Frontiers of minimally invasive thoracic surgery

FRONTIERS OF MINIMALLY INVASIVE THORACIC SURGERY

CONTENTS

Preface
xi Gaetano Rocco
Retraction
xiii
The Variability of Practice in Minimally Invasive Thoracic Surgeryfor Pulmonary Resections
235 Gaetano Rocco, Eveline Internullo, Stephen D. Cassivi,Dirk Van Raemdonck, and Mark K. Ferguson
VOL

Although minimally invasive thoracic surgery (MITS), under various denominations, iscurrently the accepted approach to the management of several thoracic diseases, its usefor the treatment of lung cancer and infectious conditions of surgical interest is stilldebated, both from a philosophic and a technical point of view. The concept ofminimally invasive pulmonary resections still provokes several controversies as to theterminology, the indications, and the techniques used by different surgeons. The issue ofthe variability of practice in this field of MITS is addressed through an analysis of themost recent literature and the results of an international survey that was originated anddevised by the European Society of Thoracic Surgeons and supported by CTSnet.

VATS Lobectomy is Better than Open Thoracotomy: What is the Evidencefor Short-Term Outcomes?
249 Eric L. Grogan and David R. Jones
Lung cancer remains the leading cause of cancer death in the United States, with morethan 200,000 new cases each year and 160,000 deaths. Surgical resection with ananatomic resection (typically a lobectomy) remains standard care for patients who havestage I and stage II non-small cell lung cancer. In the past 15 years, video-assistedthoracic surgery (VATS) has been used with increasing frequency worldwide to performanatomic resections for lung cancer. This article reviews the current VATS lobectomyseries and studies published since 2000 that compare VATS to open lobectomy.

Long-Term Outcomes of Thoracoscopic Lobectomy
259 Thomas A. D’Amico
Thoracoscopic lobectomy is associated with superior outcomes, as measured by manyimportant quality of life variables, as opposed to thoracotomy by lobectomy. Despitethese proved advantages, concern has existed regarding the long-term outcomes ofthoracoscopic lobectomy, which has limited its use. Review of the available literature

UME 18 Æ NUMBER 3 Æ AUGUST 2008 v

vi

suggests that the long-term outcomes of thoracoscopic lobectomy are at least equivalentto, and may be superior to, conventional approaches.

Video-Assisted Thoracic Surgery Lobectomy: Centers of Excellenceor Excellence of Centers?
263 Cynthia S. Chin and Scott J. Swanson
Currently, an anatomic lobectomy or segmentectomy and complete mediastinal lymphnode dissection can be achieved through two to four small incisions, without ribspreading, using videoscopic visualization. This article discusses the assimilation of thistechnique, video-assisted thoracic surgery lobectomy, into the practice of a thoracicsurgeon and attempts to answer the question: How do we, as professionals, assurequality (defined as a proper oncologic surgery) and safety while introducing this newtechnology?

Minimally Invasive Open Surgery Approach for the Surgical Resectionof Thoracic Malignancies
269 Hisao Asamura
This article describes minimally invasive open surgery for resection of intrapulmonarymalignancies. This approach compensates for the weak points of video-assisted thoracicsurgery while remaining minimally invasive. Overall, it is respected as a technicallyfeasible alternative to conventional lobectomy by way of open thoracotomy with anacceptable range of morbidity or mortality.

Complications and Learning Curves for Video-Assisted ThoracicSurgery Lobectomy
275 Robert J. McKenna Jr
Launching new techniques into a medical practice involves the educational process totrain surgeons about the new technique, a learning curve for surgeons as they introducethe new procedure to their patients, and comparison of the complications for the newand older techniques. This article addresses these issues, as well as the introduction ofthese new techniques into the practice of thoracic surgery.

The VATS Lobectomist: Analysis of Costs and Alterationsin the Traditional Surgical Working Pattern in the Modern Surgical Unit
281 William S. Walker and Gianluca Casali
Analysis of cost issues in video-assisted thoracic surgery (VATS) lobectomy iscomplicated by social and health care system factors. Overall, VATS lobectomy costsare similar to open lobectomy. Operating room costs are noticeably increased but aremore than offset by reduced inpatient stay with consequent generation of bed days forother cases. VATS lobectomy is one of a series of minimally invasive tools available tosurgeons. With appropriate skills and resourcing, VATS resections could account for30% of the lobectomies undertaken in most units.

Robotically Assisted Lobectomy: Learning Curve and Complications
289 Franca M.A. Melfi and Alfredo Mussi
The past two decades have witnessed a revolutionary transition in surgical techniqueand technology with the development of minimally invasive approaches. Manyadvantages were obtained by using video-assisted thoracoscopic surgery: less surgicaltrauma and pain, shorter hospital stay, and satisfactory cosmetic results. Limitations still

CONTENTS

CONT

remain, however, because of impaired vision, restricted instrument-maneuverability,unstable camera platform, and poor ergonomics for the surgeon. Some of the moreprominent limitations involve the technical and mechanical nature of the equipment.This article describes technical aspects, learning curve, and complications in the field ofrobotic lobectomy.

Cost Comparison of Robotic, Video-assisted Thoracic Surgeryand Thoracotomy Approaches to Pulmonary Lobectomy
297 Bernard J. Park and Raja M. Flores
The financial impact of employing minimally invasive techniques for lobectomycompared with traditional open thoracotomy was assessed. A retrospective reviewwas conducted using ICD9 codes for thoracotomy, video-assisted thoracic surgery(VATS), and robotic VATS lobectomy to determine total average costs associated with theresultant hospital stay. The difference in total average costs was calculated for eachgroup. Robotic VATS lobectomy had higher associated costs than VATS only, primarilyattributed to increased costs of the first hospital day, but was still less costly thanthoracotomy. The average cost of VATS is substantially less than thoracotomy primarilybecause of a decreased length of stay. The cost of robotic assistance for VATS is still lessthan thoracotomy, but greater than VATS alone.

Does Minimally Invasive Thoracic Surgery Warrant Fast Trackingof Thoracic Surgical Patients?
301 Robert J. Cerfolio and Ayesha S. Bryant
This article evaluates the advantages of fast-tracking the patient who has undergonevideo-assisted thoracoscopic surgery instead of open thoracotomy. Key issues such aschest tube and air leak management, pain medicine protocols, psychologic advantages,and hospital length of stay are examined. It concludes that teaching, philosophy, anddoctor and patient attitude may be more important than the type of surgery performed.

Uniportal Video-Assisted Thoracic Surgery for Diagnosisand Treatment of Intrathoracic Conditions
305 Michele Salati, Alessandro Brunelli, and Gaetano Rocco
The effort to reduce the invasiveness of thoracic surgery is increasing in this specialty.In this context, preliminary evidence has shown that uniportal video-assisted thoracicsurgery represents a valuable option to perform different diagnostic and curativeprocedures. This article addresses the topic of uniportal video-assisted thoracic surgeryas the least invasive such approach that may be used to diagnose and treat severalintrathoracic conditions.

Awake Operative Videothoracoscopic Pulmonary Resections
311 Eugenio Pompeo and Tommaso C. Mineo
General anesthesia with one-lung ventilation is considered mandatory for video-thoracoscopic pulmonary resection but has some adverse effects, which can contribute tothe overall procedure-related morbidity. This finding has led to the concept of a morephysiologic and globally less-invasive approach, entailing awake thoracoscopicpulmonary resection under sole epidural anesthesia. Indications, although stillinvestigational, include resection of undetermined solitary pulmonary nodules,pulmonary metastases, and non-small cell lung cancer in high-risk patients. Preliminaryresults have been highly satisfactory, showing that this modality is feasible, safe, andeffective. Furthermore, some evidence seems to show that this patient-friendly approachcould be more cost-effective, allow a more rapid recovery, and require reducedhospitalization. Further investigation and larger prospective studies will eventually

ENTS vii

viii

confirm the real effectiveness and proper indications of awake videothoracoscopicpulmonary resections.

Outpatient Thoracic Surgery
321 Laureano Molins, Juan J. Fibla, Jose M. Mier, and Ana Sierra
Although there has been a significant increase in ambulatory surgery activity, there isstill great potential for an increase in outpatient thoracic surgery. Video-assistedmediastinoscopy, lung biopsy, and bilateral thoracic sympathectomy can be accom-plished safely in a significant percentage as ambulatory patients. The impact of theeconomical benefit of an outpatient thoracic surgical program over the conventionalhospitalization depends on the previous department’s policy on hospital stay. Furtherexperience is needed to increase the substitution index and expand the outpatientthoracic surgical program to other procedures.

Index
329
CONTENTS

FORTHCOMING ISSUES

November 2008

Management of N2/IIIA Lung Cancer

Mithran Sukumar, MD, Guest Editor

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Diseases of the Mediastinum

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Surgical and Endoscopic Managementof End Stage Emphysema

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Hyperhidrosis

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Jean Deslauriers, MD, FRCS(C),Guest Editor

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Thorac Surg Clin 18 (2008) xi

Preface

Gaetano Rocco, MD, FRCS (Ed), FECTS

Gue
st Editor
There is little doubt that minimally invasivethoracic surgery (MITS), concealed behind a mul-

titude of acronyms, has attracted the interest ofmore than one generation of thoracic surgeonsfor the last 15 years.

The habitues of the myriad of lectures andmeetings organized on this topic still get entangled

in endless discussions about terminology, indica-tions, and techniquesdfutile discussions only onthe surface. In fact, each of these views represents

the surgeon’s interpretation of a vague conceptthat is skillfully shaped to fit the individual or in-stitutional clinical practice according to a person-alized magic recipe. Any attempts at establishing

guidelines seem to clash against insurmountableadverse factors, which range from personal pre-disposition to ethical considerations, and, last

but not least, to the availability of financial re-sources. The introduction of robotic assisted tho-racic surgery has added an element of confusion

to an already dazed theoretic environment.That is why, when exiting a meeting on MITS,

the general feeling is usually that a consensus has

been reached. However, this consensus is often ona ‘‘no consensus’’ approach to the residues of the‘‘Big Bang’’ of video assisted thoracic surgery dcall it VATS, VAT, RATS, MIS, or, in line with

one of the most recent technologic hits, simplyHybrid. The net result is that surgeons leavethe lecture hall convinced that their interpretation

1547-4127/08/$ - see front matter � 2008 Elsevier Inc. All righ

doi:10.1016/j.thorsurg.2008.06.004

of MITS is the perfect fit, the most comfort-able one.

Nowadays, the variegated approach to reducedsurgical invasiveness has reached an impasse.The more experienced surgeons struggle to tame

the shrew of innovation, whereas the youngercolleaguesdcaught between the increasing pres-sure from the media and the patients, the recentlyintroduced working-time directives, and the mar-

keting strategies of health care providersdfind ithard to characterize their clinical practice andincreasingly demand extracurricular training in

minimally invasive surgery.This issue of the Thoracic Surgery Clinics tries

to distinguish between the myth and the reality of

MITS by clarifying whether there is solid evidencefor a wider adoption of minimally invasive proce-dures based on rigorous technical criteria. Thoughfurther technical refinements are in sight, the time

has probably come to outline a comprehensiveMITS framework for the education and the clini-cal practice of all thoracic surgeons.

Gaetano Rocco, MD, FRCS (Ed), FECTSDivision of Thoracic Surgery

National Cancer InstitutePascale Foundation

Via M Semmola 81Naples, Italy

E-mail address: [email protected]

ts reserved.

thoracic.theclinics.com

mailto:[email protected]

http://www.thoracic.theclinics.com

Thorac Surg Clin 18 (2008) xiii

Retraction

Long-Term Quality of Life After Lung Resection

The article ‘‘Long-Term Quality of Life After

Lung Resection,’’ authored by John Cannon andThida Win, and published in the February 2008issue of the Thoracic Surgery Clinics (pp. 81–91),

has been retracted because portions of the articlewere copied verbatim from an article publishedin CHEST without attribution (Sugimura H,


doi:10.1016/j.thorsurg.2008.06.005

Yang P. Long-term survivorship in lung cancer:

a review. Chest 2006;129(4):1088–97).

Mark Ferguson, MD

Consulting EditorThoracic Surgery Clinics

ts reserved.



Thorac Surg Clin 18 (2008) 235–247

The Variability of Practice in Minimally InvasiveThoracic Surgery for Pulmonary Resections

Gaetano Rocco, MD, FRCS (Ed), FECTSa,*, Eveline Internullo, MDb,Stephen D. Cassivi, MD, MSc, FRCSCc,

Dirk Van Raemdonck, MD, PhDd, Mark K. Ferguson, MDe

aDivision of Thoracic Surgery, National Cancer Institute, Pascale Foundation, Naples, ItalybDivision of Thoracic Surgery, University of Parma, Parma, Italy

cDivision of General Thoracic Surgery, Mayo Clinic, Rochester, MN, USAdDepartment of Thoracic Surgery, Kathoelike Universiteit Leuven, University Hospitals, Leuven, Belgium

eUniversity of Chicago, Chicago, IL, USA

Video-assisted thoracic surgery (VATS) hasbeen extensively used to diagnose pulmonary con-

ditions, such as interstitial lung disease and solitarypulmonary nodules. The progression to minimallyinvasive techniques has been almost a natural

evolution of the use of VATS in the investigationof pleural effusions. More controversial are theindications of VATS for the treatment of pulmo-

nary parenchymal conditions. Although minimallyinvasive thoracic surgery (MITS), under variousdenominations, is currently the accepted approach

to the treatment of spontaneous pneumothorax, itsuse for the treatment of lung cancer and infectiousconditions of surgical interest is still debated bothfrom a philosophic and technical point of view.

