INTRODUCTION

Lung cancer remains the most common cause of cancer death in the United States for both men and women. Approximately 170,000 deaths each year are attributable to lung cancer, surpassing the number of deaths due to the next four most common cancers combined.¹ The majority of these cases are due to non–small cell lung carcinoma (NSCLC). Most patients present with advanced locoregional or disseminated disease, and despite advances in multimodality treatment of this disease, the 5-year survival remains 10% to 12%. However, when patients with lung cancer are diagnosed at an early stage, the overall 5-year survival may exceed 70% to 80%.²

Complete surgical resection remains the cornerstone for curative therapy of NSCLC.^3,4 The first successful resection for lung cancer, a pneumonectomy, was performed by Evarts Graham in 1933. An anatomic resection, preferably a lobectomy or pneumonectomy and, in some instances, segmentectomy, is the standard treatment for stage I or II NSCLC.⁵ Between 20% and 30% of all patients with new lung cancers have disease that is amenable to surgical treatment. The remainder of patients present with locally unresectable disease or with distant metastases. Neoadjuvant strategies involving chemotherapy, thoracic radiation, or both can render some of these patients subsequently resectable. Nonanatomic wedge resections are used for diagnostic purposes and, in rare instances, for the local control of lung cancer.

The first description of thoracoscopy appeared in 1910, when pleural adhesions were lysed with the use of a cystoscope.⁶ With the advent of selective bronchial intubation, the use of thoracoscopy expanded from addressing pleural processes to performing bullectomies and wedge resections, and it is now utilized in the surgical treatment of lung cancer with anatomic lung resections. Video-assisted thoracic surgery (VATS) lobectomy has been employed in the treatment of lung cancer since 1993.^7,8

No large, prospective, randomized studies have been reported comparing video-assisted lobectomy with those performed via the traditional open approach. There are, however, some small, nonrandomized studies comparing outcomes with these two surgical approaches.^9,10 Data from these series, as well as others,^7,8,11–13 demonstrate that in experienced hands, lobectomy by either approach is associated with minimal morbidity and mortality. The perioperative mortality rate associated with a VATS lobectomy is less than 1%, which compares favorably with the open approach. Video-assisted thoracoscopic anatomic resections are certainly more technically demanding than those carried out via a conventional approach. There have been no prognostic variables identified to date that are able to predict intraoperative complications in patients undergoing pulmonary lobectomy.

The VATS operation consists of individual hilar ligation via three to four small incisions without rib spreading. This anatomic lobectomy should replicate the identical oncologic principles as those achieved via traditional thoracotomy.¹⁴ That is, the surgeon resects the tumor with negative margins performing individual vascular and bronchial ligation and division, with a complete hilar node dissection. Furthermore, a mediastinal lymph node dissection, or sampling, is performed, as appropriate. Certain aspects in VATS lobectomies, such as avoiding rib spreading and/or the use of a rib retractor, are emphasized with the goal of improving the patient’s postoperative experience. Cosmetic aspects such as smaller scars (the largest incision is usually 5 to 8 cm) are also important. One variant, the video-assisted simultaneously stapled lobectomy, does not employ individual hilar ligation. In essence, it is a different operation and is not discussed in this chapter. Nevertheless, some surgeons have achieved excellent results with this technique.¹⁵

INDICATIONS

OPERATIVE STEPS

OPERATIVE PROCEDURE

Incision/Thoracoscopic Port Placement

Intercostal Bundle Injuries

After the patient is placed in a lateral decubitus position, the chest is typically entered through a serratus-sparing, limited posterolateral thoracotomy in either the fourth or the fifth interspace for traditional open lobectomies. To facilitate exposure and avoid unintentional rib fracture with retraction, we routinely remove a small segment of posterior rib in a subperiosteal fashion with a rib cutter.

To perform a thoracoscopic lobectomy, two ports and an access incision are usually required (Fig. 65-1). This is an incision 5 cm or less that aids in the hilar dissection and through which the specimen is extracted via an endoscopic bag. Avoiding rib spreading is the key element in VATS lobectomy to prevent postoperative pain and trauma to the intercostal nerve bundles responsible for the post-thoracotomy pain syndrome.

