Uniportal lobectomy and segmentectomy-is it for all?

Technological advances have markedly transformed the philosophy of thoracic surgery in the current era, with notable improvements in patient outcomes with video-assisted thoracoscopic surgery (VATS). More recently, innovations in uniportal VATS approaches have been promising, although robust data on their efficacy is limited. Nonetheless, the lessons learned from experience with the 2-port and 3-port VATS lobectomy and segmentectomy can be applied to further improve the efficacy of uniportal approaches, in terms of achieving oncologic efficacy and improving patient outcomes. This perspective reviews contemporary outcomes of uniportal lobectomy and segmentectomy, highlights our institutional experience, and examines future directions and challenges pertaining to widespread adoption of this innovative technique.

Thoracoscopic lobectomy after induction therapy-a paradigm shift?

Video-assisted thoracoscopic approaches (or VATS) have gained significant momentum in the management of locally advanced NSCLC in the current era. Accrual of experiences and concurrent improvements in instrumentation and video technology have further enhanced its role in patients with stage IIIA (N2) non-small cell lung cancer (NSCLC). However, substantial controversy exists around the notion of mediastinal staging and restaging after induction therapy, the utility of induction chemotherapy versus chemoradiation for N2 disease, and subsequent role of video-assisted thoracoscopic surgery (VATS) lobectomy following induction therapy. This perspective will closely examine these issues in the context of existing guidelines and contemporary studies.

Modified uniportal video-assisted thoracoscopic surgery (VATS).

Video-assisted thoracoscopic surgery (VATS) for resectable lung cancer patients has been frequently used in the past decades. The potential beneficial advantages and safety of VATS has been shown in large patient series and meta-analyses. The strategy of limiting access to one incision in one intercostal space (uniportal VATS) has been adopted by some thoracic surgeons in recent years. We have described a modified uniportal VATS technique with its potential advantages. Modified uniportal VATS potentially offers better exposure, beneficial opportunities for education and improved comfort for the thoracic surgery team in clinical usage.

Troubleshooting hilar and interlobar lymphadenopathy during thoracoscopic lobectomy for benign disease-case report.

The completion of thoracoscopic lobectomy can be more difficult in the setting of clinically positive lymph nodes, which may be found in the setting of a proximal tumor causing bronchial obstruction or a larger tumor which may create an inflammatory state, both of which cause benign significant enlargement of hilar lymph nodes. Knowledge of the typical locations of these enlarged nodes facilitates the conduct of the operation. For all video-assisted thoracoscopic surgery (VATS) lobectomies, it is prudent to remove all visible lymph nodes prior to arterial and bronchial dissection. Moreover, in cases of significant hilar adenopathy, this strategy becomes more important and effective. For left upper lobectomy, the removal of level 11 lymph node anteriorly improves visualization of both bronchi, the interlobar pulmonary artery, the arterial aspect of the fissure, and the lingular artery. Subsequent dissection of the level 10 lymph node superior to the upper lobe bronchus exposes the main pulmonary artery and the truncal branches. For right upper lobectomy, dissection of the level 11 lymph node posteriorly not only exposes the upper lobe bronchus, but also the adjacent posterior ascending pulmonary artery. Dissection of the level 10 lymph node at the superior hilum facilitates exposure of the right pulmonary artery.

Division of the bronchus: an approach to the intraoperative management of difficult lymphadenopathy.

BACKGROUND: A minimally invasive approach to lung cancer resection offers many benefits over traditional open surgery. Reasons for increased difficulty and conversion from thoracoscopic to open surgery have been studied and include abnormal hilar or interlobar lymphadenopathy. METHODS: We present a case of adherent lymphadenopathy complicating dissection of the truncus anterior branch of the pulmonary artery during thoracoscopic left upper lobectomy. RESULTS: We show one approach to the management of difficult lymphadenopathy and pulmonary arterial isolation, that of division without closure of the lobar bronchus to allow superior access to the branches of the pulmonary artery, followed by stapled closure of the bronchus. CONCLUSIONS: While adherent lymphadenopathy is a vexing problem in thoracoscopic lobectomy, minimallyinvasive approaches are safe and effective. We show that division of the bronchus can improve exposure and allow safe dissection to proceed.