Yim [1], in 2002, published a review on VATSmajor pulmonary resections aimed, after almosta decade since its introduction in clinical practice,

at defining unresolved matters, such as the lengthof the minithoracotomy, the use of rib retraction,the relevance of visualization by the VATS moni-

tor to accomplish procedure-related maneuvers,and whether the simultaneous stapled ligationtechnique could replace individual ligation of thehilar bronchovascular structures. At that time, it

had already emerged clearly that a compromise

* Corresponding author.


(G. Rocco).

1547-4127/08/$ - see front matter � 2008 Published by Elsevie

doi:10.1016/j.thorsurg.2008.06.002

solution was needed, which Yim named ‘‘mini-thoracotomy with videoassistance,’’ to summarize

the fundamental principles of a transition opera-tion from conventionally open, muscle dividing,rib retracting with or without shearing approaches

to an innovative, rigorous VATS technique whereall these elements were not included.

The reasons to resort to minimally invasive

pulmonary resections are diverse and have beenwell described in the recent literature [2].Although the need for parenchymal-sparing oper-

ations had increasingly been advocated for pa-tients with borderline respiratory function andinfectious conditions of surgical interest, theemerging view of a different oncologic approach

to early stage lung cancer has paralleled the focuson rigorous VATS techniques for pulmonarylobectomy and segmentectomy [3]. Indeed, at

some point, the consensus on a reduced immuno-logic impact of VATS lobectomy, along with thesuggestions of reduced postoperative pain and

length of hospital stay, emerged in the literature.Concurrently, equivalent survival rates to lobec-tomy were being reported after segmentectomyfor early manifestations of lung cancers, such as

ground-glass opacities and small (!2 cm) sizednodular adenocarcinomas (ie, bronchoalveolarcarcinoma [BAC]), especially if located in the

outer third of the lung.In addition, certain proponents have favored

segmentectomy to remove pulmonary metastases,

r Inc.




236 ROCCO et al

for certain nonmalignant diseases (ie, tuberculo-sis), and for patients aged over 75 years, whena pathologic margin greater than 1 cm (margin-to-

tumor ratio O1) could be obtained.The issue of the comparison between wedge

resection and anatomic segmentectomy for non–small cell lung cancer dates back to the seminal

Lung Cancer Study Group study [4]. In this trial,wedge resection was found to yield a threefold in-creased risk of recurrence compared with lobec-

tomy. In addition, segmentectomy had a lowerrecurrence risk when compared with wedge resec-tion. These findings have been subsequently con-

firmed by the independent work of Okada and elSherif [5–7].

In 2007, a meta-analysis was conducted by theInternational Society of Minimally Invasive

Cardiothoracic Surgery [8], based on a comprehen-sive review of all randomized (RCT) and non-randomized controlled trials. It was aimed at

comparing VATS with the conventional openapproach to parenchymal-sparing resections.The following results were reported:

1. Baseline prognosis was more favorable forVATS compared with open in non-RCT,

but not in RCT.2. Postoperative complications were signifi-

cantly reduced in the VATS group compared

with open surgery considering aggregateresults from non-RCT and RCT.

3. Overall blood loss was reduced with VATS(but there was no difference found in the

incidence of excessive blood loss or re-exploration for bleeding).

4. Postoperative pain was reduced at different

levels up to week 4 for VATS. As a conse-quence, there was a significantly decreaseduse of pain medications.

5. Postoperative vital capacity was significantlyimproved in the VATS group. This beneficialeffect was maintained and observed up to

1 year after surgery.6. The degree of impairment of normal activi-

ties and the time to return to normal activitywere significantly reduced in the VATS group

(although no difference in function was notedafter 3 years from surgery).

7. Length of stay in the hospital was reduced in

the VATS group (although operative timewas longer in the VATS group).

8. Time to adjuvant chemotherapy was reduced

in the VATS group, although no differencewas noted as to cancer recurrence rates.

9. The overall mortality was not different whenonly RCTs were considered. If non-RCTswere added in the analysis, however, the 1-

and 5-year mortality was significantly betterin the VATS group. Conversely, no advan-tage was seen in the stage-specific analysis.

It is clear, from the increasing use of theseapproaches, that at some point in the recent pastthe thoracic surgical community accepted that

there was a benefit to less invasive approaches forpatients with lung cancer. This was furthered bythe determination that there was at least the initial

technology necessary to perform these operations.What surgeons still cannot agree on is the exactmethodology of MITS. What thoracic surgeonsdo not agree on is as follows.

1. Video-assisted thoracic surgery is not neces-

sarily a synonym of ‘‘minimally invasive’’surgery because it specifically addresses onlythe issue of technique visualization or visuali-zation enhancement. The term VATS does

not directly address the issues of incisions orof approach in general. It does imply potentialfor improved visualization to thoracic surgi-

cal procedures by adding an ‘‘in field’’ lightsource and magnification. The difficulty aris-ing from the use over many years of different

terminology to defineMITS is apparent, espe-cially if applied to parenchymal-sparingresections.

2. The length of the use of thoracotomy, the role

of this incision in the parenchymal-sparingresection performed by MITS, and the num-ber of port sites needed to complete the oper-

ation are all unresolved matters. There seemsto be consensus on the fact that no chest wallmuscles above the intercostals should be

divided to qualify as a MITS procedure.3. When it comes to the technical definition of

VATS lobectomy, rib spreading or retraction

(even rib shearing or cutting) becomes an-other subject of controversy. According tosome proponents of a stringently definedVATS lobectomy and segmentectomy,

whereas the chest wall muscles and the over-lying skin can be retracted, no spreading isallowed in the costal plane to decrease post-

operative pain.4. Many advocates of stringently defined VATS

lobectomy claim that only the monitor

should be used for visualization while per-forming the pulmonary resection because

237VARIABILITY OF PRACTICE IN INVASIVE THORACIC SURGERY

direct visualization most often mandates theneed for rib spreading.

5. Intraoperatively, the degree of lung manipu-lation may play a role in the immunologic

disturbances and possibly on the oncologicoutcome of the procedure. For this reasonsome surgeons decry the back and forth

retraction and movement of the lung duringthe procedure and advocate for a so-called‘‘no-touch’’ technique.

Other issues also need to be addressedregarding the pattern of work distribution. In

this regard, two crucial questions demandanswers. Is a dedicated operating room scheduleand personnel (including surgeons) required for

VATS lobectomies or for MITS procedures ingeneral? Does the expected steep phase of thelearning curve for a VATS lobectomy surgeon

warrant a redistribution of the routine surgicalworkload and operating room time among his orher partners and colleagues?

These and other questions have been the

matter of a survey project by the EuropeanSociety of Thoracic Surgeons (ESTS). This surveyproject represents an attempt, by the leadership of

the ESTS, to establish a framework for thedefinition and interpretation of technical andorganizational characteristics related to the per-

formance of MITS and, in particular, to VATSpulmonary resections. The results of this surveyare hereafter reported.

The results of the European Society of Thoracic

Surgeons Survey on the interpretation of

minimally invasive thoracic surgery for major

pulmonary resections

Several issues were addressed by the MITSsurvey, which was originally an ESTS projectinitially conducted on-line through the ESTS

Web site (www.ests.org) as of November 2007.Afterward, the Survey was also made availablein the Thoracic Portal of the Cardio-ThoracicSurgical Network (CTSnet; www.ctsnet.org) until

April 2008. The questionnaire included 23 ques-tions about MITS practice; an additional requestfor comments was also included as the twenty-

fourth item on the survey.After an on-line collecting period of 125 days,

the total number of responses was 317. The ESTS

members were invited to participate in the Surveythrough an email link connected to the Society’sWeb site (www.ests.org). The overall number of

responses from ESTS members was 219, of which196 were complete answers (89%). In addition, asof December 2007, 98 responses were providedthrough the CTSnet; of these, 84 were complete

answers (86%). Out of approximately 800 notifi-cation emails sent to ESTS members in the mail-ing list at the time the survey was opened, about

50 were undelivered because of an incorrect orabsent email address. Accordingly, the responserate by ESTS members was 26.1% (196 out of

750). The response rate provided by the CTSnetlink cannot be estimated because one cannot cal-culate the potential responders who have access

to this resource (denominator). The inability tocalculate an overall response rate is an acknowl-edged limitation of the study. This was recognizedand accepted as a method of increasing accrual of

completed surveys without affecting the overallvalue of the survey because members of CTSnetare thoracic surgeons.

Overall, the number of complete answers was280 (88%) out of 317. Of these, 220 (78.6%) wereentered by established surgeons or full consul-

tants; 31 (11.1%) by junior consultants (within thefirst 5 years of practice); 18 (6.4%) by seniortrainees (last 2 years of training); and 11 (3.9%)

by junior trainees (first 3 years of training). Insummary, 251 thoracic surgeons working ata consultant level and 29 trainees participated inthe survey by providing a completed

questionnaire.Of the 251 consultants, 194 (77.3%) were

ESTS members, whereas 57 (22.7%) were non-

ESTS members. As to the age distribution of theparticipating consultants, four age groupings wereproposed. Only 5% of the consultants were

younger than 35 years. A total of 42% ofrespondents were age 35 to 45 years, whereas the45- to 50-year-old and the older than 50 yearsgroups represented 22% and 31% of the total

consultants’ answers, respectively. As to the yearsof practice as a consultant, 77% of the partici-pants had more than 5 years of practice experience

at the consultant level. Of these, 24% had between11 and 20 years of clinical practice at a consultantlevel, whereas another 21% had more than 20

years of experience at that level. As to the countryof practice, the most represented were the UnitedStates (15.5%); Italy (10.4%); Spain (8.8%);

Germany (8%); United Kingdom (5.2%); and,Turkey (4.4%). Eleven consultants (4.4%) skip-ped the question on the country of practice.

The questionnaire was structured into five

sections focused on (1) the terminology and

http://www.ests.org

http://www.ctsnet.org

http://www.ests.org

238 ROCCO et al

definitions (five questions); (2) indications forMITS (eight questions); (3) robotic thoracicsurgery (three questions); (4) case volume and

learning curve (two questions); and (5) demo-graphic data (five questions). For each question,the participant had to select one or more answersrelevant to the current controversies discussed

previously.

Results

The answers given to the questionnaire werestratified by years of experience in the consultant

position, with 10 years being the selected arbitrarycut point between the two groups. A secondstratification was done according to the socioeco-

nomic status of the country of practice of theresponding surgeon, distinguishing between low-and middle-income and high-income countries asper the ESTS three-tier subscription fee format

inspired by the criteria of the World TradeOrganization (www.ests.org).

Question 1. Which terminology do you prefer anddo you use to describe less invasive thoracic surgicalprocedures?

Overall, 45% of the responders use VATS as

the standard definition to describe less invasivethoracic procedures; VATS, in this case, meantvideo-assisted thoracic surgery. VATS intended as

‘‘video-assisted thoracoscopic surgery,’’ ‘‘mini-mally invasive thoracic surgery,’’ and ‘‘minimal-access thoracic surgery’’ were the preferred

terminology for the remaining 32%, 18%, and3%, respectively. About 1% of the responders didnot express a definitive view. No major differencesin the answer distribution were noted between the

two categories of seniority. Similarly, when theresponders were stratified by socioeconomic statusof the country of origin, answers from middle to

low income countries overlapped the ones fromhigh income countries. The most prevalent answerto the question at hand was ‘‘video-assisted

thoracic surgery’’ (Table 1).

Question 2. What is your current definition of

‘‘open’’ thoracic surgery?

The most prevalent answer to this question wasdefined by whether rib spreading was used.Furthermore, roughly 30% of the responders

also indicated that, along with rib spreading, thelength of the skin and the intercostal incision, andthe division of chest wall muscles, were important

factors in determining whether a minimallyinvasive or an open approach had been used(Table 2).

Question 3. How do you define a video-assistedthoracic surgery lobectomy? Part I

The consensus was that VATS lobectomy isperformed through two or three port incisions

with the addition of a minithoracotomy (accessincision to remove the specimen) (Table 3).

Question 4. How do you define video-assistedthoracic surgery lobectomy? Part II

There was a general agreement (nearly 60% ofthe responders) that no rib spreading was an

important component of a strictly defined VATSlobectomy (Table 4).

Question 5. How do you define video-assistedthoracic surgery lobectomy? Part III

The opinions were generally split as to whetherdirect visualization of the surgical field could also

be acceptable in VATS lobectomy. The mostprevalent answer (range, 52%–59%), however,supported the idea of the dissection being doneby visualization through only the video monitor

(Table 5).

Question 6. What are the main indications for

minimally invasive procedures in your thoracicsurgical practice?

Participants were asked to clarify the indica-tions for minimally invasive procedures in their

practice. Apparently, minimally invasive proce-dures are used primarily for diagnostic and minortherapeutic purposes, especially by surgeons from

low- to middle-income countries. Whether thisfinding reflects different resource availability ispossible but not confirmed by these data(Table 6).

Question 7. Of cases requiring access to thethoracic cavity, approximately how often do you

currently use the standard posterolateralthoracotomy (dividing at least the latissimus dorsior both the latissimus and the serratus anterior

muscles) for lung surgery?

This question addressed the use of standardposterolateral thoracotomy in the participants’practice. Overall, 39% of the responders report

still using the standard posterolateral thoracot-omy in more than 50% of their cases. Surpris-ingly, no difference was noted as to the seniority

http://www.ests.org

Table 1

Which terminology do you prefer and do you use to describe less invasive thoracic surgical procedures?

