic to robotic technique with a focus on approaching the hilar structures, and the nuances of perioperative care, in a community hospital and solo surgeon practice. It was a case-control analysis comparing 22 consecutive robotic-assisted lobectomy (RAL) procedures with 22 matched historic video-assisted lobectomy (VAL) procedures from June 2011 to December 2012. Patients undergoing VAL had 1.09days greater length of stay than did patients who underwent RAL. Although hospital charges were significantly higher for RAL patients, patients undergoing VAL had greater blood loss, required longer hospital stay, had greater readmission rates, and were transferred more often to a rehabilitation facility at discharge. Subjectively, dexterity, ergonomics, and optics with the RALs were superior to the VALs. Favorable outcomes were demonstrated for patients undergoing RALs. Effective communication is paramount for the skill set and team building for a safe transition to practice.

Video-assisted left upper bronchial sleeve lobectomy.

Compare with pneumonectomy, sleeve lobectomy has advantage in long-term outcomes and cost-effective measures. As a result, sleeve lobectomy procedure is considered and practiced as the standard therapy for central lung cancers which are anatomically suitable regardless of lung function. The advent of minimally invasive surgery brings numerous advantages, such as shorter hospital stay, alleviated post-operative pain, faster recover and so on, to the patient. In return, it did demands all the surgeons to master the video-assisted thoracic surgery (VATS) operative skill to meet the patient's expectation. Although mirror the pathway of open sleeve surgery, the video-assisted bronchial sleeve lobectomy (VABSL) brings numerous obstacles for the surgeon: one needs to accommodate transmission from direct-view to locally 2D screen, from multi-angle multi-direction operation field to one directional operation field, before he can adapt to the VATS operative skill. In addition, VATS surgery did have its' learning curve for the surgeon and the assistant. Here we present a video of a patient underwent sleeve lobectomy for communicating operative techniques.

Video-assisted thoracic surgery (VATS) left upper sleeve lobectomy with partial pulmonary artery resection.

Compare with pneumonectomy, sleeve lobectomy has advantage in long-term outcomes and cost-effective measures. As a result, sleeve lobectomy procedure is considered and practiced as the standard therapy for central lung cancers which are anatomically suitable regardless of lung function. In some cases, the lesion invades hilar and mediastinal vessels, the surgeon may faces more technically challenging in vascular reconstruction procedures together with the sleeve lobectomy procedure. The advent of minimally invasive surgery brings numerous advantages, such as shorter hospital stay, alleviated post-operative pain, faster recover and so on, to the patient. In return, it did demands all the surgeons to master the VATS surgery operative skill to meet the patient's expectation. Although mirror the pathway of open sleeve surgery, the video-assisted bronchial sleeve lobectomy (VABSL) brings numerous obstacles for the surgeon: One needs to accommodate transmission from direct-view to locally 2D screen, from multi-angle multi-direction operation field to one directional operation field, before he can adapt to the VATS operative skill. In addition, VATS surgery did have its' learning curve for the surgeon and the assistant. Here we present a video of a patient underwent sleeve lobectomy with partial pulmonary artery resection for communicating operative techniques.

Bronchial anastomosis using complete continuous suture in video-assisted thoracic surgery sleeve lobectomy.

Thoracotomy is the traditional way to perform a bronchial sleeve lobectomy, but it also can be performed by video-assisted thoracic surgery (VATS). The worldwide experience with VATS lobectomy is now sufficiently large enough to compare this procedure with open thoracotomy. Multiple interrupted sutures are preferred in bronchial anastomosis, but it can be done using complete continuous suture. We reported a case of VATS sleeve resection using continuous suture in bronchial anastomosis.

Contraindications of video-assisted thoracoscopic surgical lobectomy and determinants of conversion to open.