Management of pulmonary arterial bleeding in the post induction setting.

BACKGROUND: A minimally invasive approach to lung cancer resection offers many benefits over traditional open surgery. Pulmonary arterial injury is a widely cited reason for conversion to open surgery. METHODS: We present a case of pulmonary arterial injury complicating dissection of the pulmonary artery during thoracoscopic left upper lobectomy. Ethical approval was obtained from the institutional ethics board and written consent was obtained from the patient. RESULTS: Thoracoscopic management of pulmonary arterial bleeding is demonstrated. We show maintenance of a thoracoscopic approach with establishment of proximal pulmonary arterial control, allowing suture repair of an injury to the ongoing pulmonary artery. CONCLUSIONS: While pulmonary arterial injury may be a significant problem during thoracoscopic lobectomy, minimally invasive approaches to repair are safe and effective.

Training Assistants Improves the Process of Adoption of Video-Assisted Thoracic Surgery Lobectomy.

BACKGROUND: Despite overwhelming evidence of decreased pain, fewer complications, and shorter length of stay with equivalent oncologic outcomes, video-assisted thoracic surgery (VATS) lobectomy has been slow to be adopted in the community. This study evaluates the role of training surgical assistants to ease the transition to VATS lobectomy. METHODS: A half-day training course for physician assistants in the specific skills needed to assist with VATS lobectomy was developed to be offered annually in conjunction with a national meeting. Each participant completed a needs assessment before the course and a course assessment afterward. One-year follow-up data were obtained from the first cohort to determine the effects of the course on their practice. RESULTS: Forty-four physician assistants participated in the course in either 2013 or 2014. Participant-identified educational needs included enhanced camera navigation skills, use of specialized instruments, and knowledge of the steps of the operation to provide proactive assistance. After completing the course, 90% (n = 39) felt more confident in their ability to provide optimal visualization for the operating surgeon, and 93% (n = 40) felt more confident in their ability to recognize and anticipate the steps of a VATS lobectomy. These changes persisted at 1 year. CONCLUSIONS: Specific training directed at surgical assistants may improve the adoption of new technology by mechanisms including improved visualization and better understanding of methods to facilitate the operation and avoid frustration. This type of training should be made available to assistants of surgeons learning new operations.

Modified uniportal video-assisted thoracoscopic lobectomy: Duke approach.

Traditional thoracoscopic strategies using two to four ports has been demonstrated to be oncologically successful for patients with resectable lung cancer, with numerous advantageous over thoracotomy. A single-incision approach has been described, but it is associated with potential disadvantages. The modified uniportal approach described may address those disadvantageous, with retention of the potential advantages of using a single incision.

Challenging cases: thoracoscopic lobectomy with chest wall resection and sleeve lobectomy-Duke experience.

Video-assisted thoracoscopic surgery (VATS) had recent advances in both equipment and technique so has been applied to more complex conditions in some thoracic surgery centers. We have adopted our VATS lobectomy experience for patients with chest wall invasion and endobronchial localized tumor requiring bronchial sleeve resection. We are describing our decision-making and surgical methods for these patients which we believe will be decreasing the number of contraindications for VATS and offering this surgical method for more patients.

Thoracoscopic pneumonectomy in management of histoplasmosis and fibrosing mediastinitis.

Pulmonary histoplasmosis is generally a self-limited respiratory illness in endemic areas. Fibrosing mediastinitis is a severe chronic complication of pulmonary histoplasmosis in which pulmonary vessels and airways can be compressed with the potential for life-threatening implications. We present a 50-year-old male patient who presented with a total occlusion of the left pulmonary artery due to fibrosing mediastinitis.

Needs assessment for an errors-based curriculum on thoracoscopic lobectomy.

