Video-assisted Thoracic Surgical Lobectomy Research Articles

Robotic assistance for video-assisted thoracic surgical lobectomy: Technique and initial results

There is little experience with telerobotic assistance for video-assisted thoracic surgical lobectomy. We developed a technique for robotic assistance during video-assisted thoracic surgical lobectomy and report our initial results. Video-assisted thoracic surgical lobectomy with the da Vinci Surgical System (Intuitive Surgical, Sunnyvale, Calif) was attempted in 34 patients (median age, 69.0 years; age range, 12-85 years). Robotic instruments were used for individual dissection of the hilar structures through 2 thoracoscopic ports and a 4-cm utility incision without rib spreading. Data on patient characteristics and perioperative results were collected prospectively. Robot-assisted video-assisted thoracic surgical lobectomy was accomplished in 30 patients (19 female and 11 male patients). Every type of lobectomy was performed. Four (4/34 [12%]) patients required conversion to thoracotomy. The majority of patients had non-small cell lung cancer (32/34 [94%]), and 1 patient each had a typical carcinoid tumor and an extranodal B-cell lymphoma. Every patient underwent an R0 resection. The median number of lymph node stations dissected with robotic assistance was 4 (range, 2-7). Operative mortality was 0%, with no in-hospital or perioperative deaths. Nine (26%) patients experienced National Cancer Institute Common Toxicity Criteria for Adverse Events version 3.0 grade 2 or 3 complications. The median chest tube duration was 3.0 days (range, 2-12 days), and the median length of stay was 4.5 days (range, 2-14 days). The median operative time was 218 minutes (range, 155-350 minutes). Robot assistance for video-assisted thoracic surgical lobectomy is feasible and safe. The utility and advantages of robotic assistance for video-assisted thoracic surgical lobectomy require further refinement and study of the technique.

Long-term Benefits for the Quality of Life After Video-assisted Thoracoscopic Lobectomy in Patients With Lung Cancer

Quality of life (QOL) after video-assisted thoracic surgical (VATS) lobectomy remains to be defined. Forty-four consecutive patients with clinical stage I lung cancer underwent lobectomy by the VATS approach (n = 22 patients) or thoracotomy approach (n = 22 patients). Acute pain was quantitated by postoperative narcotic requirements and the need for epidural anesthesia. Long-term QOL was assessed by questioning patients about the presence of chronic chest pain, ongoing limitations in arm or shoulder function, time until return to preoperative activity, and satisfaction with the operation. Patients who underwent VATS lobectomy had significant decreases in both acute and chronic chest pain and time until return to preoperative activity. Patients also had more confidence regarding wound size and their overall impression of the operation. In this series, VATS lobectomy was associated with long-term benefits for the QOL in patients with lung cancer. However, the exact role of this approach should be defined by carefully-designed controlled trials studying long-term survival.

Video-Assisted Thoracic Surgical Non-Rib Spreading Simultaneously Stapled Lobectomy: A More Patient-Friendly Oncologic Resection

To evaluate the outcomes from a new surgical technique for lobectomy. Two hundred fifty consecutive patients with an average age of 67.3 years underwent simultaneously stapled lobectomy. Video-assisted thoracic surgical non-rib spreading lobectomy (VNSSL) is a new technique that has been evolving for approximately 6.5 years. During 1990, we began using video-assisted thoracic surgery (VATS) for simple, benign diseases. Throughout 1991, VATS was applied to malignant problems, ie, mediastinal masses, staging of lymph nodes, malignant effusions, and coin lesions. As experience was acquired, more complex procedures were attempted, such as lobectomy. On September 9, 1991, our first VATS lobectomy, using anatomic hilar dissection and lymph node sampling, was performed for primary carcinoma of the lung. One year later, we performed our first VNSSL using simultaneous stapling. Currently, 400 VNSSLs have been performed. In this entire series, there have been no surgical mortality, bronchopleural fistulas, port implantations, or transfusions. Bronchial stumps have averaged 4 mm in length, and all have been microscopically negative for neoplasm. In order to evaluate long-term survival for primary carcinoma of the lung in patients with an adequate duration of follow-up, the first 250 consecutive VNSSLs have been reviewed. There were 120 male and 130 female patients ranging in age from 20 to 92 years old who had 62 right upper lobe, 20 right middle lobe, 58 right lower lobe, 63 left upper lobe, and 33 left lower lobe lobectomies, and 14 bilobectomies. The lesions consisted of 214 primary carcinomas, 8 metastatic lesions, and 28 benign problems. Seven to 18 lymph nodes could be resected during staging of the primary neoplasms. The tumors ranged in size from 1 to 9 cm, and operating times averaged 78.6 min. Hospitalization averaged 2.83 days. No patient was admitted to the ICU. Intensive monitoring or narcotic analgesia were not needed. No epidural or intercostal anesthesia was used. Complications were infrequent and minor. Most patients returned to preoperative levels of physical activity within 7 to 10 days. Overall survival at a mean of 34 months, when all stages of neoplasms were combined, is 83%. For stage I, overall survival is 92%. The cost of VNSSL is approximately 50% less than the traditional open thoracotomy. VNSSL is an oncologic technique that has been clinically rewarding and economically beneficial for patients with malignant lesions. Long-term survival for primary carcinoma currently exceeds reports being published for the traditional open thoracotomy. Scientific reasons for this extraordinary survival are emerging. Complications, surgical mortality, pain, and length of stay have all been reduced. Patient recovery, comfort, and satisfaction have been extraordinary.

Postoperative pain-related morbidity: Video-assisted thoracic surgery versus thoracotomy

One hundred thirty-eight consecutive, nonrandomized patients, with equivalent demographic and preoperative physiologic parameters, underwent either a video-assisted thoracic surgical (VATS) approach (n = 81) or a limited lateral thoracotomy (LLT) approach (n = 57) to accomplish pulmonary resection for peripheral lung lesions (≤3 cm in diameter). Wedge resection was done in 74 VATS patients and 19 LLT patients. Seven patients underwent VATS lobectomy and 38 patients had lobectomy performed through an LLI Pain was quantitated by postoperative narcotic requirements, the need for intercostal/epidural analgesia, and patient perception of pain index scoring. Shoulder and pulmonary function (forced expiratory volume in 1 second) were measured preoperatively, 3 days postoperatively, and at 3 weeks of follow-up. Patients undergoing VATS experienced significantly less postoperative pain. No patients undergoing VATS required intercostal block/epidural analgesia; 31 LLT patients (54%) required this treatment for breakthrough pain ( p = 0.001). Narcotic requirements were less ( p = 0.05) among VATS patients, which correlated with lower perception of pain index after operation for VATS patients. Shoulder girdle strength was equally impaired at day 3, but function was more improved in VATS patients at 3 weeks ( p = 0.01) Patients undergoing wedge resection alone by LLT had greater impairment in early (day 3) pulmonary function (forced expiratory volume in 1 second) ( p = 0.302); this difference from VATS was not sustained at 3 weeks. Video-assisted thoracic surgery is associated with reduced pain, shoulder dysfunction, and early pulmonary impairment compared with LLT for select patients requiring pulmonary resection.