Video-assisted Thoracoscopic Surgery Approach Research Articles

Robotic-assisted minimally invasive vs. thoracoscopic lung lobectomy: comparison of perioperative results in a learning curve setting

Minimally invasive lung lobectomy was introduced in the late 1990s. Since that time, various different approaches have been described. At our institution, two different minimally invasive approaches, a robotic and a conventional thoracoscopic one, were performed for pulmonary lobectomies. This study compares perioperative outcome of the two different techniques in a learning curve setting. Between 2001 and 2008, 26 patients underwent lung lobectomy with a robotic-assisted thoracoscopic surgery (RATS) technique. In 2009, the minimally invasive approach was changed to a conventional video-assisted thoracoscopic surgery (VATS) technique. Perioperative results of the first 26 VATS patients were compared to the results of the robotic group. There were significantly more patients with clinical stage >IB in the VATS group than in the robotic-assisted group (23.1 vs. 0%). Otherwise, demographic data were equal between the groups. Operative time was significantly longer in the robotic group (215 vs. 183min, p = 0.0362). Median difference between preoperative hemoglobin levels and levels on postoperative day 1 was higher in the RATS group, suggesting a higher blood loss. No difference was found in conversion rate, acute phase protein levels (C-reactive protein), chest drain duration, postoperative morbidity and mortality, and length of hospital stay. Procedural costs were higher for the robotic approach (difference, 770.55 <euro>, i.e., 44.4%). Shorter operative times, a lower drop of postoperative hemoglobin levels indicating less blood loss, and lower procedural costs suggest a benefit of the VATS approach over the robotic approach for minimally invasive lung lobectomy.

Surgical Management of Lung Cancer

Surgery serves an important role in the diagnosis, staging, and definitive management of non-small cell lung cancer (NSCLC). Resection is the primary mode of treatment for stage I and II NSCLC and an important component of the multimodality approach to stage IIIA disease. Standard resections include removal of the lobe involved with tumor and systematic evaluation of ipsilateral hilar and mediastinal lymph nodes. For early stage disease the evolving surgical treatment goals are aimed at decreasing morbidity and mortality through less invasive approaches including video-assisted thoracoscopic surgery and robotic approaches, and potentially decreasing the volume of lung removed for select patients with well-staged small peripheral tumors. For patients with locally advanced disease, ongoing research is focused on appropriately identifying patients who will most benefit from the addition of surgery to a multimodality regime and safely integrating resection with chemotherapy and radiotherapy.

Minimally invasive right pneumonectomy: case report

Background Minimally invasive video-assisted thoracoscopic surgery (VATS) is considered as an alternative to thoracotomy for early-stage lung cancer (Scott et al. Chest 132:234–42, 2007). Since 2009, we have used a VATS approach for all early-stage lung tumors as well as benign indications for lung lobectomy. (Bodner et al. Eur Surg 43:224–8, 2011) As experience with the technique is growing, indications are expanded. Here, we report our first right-sided minimally invasive pneumonectomy.

Video-assisted thoracoscopic surgery versus posterolateral thoracotomy lobectomy: A more patient-friendly approach on postoperative pain, pulmonary function and shoulder function.