Overall

response

count

Overall

response

%

!10-y

practice

count

!10-y

practice

%

O10-y

practice

count

O10-y

practice

%

Video-assisted thoracic surgery 114 45.4 48 42.9 66 47.5

Video-assisted thoracoscopic

surgery

81 32.3 34 30.4 47 33.8

Minimally invasive thoracic

surgery

45 17.9 24 21.4 21 15.1

Minimal-access thoracic surgery 8 3.2 3 2.7 5 3.6

I do not know 3 1.2 3 2.7 0 0

Answered question 251 100 112 100 139 100

Skipped question 0 0 0 0 0 0

Table 2

What is your current definition of open thoracic surgery?

Overall

response

count

Overall

response

%

!10-y

practice

count

!10-y

practice

%

O10-y

practice

count

O10-y

practice

%

It depends on the length of the thoracic skin

incision

29 11.6 16 14.3 13 9.4

It depends on the length of the incision

at the level of the intercostal muscles

10 4 5 4.5 5 3.6

It depends on whether the chest wall muscles

(latissimus dorsi, serratus anterior) are divided

19 7.6 8 7.1 11 7.9

It depends on whether the ribs are spread 113 45 46 41.1 67 48.2

It depends on whether a rib is cut or sheared 1 0.4 0 0 1 0.7

All of the above 79 31.5 37 33 42 30.2



Table 3

How do you define a video-assisted thoracic surgery lobectomy? Part I

Overall

response

count

Overall

response

%

!10-y

practice

count

!10-y

practice

%

O10-y

practice

count

O10-y

practice

%

One port-sized incision with an additional

minithoracotomy (access incision)

18 7.2 7 6.3 11 7.9

Two port-sized incisions with an

additional minithoracotomy

109 43.4 57 50.9 52 3.4

Three or more port-size incisions

with an additional minithoracotomy

120 47.8 47 42 73 52.5

Muscle-sparing thoracotomy 4 1.6 1 0.9 3 2.2




Table 4

How do you define video-assisted thoracic surgery lobectomy? Part II

Overall

response

count

Overall

response

%

!10-y

practice

count

!10-y

practice

%

O10-y

practice

count

O10-y

practice

%

No skin retraction or rib retraction

or cutting

67 26.7 33 29.5 34 24.5

No rib spreading or cutting 141 56.2 62 55.4 79 56.8

With rib spreading 42 16.7 17 15.2 25 18

With rib cutting 1 0.4 0 0 1 0.7



Table 5

How do you define video-assisted thoracic surgery lobectomy? Part III

Overall

response

count

Overall

response

%

!10-y

practice

count

!10-y

practice

%

O10-y

practice

count

O10-y

practice

%

Dissection done using only the video monitor

for visualization

139 55.4 66 58.9 73 52.5

Dissection can be done using both video monitor

images and direct visualization

112 44.6 46 41.1 66 47.5



Table 6

What are the main indications for minimally invasive procedures in your thoracic surgical practice?

Overall

response

count

Overall

response

%

!10-y

practice

count

!10-y

practice

%

O10-y

practice

count

O10-y

practice

%

Diagnostic only (ie, mediastinoscopy, video-assisted

thoracic surgery for pleural effusions)

7 2.8 1 0.9 6 4.3

Diagnostic and minor therapeutic (ie, wedge

resections of the lung for solitary pulmonary

nodules, pneumothorax)

127 50.6 54 48.2 73 52.5

Diagnostic, minor and major therapeutic (typical

segmentectomy, lobectomy, thymectomy)

117 46.6 57 50.9 60 43.2



Table 7

Of cases requiring access to the thoracic cavity, approximately how often do you currently use the standard posterolat-

eral thoracotomy (dividing at least the latissimus dorsi or both the latissimus and the serratus anterior muscles) for lung

surgery?

Overall

response count

Overall

response %

!10-y

practice count

!10-y

practice %

O10-y

practice count

O10-y

practice %

O50% of the cases 98 39 42 37.5 56 40.3

!30% of the cases 51 20.3 19 17 32 23

!10% of the cases 29 11.6 16 14.3 13 9.4

!5% of the cases 73 29.1 35 31.3 38 27.3



240 ROCCO et al

Table 8

For what do you use video-assisted thoracic surgery for lung surgery

Overall

response

count

Overall

response

%

!10-y

practice

count

!10-y

practice

%

O10-y

practice

count

O10-y

practice

%

Never, I only use video-assisted thoracic surgery

to diagnose pleural conditions

6 2.4 1 0.9 5 3.6

Diagnosis of interstitial lung disease and peripheral

solitary pulmonary nodules and treatment of

pneumothorax

129 51.4 51 45.5 78 56.1

The above and for segmental or lobar lung resections 116 46.2 60 53.6 56 40.3



Table 9

Among the following answers, what is the main reason that you perform video-assisted thoracic surgery lobectomy?

Overall

response

count

Overall

response

%

!10-y

practice

count

!10-y

practice

%

O10-y

practice

count

O10-y

practice

%

Better ability to tolerate the procedure in cases

of borderline cardiopulmonary function

44 17.5 22 19.6 22 15.8

Better oncologic operation 2 0.8 1 0.9 1 0.7

Decreased postoperative pain 152 60.6 65 58 87 62.6

Decreased length of hospitalization 53 21.1 24 21.4 29 20.9



Table 10

What is the second most important reason that you perform video-assisted thoracic surgery lobectomy?

Overall

response

count

Overall

response

%

!10-y

practice

count

!10-y

practice

%

O10-y

practice

count

O10-y

practice

%

Better ability to tolerate the procedure in cases

of borderline cardiopulmonary function

58 23.1 20 17.9 38 27.3

Better oncologic operation 1 0.4 0 0 1 0.7

Decreased postoperative pain 76 30.3 35 31.3 41 29.5

Decreased length of hospitalization 116 46.2 57 50.9 59 42.4



Table 11

Of the lobectomies you perform every year, what percentage are video-assisted thoracoscopic surgery lobectomies?

Overall

response count

Overall

response %

!10-y

practice count

!10-y

practice %

O10-y

practice count

O10-y

practice %

O50% of the cases 37 14.7 23 20.5 14 10.1

!30% of the cases 31 12.4 15 13.4 16 11.5

!10% of the cases 36 14.3 16 14.3 20 14.4

!5% of the cases 147 58.6 58 51.8 89 64




Table 12

Over time, which factors have been influential in increasing or decreasing your likelihood to offer minimally invasive

procedures?

Overall

response

count

Overall

response

%

!10-y

practice

count

!10-y

practice

%

O10-y

practice

count

O10-y

practice

%

Scientific evidence on safety and effectiveness 126 50.2 60 53.6 66 47.5

Patient demand for less invasive options 26 10.4 13 11.6 13 9.4

Referring physician demand for less invasive options 6 2.4 1 0.9 5 3.6

Medicolegal litigation environment 1 0.4 1 0.9 0 0

Changes in technology available to assist with these

procedures

58 23.1 20 17.9 38 27.3

Opinion and practice of peers and partners 34 13.5 17 15.2 17 12.2



Table 13

Why do you think video-assisted thoracic surgery lobectomy has not yet gained widespread popularity?

Overall

response

count

Overall

response

%

!10-y

practice

count

!10-y

practice

%

O10-y

practice

count

O10-y

practice

%

Not enough scientific evidence to establish

safety and effectiveness

33 13.1 13 11.6 20 14.4

Difficult technique, steep learning curve 48 19.1 24 21.4 24 17.3

Resistance by older surgeons 22 8.8 14 12.5 8 5.8

Logistic and financial issues (ie, capital cost

of necessary equipment and technology)

12 4.8 5 4.5 7 5

Lack of adequate training and retraining in

video-assisted thoracic surgery pulmonary

resections

28 11.2 13 11.6 15 10.8

All of the above 108 43 43 38.4 65 48



Table 14

Do you consider robotic thoracic surgery to be a component of minimally invasive thoracic surgery?

Overall

response

count

Overall

response

%

!10-y

practice

count

!10-y

practice

%

O10-y

practice

count

O10-y

practice

%

Yes, it is an evolution of video-assisted thoracic

surgery

150 59.8 67 59.8 83 59.7

Yes, simply because it avoids a traditional

sternotomy or thoracotomy

19 7.6 13 11.6 6 4.3

Yes, because it entails a lesser degree of lung

manipulation, hence less immunologic

disturbances

3 1.2 2 1.8 1 0.7

No, my criteria for minimally invasiveness are

not met by robotic surgery

79 31.5 30 26.8 49 35.3



242 ROCCO et al

Table 15

What proportion of your procedures do you perform with the use of robotic assistance each year?

Overall

response count

Overall

response %

!10-y

practice count

!10-y

practice %

O10-y

practice count

O10-y

practice %

None 230 91.6 101 90.2 129 92.8

!3% 10 4 5 4.5 5 3.6

!5% 5 2 3 2.7 2 1.4

!10% 4 1.6 3 2.7 1 0.7

O10% 2 0.8 0 0 2 1.4



Table 16

Why do you think robotically guided thoracic surgery has not yet gained widespread popularity?

Overall

response

count

Overall

response

%

!10-y

practice

count

!10-y

practice

%

O10-y

practice

count

O10-y

practice

%

Financial issue (ie, capital costs, nonreusable

equipment costs, and so forth)

69 27.5 31 27.7 38 27.3

Lack of technologic refinement in current

generation of equipment

10 4 4 3.6 6 4.3

Robotic-assisted procedures are unlikely to gain

widespread popularity until there is more

widespread acceptance and use of video-

assisted thoracic surgery and other minimally

invasive approaches

14 5.5 5 4.5 9 6.5

Lack of evidence demonstrating advantage for

the patients over video-assisted thoracic

surgery

30 12 17 15.2 13 9.4

All of the above 128 51 55 49.1 73 52.5



Table 17

If you worked in a group of four surgeons, how many should be doing video-assisted thoracic surgery lobectomies?

Overall

response count

Overall

response %

!10-y

practice count

!10-y

practice %

O10-y

practice count

O10-y

practice %

Depends on the workload

and the available

resources but at least one

99 39.4 40 35.7 59 42.4

Only one 20 8 14 12.5 6 4.3

Only two 32 12.7 12 10.7 20 14.4

Everybody 100 39.8 46 41.1 54 38.8




Table 18

How do you envisage the training pathway of a resident for video-assisted thoracic surgery lobectomy?

Overall

response

count

Overall

response

%

!10-y

practice

count

!10-y

practice

%

O10-y

practice

count

O10-y

practice

%

Stepwise, from classic open to classic video-

assisted thoracic surgery to video-assisted

thoracic surgery lobectomy

202 80.5 95 84.8 107 77

With separate video-assisted thoracic surgery

lobectomy fellowship after conventional

training

49 19.5 17 15.2 32 23



244 ROCCO et al

level, whereas fewer surgeons from high-incomecountries seemed to use this approach for most oftheir cases (Table 7).

Question 8. For what do you use video-assistedthoracic surgery for lung surgery?

As expected, more than half of the participants

claimed to use VATS lung surgery for thediagnosis of interstitial lung disease and pulmo-nary nodules, in addition to the treatment of

pneumothorax. Nevertheless, 46% of respondentsdeclared using VATS lung surgery also for ana-tomic sublobar and lobar resections. Of these,

most (54%) were surgeons within the first 10 yearsof independent practice. Once again, worthy ofnote was the minor impact of VATS lung surgery

for major pulmonary resections amongresponders from low- to middle-income countries(38%) compared with the ones from high-incomecountries (49%) (Table 8).

Question 9. Among the following answers, what is

the main reason that you perform video-assistedthoracic surgery lobectomy?

By far, the primary reason was the reducedincidence of pain compared with standard thora-

cotomy (61%) with a substantial agreementbetween consultants with different experienceand from countries of differing socioeconomic

status (Table 9).

Question 10. What is the second most importantreason that you perform video-assisted thoracicsurgery lobectomy?

When the participants were asked for the

secondary reason for performing VATS lobecto-mies, 46% claimed a reduced length of hospital-ization compared with standard thoracotomy,

again with no difference between consultants’subgroups (Table 10).

Question 11. Of the lobectomies you perform every

year, what percentage are video-assisted thoracicsurgery lobectomies?

Most (59%) declared that VATS lobectomiesaccount for less than 5% of their lobectomy cases.

About 15% of the participants claimed to performmore than 50% of their lobectomies by the VATSapproach. In this subset of responders, there were

twice as many younger consultants than consul-tants with more than 10 years of seniority. If oneanalyzes the answers according to the socioeco-nomic backgrounds, 69% of surgeons from low-

to middle-income countries performed less than5% of their lobectomies by VATS, as opposed to56% in the higher-income subset. Compared with

surgeons from low- to middle-income countries,the prevalence of surgeons from high-incomecountries performing VATS lobectomies in over

50% of their lobectomy candidates was threefoldhigher (18% versus 5%) (Table 11).

Question 12. Over time, which factors have been

influential in increasing or decreasing yourlikelihood to offer minimally invasive procedures?

Overall, 50% thought that the availability ofscientific evidence on safety and effectiveness of

these procedures played a major role in theirdecision to adopt these new approaches in theirclinical practice. This was a shared opinion among

surgeons, irrespective of their seniority and theirsocioeconomic background. Interestingly, themost senior surgeons seemed to believe that

additional technologic advancements were stillneeded to increase the impact of minimallyinvasive surgery on their practice (Table 12).


Question 13. Why do you think video-assistedthoracic surgery lobectomy has not yet gainedwidespread popularity?

Most (43%) were inclined to think that there

was an ensemble of factors preventing furtherdiffusion of VATS lobectomy. Most (48%) of theconsultant surgeons in practice for more than10 years supported this view. Worthy of note was

the fact that younger consultants hinted at theissue of a possible resistance to change by oldersurgeons (12% versus 6%). Interestingly,

although surgeons from high-income countriesseemed to emphasize the difficult learning curvefor this procedure, their counterparts from mid-

dle- to low-income countries tended to relate thelack of widespread popularity of VATS lobec-tomy to logistic and financial issues (Table 13).