BACKGROUND: Research suggests a benefit from a skills curriculum emphasizing error prevention, identification, and management. Our purpose was to identify common errors committed by trainees during simulated thoracoscopic lobectomy for use in developing an error-based curriculum. METHODS: Twenty-one residents (postgraduate years 1 to 8) performed a thoracoscopic left upper lobectomy on a previously validated simulator. Videos of the procedure were reviewed in a blinded fashion using a checklist listing 66 possible cognitive and technical errors. RESULTS: Of the 21 residents, 15 (71%) self-reported completing the anatomic lobectomy; however, only 7 (33%) had actually divided all of the necessary structures correctly. While dissecting the superior pulmonary vein, 16 residents (76%) made at least one error. The most common (n=13, 62%) was dissecting individual branches rather than the entire vein. On the bronchus, 14 (67%) made at least one error. Again, the most common (n=9, 43%) was dissecting branches. During these tasks, cognitive errors were more common than technical errors. While dissecting arterial branches, 18 residents (86%) made at least one error. Technical and cognitive errors occurred with equal frequency during arterial dissection. The most common arterial error was excess tension on the vessel (n=10, 48%). CONCLUSIONS: Curriculum developers should identify skill-specific technical and judgment errors to verify the scope of errors typically committed. For a thoracoscopic lobectomy curriculum, emphasis should be placed on correct identification of anatomic landmarks during dissection of the vein and airway and on proper tissue handling technique during arterial dissection.

Validation of a thoracoscopic lobectomy simulator.

OBJECTIVES: Although simulation is considered integral to general surgery training, its role has only recently been recognized in thoracic surgical education, perhaps due to a lack of widely available, validated simulators for advanced thoracic procedures. This study evaluates the construct, content and face validity of an inexpensive, easily reproducible simulator for teaching thoracoscopic lobectomy. METHODS: Construct validity (ability of the simulator to discriminate between users of different skill levels) was assessed by having surgical trainees perform a lobectomy on the simulator. Participants were divided into three groups (experienced, intermediate and novice) based on self-reported experience with minimally invasive surgery. After instruction and practice time to limit the effect of any simulator-specific learning curve, each performed a left upper lobectomy that was scored using a standardized assessment tool incorporating total time plus weighted penalty minutes assigned for errors. Content validity (simulator requires same steps and decision-making as a clinical lobectomy) was assessed using a Likert scale by those participants who had previously seen a thoracoscopic lobectomy in a patient. RESULTS: Thirty-one residents participated in the study (12 experienced, 6 intermediate and 13 novice). All 12 experienced participants completed the lobectomy. The other groups were less successful with 4 of 6 in the intermediate group and 5 of 13 in the novice group completing the lobectomy (P = 0.004). The mean times for lobectomy + penalty minutes were 35 + 6.8 (experienced), 50 + 13 (intermediate) and 54 + 20 (novice). Differences between groups were statistically significant for experienced vs. novice (P < 0.001) and experienced vs. intermediate (P < 0.04). Content validity was assessed by the 18 participants who had previously seen a thoracoscopic lobectomy with a mean of 9.2 of 10 possible points. CONCLUSIONS: The thoracoscopic lobectomy simulator used in this study demonstrates acceptable validity and can be a useful tool for teaching thoracoscopic lobectomy to trainees or experienced surgeons.

Feasibility of hybrid thoracoscopic lobectomy and en-bloc chest wall resection.

OBJECTIVES: Lobectomy with an en-bloc chest wall resection is an effective but potentially morbid treatment of lung cancer invading the chest wall. Minimally invasive approaches to lobectomy have reduced morbidity compared with thoracotomy for early stage lung cancer, but there is insufficient evidence regarding the feasibility of hybrid thoracoscopic lobectomy chest wall resection. We reviewed our experience with an en-bloc chest wall resection and lobectomy to evaluate the outcomes of a hybrid approach using thoracoscopic lobectomy combined with the chest wall resection where rib spreading is avoided. METHODS: All patients who underwent lobectomy and en-bloc chest wall resection with ribs for primary non-small cell lung cancer from January 2000 to July 2010 were reviewed. Starting in April 2003, a hybrid approach was introduced where thoracoscopic techniques were utilized to accomplish the pulmonary resection and a limited counter incision was used to perform the en-bloc resection of the chest wall, avoiding scapular mobilization and rib spreading. Preoperative, perioperative and outcome variables were assessed using the standard descriptive statistics. RESULTS: During the study period, 105 patients underwent en-bloc lobectomy and chest wall resection, including 93 patients with resection via thoracotomy and 12 patients with resection via the hybrid thoracoscopic approach. Complete resection was achieved in all patients in both groups. Tumour size and the extent of resection were similar in the two groups. There were no conversions and no perioperative mortality in the hybrid group. Post-operative outcomes were similar, although patients who underwent the hybrid approach had a shorter length of stay (P = 0.03). CONCLUSIONS: A hybrid approach that combines thoracoscopic lobectomy and chest wall resection is feasible and effective in selected patients. The use of a limited counter incision without rib spreading does not compromise oncologic efficacy. Further experience is needed to determine if this approach provides any advantage in outcomes, including post-operative morbidity.