Figure 65-1 The three thoracoscopic port incisions for completion of a video-assisted thoracic surgery (VATS) right upper lobectomy. The 5-cm access incision is placed in the fourth intercostal space and in the anterior axillary line. The camera port is placed in the seventh interspace, and the posterior port is located in the fourth intercostals space, posterior to the tip of the scapula.

(From Nicastri DG, Yun J, Swanson SJ. VATS lobectomy. In Sugarbaker DS, Bueno R, Zellos L (eds): Adult Chest Surgery: Concepts and Procedures. New York: McGraw-Hill, Inc., 2006. Reprinted with permission.)

Port placement may vary slightly owing to patient body habitus, location of the tumor, and surgeon preference. However, optimal port placement is important for safe and successful resection. The first port is the camera port, and it is usually placed within the seventh or eighth intercostal space. Whether it is in the anterior, middle, or posterior axillary line depends on the level of the diaphragm as seen from a review of a preoperative chest x-ray, on the location of the pathology, and on left-versus right-sided procedures. Ideally, this port should provide views of the anterior and posterior hilum and should align with the major fissure. We almost exclusively use a 30° thoracoscope. It provides optimal views, not afforded by a 0° scope, particularly during the difficult dissection around the superior hilum. The anterior port should be placed right over the hilum because this will be used as the access/utility port. Dissection of both the hilum and the fissure will be performed through this port. This incision is initially 1 to 2 cm. It is not extended to 5 centimeters in length until we have decided to proceed with the VATS lobectomy. The port is usually created anterior to the latissimus dorsi in the fourth intercostal space for upper lobectomies and in the fifth intercostal space for lower lobectomies. The third port is usually in the fourth or fifth intercostal space, either inferior or posterior to the scapular tip. This port usually serves as the lung retraction port. Hemostasis is very important when creating the ports because bleeding from the port sites onto the camera, and onto the surgical field, during the procedure is a nuisance and can significantly prolong the operation.

Post-thoracotomy pain is believed to be caused by rib spreading with resultant trauma to the intercostal nerve. Benedetti and coworkers¹⁶ analyzed superficial abdominal reflexes in patients after posterolateral thoracotomy and concluded that increased incisional pain intensity may be due to intercostal nerve impairment. Many studies evaluated the intensity of acute pain after minimally invasive thoracic surgery. In particular, Landreneau and associates¹⁷ performed a study comparing 165 patients who had a lung resection through a posterolateral thoracotomy with 178 patients who had a VATS resection.¹⁷ At 1-year follow-up, there was a significant difference in overall pain, pain intensity scores, and shoulder function between the two groups, favoring a VATS approach.

• Consequence

Intercostal nerve trauma may be associated with chronic pain syndromes such as intercostal neuralgias.

Grade 1/2 complication

• Repair

Once the intercostal nerve has been injured, little can be done to repair it. Usually, such an injury is not recognized until subsequent postoperative visits. At this time, the patient complains of a chronic pain syndrome that does not improve with healing.

• Prevention

Avoiding pressure on the intercostal bundle while using the thorascopic instruments is the best way to prevent injury to these structures.

Lung Mobilization

Phrenic Nerve Injury

Once access to the chest cavity is obtained, a thorough exploration is performed. The pleural surface is inspected for tumor implants and any adhesions are lysed sharply with cautery or with an ultrasonic cutting and coagulation device. Extensive pleural adhesions are not a contraindication to proceed with a VATS lobectomy. Careful and complete adhesiolysis allows full mobility of the lung. Retraction of the lung is critical to being able to complete the resection.

The discovery of tumor invasion into the chest wall is a contraindication to a VATS approach because it requires en-bloc chest wall resection. Digital palpation of the tumor and lung is performed through the anterior/access port to confirm the location and presence of the tumor and also to rule out additional unsuspected nodules or pathology not identified on preoperative studies. In VATS resections, ipsilateral mediastinal lymph node sampling is performed, especially if mediastinoscopy was not performed earlier. If N2 disease is discovered on frozen section, the VATS resection is aborted and the patient is treated with neoadjuvant therapy. If a preoperative tissue diagnosis has not been determined, a wedge or core biopsy is performed initially, followed by lobectomy if frozen section reveals carcinoma.