Question 14. Do you consider robotic thoracicsurgery to be a component of minimally invasivethoracic surgery?

Overall, 60% replied that they consideredrobotic surgery a direct evolution of VATS. In

this setting, consultants with lower seniority andthe ones from middle- to low-income countrieswere more convinced than senior colleagues that

robotic surgery could fully replace, at some point,the thoracotomy or the sternotomy approach.More than 30%, however, especially the consul-

tants with longer seniority, denied that roboticsurgery met their criteria for minimal invasive-ness. In addition, when the collected data were

stratified by national income, surgeons fromhigher-income countries also tended to be moreskeptical about considering robotic surgery asa part of the minimally invasive armamentarium

compared with their counterparts from the mid-dle- to low-income countries (34% versus 25%)(Table 14).

Question 15. What proportion of your proceduresdo you perform with the use of robotic assistanceeach year?

Overall, 92% of the respondents did not

perform any robotic cases. When the resultswere stratified according to the socioeconomicbackground, this percentage increased to 98%

and decreased to 89% for middle- to low-incomeand higher-income countries, respectively(Table 15).

Question 16. Why do you think robotically guidedthoracic surgery has not yet gained widespreadpopularity?

Participants replied that many issues factored

into this situation but a particularly importantconsideration seemed to be the costs of the device.Moreover, 15% of the younger surgeons (versus9% senior) and 13% of those from higher-income

countries (versus 5% from middle- to low-incomecountries) seemed to believe that no distinctadvantage of robotic over VATS has been dem-

onstrated. A total of 9% of the consultants frommiddle- to low-income countries (versus 4% fromhigh-income countries) thought that the evolution

to robotic approaches will be limited until VATSclearly defines its role in the thoracic surgicalarmamentarium (Table 16).

Question 17. If you worked in a group of four

surgeons, how many should be doing video-assistedthoracic surgery lobectomies?

The opinions were split between the view thateverybody should be equally able with this

procedure and that, given a definite workload, atleast one surgeon should be dedicated to VATSlobectomy. The latter argument, in particular,

seemed to be supported by surgeons with higherseniority (12.5% versus 4.3%) (Table 17).

Question 18. How do you envisage the trainingpathway of a resident for video-assisted thoracic

surgery lobectomy?

There was an overwhelming majority (80%)favoring a stepwise approach to this procedure,from open to VATS. Younger surgeons expressed

this view slightly more consistently than oldersurgeons (85% versus 77%) who were moreinclined to propose an extracurricular training

time rather than including this into the traditionaltraining programs (23% versus 15%). When thesocioeconomic background was analyzed,surgeons from middle- to low-income countries

favored the learning of VATS lobectomy as partof a classic stepwise approach, contrary to theircolleagues from higher-income countries who

seemed to prefer a separate, dedicated VATSlobectomy training period (Table 18).

Summary

Thoracic surgeons participating in this surveyseemed to have clearly indicated their perception

246 ROCCO et al

of VATS major lung resections, in particularVATS lobectomy.

1. The acronym VATS as a short form of‘‘video-assisted thoracic surgery’’ was thepreferred terminology.

2. According to the respondents, the need oruse of rib spreading served as the definingcharacteristic of ‘‘open’’ thoracic surgery.

3. It was most commonly suggested that VATS

lobectomy is performed by means of two orthree port incisions with the addition ofa minithoracotomy or access incision.

4. Rib spreading (shearing) was not deemedacceptable as part of a strictly definedVATS procedure.

5. Although there was no general consensus,respondents suggested that the preferredapproach for visualization in a VATS proce-

dure was only through the video monitor.6. Although minimally invasive procedures for

lung resection are still mainly being usedfor diagnostic and minor therapeutic pur-

poses, young surgeons seemed to be morelikely to recommend VATS lung surgery formajor pulmonary resections than their more

senior colleagues.7. The survey confirmed that the use of the

standard posterolateral thoracotomy is still

widespread. Almost 40% of the surgeonsclaimed to use the standard posterolateralthoracotomy for more than 50% of theircases and less than 30% use it for less than

5% of cases.8. The major reasons to perform VATS lobec-

tomy were perceived to be reduced pain and

decreased hospitalization.9. Approximately 60% of the surgeons claimed

to perform VATS lobectomy in less than 5%

of their lobectomy cases. Younger consul-tants reported using VATS lobectomy in upto 50% of their lobectomy cases. There was

the suggestion that lack of resources couldjustify the minor impact of VATS lobectomyin the thoracic surgical practice in middle- tolow-income countries.

10. The currently available scientific evidence onsafety and effectiveness, and technologic ad-vancements were emphasized as the two fac-

tors having a major impact on thedevelopment of minimally invasive thoracicsurgical practice.

11. Any lack of popularity of VATS lobectomywas presumed to be caused by several

equally important factors. Resistance tochange by more senior surgeons rankedhighly among younger surgeons, however,

as an explanation for the slow adoption ofthis technique. Senior surgeons, however,seemed to focus their attention on the steeplearning curve of VATS lobectomy. In addi-

tion, surgeons from middle- to low-incomecountries recognized certain financial and lo-gistic difficulties as major determinants of the

lack of popularity of VATS lobectomy.12. Most surgeons thought that robotic tho-

racic surgery represented an evolution of

VATS. Nevertheless, almost 30% did notthink current robotic methods meet the cri-teria for minimally invasive surgery. Morethan 90% of the participants stated that

they did not perform robotic thoracic sur-gery. This was reportedly because of costs,but also because of the fact that robotic

approaches have not yet demonstrateda distinct advantage over nonrobotic VATSprocedures.

13. It was suggested that in every unit ordepartment there should be at least onesurgeon with a specific interest and capability

in VATS lobectomy. The younger surgeons,however, seemed to envisage more wide-spread competency being optimal.

14. Most suggested that training in VATS lobec-

tomy be done in a stepwise fashion startingfrom the classical open technique. Older sur-geons wanted to see this as an extracurricular

activity following completion of the currenttraining curriculum rather than included inthe traditional training program.

In the opinion of the thoracic surgeons takingpart in this survey, pulmonary resections not

performed according to these standards couldnot be called VATS procedures but should beincluded within the MITS category at large, along

with other diagnostic and therapeutic interven-tions. In addition, the survey confirmed that thetime-honored muscle-dividing thoracotomy is stillwidely used. The opportunity for a progressive

move toward the routine use of less invasiveapproaches for major pulmonary resections, how-ever, is already well within sight. Given the results

of the ESTS survey supporting a stepwise teachingprocess leading to VATS lobectomy, hybrid andminimally invasive open lung resections (discussed

elsewhere in this issue) collectively defined asMITS may serve as starting point in this process


to expand the appropriate use of VATS lobec-tomy in the modern thoracic surgical practice.

Acknowledgments

The authors thank Carol Blasberg and TomFerguson, MD, for their support with this project.

References

[1] Yim AP. VATS major pulmonary resection revisited:

controversies, techniques, and results. Ann Thorac

Surg 2002;74:615–23.

[2] Shaw JP, Dembitzer FR, Wisnivesky JP, et al. Video-

assisted thoracoscopic lobectomy: state of the art

and future directions. Ann Thorac Surg 2008;85:

S705–9.

[3] D’Amico TA. Thoracoscopic segmentectomy: techni-

cal considerations and outcomes. Ann Thorac Surg

2008;85:S716–8.

[4] Ginsberg RJ, Rubinstein LV. Randomized trial of

lobectomy versus limited resection for T1 N0 non-

small cell lung cancer. Lung Cancer Study Group.

Ann Thorac Surg 1996;62:1249–50.

[5] Okada M, Nishio W, Sakamoto T, et al. Effect of

tumor size on prognosis in patients with non-small

cell lung cancer: the role of segmentectomy as a type

of lesser resection. J Thorac Cardiovasc Surg 2005;

129:87–93.

[6] El-Sherif A, Fernando HC, Santos R, et al. Margin

and local recurrence after sublobar resection of non-

small cell lung cancer. Ann Surg Oncol 2007;14:

2400–5.

[7] Schuchert MJ, Pettiford BL, Luketich JD, et al.

Parenchymal-sparing resections: why, when, and

how. Thorac Surg Clin 2008;18:93–105.

[8] Cheng D, Downey R, Kempf K, et al. Videoassisted

thoracic surgery in lung cancer resection: a meta-

analysis and systematic review of controlled trials.

Innovations 2007;2:226–92. DOI:10.1097/IMI.0b013

e3181662c6a.


VATS Lobectomy is Better than Open Thoracotomy:What is the Evidence for Short-Term Outcomes?

Eric L. Grogan, MD, MPHa,b, David R. Jones, MDa,*aDivision of Thoracic and Cardiovascular Surgery, University of Virginia, P.O. Box 800679,

Charlottesville, VA 22908-0679, USAbDepartment of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA

Lung cancer remains the leading cause of

cancer death in the United States, with morethan 200,000 new cases each year and 160,000deaths [1]. Surgical resection with an anatomic

resection (typically a lobectomy) remains standardcare for patients who have stage I and stage IInon-small cell lung cancer (NSCLC). Various tho-

racotomy incisions provide exposure for lobecto-mies with mediastinal lymph node dissection(MLND). Wedge resections and segmentectomiesare reserved for patients who do not have the pul-

monary reserve to tolerate a lobectomy [2]. In thepast 15 years, video-assisted thoracic surgery(VATS) has been used with increasing frequency

worldwide to perform anatomic resections forlung cancer [3–6]. This article reviews the currentVATS lobectomy series and studies published

since 2000 comparing VATS with open lobectomy.

Background and history

Jacobaeus [7] first used the thoracoscope in1910. Improvements in video technology and singlelung ventilation expanded the use of thoracoscopy

in the 1980s. In the early 1990s, the first reports ofVATS lobectomies began to emerge, describingtechniques and the early success of these proce-

dures [8–12]. Subsequent larger series have definedthe safety profile and survival associated withVATS lobectomy for early-stage lung cancer[3,6,13–15]. Case-control studies and a randomized

control trial have studied the pain, pulmonary



(D.R. Jones).


doi:10.1016/j.thorsurg.2008.04.007

function, inflammatory response, and oncologic

control that VATS provides compared with a stan-dard open thoracotomy for patients who have lungcancer. These studies have also defined patient

populations that may benefit from a VATS lobec-tomy because of reduced complications [16–25].

Since these first reports of VATS lobectomies,

equivalent or improved cancer clearance for stage Ilung cancer has been shown with acceptablemorbidity and mortality [3,6,13–15,21,26]. CurrentAmerican College of Chest Physicians evidence-

based clinical practice guidelines recommend that,‘‘Inpatientswith stage INSCLCwhoare consideredappropriate candidates for thoracoscopic anatomic

lung resection (lobectomy or segmentectomy), theuse of VATS by surgeons experienced in thesetechniques is an acceptable alternative to open

thoracotomy [27].’’

Definitions of video-assisted thoracic

surgery lobectomy

The operative technique used in the initialreports of VATS lobectomy varied considerably,

making useful comparisons in postoperative mea-surements among studies difficult [8,28–31]. How-ever, efforts to standardize the technique and

definition used for VATS lobectomy have resultedin more uniform procedures, and therefore moremeaningful comparisons [13].

The three major types of VATS lobectomy

described in the literature are video-assisted mini-thoracotomy,video-assisted simultaneously stapledlobectomy, and video-assisted non–rib spreading

lobectomy [32]. Video-assisted minithoracotomyinvolves the use of a small rib retractor and possible

ts reserved.




250 GROGAN & JONES

rib division in a 6- to 8-cm incision in either the pos-terior or anterior location. This incision is similar toa small muscle–sparing thoracotomy.

Video-assisted simultaneously stapled lobec-tomy is not considered an anatomic lobectomy,because the vessels and bronchus are not individ-ually divided.The video-assisted non–rib spreading

lobectomy is currently the standard procedure usedin most current literature and uses 1 to 3 port siteswith an anterior 5- to 8-cm access incision in the

fourth to sixth intercostal space. It does not involverib division or spreading with a rib retractor for theaccess incision [13] and is the currently accepted

definition of VATS lobectomy by surgeons whouse this approach.

Surgeons performingVATS lobectomies shouldbe able to achieve the same surgical oncologic result

as a standardopen lobectomy, including removal ofthe tumor with individual ligation of the bronchusand appropriate vessels and complete removal or

adequate sampling of the regional lymph nodes.Although VATS wedge resections, segmentecto-mies, pneumonectomies, and even sleeve resections

have been reported, most studies evaluate the out-comes of VATS lobectomies [2,33–38]. Therefore,this article focuses on the improved short-term re-

sults ofVATS lobectomyversus open thoracotomy.

Short-term results for video-assisted thoracic

surgery lobectomy versus open thoracotomy

Short- and long-term results after VATS lo-bectomy for lung cancer have been reported.

Swanson and Batirel [32] reviewed VATS resec-tion for lung cancer in 2002, but variability inthe operative techniques made these initial studies

difficult to compare. More recent studies using theprevious definition of VATS lobectomy have beenpublished. This article summarizes the case-series

and case-control studies published since 2000,which collectively show the improved short-term

Table 1

Morbidity, mortality, and conversion rates for large video-ass

Study Year

Number of

patients

Shaw et al, [14] 2008 180

Swanson et al, [13]a 2007 127

McKenna et al, [3] 2006 1100

Onaitis et al, [15] 2006 500

Total/Mean d 1907

a Grade 1 and 2 complications not reported.

outcomes of VATS lobectomy compared withopen thoracotomy for treating lung cancer.