Thoracoscopic lobectomy is a safe and versatile procedure: experience with 500 consecutive patients.

OBJECTIVE: Advantages of thoracoscopic lobectomy for early stage non-small cell lung cancer (NSCLC), as compared with lobectomy by conventional thoracotomy, include less postoperative pain and shorter length of hospitalization. The outcomes after thoracoscopic lobectomy in patients with more complex pulmonary conditions are analyzed to determine safety, efficacy, and versatility. METHODS: A prospective database of 500 consecutive patients who underwent thoracoscopic lobectomy between June 1999 and January 2006 was queried. Demographic, histopathologic, perioperative, and outcome variables were assessed using standard descriptive statistics and Kaplan-Meier survival analyses. RESULTS: Thoracoscopic lobectomy was successfully performed in 492 patients (conversion rate, 1.6%). Pathologic analysis included primary NSCLC in 416 patients (83.2%), centrally located secondary pulmonary malignancy in 37 patients (7.4%), and a variety of benign conditions in 45 patients (9%). Among the 416 patients with NSCLC, pathologic analysis demonstrated stage I in 330 patients (55.3%), stage II in 40 patients (9.6%), and stage III or greater NSCLC in 44 patients (10.6%). The operative and perioperative (30-day) mortality was 0% and 1%, respectively. The overall 2-year survival rate for the entire cohort was 80%, and the 2-year overall survival rates for stage I NSCLC, stage II or greater NSCLC, secondary pulmonary malignancy, and granulomatous disease patients were 85%, 77%, 73%, and 89%, respectively. CONCLUSIONS: Thoracoscopic lobectomy is applicable to a spectrum of malignant and benign pulmonary disease and is associated with a low perioperative morbidity and mortality rate. Survival rates are comparable to those for lobectomy with thoracotomy.

Thoracoscopic lobectomy: a safe and effective strategy for patients with stage I lung cancer.

BACKGROUND: Thoracoscopic lobectomy is emerging as a potential alternative to thoracotomy for early stage lung cancer. The issues of safety and oncologic efficacy should be analyzed before recommending this procedure for widespread use. METHODS: Thoracoscopic lobectomy was attempted in 110 consecutive patients (age, 35 to 81 years) with tumors that were judged to be amenable to lobectomy over a 26-month period. Exclusion criteria included tumors greater than 5 cm in diameter, T3 tumors, endobronchial tumors visible at bronchoscopy, the use of induction therapy, extensive N1 disease on computed tomographic scan, and N2 disease at mediastinoscopy. The procedures were performed without rib spreading using two ports and included anatomic hilar dissection and individual vessel stapling. RESULTS: Thoracoscopic lobectomy and mediastinal lymph dissection was successfully performed in 108 patients (98.2%); 2 patients required conversion to thoracotomy to control bleeding in the setting of dense hilar adenopathy. There were no intraoperative deaths and 4 perioperative deaths (3.6%) caused by pneumonia and associated adult respiratory distress syndrome (3 patients) and stroke (1 patient). Major complications included pneumonia (5 patients), stroke (1 patient), and return to the operating room to revise the bronchial closure (1 patient). Minor complications included prolonged air leak (6 patients), atrial fibrillation (4 patients), blood transfusion (2 patients) and ileus (1 patient). Median time to chest tube removal was 3 days, and median length of stay was 3 days. CONCLUSIONS: Thoracoscopic lobectomy is a safe and effective strategy for patients with early stage lung cancer. Long-term follow-up is required to determine if recurrence rate and 5-year survival are comparable with thoracotomy for lobectomy.