We evaluated the physiological benefits following video-assisted thoracoscopic surgery (VATS) lobectomy or posterolateral thoracotomy (PLT) lobectomy for lung cancer patients. One hundred and three patients were included in this study, who underwent either a VATS approach (n= 51) or a PLT approach (n= 52) lobectomy for clinical stage I lung cancer. Pain scores were measured preoperatively and on postoperative day (POD) one, three, seven, 30, and 90, by using a visual analog scale. Pulmonary function and shoulder function were measured preoperatively and on POD seven, 30 and 90 by using a portable spirometer and by the American Shoulder and Elbow Surgeons (ASES) standardized shoulder assessment form, respectively. Postoperative pain was experienced less in the VATS group than in the PLT group on POD one, three, seven, 30, and 90 (P= 0.060, 0.055, 0.000, 0.000, 0.000, respectively). Analgesic requirements were significantly less in the VATS group than in the PLT group during hospital stay (90.2 ± 60.8 mg vs. 119.2 ± 70.8 mg, P= 0.028). The pain score returned to the preoperative reference level on POD seven in the VATS group, but not until POD 30 in the PLT group. The recovery of forced vital capacity (FVC) was statistically better in the VATS group on POD seven, postoperative month (POM) one, and POM three (P= 0.000, 0.000, 0.002, respectively). The recovery of forced expiratory volume in 1 second (FEV1) was better in the VATS group, but the differences were not significant. The shoulder function in the VATS group was significantly well preserved on POD seven, 30 and 90, compared with the PLT group. Lobectomy by the VATS approach generates less pain, and preserves better pulmonary function and shoulder function in the early postoperative phase.

Video-assisted thoracoscopic pneumonectomy: a minimally invasive approach for a rare inidication

Minimally invasive video-assisted thoracoscopic surgery (VATS) is considered as an alternative to thoracotomy for early stage lung cancer. Since 2009, we use a VATS approach for all early stage lung tumors as well as benign indications for lung lobectomy. As experience with the technique is growing, indications are expanded. Here, we report our first minimally invasive pneumonectomies of two patients with non-small cell lung cancer (NSCLC). Case 1: A 60-year-old man was diagnosed with a centrally located tumor of the right lung invading all three lobes without any obvious lymph node metastasis in the preoperative work-up. The patient was scheduled for a right-sided VATS pneumonectomy. Case 2: A 62-year-old woman was diagnosed with a centrally located tumor of the left lung with an ipsilateral positron emission tomography (PET) positive lymph node (aortopulmonary window). After neoadjuvant treatment, the patient was scheduled for a left-sided pneumonectomy. Written informed consent was given in both cases. The procedures were completed using three incisions. A complete mediastinal lymph node dissection was performed. The postoperative courses were uneventful. VATS pneumonectomy is feasible in highly selected cases. It offers all advantages known from minimally invasive lung lobectomy with less pain and faster rehabilitation, which might facilitate the delivery of adjuvant treatment.

Bulectomia bilateral por cirurgia torácica vídeo-assistida uniportal combinada com acesso contralateral ao mediastino anterior

OBJECTIVE: Video-assisted thoracoscopic surgery (VATS) has been a surgical intervention of choice for the treatment of spontaneous pneumothorax (SP) with lung bulla. Our objective was to introduce a uniportal VATS approach for simultaneous bilateral bullectomy and to evaluate its therapeutic efficacy. METHODS: Between May of 2011 and January of 2012, five patients underwent bilateral bullectomy conducted using this approach. All of the patients presented with bilateral SP. Preoperative HRCT revealed that all of the patients had bilateral apical bullae. We reviewed the surgical indications, surgical procedures, and outcomes. RESULTS: All of the patients were successfully submitted to this approach for bilateral bullectomy, and there were no intraoperative complications. The median time to chest tube removal was 4.2 days, and the median length of the postoperative hospital stay was 5.2 days. The median postoperative follow-up period was 11.2 months. One patient experienced recurrence of left SP three weeks after the surgery and underwent pleural abrasion. CONCLUSIONS: Bilateral bullectomy through uniportal VATS combined with contralateral access to the anterior mediastinum is technically reliable and provides favorable surgical outcomes for patients with bilateral SP who develop bilateral apical bullae. However, among other requirements, this surgical procedure demands that surgeons be experienced in VATS and that the appropriate thoracoscopic instruments are available.

Thoracotomy versus VATS: is there an optimal approach to treating pneumothorax?