Mortality

Operative mortality after VATS lobectomyranges from 0% to 2.7% [3,13–15,26], which iscomparable to the 2.5% operative mortality rate

from current estimates of the Society of ThoracicSurgeons (STS) database for all lung cancer sur-gery [39]. The combined average mortality for

more than 1900 patients in current large VATSlobectomy series is 1.3% (Table 1).

Morbidity

Large case series have shown an acceptablemorbidity rate (19%) for the institutions perform-

ing VATS lobectomy (see Table 1) [3,13–15,26].As with open lobectomies, arrhythmias, pro-longed air leak, and pneumonia are the mostcommon complications after VATS lobectomy

(Table 2). Pneumothorax, respiratory failure,and myocardial infarction are the next mostcommon events but occur in less than 1% of cases.

Table 2 lists the most common complications thatoccur after VATS lobectomy. Totals were com-piled from the large case series to provide an

average percent a specific complication occurredfor more than 1900 patients in these series.

Many of the current case-control studies com-

pare complications after VATS and open lobec-tomies. Table 3 lists the current case-controlstudies and one randomized control trial. Sum-mary statistics (c2 test) of these trials show

a reduction in the total number of complicationsin the VATS group compared with the openthoracotomy group (P!.01).

Whitson and colleagues [16] compared patientswho underwent VATS or open lobectomy andfound that, although the VATS group having

more preoperative hypertension, chronic renalinsufficiency, and malignancies, they had less

isted thoracic surgery lobectomy case series

Mortality

(%)

Morbidity

(%)

Conversion

rate (%)

0.6 30 9.2

2.7 7.4 13

0.8 15 2.5

1.2 22 1.6

1.3 19 6.6

Table 2

Complications after video-assisted thoracic surgery

lobectomy, combined for four current case series

Complication Totala Percent (%)b

Arrhythmia 105 5.5

Air leakc 90 4.7

Pneumonia 41 2.1

Pneumothorax or

subcutaneous emphysema

16 0.8

Respiratory failure 10 0.5

Myocardial infarction 12 0.6

Empyema 6 0.3

Cerebral vascular event 4 0.2

Bronchopleural or

pleurocutaneous fistula

3 0.2

Deep venous thrombosis

or pulmonary embolus

1 0.05

Pleural effusion 1 0.05

Postoperative hemorrhage 1 0.05

Hypotension 1 0.05

Other minor 21 1.1

a Total number of each complication from the case se-

ries reported in Table 1 [3,13–15]. Total patients ¼ 1907.b Complication rate for combined case series for

1907 patients.c Prolonged air leak was defined as R5 days [15] or

7 days [3,14].

251VATS LOBECTOMY VERSUS OPEN THORACOTOMY

postoperative pneumonia. However, the operativetimes, blood loss, length of stay, and survival wereequivalent. Similarly, in a well-matched case-con-

trol study in patients older than 70 years, patientswho underwent VATS lobectomy had signifi-cantly less severe complications (28% versus

Table 3

Summary of complications comparing video-assisted thoracic

Study Year Type of study

Cattaneo et al, [19] 2008 Case-control

Whitson et al, [16] 2007 Case-control

Muraoka et al, [17] 2006 Case-control

Shiraishi et al, [58] 2006 Case-control

Watanabe et al, [22] 2005 Case-control

Demmy et al, [18] 2004 Case-control

Craig et al, [23] 2001 Randomized

Nagahiro et al, [25] 2001 Case-control

Yim et al, [24] 2000 Case-control

Total d d

Abbreviations: NR, not recorded; VATS, video-assisted thoa The total number of complications was added in each stu

numbers were calculated.b P ! .05 in original study.c P! .01 by c2 test.

45%) and decreased in-hospital deaths [19]. Mur-aoka and colleagues [17] also compared patientswho underwent VATS lobectomy or open lobec-tomy and noted lower total morbidities (25.6%

versus 47.6% P!.05), with a statistically signifi-cant decrease in the number of arrhythmias andsputum retention. In summary, VATS lobectomy

has similar complication pattern compared withopen thoracotomy but at a significantly reducedrate.

Perioperative course

Table 4 summarizes the effects of VATS versusopen thoracotomy on operative time, intraopera-tive blood loss, chest tube drainage, and length

of stay. Wilcoxon rank sum tests were used totest for significant differences between the VATSand open lobectomy groups.

Initial studies comparing operative timessuggested longer operative times for VATS lobec-tomies compared with open thoracotomy [32].

However, a summary of operative timesfor more recent studies show no difference (seeTable 4). Muraoka and colleagues [17] and Shir-aishi and colleagues [34] showed a significant

reduction in intraoperative blood loss. Summarystatistics of current studies (see Table 4) alsoshow a reduced blood loss for VATS lobectomies

compared with thoracotomy (average, 193 versus236 mL; P ¼ .04). Chest tube duration is also lessin the VATS group (3.9 versus 4.6 days; P ¼ .03)

compared with open thoracotomy for the six stud-ies with available data. Patients who underwent

surgery and open lobectomy

Number of patients Total complicationsa

VATS Open VATS Open

82 82 91 107b

59 88 20 42

43 42 11 20b

81 79 NR NR

221 190 11 15

20 38 5 12

22 19 NR NR

13 9 NR NR

18 18 NR NR

559 565 138 196c

racoscopic surgery.

dy. In cases where only percentages were given, absolute

Table 4

Perioperative results of current video-assisted thoracic surgery and open lobectomy

Study

Operative time

(min)

Intraoperative

blood loss (mL)

Chest tube

drainage (d)

Length of

stay (d)Acute

paina,bVATS Open VATS Open VATS Open VATS Open

Cattaneo et al, [19] NR NR NR NR NR NR 5 6b NR

Whitson et al, [16] 228 212 251 255 5 6.1 6.4 7 NR

Muraoka et al, [17] 288 293 151 362b 3 3.9b NR NR Less pain

on POD 7

Shiraishi et al, [58] 227 225 142 204b NR NR NR NR NR

Watanabe et al, [22] 215 221 236 238 5.8 7.8b NR NR Less pain

on POD 7

Demmy et al, [18] 133 312b NR NR 3 4.2 4.6 6.4b Less pain

at 3 months

Craig et al, [23] 121 141 NR NR NR NR 7.9 8.6 NR

Nagahiro et al, [25] 250b 186 187 216 3.6 3.8 NR NR Less pain

on POD 1, 7,

and 14

Yim et al, [24] 78 82 NR NR 3.2 4.1 4.1 5.3 Fewer pain

medications

Mean 192 195 193 236c 3.9 4.6c 5.8 7.0c d

Abbreviations: NR, not recorded; POD, postoperative day; VATS, video-assisted thoracoscopic surgery.a Less pain refers to VATS groups.b P ! .05 in original study.c P ! .05 by Wilcoxon rank sum test.

252 GROGAN & JONES

VATS lobectomy had a significant reduction in thelength of hospital stay in two of the case-controlstudies [18,19]. Summary statistics for the five stud-

ies that contained this data show a significant im-provement in the length of stay with VATSsurgery (5.8 versus 7.0 days; P ¼ .04).

Conversion rate

Conversion to open thoracotomy froma planned VATS lobectomy occurs in 0% to13% of cases (see Table 1) in current large series,

although the 13% conversion rate was seen ina multi-institutional study [13]. The case-controlstudies and randomized controlled trial reviewed

in Tables 3 and 4 had a mean conversion rate of6.6%, with a range of 1% to 9%. Cited reasonsfor conversion include hemorrhage, calcifiedlymph nodes, pleural adhesions, and the inability

to tolerate one-lung ventilation.

Lymph node dissection

Mediastinal lymph node sampling or dissection

is a critical component of a lobectomy performedfor lung cancer. Watanabe and colleagues [40]compared the number of lymph nodes dissected

in 221 patients who underwent VATS lobectomywith 190 who underwent open thoracotomy. Nodifference was seen in the number of dissected

lymph nodes (31 � 12 for VATS versus 31 � 18for open thoracotomy; P ¼ .889) or mediastinaland station-specific lymph nodes on the right.

The total number of lymph nodes dissected onthe left (28 � 10 for VATS versus 27 � 15 foropen thoracotomy; P ¼ .714) with the mediastinalnodes and nodes in each group was also similar.

Sagawa and colleagues [41] performed a VATSlobectomy and an MLND to assess the adequacyof an MLND. A second surgeon then performed

an open thoracotomy on the same patient usingan MLND. On the right and left side, an averageof only 1.2 lymph nodes remained. The authors

noted that VATS only missed 2% to 3% of lymphnodes, and all were negative for malignancy.

Pain

Swanson and Batirel’s [32] 2002 review of eightstudies before 2001 showed a significantly redu-

ced pain (measured with pain scales or pain med-ication use) in patients who underwent VATS lo-bectomy compared with open lobectomy. Most

studies were only significant for the immediatepostoperative period (POD 1–7), and only one re-corded less pain medication use at 3 weeks [42].

Early studies showed variability in the VATSlobectomy definition, and several authors usedrib-spreading techniques.


Studies since 2000 that report pain outcomes(see Table 4) show a significant reduction in painin the early postoperative period. The study byDemmy and colleagues [18] was the only one

showing an improvement in pain at 3 monthsin patients who underwent VATS. In a recentupdate, Demmy and Nwogu [43] showed a sub-

stantial and statistically significant reduction inpain and severe pain, determined using pain med-ication requirements at 3 weeks (Fig. 1). Using

visual analog scores, Tajiri and colleagues [44]recently reported a statistically significant reduc-tion in pain up to a year for VATS lobectomy

compared with a posterolateral thoracotomy.Balduyck and colleagues [45] reported their re-

sults of a prospective study of 100 patients under-going lung cancer surgery. Serial quality of life

and lung cancer–specific questionnaires wereadministered preoperatively and at 1-, 3-, 6-, and12-month intervals. Patients who underwent

VATS lobectomy experienced improved physicalfunctioning up to 12 months compared with thosewho underwent thoracotomy. Significant differ-

ences were seen in pain, favoring VATS over tho-racotomy, that also continued up to 12 months.Although no large randomized controlled trials

exist, considerable evidence shows that VATSlobectomy is less painful than standard openlobectomy in the early postoperative period andthat patients may experience less pain for up to

1 year.

Fig. 1. Pain control at 3 weeks after VATS lobectomy

compared with open thoracotomy. The charts show

that patients undergoing VATS have significantly less

pain as measured by the most potent analgesic still re-

quired: severe: schedule 2 narcotic; moderate: schedule

3 or lower; and mild: nonsteroidal anti-inflammatory

drugs or acetaminophen. (From Demmy TL, Nwogu C.

Is video-assisted thoracic surgery lobectomy better?

Quality of life considerations. Ann Thorac Surg

2008;85(2):S719–28; with permission.)

Biologic response

Several authors have studied the biologic re-sponse by evaluating inflammatory mediators andcytokines after VATS lobectomy compared with

an open thoracotomy. Plasma levels of tumornecrosis factor a (TNF-a), interleukin (IL)-1b,IL-6, IL-8, IL-10, and C-reactive protein (CRP)have been reported in several comparison studies

[17,23–25,44].Yim and colleagues [24] found a significant de-

crease in the IL-6, IL-8, and IL-10 levels in the

early postoperative period but no difference inTNF-a or IL-1b levels. Nagahiro and colleagues[25] also evaluated IL-6, IL-8, IL-10, and TNF-alevels but only found a significant decrease inthe IL-6 levels. Similarly, Craig and colleagues[23] found a decrease in IL-6 levels but no changein TNF-a levels. CRP levels in VATS versus open

lobectomy groups was lower in the VATS groupin all three studies evaluating this inflammatorymediator [17,23,46].

Other studies have also attempted to evaluatethe differences in immunosuppressive effects ofVATS and open lobectomies, comparing the

lymphocyte responses [47,48]. Both Leaver andcolleagues [47] and Ng and colleagues [48] foundthat VATS lobectomy had less effect on circulat-

ing T and natural killer (NK) cells.In summary, VATS lobectomy is associated

with a decrease in IL-6 and CRP levels (acuteinflammation) and quicker return of NK and T

cells (immune function) compared with openthoracotomy lobectomy. The clinical significanceof these findings has not been determined.

Pulmonary function

Studies comparing pulmonary function of

VATS lobectomy with open thoracotomy haveconsistently shown improvement in pulmonaryfunction in patients undergoing VATS [21,25,

49–51]. Pre- and postoperative evaluation offorced expiratory volume in 1 second (FEV1)and vital capacity were improved in patientsundergoing VATS lobectomy at 3 months [21].

Nagahiro and colleagues [25] found a quickerrecovery in the first 2 weeks of vital capacity,FEV1, and forced vital capacity (FVC) after

surgery.In a small study (10 VATS versus 11 open

thoracotomy), Nakata and colleagues [51] found

a significant improvement in peak flow rate onthe 7th and 14th postoperative days. A trend wasseen toward improvement in FEV1 (P ¼ .08),

254 GROGAN & JONES

FVC (P ¼ .10), and arterial oxygen pressure(PaO2) at POD 7.

Nomori and colleagues [50] used vital capacity

and the 6-minute walking (6 MW) test to compareVATS lobectomy, anterior limited thoracotomy,anteroaxillary thoracotomy, and posterolateralthoracotomy. The 6 MW test and vital capacity

measured at 1 to 24 weeks after surgery showeda significant improvement among VATS andall groups except axillary thoracotomy. These

authors compared VATS lobectomy and axillarythoracotomy and found no difference in the VCand 6 MW test at 1 and 2 weeks postoperatively.