Since the introduction of anatomic lung resection by video-assisted thoracoscopic surgery (VATS) was introduced 20 years ago, VATS has experienced major advances in both equipment and technique, introducing a technical challenge in the surgical treatment of both benign and malignant lung disease. The demonstrated safety, decreased morbidity, and equivalent efficacy of this minimally invasive technique has led to the acceptance of VATS as a standard surgical modality for early-stage lung cancer and increasing application to more advanced disease. However, only a minority of lobectomies are performed using the VATS technique, likely owing to concern for intraoperative complications. Optimal operative planning, including obtaining baseline pulmonary function tests with diffusion measurements, positron emission tomography and/or computed tomography scans, bronchoscopy, and endobronchial ultrasound or mediastinoscopy, can be used to anticipate and potentially prevent the occurrence of complications. With increasing focus on operative planning, as well as comfort and experience with the VATS technique, the indications for which this technique is used has grown. As such, the absolute contraindications have narrowed to inability to tolerate single lung ventilation, inability to achieve complete resection with lobectomy, T3 or T4 tumors, and N2 or N3 disease. However, as VATS lobectomy has been applied to more advanced stage disease, the rate of conversion to open thoracotomy has increased, particularly early in the surgeon's learning curve. Causes of conversion are generally classified into four categories: intraoperative complications, technical problems, anatomical problems, and oncological conditions. Though it is difficult to anticipate which patients may require conversion, it appears that these patients do not suffer from increased morbidity or mortality as a result of conversion to open thoracotomy. Therefore, with a focus on a safe and complete resection, conversion should be regarded as a means of completing resections in a traditional manner rather than as a surgical failure.

English

Mortality and complication rates after on-pump versus off-pump coronary artery bypass grafting (CABG), and open lung lobectomy (OL) versus video-assisted lobectomy (VAL), have previously been reported, but further research regarding functional outcomes is needed. This study compared functional recovery at discharge between patients who underwent on-pump versus off-pump CABG, and OL versus VAL. In patients discharged during July to December, from 2006 to 2010, functional recovery was measured by comparing the Barthel index at admission and discharge. Complication rates and functional deterioration were compared in propensity score-matched groups of patients aged over 15 years who underwent isolated CABG of two or more arteries or lobectomy, and survived until discharge. The study included 3,901 on-pump CABG patients, 3,672 off-pump CABG patients, 6,029 OL patients, and 14,378 VAL patients. Patient and hospital characteristics, comorbidities, and preoperative care procedures were associated with on-pump versus off-pump CABG, and OL versus VAL, but functional deterioration was not. The complication rate was lower after VAL than OL. Dependent functional status at admission was associated with functional deterioration in patients who underwent lobectomy. Multidisciplinary treatment strategies to maintain functional status should be developed, and appropriate indications for lobectomy according to functional status at admission should be determined. Key words: Coronary artery bypass grafting, complications, functional outcomes, lung lobectomy.

Is video-assisted lobectomy for non-small-cell lung cancer oncologically equivalent to open lobectomy?†

The purpose of this study was to compare overall and disease-free survival after VATS and open lobectomy for clinical Stage I and II non-small-cell lung cancer (NSCLC). A retrospective review of a prospective database of all patients undergoing VATS or open lobectomy for clinical Stage I or II NSCLC between 2002 and 2010 was performed. Postoperative outcomes, disease-free survival and overall survival were compared between the two groups after optimum 1:1 propensity matching for age, gender, tumour histology and pathological stage. Over an 8-year period, 608 patients underwent lobectomy for NCSLC by VATS (n = 196, 32%) or open technique (n = 412, 68%). After matching, there were 190 patients in each group. Adenocarcinoma was found in 80% (open: 149, VATS: 152) and 55% of tumours were T1 (open: 108, VATS: 105). Pathological N1 disease was found in 21 and 19 patients in the open and VATS group, respectively. Disease-free 5-year survival was 69.1% for the open group vs 69.7% for VATS (P = 0.94). Cancer-specific 5-year survival was 82.9% for the open group vs 76.7% for VATS (P = 0.170). Five-year overall survival was 73% in the open group vs 64% in the VATS group (P = 0.17). Operative mortality and postoperative complications were not significantly different between groups. Overall survival and disease-free survival are not significantly different when compared between VATS lobectomy and open lobectomy. VATS resection appears to provide an adequate oncological operation for patients with operable clinical Stage I and II NSCLC.

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.

Left lower apical segmentectomy after video-assisted left upper lobectomy for relapse in lung cancer: benefit to avoid completion pneumonectomy

Segmental resection is a useful procedure to preserve respiratory function. We report a case of lower apical segmentectomy for relapse after initial video-assisted left upper lobectomy to avoid completion pneumonectomy. After 4years of follow-up, the patient is doing well with no evidence of disease.

A video-assisted thoracic surgical lobectomy for a lung tumour with a rare anomalous pulmonary artery

A detailed knowledge of anomalies of the anatomical course of the pulmonary vessels is extremely important for video-assisted thoracic surgery (VATS). Inadvertent vascular ligation and dissection are catastrophic for patients undergoing lobectomy. We describe a case with a rare anomaly of the left pulmonary artery and highlight the importance of identifying the courses of pulmonary vessels for VATS lobectomy.