IntroductionThe 2010 British Thoracic Society guidelines recommend that a weighted decision be made by clinicians with regard to surgical intervention for pneumothorax as the video assisted thoracoscopic surgery (VATS) approach is better tolerated by patients but carries a higher rate of recurrence (5% vs 1%).MethodsOverall, 163 patients underwent surgical intervention for pneumothorax at our institution and data were collected prospectively for almost 7 years. Of these, 86 patients underwent VATS under a single surgeon with extensive VATS experience to compensate for the associated learning curve while 79 patients underwent an open procedure.ResultsThere was no statistically significant difference in the recurrence rate between the open and the VATS group (1% vs 3.5%, p=1.0). The VATS group was superior to the open group in terms of reduced postoperative bleeding (7.5% vs 0%, p=0.01), reduced number of intensive care unit admissions (16% vs 0%, p<0.01) and a reduced adjusted length of stay (3 vs 5.5 days, p<0.01).ConclusionsA comparable recurrence rate is attainable with a VATS approach once the learning curve is surpassed and a reduction in morbidity is an additional merit.

Technique of Video-Assisted Thoracoscopic Left Pneumonectomy

Video-assisted thoracoscopic surgery (VATS) approaches to lobectomy for treatment of early stage non-small cell lung cancer (NSCLC) have generally been accepted to be beneficial. Experience and results for more extensive resections, including thoracoscopic pneumonectomy are limited. Here we report a case with attached videos describing key technical aspects of performing a thoracoscopic left pneumonectomy. This demonstrates the adoption of VATS for tumor pathology requiring pneumonectomy is feasible and can be done safely. Further study is needed to clarify potential advantages or drawbacks to approaching more complex tumor pathology by VATS.

Clinical Outcomes of Thoracoscopic Lobectomy for Patients With Clinical N0 and Pathologic N2 Non-Small Cell Lung Cancer

We compared the surgical outcomes in patients with clinical N0 and pathologic N2 (cN0-pN2) non-small cell lung cancer (NSCLC) who underwent video-assisted thoracoscopic surgery (VATS) lobectomy and open thoracotomy to evaluate the role of VATS lobectomy for cN0-pN2 disease. Between March 2006 and August 2011, 1,456 patients with clinical N0 NSCLC disease underwent lobectomy with systematic node dissection (SND) at Shanghai Chest Hospital. Of those patients, 157 were shown to have cN0-pN2 NSCLC. Of those, 67 patients underwent VATS lobectomy, and 90 patients underwent open lobectomy. SND was performed in all 157 patients. Clinicopathologic factors, local recurrence rates, and survival rates were compared. The two groups were similar in age, sex, and pulmonary function. The VATS approach was associated with significantly shorter chest tube duration and postoperative stay than was the thoracotomy approach. Operative mortality, morbidity, and recurrence did not differ between the two groups. There was no significant difference between the two types of operation in numbers of total lymph nodes removed (17.4 ± 6.1 in the VATS group vs 18.1 ± 7.2 in the open group, p = 0.78) and mediastinal lymph nodes removed (11.7 ± 5.6 in the VATS group vs 12.0 ± 5.1 in the open group, p = 0.84). Similarly, the two groups were not significantly different with regard to stations of total lymph nodes removed (7.6 ± 1.9 in the VATS group vs 7.8 ± 2.3 in the open group, p = 0.81) and mediastinal lymph nodes removed (4.5 ± 1.1 in the VATS group vs 4.7 ± 1.3 in the open group, p = 0.71). The rates of overall survival and disease-free 5-year survival were not significantly different between the two groups. The clinical outcomes of thoracoscopic lobectomy were comparable to those of thoracotomy for patients with cN0-pN2 NSCLC. Single-station N2 is a good prognostic factor for disease-free survival in these patients.