• Consequence

Circumferential evaluation of the hilar structures should then be performed to determine lung resectability. The salient goal of lobectomy is to ligate and divide the major vessels and bronchus with clear margins. To achieve this, the hilar pleura is opened. Anteriorly, the course of the phrenic nerve should be identified and the pleura should be opened posterior to this structure (Fig. 65-2). Inadvertent injury of the phrenic nerve leads to paralysis of the ipsilateral hemidiaphragm. This complication has not been adequately described in the literature for patients undergoing pulmonary lobectomy. The effects of unilateral phrenic nerve transection have been studied in young patients with normal preoperative respiratory function who have undergone phrenic nerve transfer for brachial plexus injuries.¹⁸ In these patients with normal lung function, there was no evidence of diminished pulmonary function parameters within 1 year. One could anticipate significant pulmonary compromise and complications with phrenic nerve injuries in patients undergoing pulmonary lobectomy. Most of these patients have baseline pulmonary dysfunction and will also have reduced pulmonary capacity associated with lung resection.

Grade 2/3 complication

Figure 65-2 A, The right upper lobe is retracted posteriorly, exposing the superior pulmonary vein (thin arrow). The right phrenic nerve is visualized (thick arrow) as it lies anterior to the pulmonary hilum. The nerve should be carefully mobilized away from the anterior hilum to avoid inadvertent injury. B, The left upper lobe is retracted posteriorly. The left phrenic nerve (thin arrow) is visualized and dissected anteriorly during isolation of the left superior pulmonary vein (thick arrow).

• Repair

Direct neural repair is not recommended. If significant postoperative respiratory insufficiency exists, potential surgical interventions can be performed to improve respiratory function. Diaphragmatic plications via thoracoscopic and open techniques have been developed to achieve this goal.^19,20 In a recent study of 22 patients with unilateral diaphragm paralysis, VATS diaphragmatic plication resulted in significant improvements in patients’ functional status, pulmonary spirometry, and dyspnea scores.¹⁹ There was no operative mortality, and the mean length of hospital stay was 3.7 days. Long-term follow-up in a similar group of patients undergoing plication via a thoracotomy found durable results exceeding 10 years.²⁰ Phrenic nerve pacing with diaphragmatic electrodes has also resulted in clinical improvements in ventilator-dependent, quadriplegic patients.²¹ This technique has not been employed for patients with unilateral phrenic nerve dysfunction.

• Prevention

Early identification and preservation of the phrenic nerve should allow the surgeon to avoid this potentially devastating injury.

Esophageal Injury

The inferior pulmonary ligament is typically divided in all pulmonary lobectomies. This is performed during upper lobectomies, allowing the lower lobe to potentially decrease the amount of intrathoracic space associated with lung resection. Access to the inferior pulmonary vein for lower lobectomies is facilitated by division of the pulmonary ligament. This structure is a remnant of the embryologic pleural fold and lies in close proximity to the inferior pulmonary vein and esophagus.

• Consequence

Unrecognized esophageal injury can lead to a delayed presentation of esophageal perforation and sepsis. Esophagopleural fistulas, although uncommon, have been most frequently described after pneumonectomy for both benign and malignant diseases.²² This can be secondary to injury directly onto the esophagus or to its vascular supply from extensive dissection.

Grade 3/4/5 complication

• Repair

If recognized intraoperatively, esophageal injuries from electrocautery or sharp dissection can be repaired with layered repair and vascularized tissue buttress. Delayed recognition of esophageal injuries often requires control of infection, hyperalimentation, and either closure of the injury or possibly esophagectomy. Covered esophageal stent placement can be considered as an alternative approach in selected cases.

• Prevention

The lower lobe is gently grasped and retracted cephalad. The pulmonary ligament is placed on adequate tension and then divided with electrocautery. Care must be taken to identify the underlying esophagus and inferior pulmonary vein (Fig. 65-3). Adequate exposure should prevent esophageal injury as well as possible life-threatening hemorrhage associated with damage to the inferior pulmonary vein.

Figure 65-3 The right lower lobe is retracted anteriorly, placing the right inferior pulmonary ligament in tension. This maneuver allows proper visualization of the esophagus (arrow) and avoids esophageal injury during division of the pulmonary ligament.

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