In summary, pulmonary function is improvedin patients undergoing VATS lobectomy com-pared with those undergoing open thoracotomy,but this improvement may be lost in those who

undergo a limited axillary thoracotomy.

Results in high-risk patients

With the reduction of complications, postop-

erative pain, and improved pulmonary function inpatients undergoing VATS lobectomy, one of thedistinct advantages several recent studies show is

the improved complication profile in high-riskpatients [14,16,18–20,50]. In a retrospective case-control series, Whitson and colleagues [16] found

that despite these patients having more preopera-tive comorbidities, they had fewer complicationswith equivalent operative times, blood loss, lengthof stay, and survival rate.

A matched case-control study comparing theoutcomes of patients older than 70 years foundthat those undergoing VATS lobectomy had

significantly fewer complications, a shorter lengthof stay, and a reduction in the severity ofcomplications compared with those undergoing

open thoracotomy [19]. In a similarly designedstudy, Demmy and colleagues [18] showed thatpatients undergoing open thoracotomy were

more likely to be discharged to an additionalcare facility or require home assistance than thoseundergoing VATS lobectomy. In a small case se-ries of 25 patients older than 80 years, Shaw and

colleagues [14] showed a successful outcome withno difference in complications.

In a small series of patients who had poor lung

function defined by a FEV1 less than 0.8 L ora predicted postoperative FEV1 less than 50%,Garzon and colleagues [20] showed a complication

rate of 29% with no mortality. In this study, 13patients underwent lobectomy and 12 sublobarresections.

In summary, VATS lobectomy has been shownto have a lower complication rate than openthoracotomy in elderly patients and an acceptable

complication rate in patients who have poor lungfunction.

Quality of life

Data regarding quality of life assessment usingstandard quality of life measurement instrumentsafter VATS lobectomy is limited [45,52,53]. Ina prospective quality of life evaluation of patients

undergoing surgery for lung cancer (VATS andopen thoracotomy), Balduyck and colleagues[45] used the European Organization for Research

and Treatment of Cancer (EORTC) Quality ofLife Questionnaire-C30 and the lung cancer–specific module. Baseline and postoperative

assessments were performed before surgery andat 1, 3, 6, and 12 months. Compared with patientsundergoing open thoracotomy, those undergoing

VATS showed a more favorable evolution (statis-tically significant) in physical functioning, pain ingeneral, quality of life at 6 months, and thoracicpain over the 12-month study period.

In a retrospective study using similar question-naires, the long-term quality of life of 27 patientswho underwent VATS lobectomy and was com-

pared with that of 24 patients who underwentopen lobectomy [52]. Mean follow-up occurred at33.5 and 39.4 months. A trend was seen toward

improved long-term quality of life measures, butthey did not reach statistical significance. Sugiuraand colleagues [53] also performed a retrospective

long-term quality of life survey but found a signif-icant improvement in return to activity, chronicpain, and overall impression of the operation.

In summary, quality of life in the first year

seems to be improved in patients undergoingVATS lobectomy according to responses to stan-dard questionnaires, but additional prospective

studies are needed to determine the long-termbenefits.

Cost

Studies comparing the costs of VATS lobec-tomy with open thoracotomy are lacking. TwoJapanese cost-analysis studies comparing these

procedures have been reported, but both havegreater than 17 days average length of stay forlobectomies. Sugi and colleagues [54] reported an

increase in cost of VATS lobectomy for patients(1992–1995), but Nakajima and colleagues [55]reported a cost savings (1997–1998). The long


length of stay and time since the studies wereperformed make application to current practicedifficult. However, these studies both showedthat VATS lobectomies were more costly to per-

form because of equipment and supplies, butthat reduction in length of stay for patients under-going VATS lobectomies can decrease the overall

cost compared with open thoracotomy.McKenna and colleagues [56] discussed the

profound impact that reducing the stay from 7

to 2 days can have for annual hospital revenueper individual room ($776,100–$2,254,000) fromthe increase in number of patients that can use

the room in a diagnosis-related group paymentsystem. In a similar inference, Demmy andcolleagues [18] described the savings that occurfor individuals ($1150–$2550) undergoing

a VATS lobectomy compared with open lobec-tomy because of reduced necessary dischargecare (home health and care facility). More studies

are needed to determine if VATS lobectomy is lessexpensive than open lobectomy, and specificallyfor which patient populations.

Delivery of adjuvant chemotherapy

Patients who have stage II or III NSCLC mayrequire adjuvant chemotherapy or chemoradia-tion therapy. Successful delivery of these therapies

may be reduced if a patient has a difficult post-operative recovery. In reviewing the success ofadjuvant chemotherapy delivery after VATS or

open lobectomy, Petersen and colleagues [57]found that patients undergoing open lobectomywere more likely to experience a statistically

significant delay in the initiation of adjuvant che-motherapy and a reduction in the doses. A higherpercentage of patients in the VATS group (61%versus 40%) received 75% or more of the planned

dose.

Survival

In patients who have NSCLC, in-hospital

survival has been shown to be comparable forVATS lobectomy and open thoracotomy[3,6,13,15,16,30,40,58,59]. Short-term survival isrelated to the mortality of the procedure, whereas

long-term survival is related to disease progres-sion or death from other comorbidities.

Stage of lung cancer

In most large VATS lobectomy series, mostpatients had pathologic stage I disease (74%–87%). Of these patients, approximately 50% had

stage IA disease [3,13,15]. The VATS groups incase-control studies comparing VATS with openlobectomy all had a higher percentage of patientswho had stage I disease [16,19,24,25,40].

VATS lobectomy has a low morbidity andmortality rate, but these studies have typicallyevaluated patients who have stage I disease. More

data are needed to determine the safety andefficacy of VATS lobectomy in the surgicalmanagement of patients who have stage II and

III lung cancer.

Robotic lobectomy

Experience with robotic technology for lobec-tomy is limited to a few case reports and one caseseries [60–63]. In a case series from Park and

colleagues [62], robotically assisted lobectomywas attempted in 34 patients, with 4 requiringconversion to open lobectomy. No deaths

occurred and the median chest-tube duration(3.0 days), length of stay (4.5 days), and complica-tion rate (26%) was comparable to current VATSlobectomy series. The median operative time was

218 minutes and a mediastinal lymph node dissec-tion was performed in all cases. More experienceis needed to determine the usefulness of robotic

assistance in VATS lobectomy.

Summary

VATS lobectomy is an acceptable alternativeto open lobectomy for treating early-stageNSCLC. Although no large randomized control

trial has compared these procedures, recent largeseries and case-control studies provide strongevidence that patients undergoing VATS lobec-

tomy have less pain, fewer perioperative compli-cations, shorter chest-tube duration, anddecreased length of stay. Increasing evidence

supports improved quality of life up to 1 year,less inflammation, and greater safety profile inhigh-risk patients. More data are needed to bettershow an improvement in the economic efficacy,

ability to more effectively administer adjuvanttherapies, and benefit of robotic assistance inVATS lobectomy.

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Thorac Surg 2007;83(4):1245–9 [discussion: 1250].

[58] Iwasaki A, Shirakusa T, Shiraishi T, et al. Results of

video-assisted thoracic surgery for stage I/II non-

small cell lung cancer. Eur J Cardiothorac Surg

2004;26(1):158–64.

[59] Shiraishi T, Shirakusa T, Hiratsuka M, et al. Video-

assisted thoracoscopic surgery lobectomy for

c-T1N0M0 primary lung cancer: its impact on

locoregional control. Ann Thorac Surg 2006;82(3):

1021–6.

258 GROGAN & JONES

[60] Bodner J, Wykypiel H,Wetscher G, et al. First expe-

riences with the da Vinci operating robot in thoracic

surgery. Eur J Cardiothorac Surg 2004;25(5):

844–51.

[61] Morgan JA, Ginsburg ME, Sonett JR, et al.

Advanced thoracoscopic procedures are facilitated

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othorac Surg 2003;23(6):883–7 [discussion: 887].

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for video-assisted thoracic surgical lobectomy: tech-

nique and initial results. J Thorac Cardiovasc Surg

2006;131(1):54–9.

[63] Melfi FM, Menconi GF, Mariani AM, et al. Early

experience with robotic technology for thoraco-

scopic surgery. Eur J Cardiothorac Surg 2002;

21(5):864–8.


Long-Term Outcomes of Thoracoscopic LobectomyThomas A. D’Amico, MD

Duke University Medical Center, Durham, NC 27710, USA

Thoracoscopic lobectomy has emerged asa reasonable option for the management of earlystage non-small cell lung cancer [1,2] and is sup-

ported by evidence-based treatment guidelines[3]. Early attention focused on advantages inshort-term quality of life (QOL) outcomes, such

as decreased postoperative pain [4], shorter chesttube duration and length of hospital stay [5–8],and preservation of postoperative pulmonary

function [9,10]. These studies demonstrated im-portant advantages for thoracoscopic lobectomyover open lobectomy, including the ability to per-form the operation safely in high-risk patients

[4,11].Despite the demonstrated QOL advantages,

concern regarding the long-term outcomes ap-

pears to have limited the prevalence of thoraco-scopic lobectomy, as demonstrated by the Societyof Thoracic Surgeons database [12]. Specifically,

uncertainty regarding oncologic equivalency out-weighed the acknowledged short-term benefits inQOL when other variables, such as morbidity

and mortality, were as of yet unstudied [13].Thus, recent advances in the understanding ofthe long-term outcomes of thoracoscopic lobec-tomy are reviewed, including oncologic outcomes,

morbidity, and mortality.

Oncologic outcomes

Thoracoscopic lobectomy is defined as theanatomic resection of an entire lobe of the lung,using a videoscope and an access incision, with-

out the use of a mechanical retractor and withoutrib-spreading [1–8]. The anatomic resection in-cludes individual dissection and stapling of the

involved pulmonary vein, pulmonary artery, and



doi:10.1016/j.thorsurg.2008.04.002

bronchus, and appropriate management of themediastinal lymph nodes, as would be performedwith thoracotomy. To be considered a viable

alternative to conventional lobectomy, thoraco-scopic lobectomy must be applied with the sameoncologic principles: individual vessel ligation,

complete anatomic resection with negative mar-gins, complete hilar lymph node dissection, andappropriate management of the mediastinal

lymph nodes. In summary, the properly per-formed thoracoscopic lobectomy is the same op-eration as the open lobectomy but is performedwithout rib spreading.

Stage-specific survival

The safety and efficacy of thoracoscopic lobec-tomy for patients with early-stage lung cancer has

been established [1–8,14–18]. Although there areno large prospective, randomized series that com-pare thoracoscopic lobectomy to conventional

approaches, a sufficient number of series havebeen published, both single-institution andmulti-institution experiences, to conclude thatthoracoscopic lobectomy is a reasonable strategy

for patients with clinical stage I lung cancer.Daniels and colleagues [5] reported the results

of thoracoscopic lobectomy in 110 consecutive pa-

tients. The 30-day mortality was 3.6%, with no in-traoperative deaths. The conversion rate was1.8%, and none were emergent. The median chest

tube duration was 3 days and median length ofstay was 3 days. This series was updated by Onai-tis and colleagues [7], and stage-specific survivalwas analyzed as well. In this series of 500 patients,

the 5-year survival for those with stage I non-small cell lung cancer was 78%, comparable tolarge published databases of stage-specific results

[19,20]. Sugi and colleagues [15] analyzed out-comes of 100 patients with stage IA lung cancerrandomized to thoracoscopic lobectomy or open

ts reserved.




260 D’AMICO

lobectomy, and found at least equivalent survivalat 3 and 5 years for patients who underwent thor-acoscopic lobectomy (90%; 90%), compared with

those who underwent open lobectomy (93%;85%, P ¼ .9). Long-term survival as reported inrecent series of thoracoscopic lobectomy is sum-marized in Table 1 [6,7,14–18].

Complete resection rate

The Cancer and Leukemia Group B reported

on the results of a multi-institutional series of 97patients who underwent thoracoscopic lobectomy[8]. In this series, including numerous surgeons

and institutions, the results were uniformlygood, with complete resection in all patients. Inaddition, the operative mortality was 2%, the op-erative time was 130 minutes, and the median

length of stay was 3 days [8]. Numerous otherseries have reported no difficulty in achievingcomplete resection with thoracoscopic lobectomy

[4–7,14–18].


The ideal approach to the assessment ofmediastinal lymph nodes is a topic of debate,which may be settled by a recently completedclinical trial [21]. Purported advantages of com-

plete mediastinal lymph node dissection (as com-pared with systematic sampling) includeimprovement in local control and survival, but

there is convincing evidence to support the con-cept that complete mediastinal lymph node dissec-tion is performed just as effectively using the

thoracoscopic approach.Several studies have been performed compar-

ing thoracoscopic to conventional lymph node

dissection [22–24]. In one study, Kondo and col-leagues [24] performed complete mediastinallymph node dissection during thoracoscopic

Table 1

Recent series of thoracoscopic lobectomy

Series N

Operative

(30-day)

mortality

Survival

stage I

Kaseda [14] 128 0.8% 94% (4 yr)

Sugi [15] 50 0 90% (5 yr,

stage IA)

Solaini [16] 125 0% 90% (3 yr)

Walker [17] 158 1.8% 78% (5 yr)

Roviaro [18] 193 1% 64% (5 yr)

McKenna [6] 1,100 0.5% 77% (5 yr)

Onaitis [7] 500 1.2% 78% (4 yr)

lobectomy, followed by thoracotomy. In thisstudy, 27 to 48 lymph nodes were resected thora-coscopically, and subsequent thoracotomy yielded

minimal extra lymph node tissue: mean 1.3 andmedian 0 lymph nodes. In the randomized studyby Sugi and colleagues [15], there was no differ-ence in the number of hilar or mediastinal lymph

nodes resected using the open or thoracoscopicapproaches. Watanabe and colleagues [25] dem-onstrated similar lymph node resection rates for

the open and thoracoscopic approaches ina lobe-specific study.