Surgical treatment for nonspecific esophageal motility disorders

Nonspecific esophageal motility disorder (NEMD) is a vague category that includes patients with poorly defined contraction abnormalities observed during esophageal manometry. This study investigated the therapeutic effects of the video-assisted thoracoscopic surgery (VATS) approach using long myotomy and fundopexy for NEMD. The VATS approach using myotomy and fundopexy was performed for 4 patients of NEMD between 2005 and 2008. A total of 4 patients with NEMD that underwent treatment at our institution were analyzed retrospectively. The patients included 2 males and 2 females with a median age of 48 years (range 21-74 years). The median duration of NEMD symptoms was 58 months (range 4-108 months). Dysphagia was a primary symptom in all patients. Chest pain was a primary symptom in 3 of 4 patients (75 %). Treatment with medication was attempted before the operation. The median operative time was 344.5 min (range 210-476 min). The median time before starting oral feeding was 2.5 days (range 2-22 days). All patients achieved a significant improvement of their previous condition. The VATS approach using myotomy and fundopexy for NEMD is a good treatment in cases resistant to medication and balloon dilation.

Diaphragmatic plication offers functional improvement in dyspnoea and better pulmonary function with low morbidity

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was as follows: In adults with unilateral diaphragmatic paralysis, does diaphragmatic plication offer functional improvement in dyspnoea, better pulmonary function tests (PFTs) and return to activity? A total of 126 papers were found using the reported search, of which 13 represented the best evidence to answer the clinical question. The authors, date and country of publication, patient group studied, surgical approach, study type, relevant outcomes and results of these articles are tabulated. Those articles reporting improvement in PFTs following plication, documented this benefit in the following parameters: mean forced vital capacity (range 17-40%), forced expiratory volume at 1 sec (range 21-27%), functional residual capacity (range 20-21%) and total lung capacity (range 16-19%). The percentage of postoperative improvement in shortness of breath as measured by a dyspnoea score was reported to be between 90 and 96% in the thoracotomy group and 100% in the Video Assisted Thoracoscopic Surgery (VATS) group, the dyspnoea score that was used in all the studies was a visual analogue scale between 0 and 10 where 0 is no dyspnoea and 10 is the worst dyspnoea a patient can have. One of the studies reported postoperative normalization in ventilation perfusion scan (VQ) scan parameters when compared with the preoperative mismatch. Complication rate was similar between the two groups, while the mortality rate was 4% in the thoracotomy group and 0% in the VATS group. The total number of patients included in all the studies combined was 161. All reports included in this review are observational studies (one cohort study and the remainder being case series); therefore, the risk of selection, information and publication biases are high and conclusions should be implemented with caution. We conclude that diaphragmatic plication can improve the functional status, shortness of breath and PFTs of patients with unilateral diaphragm paralysis. Patients undergoing a VATS approach appear to have more advantages in objective and subjective measures (including PFTs, dyspnoea score, length of hospital stay and postoperative complications). Further research with high-quality study designs is advised, focussing mainly on the long-term benefits and assessment of health-related quality of life.

Training in video-assisted thoracoscopic lobectomy.

Video-assisted thoracoscopic surgery (VATS) is a minimally invasive alternative to open thoracotomy for major pulmonary resection and has been shown to have a number of benefits. VATS lobectomy is a safe and cost-effective treatment option (1,2). Compared to open thoracotomy, VATS lobectomy is associated with a reduction in post-operative pain, lower incidence of pneumonia and a shorter hospital stay, whilst maintaining equivalent oncological outcomes and long-term survival (3-9). However, despite the perceived benefits of VATS lobectomy, the majority of lobectomies are still performed as open procedures with relatively few centres offering VATS. This may be because the VATS approach is considered to be technically demanding with the potential for catastrophic haemorrhage in the hands of an inexperienced surgeon. Furthermore, the difficulty in arranging training in VATS lobectomy has meant that the technique has been disseminated slowly. We believe that senior trainees and consultants with ample experience of open lobectomy can be trained to perform VATS lobectomy by an experienced VATS surgeon without affecting patient outcomes. We here report the experience of a senior cardiothoracic surgical trainee undertaking a one-year fellowship with intensive exposure to VATS lobectomy under the supervision of a highly experienced consultant in a high-volume thoracic surgical unit.