Pathologic analysis of transbronchial lung biopsy in workers exposed to dusts

To explore the role of transbronchial lung biopsy (TBLB) in pathologic diagnosis of pneumoconiosis. In our hospital during May 2011 and Sep 2011, the TBLB samples from 35 cases occupationally exposed to dusts were compared with the video-assisted thoracoscopic surgery or lobectomy samples from 27 cases not exposed to dusts for pathological indexes, including fibrotic proliferation, nodule or nodule-like, dust deposition and needle-shaped birefringent particles. In group exposed to dusts, there were 6 cases (17.1%) with the moderate dust deposition and 28 cases (80.0%) with fibrotic proliferation. But in group not exposed to dusts, there were 0 case with the moderate dust deposition and 11 cases (40.0%) with fibrotic proliferation. There were significant differences between two groups (P < 0.05). In group exposed to dusts, there were 6 cases (17.1%) with Nodules-like and needle-shaped birefringent particles, but in group not exposed to dusts, there was 0 case with Nodules-like and needle-shaped birefringent particles. TBLB could provide the evidence of pathological changes in lung tissue induced by dusts, and TBLB play an important role in pneumoconiosis diagnosis.

Off-the-job training for VATS employing anatomically correct lung models

We evaluated our simulated major lung resection employing anatomically correct lung models as "off-the-job training" for video-assisted thoracic surgery trainees. A total of 76 surgeons voluntarily participated in our study. They performed video-assisted thoracic surgical lobectomy employing anatomically correct lung models, which are made of sponges so that vessels and bronchi can be cut using usual surgical techniques with typical forceps. After the simulation surgery, participants answered questionnaires on a visual analogue scale, in terms of their level of interest and the reality of our training method as off-the-job training for trainees. We considered that the closer a score was to 10, the more useful our method would be for training new surgeons. Regarding the appeal or level of interest in this simulation surgery, the mean score was 8.3 of 10, and regarding reality, it was 7.0. The participants could feel some of the real sensations of the surgery and seemed to be satisfied to perform the simulation lobectomy. Our training method is considered to be suitable as an appropriate type of surgical off-the-job training.

Invited Commentary

The current study by Cerfolio and Bryant [1Cerfolio R.J. Bryant A.S. Daily chest roentgenograms are unnecessary in nonhypoxic patients who have undergone pulmonary resection by thoracotomy.Ann Thorac Surg. 2011; 92: 440-444Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar] describes the impact of daily postoperative chest radiography in the management of 1,037 patients who underwent pulmonary resection during a 4-year period. The authors emphasize that all patients included in this study underwent thoracotomy. Patients who underwent pneumonectomy, video-assisted thoracoscopic procedures, or admission to the intensive care unit were excluded. The majority of the analysis was predicated on the presence of postoperative pneumothorax or hypoxia. The influence of other parameters such as fever, leukocytosis, arrhythmia, or bleeding is less clear. The authors observed that chest roentgenograms changed clinical management in 72% (49 of 62) of patients exhibiting hypoxia during their hospitalization, thus justifying the need for chest radiography. In contrast, only 27% (26 of 975) of patients required an alteration in clinical management in the absence of hypoxia. The authors conclude that daily chest roentgenograms provide little benefit in patients demonstrating no postoperative pneumothorax or in the absence of hypoxia during their hospitalization. One could argue that because a chest roentgenogram changed clinical management in nonhypoxic patients nearly one third (27%) of the time, daily chest radiography remains beneficial. There are occult findings on postoperative chest roentgenograms (lobar collapse, retained blood, alveolar infiltrates, small to moderate pneumothorax) that cannot always be detected clinically, and often precipitate alteration in clinical management. Moreover the adoption of video-assisted lobectomy in lung cancer care has led to fewer hospital days, thus already reducing the total number of postoperative chest roentgenograms. In an era of health care cost containment and increased awareness of cumulative radiation from diagnostic imaging modalities, the authors ask a valid question: Is it necessary to obtain daily chest roentgenograms in patients who experience routine pulmonary resection? There is little debate that chest radiography is overused in the postoperative management of routine pulmonary resection; however evidence-based recommendations are lacking. A redesign of clinical pathways for routine lobectomy, segmentectomy, or wedge resection will need to address this phenomenon. A simple prospective randomized controlled trial with some reasonable exclusion criteria can be constructed to understand the role of daily versus specifically indicated postoperative chest radiography in routine pulmonary resection. Daily Chest Roentgenograms Are Unnecessary in Nonhypoxic Patients Who Have Undergone Pulmonary Resection by ThoracotomyThe Annals of Thoracic SurgeryVol. 92Issue 2PreviewThe purpose of this study is to assess the clinical benefit of performing a daily chest roentgenogram (CXR) on patients who have had a pulmonary resection. Full-Text PDF

