Chapter 65 Lobar Resections
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
OPERATIVE PROCEDURE
Incision/Thoracoscopic Port Placement
Intercostal Bundle Injuries
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.
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
Lung Mobilization
Phrenic Nerve Injury
• Consequence
• Repair
Esophageal Injury
• Consequence
• Repair
• Prevention
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