Local recurrence

Initial experience with thoracoscopic resections

was notable for a high local recurrence rate at theport sites [26], which is related to removing speci-mens without protection. Currently, all lobectomy

specimens are removed using a protective speci-men bag to prevent implantation of tumor cellsin the incision [1–8], and there is no evidence

that there is increased local recurrence. In addi-tion, the lobectomy specimen and hilum are eachinspected to ascertain that anatomic lobectomyhas been performed [1,2].

Compliance with adjuvant chemotherapy

One of the most promising advantages associ-ated with thoracoscopic lobectomy relates to theability of patients to tolerate adjuvant therapy. It

has been demonstrated that adjuvant chemother-apy confers a significant survival advantage forpatients with completely resected stage II and

stage IIIA non-small cell lung cancer [3,27,28]. Ina recent study, the ability to deliver adjuvant che-motherapy was compared in 100 patients who un-

derwent complete resection for non-small cell lungcancer, by thoracotomy in 43 patients and bythoracoscopy in 57 patients [29]. Those undergo-

ing thoracoscopic lobectomy had significantlyfewer delayed (18% versus 58%, P!.001) and re-duced (26% versus 49%, P ¼ .02) chemotherapydoses. A higher percentage of patients undergoing

thoracoscopic resection received 75% or more oftheir planned adjuvant regimen without delayedor reduced doses (61% versus 40%, P ¼ .03). Al-

though long-term survival was not an end-pointof this study, similar differences in other tumortypes are associated with improved survival [30].

Finally, it has been demonstrated that thoraco-scopic lobectomy is safe and feasible in patientsafter induction therapy [31].

261OUTCOMES AFTER VATS LOBECTOMY

Morbidity and mortality

Morbidity and mortality (including virtuallyevery postoperative event) associated with thor-acoscopic resection [4–11] are comparable or lower

than expected for conventional thoracotomy andresection [21]. In one study, using a case-matchedstrategy, 122 patients undergoing thoracoscopic

surgery and 122 patients undergoing thoracotomywere compared [32]. Overall, complications werelower in the thoracoscopic group (17.2% versus

27.9%, P ¼ .046). In a second study, focusing onelderly patients (age R 70 years), a retrospective,matched case-controlled study was performed

evaluating the perioperative outcomes after lobec-tomy by thoracoscopy and thoracotomy [33]. Af-ter matching based on age, gender, presence ofcomorbid conditions, and preoperative clinical

stage, there were 82 patients in each group. Thor-acoscopic lobectomy resulted in a significantlylower rate of complications compared with thora-

cotomy (28% versus 45%, P ¼ .04). No patientsundergoing thoracoscopic lobectomy had higherthan grade 2 complications, whereas 7% of com-

plications in the open lobectomy group were grade3 or higher. There were no perioperative deaths inthe thoracoscopic lobectomy patients, compared

with an in-hospital mortality rate of 3.6% for tho-racotomy patients.

Summary

Thoracoscopic lobectomy is emerging as theprocedure of choice for patients with early stagenon-small cell lung cancer, based on advantages in

quality of life as well as long-term outcomes. Inaddition, thoracoscopic lobectomy has been dem-onstrated to be safe and effective for selected

patients with locally advanced disease and forthose after induction therapy. Concerns relatingto oncologic efficacy, as measured by complete

resection rate, ability to perform complete medi-astinal lymph node dissection, or cancer-specificsurvival, have not been supported by evidence inthe literature. In addition there is increasing

evidence that thoracoscopic lobectomy may actu-ally have superior outcomes, based on advantagesin morbidity and mortality after resection and in

the delivery of adjuvant chemotherapy.

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Video-Assisted Thoracic Surgery Lobectomy:Centers of Excellence or Excellence of Centers?

Cynthia S. Chin, MD*, Scott J. Swanson, MDDivision of Thoracic Surgery, Mount Sinai Medical Center,

1190 5th Avenue, Box 1020, New York, NY 10029, USA

The resection of lung cancer using minimally

invasive approaches has evolved over the past 16years. Currently, an anatomic lobectomy or seg-mentectomy and complete mediastinal lymph

node dissection can be achieved through two tofour small incisions, without rib spreading, usingvideoscopic visualization. It would seem intuitivethat this is a better approach than using a thora-

cotomy to resect the lung. The data for this isdetailed earlier in this issue. Despite what isbecomingdover timedquite strong evidence

that a minimally invasive lobectomy is superiorto a thoracotomy and lobectomy, less than 20%of lobectomies registered in the Society of Tho-

racic Surgeons database are done using a thoraco-scopic approach [1]. Assimilation of video-assistedthoracic surgery (VATS) lobectomy into the prac-

tice of a thoracic surgeon begs the question ofhow do we, as a profession, assure quality (definedas a proper oncologic surgery) and safety while in-troducing this new technology? The goal of this

article is to answer this question.

Standardizing terminology

To discuss VATS lobectomy and its results, wemust standardize the terminology. Since Lewis andcolleagues [2] published the first report of VATS

lobectomy in 1992, a PubMed search on VATS lo-bectomy produces 332 citations. The descriptionof the procedure varies greatly. In some publica-

tions on VATS lobectomy, the investigatorsspread the ribs and use the access port to directly



(C.S. Chin).


doi:10.1016/j.thorsurg.2008.04.001

visualize the thoracic cavity, while the camera is

used for lighting and the education of those watch-ing. Others have reported a non-rib-spreadingtechnique in which the entire surgery is done

with video-assistance. The access port in this caseis not enlarged until the specimen is removed.Some investigators will dissect and ligate the hilarstructures as they would in an open surgery, while

others report on the use of one stapler to divide allhilar structures and lung parenchyma simulta-neously. All of these different techniques,

described as the same procedure, makes the resultsunclear.

The Cancer and Leukemia Group B (CALGB)

designed a prospective study to evaluate thetechnical feasibility and safety of VATS lobec-tomy. This study was conducted based on a stan-

dardized definition of a VATS lobectomy toencompass a true anatomic lobectomy with in-dividual ligation of lobar vessels and bronchus, aswell as hilar lymph node dissection or sampling,

using the video screen for guidance, two or threeports, and no retractor use or rib spreading [3].This definition describes the procedure for a stan-

dard lobectomy that surgeons have performed fordecades through a thoracotomy. The only differ-ence is that the definition replaces a thoracotomy

incision used for access and visualization with twoor three ports and no rib spreading. The authorsbelieve that this standardized definition put forthby CALGB should be employed by all those re-

porting and publishing on VATS lobectomy [3].

Quality assurance

Generally, board certification in cardiothoracic

surgery is used to demonstrate competence of the

ts reserved.




264 CHIN & SWANSON

individual for the operations within the field.However, over time the field has become socomplex and new technologies and treatments

have evolved so much, that we have reached thepoint where it is reasonable to ask whether allsurgeons that have board certification in cardio-thoracic surgery should be credentialed to do all

operations within the field. This is clearly a con-troversial area, but one that should be addressedby our societies before rules and regulations are

mandated by outside groups, such as governmentagencies. To date The American Board of Tho-racic Surgery has deemed that there is not a need

to create separate certification for specializedprocedures within the field of cardiothoracicsurgery. Certainly there is widespread support toeducate surgeons about new techniques and

technologies, and courses are regularly held withour society’s backing to do this.

Volume measures are used by some hospitals

as a method for determining which surgeonsshould be credentialed to do specific operations.The logic of this of course suggests that, for

whatever reason, if a surgeon does not performa certain minimum number of operations ina given area in a given year, then that is evidence

that the surgeon is not competent to do thatspecific procedure. The problem is that thiscriteria alone is not adequate demonstration ofcompetence and might create the wrong incentive

for the surgeon. Rather than refer a patient orcounsel a patient not to have a certain procedure,a surgeon will feel compelled to do the operation

in question to maintain an adequate volume tostay credentialed. In addition, volume will nottake outcome into account.

In the recent past, several fields of surgery haveintroduced new technology and procedures. Theassimilation of laparoscopic cholecystectomy,bariatic surgery, and lung volume reduction

surgery (LVRS) will be discussed to illustratethis point for comparison with the current evolu-tion of VATS lobectomy.

In 1987, the first laparoscopic cholecystectomywas performed by Mauriat in France. A year laterMckernan and Saye [4] reported the first laparo-

scopic cholecystectomy in the United States. Therapid integration of this procedure was a result,in part, of a high patient demand. Several groups

recognized that residency training would not beable to keep pace with the rising demand. In1993, the National Institute of Health (NIH) [5]published its consensus conference on gallstones

and laparoscopic cholecystectomy. The NIH

stated that the skill of the surgeon was the singlemost important variable in the safety and efficacyof this procedure. They recognized that direct sys-

tematic comparison of open and laparoscopiccholecystectomy was not feasible because of theapparent unwillingness of patients to forgo thisnew technical achievement. To compare results

of the different surgeries, they emphasizeda need for all operators to input data on laparo-scopic cholecystectomy and associated morbidity

and mortality into a centralized, accurate regis-trar. The Society of American Gastrointestinaland Endoscopic Surgeons (SAGES) introduced

in 1999 the SAGES outcome initiative to trackoutcomes of its members. The Society has usedthis database to report on outcomes of cholecys-tectomy surgery from 1999 to 2005 [6].

Almost a decade later, bariatric surgery hada similar crisis in balancing new technology withpatient safety. In 2004, 120,000 bariatric pro-

cedures were performed for morbid obesity [7].As the number of surgeries rose exponentially,morbidity and mortality was also rising. At this

time, third party payers, such as Blue Cross BlueShield of Florida and CIGNA Health Care, an-nounced they would no longer cover the cost of

the surgery. Dismissal of this surgery was not pos-sible because The National Institute of HealthConsensus Conference on the Surgery of Obesityin 1991 concluded that nonsurgical approaches

to morbid obesity were not effective and patientswith high body mass index were surgical candi-dates. The American Society for Bariatric Surgery

(ASBS) leadership responded with a task force toinvestigate the safety of these procedures. Duringthe process, the ASBS developed 11 requirements

and a system to be a Center of Excellence. Severalrequirements addressed the need for ancillarystaff, such as nutritionists and coordinators, tobe dedicated to postoperative bariatric patients.

It also required that the applicant had performedat least 125 bariatric surgical cases in the past yearand at least 50 in the year before. The tenth and

eleventh tenets demanded that the applicant bededicated to long-term follow-up of at least 75%of the patients and that these outcomes all be en-

tered into a database [8]. Medicare released the‘‘Decision memo for bariatric surgery for thetreatment of morbid obesity’’ on February 21,

2006. After review of the American College ofSurgeons and ASBS requirements for credential-ing in bariatric surgery, Medicare instituted thispolicy, stating that Medicare patients will only

be reimbursed if bariatric surgery is performed

265VATS LOBECTOMY

in institutions meeting all nine of the criteriastated in the memo. Many of the componentswere in regard to the institution and ancillarystaff; however, one criteria mandated that the sur-

geon must perform a minimum of 50 bariatric sur-geries a year and have performed at least 125bariatric procedures at the time of initial applica-

tion [9].The National Emphysema Treatment Trial was

a randomized protocol to examine the potential

benefits of lung volume reduction surgery versusbest medical care for patients with advancedemphysema [10]. Seventeen clinical sites were se-

lected to carry out the surgery. Medicare wouldnot pay for this operation outside of this trial.The 17 clinical sites were selected based on an appli-cation that demonstrated excellence in the work-up

and care, including surgical expertise, of advancedemphysema patients. In most patient subgroups,the trial results showed a benefit in favor of surgical

treatment over medical treatment. Once the trialwas completed the original 17 sites, as well as allhospitals that have a Medicare-approved lung

transplant program, were approved by the Centerfor Medicare and Medicaid Services to performlung volume reduction surgery. This suggests that

there is precedent for focusing the care of patientsin need of complex thoracic technical proceduresto a designated group of surgeons based on demon-strated competence.

Unlike bariatric surgery and LVRS, VATSlobectomy is the introduction of technology toan already established procedure. The initial

pitfalls of bariatric surgery and LVRS wereaddressed by insuring competence of the surgeonto perform a procedure and care for the patient in

the postoperative setting. Quality assurance ofVATS lobectomy requires we address the former,not necessarily the latter. Proper algorithms forpreoperative evaluation and postoperative care of

patients undergoing pulmonary resections havelong been established. There is an inherent as-sumption that those performing VATS lobectomy

have already mastered these algorithms.Although bariatric surgery and LVRS are less

similar, all three procedures and the response to

quality assurance are of value when discussingVATS lobectomies. To have a successful and safeVATS lobectomy program, the surgeon should:

(1) have a dedicated operating room team; (2) becredentialed in VATS lobectomy; (3) maintaineducation in the field; and (4) participate ina national database committed to identifying

short-term and long-term outcomes in this field.