Video-assisted lobectomy for endobronchial leiomyoma

Endobronchial leiomyomas are rare tumours arising from the smooth muscle on the bronchial tree. We describe a patient with a six-month history of chest infections, who was treated surgically with a video-assisted thoracic surgery (VATS) lobectomy. The pathology revealed an endobronchial leiomyoma that coexisted with postobstructive pulmonary non-necrotising granulomas.

Intercostal–subcostal combined complete port-accessed video-assisted lobectomy

Video-assisted lobectomy procedures include a broad spectrum of operative techniques that range from complete thoracoscopic surgery to minithoracotomy with a thoracoscope serving only as a light source. We describe a modified method for thoracoscopic approach for lobectomy with thoracic muscle sparing based on a combined complete port-accessed technique with a subcostal incision. We have successfully used this technique for lobectomies in stage I lung tumors. Intercostal muscles and nerve injury preservation allied to fast track rehabilitation perioperative care allowed rapid postoperative recovery.

Importance of preoperative assessment of pulmonary venous anomaly for safe video-assisted lobectomy

During the treatment of 86 patients with video-assisted thoracoscopic surgery (VATS) anatomical resection (include segmentectomy) within the last two years, we have encountered five patients (5.8%) with anomalous venous returns. Anomalous returns included: 1) common trunk of the left pulmonary vein; 2) right middle pulmonary vein (V4) draining into the inferior pulmonary vein (IPV); 3) left lingular vein (V4+5) draining into the IPV; 4) right posterior pulmonary vein (V2) draining directly into the left atrium; and 5) left upper lobe vein draining into the left innominate vein. If a surgeon were to perform VATS lobectomy without paying attention to these anomalies according to the affected lobe, serious surgical complications might result. Multi-detector row angiography is useful for recognizing such anomalies before surgery and allow safe VATS lobectomy.

Video-assisted thoracic surgery versus open lobectomy for lung cancer: A secondary analysis of data from the American College of Surgeons Oncology Group Z0030 randomized clinical trial

Video-assisted thoracoscopic lobectomy remains controversial. We compared outcomes from participants in a randomized study comparing lymph node sampling versus dissection for early-stage lung cancer who underwent either video-assisted thoracoscopic or open lobectomy. Data from 964 participants in the American College of Surgeons Oncology Group Z0030 trial were used to construct propensity scores for video-assisted thoracoscopic versus open lobectomy (based on age, gender, histology, performance status, tumor location, and T1 vs T2). Propensity scores were used to estimate the adjusted risks of short-term outcomes of surgery. Patients were classified into 5 equal-sized groups and compared using conditional logistic regression or repeated measures analysis of variance. A total of 752 patients (66 video-assisted and 686 open procedures) were analyzed on the basis of propensity score stratification. Median operative time was shorter for video-assisted thoracoscopic lobectomy (video-assisted thoracoscopy 117.5 minutes vs open 171.5 minutes; P < .001). Median total number of lymph nodes retrieved (dissection group only) was similar (video-assisted thoracoscopy 15 nodes vs open 19 nodes; P = .147), as were instances of R1/R2 resection (video-assisted thoracoscopy 0% vs open 2.3%; P = .368). Patients undergoing video-assisted thoracoscopic lobectomy had less atelectasis requiring bronchoscopy (0% vs 6.3%, P = .035), fewer chest tubes draining greater than 7 days (1.5% vs 10.8%; P = .029), and shorter median length of stay (5 days vs 7 days; P < .001). Operative mortality was similar (video-assisted thoracoscopy 0% vs open 1.6%, P = 1.0). Patients undergoing video-assisted lobectomy had fewer respiratory complications and shorter length of stay. These data suggest video-assisted thoracoscopic lobectomy is safe in patients with resectable lung cancer. Longer follow-up is needed to determine the oncologic equivalency of video-assisted versus open lobectomy.