Comparison of the short-term outcomes of surgical treatment for non-small cell lung cancer via video assisted thoracoscopic surgery and open thoracotomy

To compare the short-term outcomes of surgical treatment for non-small cell lung cancer (NSCLC) by video-assisted thoracoscopic surgery (VATS) and open thoracotomy (OT). Data of 737 consecutive NSCLC patients who underwent surgical treatment for non-small cell lung cancer by video-assisted thoracoscopic surgery and 630 patients who underwent pulmonary resection via open thoracotomy (as controls) in Cancer Institute & Hospital, Chinese Academy of Medical Sciences between January 2009 and August 2011 were retrospectively reviewed. The risk factors after lobectomy were also analyzed. In the 506 NSCLC patients who received VATS lobectomy, postoperative complications occurred in 13 patients (2.6%) and one patient died of acute respiratory distress syndrome (0.2%). In the 521 patients who received open thoracotomy (OT) lobectomy, postoperative complications occurred in 21 patients (4.0%) and one patient died of pulmonary infection (0.2%). There was no significant difference in the morbidity rate (P > 0.05) and mortality rate (P > 0.05) between the VATS group and OT group. In the 190 patients who received VATS wedge resections, postoperative complications occurred in 3 patients (1.6%). One hundred and nine patients received OT wedge resections. Postoperative complications occurred in 4 patients (3.7%). There were no significant differences for morbidity rate (P = 0.262) between these two groups, and there was no perioperative death in these two groups. Univariate and multivariate analyses demonstrated that age (OR = 1.047, 95%CI: 1.004 - 1.091), history of smoking (OR = 6.374, 95%CI: 2.588 - 15.695) and operation time (OR = 1.418, 95%CI: 1.075 - 1.871) were independent risk factors of postoperative complications. To compare with the NSCLC patients who should undergo lobectomy or wedge resection via open thoracotomy, a similar short-term outcome can be achieved via VATS approach.

Cervical Video-Assisted Thoracoscopic Surgery Using a Flexible Endoscope for Bilateral Thoracoscopy

Video-assisted thoracoscopic surgery (VATS) has become the standard of care for pleural evaluation, drainage, and pleurodesis. The major limitations to standard VATS techniques include intercostal pain and the unilateral nature of the procedure. We report on a cervical VATS approach for bilateral thoracoscopy, pleural biopsy, and talc pleurodesis using a flexible video endoscope without any intercostal incision. A 64-year old male with peritoneal carcinomatosis was noted to have significant bilateral pleural effusions. A cervical video-assisted thoracoscopic surgery (C-VATS) procedure was performed through a 2-cm cervical incision using a sterile flexible gastroscope. Bilateral thoracoscopy, pleural drainage, pleural biopsies, lung biopsy, and talc pleurodesis were performed. No thoracic intercostal incisions were performed. Total operative time was 48 minutes. The procedure was successful and the recovery was uneventful. The patient was discharged 4 days after the procedure. C-VATS is an extremely minimally invasive procedure. It avoids intercostal incisions and allows for bilateral pleural procedures through a single small cervical incision.