Long-term prognosis of video-assisted limited surgery for early lung cancer☆

The present intervention study was conducted to prospectively evaluate the long-term prognosis for video-assisted limited surgery, such as wedge resection and segmentectomy, for clinically early lung cancers depending on findings in high-resolution computed tomography (HRCT). Patients were enrolled in the study between 2001 and 2004, and followed up for five subsequent years. Of these patients, those with a clinical stage IA lung cancer mainly comprising a ground glass-opacity (GGO) less than 1.5 cm across underwent thoracoscopic wedge resection of the lung (Group A). Patients with a tumour less than 2.0 cm in diameter, not classified in Group A, underwent video-assisted segmentectomy and hilar lymph node dissection with lobe-specific mediastinal nodes sampling (Group B). For patients with a tumour less than 3.0 cm in diameter, not classified in to any of the foregoing two groups, underwent video-assisted lobectomy and hilar and mediastinal lymph node dissection (Group C). During the case registration period, 159 patients were registered for enrollment in the study (21 for Group A, 43 for Group B and 95 for Group C). Of the patients in Groups A and B, 28% were shifted to a surgical procedure involving a larger volume resected; 6% of the entire study population were shifted to thoracotomy. All patients completed the 5-year follow-up. The recurrence-free survival rate was 100% for Group A, 90.5% for Group B and 94.5% for Group C, with no significant difference among the groups. The total recurrence rate was 11.9% with localised recurrences observed in 6.3% of the patients and remote recurrences in 5.7%. The localised recurrences observed included stump recurrence in one case of Group B, and malignant pleural effusions/pleural dissemination in two cases of Group B and one case of Group C. Intrathoracic lymph node recurrences were observed in one case of Group B and five cases of Group C. The present intervention study showed that thoracoscopic-limited surgery for clinically early lung cancers depending on findings in preoperative HRCT is feasible and appropriate from the viewpoint of oncology.

Video‐Assisted Thoracic Surgery (VATS) Compares Favorably with Thoracotomy for the Treatment of Lung Cancer: A Five‐Year Outcome Comparison

Although video-assisted thoracic surgery (VATS) lobectomy has been demonstrated to be safe and technically feasible, it is infrequently performed in most Chinese hospitals and few thoracic surgeons have performed the operation. We have therefore reviewed our experience with all VATS lobectomies, attempting to define long- and short-term outcomes of these surgeries. We retrospectively analyzed the results in patients who underwent VATS lobectomy and open lobectomy between March 1996 and August 2003. The VATS surgery was performed with the endoscopic hilar dissection technique. Perioperative data were collected and long-term outcomes were assessed by 5-year census. We successfully performed VATS procedures in 113 of 120 patients. The median operative time was 152 min and the median hospitalization was 8.6 days. The median operative blood loss was 130 ml and the median drainage time was 3.5 days. The operative and perioperative (30-day) mortality rates were 0% and 0.9%, respectively; the postoperative complications rate was 10.6%. The 5-year overall survival rates for stage I, stage II, and stage III or greater non-small cell lung cancer (NSCLC), secondary pulmonary malignancy, and benign disease were 79.1%, 45.5%, 22.2%, 33.3%, and 88.6%, respectively. Video-assisted lobectomy is a safe and feasible surgical procedure, and it gives the same long-term results as conventional open lobectomy. The VATS approach to lobectomy is a beneficial alternative to standard thoracotomy for selected cases of pulmonary lesions.

Variance analysis of a clinical pathway of video-assisted single lobectomy for lung cancer

Clinical pathways have contributed to standardized postoperative management, but analyzing variance is also important to maintain quality control. To evaluate the validity of our own clinical pathway for managing video-assisted lobectomy for lung cancer, we analyzed the variances influencing postoperative recovery. Between April 2003 and April 2004, 62 consecutive patients with lung cancer underwent video-assisted single anatomic lobectomy with lymph node dissection. We evaluated 61 of these patients after the exclusion of one, who deviated from the clinical pathway management immediately as a result of serious complications. There were 29 men and 32 women, with an average age of 65.7 years. Complications developed in 29 patients, but there was no operative mortality. The occurrence of variance ranged from 1.6% to 34.4% for each activity and included prolonged supplemental oxygen therapy, out-of routine examination, prolonged epidural anesthesia, and delayed bathing frequently. Complications and an abnormal body mass index were significant and independent clinical factors affecting the increase in variance. Our original clinical pathway management was tolerable for lung cancer patients undergoing a video-assisted lobectomy. Complications and an abnormal body mass index were significant predictive factors for an increase in variance of our clinical pathway.