Local Failure in Resected N1 Lung Cancer: Implications for Adjuvant Therapy

To evaluate actuarial rates of local failure in patients with pathologic N1 non-small-cell lung cancer and to identify clinical and pathologic factors associated with an increased risk of local failure after resection. All patients who underwent surgery for non-small-cell lung cancer with pathologically confirmed N1 disease at Duke University Medical Center from 1995-2008 were identified. Patients receiving any preoperative therapy or postoperative radiotherapy or with positive surgical margins were excluded. Local failure was defined as disease recurrence within the ipsilateral hilum, mediastinum, or bronchial stump/staple line. Actuarial rates of local failure were calculated with the Kaplan-Meier method. A Cox multivariate analysis was used to identify factors independently associated with a higher risk of local recurrence. Among 1,559 patients who underwent surgery during the time interval, 198 met the inclusion criteria. Of these patients, 50 (25%) received adjuvant chemotherapy. Actuarial (5-year) rates of local failure, distant failure, and overall survival were 40%, 55%, and 33%, respectively. On multivariate analysis, factors associated with an increased risk of local failure included a video-assisted thoracoscopic surgery approach (hazard ratio [HR], 2.5; p = 0.01), visceral pleural invasion (HR, 2.1; p = 0.04), and increasing number of positive N1 lymph nodes (HR, 1.3 per involved lymph node; p = 0.02). Chemotherapy was associated with a trend toward decreased risk of local failure that was not statistically significant (HR, 0.61; p = 0.2). Actuarial rates of local failure in pN1 disease are high. Further investigation of conformal postoperative radiotherapy may be warranted.

Video-Assisted Thoracoscopic Lobectomy Is Less Costly and Morbid Than Open Lobectomy: A Retrospective Multiinstitutional Database Analysis

The Premier Perspective Database (Premier Inc, Charlotte, NC) was used to compare hospital costs and perioperative outcomes for video-assisted thoracoscopic surgery (VATS) and open lobectomy procedures in the United States. Eligible patients underwent a lobectomy for cancer by a thoracic surgeon, by VATS or open thoracotomy and were captured in the database between third quarter of 2007 and through 2008. Multivariable logistic regression analyses were performed for binary outcomes. Ordinary least-squares regressions were used to estimate continuous outcomes. All models were adjusted for patient and hospital characteristics. A total of 3,961 patients underwent a lobectomy by a thoracic surgeon by open (n = 2,907) or VATS (n = 1,054) approach. Hospital costs were higher for open versus VATS; $21,016 versus $20,316 (p = 0.027). Adjustment for surgeon experience with VATS over the 6 months prior to each operation showed a significant association between surgeon experience and cost. Average costs ranged from $22,050 for low volume surgeons to $18,133 for high volume surgeons. For open lobectomies, cost differences by surgeon experience were not significant and both levels were estimated at $21,000. Length of stay was 7.83 versus 6.15 days, for open versus VATS (p = 0.000). Surgery duration was shorter for open procedures at 3.75 versus 4.09 for VATS (p = 0.000). The risk of adverse events was significantly lower in the VATS group, odds ratio of 1.22 (p = 0.019). Lobectomy performed by the VATS approach as compared with an open technique results in shorter length of stay, fewer adverse events, and less cost to the hospital. Economic impact is magnified as the surgeon's experience increases.

Invited Commentary

Invited Commentary

Video-assisted thoracoscopic surgery (VATS) anatomic lung resection.

Video-assisted thoracoscopic surgery (VATS) anatomic lung resections are rapidly gaining popularity around the world due to the minimally invasive nature of the procedure when compared to the traditional thoracotomy incision. Nevertheless, only 5-20% of anatomic lung resections performed in the U.S. are done via the VATS approach (1,2). Numerous publications, similar to the current study by Dr. Wang and colleagues (3), have demonstrated the feasibility of VATS lobectomy (4,5). There are many single institution retrospective studies demonstrating superiority of VATS lobectomy over the standard thoracotomy approach (6-8). If VATS lobectomy is so much better than open thoracotomy, why are there still an overwhelming majority of lung resections being performed through the standard open thoracotomy approach? Why hasn't VATS lobectomy procedure reached the same status as laparoscopic cholecystectomy? The answer may be simple. Currently, there is no level I evidence that VATS lobectomy is better than open thoracotomy approach. However, at the same time, there has never been a prospective randomized trial comparing laparoscopic cholecyctectomy versus open cholecystectomy either. To be fair, the analogy between lung resection and gallbladder resection may not be completely accurate. As oppose to cholecystectomy, the risk of life-threatening intraoperative hemorrhage from lung resection is much higher due to its anatomic proximity to great vessels such as pulmonary arteries and veins. When these bleeding complications occur, patients decompensate quickly. Our group has recently showed that VATS lobectomy incurred a higher intraoperative complication rate than open thoracotomy approach (1). Unlike cholecystectomy, intraoperative complications during VATS lobectomy are often immediately life-threatening. This may be the real reason why VATS has not been as rapidly adopted as other minimally invasive procedures. The size of the incision may not be the main cause of postoperative pain in open thoracotomy if one minimizes rib spreading and avoid compressing the intercostals nerve bundles. The major determinant of postoperative length of stay for lobectomy patients is usually the duration of air leak. In light of the aforementioned points and the potential deadly bleeding complications from VATS, most thoracic surgeons have not adopted this technique widely. There is no doubt that in centers of excellence, VATS lobectomy can be performed with more superior outcomes than the standard thoracotomy approach. However, as competent and ethical surgeons, we must inform our patients of potential benefits and risks of both VATS and thoracotomy approach prior to proceeding with the operation.

Outcomes of a hybrid technique for video-assisted thoracoscopic surgery (VATS) pulmonary resection in a community setting.

Video-assisted thoracoscopic surgery (VATS) for pulmonary resection was first described 18 years ago; however, it has yet to gain widespread acceptance in community hospitals in the United States. The majority of surgeons who routinely perform VATS resections work in academic or government institutions. There is little data reporting outcomes of VATS pulmonary resections by community-based surgeons. This article reports the outcomes of a hybrid technique for VATS pulmonary resection in a single-surgeon, community-based practice. A retrospective study was performed on all VATS pulmonary resections performed from January 2000 to March 2008 by a community-based, solo-practice surgeon using a hybrid VATS technique, which utilizes dual access through a thoracoscopy port and a utility incision. A total of 1170 VATS pulmonary resections were performed over the study period, which is the largest single-surgeon series on VATS pulmonary resection to our knowledge. Among them, 746 cases were for malignant disease. Mean operative time was 52 minutes (median 48 minutes). Mean length of stay was 7 days (median 4 days). Mean length of ICU stay was 1.4 days, with 83% of patients having no days spent in the ICU. Mean length of chest tube duration was 4.5 days. The morbidity rate was 21.1 %, with neuropraxia as the most frequent complication. Perioperative mortality was 4.3% and overall mortality was 16.4%, with a mean follow-up of 425 days. This series shows that our hybrid VATS approach to pulmonary resection is safe and feasible at community hospital-based practices.

The results of wedge resection and partial pleurectomy in the surgical treatment of primary spontaneous pneumothorax: videothoracoscopy or axillary thoracotomy?

Background: In this study we compared the results of wedge resection and partial pleurectomy in primary spontaneous pneumothorax (PSP) patients treated using video-assisted thoracoscopic surgery (VATS) and axillary thoracotomy approaches. Methods: Four-hundred and seventy-eight patients were treated in our clinic for PSP between January 2007 and December 2008. We performed 110 apical wedge resections with a stapler and a partial pleurectomy in 101 patients. Fortyfive of the procedures were performed with VATS (group V) and 65 with axillary thoracotomy (group T) approaches. The two groups were compared with respect to the duration of the procedure, number of stapler reload units used, duration of chest tube, requirement for postoperative narcotic analgesics, postoperative complications, need for reoperation, and recurrence rate. Student's t-test, the chi-square test, and Fisher's exact test were used for the statistical analysis. Results: There were no significant differences between groups V and T in terms of age, gender, smoking habits, pneumothorax side, surgical indications, duration of surgery, postoperative duration of chest tube, postoperative complication rate, reoperation rate, or recurrence rate. Narcotic analgesics were needed in five cases in group V and 20 cases in group T (p=0.02). The mean number of stapler reload units used during the operation was 2.7 in group V and 1.43 in group T (p