Dedicated surgical team

One of the key determinations of any success-ful operation is the team effort put forth by theoperating room staff. VATS lobectomy is no

different. The entire team needs to be dedicatedand committed to a video-assisted procedure. Thesurgeon and the assistant, through various ways

discussed below, need to be familiar with theanatomy from a videoscopic viewpoint. Thenurses and physicians need to be familiar with

the instruments and stapling devices required tocomplete the procedure. It is important for thenurse and assistant to understand critical points in

the procedure. For example, when dividing a vas-cular structure, the authors’ team’s scrub nurseknows to have a dental pledget on a long straightclamp ready in the unfortunate and rare event of

a stapler misfiring. The authors have had thismisfortune, which required the dental pledget beplaced immediately through the access port to

hold pressure on the area of bleeding. Theassistant maintained this position while the sur-geon converted to a thoracotomy. The anesthesi-

ology resident knew to call for their attending aswell as for blood. The nurse immediately preparedthe instruments for a thoracotomy. This sequence

of events described above was not determined atthat moment but had been previously discussed atlength. This knowledge and team effort allowedfor safe repair of the bleeding vessel and comple-

tion of the intended resection.Dedicated thoracic anesthesiologists are a vital

part of a VATS lobectomy team. Expert place-

ment of a double-lumen tube and subsequentfiber-optic bronchoscopy are necessary. Single-lung ventilation is mandatory during VATS

lobectomy. Unlike open lobectomy, an inflatedor partially inflated lung will hinder propervisualization. During a VATS lobectomy instru-ments are used for lung retraction. When lungs

are partially inflated in an open thoracotomy,nontraumatic instruments, such as an Allisonretractor or the assistant’s hand, can be used to

retract the lung. In VATS lobectomy, the in-struments can cause parenchymal damage to aninflated lung.

Training

Training in VATS lobectomy can be obtained

in several ways. For those residents training ata program performing VATS lobectomy, acquisi-tion of this skill may be achieved during this time

266 CHIN & SWANSON

period. The American Board of Thoracic Surgery(ABTS) recently adjusted operative criteria forresidents obtaining board certification in cardio-

thoracic surgery. A cardiothoracic resident whobegan their fellowship before June of 2007 isrequired to have performed 30 cases in the sub-category of anatomic lung resection (pneumonec-

tomy, lobectomy, or segmental resection). Aresident starting their cardiothoracic training afterJuly 1, 2007 is required to perform 50 anatomic

resections [11]. Performance of VATS lobectomyis not directly addressed in this subcategory orin the VATS category in the list of ABTS require-

ments. It is the authors’ opinion that a residentneeds to document performing 25 VATS lobecto-mies during his or her training in order to gaincertification in this highly skilled procedure.

For those residents not in a training programwith adequate VATS lobectomy volume or forthose surgeons already in practice and contem-

plating a VATS program, additional trainingshould be sought. This can be achieved in manyways. Certainly, minimally invasive thoracic sur-

gery fellowships exist that provide an excellentway to obtain skills in this field. However, thisoption is very time intensive and may not be

feasible for those with an established practice.New technology can help overcome these

limitations. Systems, such as learning manage-ment systems, are Internet-based software pack-

ages that allow lectures and movies to be accessedon-line [12]. Internet based videos of VATS lo-bectomy performed at high volume centers can

be placed on-line and users can log on to watchvideo clips at their convenience. The library ofvideos should contain several VATS lobectomies

of each of the five lobes and VATS mediastinalnode dissection. The viewer should have the abil-ity to review each segment of the clip for as longas they need.

An another advancement in technology is thedevelopment of surgical simulators that reproducethe operating room and can be a safe environment

for the acquisition of VATS lobectomy skills.Educational centers that provide additional sur-gical education have been built in North America.

These centers provide a spectrum of educationaltools, which include lecture series, dry and wetlaboratories, and simulations of operating rooms

and trauma bays [12]. The Thoracic Surgery Res-ident Association, in conjunction with the Tho-racic Surgery Directors Association and theCTSnet.org Resident Section, have developed

a symposium that will consist of didactic sessions,

hands-on cadaveric and animal laboratory experi-ences, a porcine cardiac wet lab, and endovascularsimulation [13]. This type of education allows for

new technology in the cardiothoracic field to beexperienced while preserving patient safety. It isnot specific for video-assisted surgery; however,it can serve as a template for the development of

a VATS simulation center. Our laparoscopic col-leagues have instituted such simulators for educa-tion and acquisition of skill. Some have proposed

that these simulators be used to access the profi-ciency of students, residents, and attending sur-geons. Van Sickle and colleagues [14] have

suggested the use of these simulators for certifica-tion and recertification. The authors would agreethat simulators will be helpful in developing thehighly technical skills required in video-assisted

surgery, but would caution against its use in thecredentialing process until proper validation ofthis system is performed.

An additional source of training and exposureto VATS lobectomy are symposiums and coursesdedicated to minimally invasive surgery. These

courses often have experts and leaders of the fielddiscussing various aspects of minimally invasivethoracic surgery. Often there are live surgeries

with an expert panel available to answer questionsfrom the participants.

Several institutions with minimally invasivethoracic surgery programs afford opportunities

to a visiting physician to come and observe. Thesesmall groups allow for an observing surgeon toask questions focused on the parts of the pro-

cedure that have been troublesome to perfect. Asone can imagine, this is potentially a high-yieldexperience for the observer.

Even with proper training and credentialing,a VATS program should make a gradual ap-proach to VATS lobectomy. A surgeon startinga new program should progress from VATS

pleural biopsy and pleurodesis through wedgebiopsy to VATS lobectomy and possibly VATSsleeve lobectomy. Even the performance of VATS

lobectomy should have a progression from thehistorically easier lobectomy to the harder ones.Therefore, a surgeon should attempt a VATS

lobectomy of the right lower lobe followed bythe left lower lobe, the right middle lobe, the rightupper lobe, and finally the left upper lobe. The

surgeon should also progress from a muscle-sparing thoracotomy to a hybrid procedure (tho-racotomy, but the procedure is performed usinga videoscope for guidance) to a complete VATS

lobectomy.

267VATS LOBECTOMY

Maintenance of training

As with any other surgical procedure, the skillsrequired to perform a safe oncologic VATS lobec-tomy must be maintained. If one examines the

literature on robotic prostatectomy, one finds it hasbeen reported that a surgeonbe required toperformabout 20 of these procedures to become proficient.

Samadi and colleagues [15] reviewed their first 70cases in terms of length of stay, estimated bloodloss, and length of surgery. They published that

even after 70 cases, the learning curve had notreached a plateau. The extrapolation of the datawould be that having command of a procedure

does not necessarily translate to being an expert.Surgeons certified in VATS lobectomy should con-tinue to ascertain skills and knowledge.

Starting in January of 2008, The ABTS has

replaced its recertification process with its newmaintenance of certification process. The Boardhas developed four maintenance of certification

components that will not be discussed here [16].The authors note this change as an indicationthat the ABTS recognizes the need for continued

emphasis on technical skills and patient outcomesas well as cognitive skills.

To ensure that certified surgeons are dedicated

to high clinical standards with regards to video-assisted surgery, a certified VATS lobectomysurgeon must be a dedicated and compulsivemember of the national database. Surgeons

should also obtain continuing medical educationcredits by attending yearly conferences and view-ing on-line VATS lobectomy surgery.

National database

Credentialing should mandate enrollment into

a national database. All patients operated on bya surgeon should be entered. The surgeon shouldbe dedicated to short- and long-term follow-up of

these patients with dutiful data entry. Nationaldatabases as part of a quality improvement planare not novel and have been implemented in manyother fields, including other areas of cardiotho-

racic surgery [17–19]. Monitoring of surgical pro-cedures and outcomes may have contributed tothe improved mortality rates in patients undergo-

ing coronary surgery [20,21].Short-term follow up will help evaluate things

such as length of stay, blood loss and transfusion

requirements, pain scales, and return to function.As with oncologists, the VATS database alsoneeds a portion dedicated to long-term follow-up

to determine the efficacy of the procedure andthe surgeon. As suggested by Samadi and col-leagues [15], surgeons skilled in a highly technicalprocedure, such as robotic prostatectomy or

VATS lobectomy, may not plateau until later intheir career. If outcome data is gathered fromthose just starting to perform the procedure, the

database will not be realistic. It is vital that expertsurgeons continue to input data to obtain moreaccurate statistics of the procedure.

Credentialing

Currently, credentialing is achieved at the local

hospital level. A surgeon is awarded privileges toperform a defined number of procedures by thehospital administrators and department chair.The authors believe that this practice should

continue; however, surgeons applying for permis-sion to perform VATS lobectomy should fulfillthe following criteria:

The applicant is currently a board certified car-diothoracic surgeon in good standing.

The applicant needs to document performing25 VATS lobectomies as the surgeon.

A video-clip of a VATS lobectomy performed

by the applicant should be included withthe application.

There needs to be documentation that the op-

erating room staff is familiar with VATS lo-bectomy and there is a commitment tomaintenance of the equipment.

The applicant must be dedicated to follow-up

of at least 75% of the VATS lobectomy pa-tients for a minimum of 5 years.

This data should be sent to a centralizeddatabase. Then, once certified in VATS lobec-tomy, a surgeon must document the following:

Maintenance of certification from the ABTS;Performance of a minimum of 20 VATS lobec-

tomies a year;Regular attendance to a minimally invasivesymposium or the viewing of on-line VATS

lobectomy videos once a month; andSubmission of all VATS lobectomy cases andfollow-up to a national database.

Summary

VATS lobectomy, as defined by CALGB

39802, provides the same oncologic surgery asthat performed through a thoracotomy. Standard-izing the terminology is the first step that must be

268 CHIN & SWANSON

undertaken to standardize the operation. VATSlobectomy is the use of technology to aid inperforming an established procedure. This tech-

nology and development of the skills required toperform a safe VATS lobectomy must be carefullymonitored to protect the quality of the product,which ultimately is defined as patient outcome.

‘‘Center of Excellence’’ is a determination used inseveral other specialties to provide quality assur-ance for new procedures or technologies, or for

those surgeries not widely performed, such asesophageal surgery. The authors believe that theprofession should designate Centers of Excellence

based on the credentialing guideline discussedearlier. The authors do believe that the currentresidency and fellowship training will provide, intime, ample surgeons skilled in VATS lobectomy.

As these surgeons become certified and dissemi-nate throughout the country, it is expected thatVATS lobectomy will be readily available in most

institutions. Over time this will allow VATSlobectomy to evolve from specific Centers ofExcellence to a broader group of hospitals based

on widespread availability of a surgeon certified inVATS lobectomy. During this transition, theauthors would encourage the community of

surgeons performing this procedure to submittheir statistics to a nationwide database. Thiswill provide an excellent database for evidence-based medicine. Such rigorous data collection

should permit thoracic surgeons to be appropri-ately compensated for performing these techni-cally challenging procedures.

References

[1] BoffaDJ, AllenM,Grab JD, et al. Data from the So-

ciety of Thoracic Surgeons general thoracic surgery

database: the surgical management of primary lung

tumors. J Thorac Cardiovasc Surg 2008;135(2):

247–54.

[2] Lewis RJ, Caccavale RJ, Sisler GE, et al. One hun-

dred consecutive patients undergoing video-assisted

thoracic operations. Ann Thorac Surg 1992;54(3):

421–6.

[3] Swanson SJ, Herndon JE, D’Amico TA, et al.

Video-assisted thoracic surgery lobectomy: report

of CALGB 39802da prospective, multi-institution

feasibility study. J Clin Oncol 2007;25:4993–7.

[4] Gaskin TA, Isobe JH, Mathews JL, et al. Laparos-

copy and the general surgeon. Surg Clin North Am

1991;71(5):1085–96.

[5] NIH Consensus Conference. Gallstones and laparo-

scopic cholecystectomy. JAMA 1993;269(8):

1018–24.

[6] Velanovich V, Morton JM, McDonald M, et al.

Analysis of the SAGESoutcomes initiative cholecys-

tectomy registry. Surg Endosc 2006;20:43–50.

[7] NguyenNT, Root J, Zainabadi K, et al. Accelerated

growth of bariatric surgery with the introduction of

minimally invasive surgery. Arch Surg 2005;140(12):

1198–202.

[8] Rendon SE, And Poires WJ. Quality assurance in

bariatric surgery. Surg Clin North Am 2005;85:

757–71.

[9] Centers for Medicare and Medicaid Services. Deci-

sion memo for bariatric surgery for the treatment of

morbid obesity. Available at: http://www.cms.hhs.

gov/mcd/viewdecisionmemo.asp?id¼160. Accessed

February 1, 2008.

[10] National Emphysema Treatment Trial Research

Group. A randomized trial comparing lung-volume-

reduction surgery with medical therapy for severe

emphysema. N Engl J Med 2003;348(21):2059–73.

[11] American Board of Thoracic Surgery. Booklet of in-

formation. 2007.

[12] QayumiK. Centers of excellence: a new dimension in

surgical education. Surg Innov 2006;13(2):120–8.

[13] CardiothoracicTechnologySymposium.Available at:

www.ctsymposium.org. Accessed February 1, 2008.

[14] Van Sickle KR, Ritter EM, McClusky DA, et al.

Attempted establishment of proficiency levels for lap-

aroscopic performance on a national scale using sim-

ulation: the results from the 2004 SAGES minimally

invasive surgical trainer-virtual reality (MIST-VR)

learning center study. Surg Endosc 2007;21:5–10.

[15] Samadi D, Levinson A, Hakimi A, et al. From pro-

ficiency to expert, when does the learning curve for

robotic-assisted prostatectomy plateau? The Colum-

bia University experience. World J Urol 2007;25:

105–10.

[16] Available at: http://www.ABTS.org/sections/Main

tenance_of_certi/index.html. Accessed February 1,

2008.

[17] Astor B, Kaczmarek RG, Hefflin B, et al. Mortality

after aortic valve replacement: results from a nation-

ally representative database. Ann Thorac Surg 2000;

70:1939–45.

[18] Ferguson TB, Dziuban SW, Edwards F, et al. The

STS national database: current changes and chal-

lenges for the new millennium. Ann Thorac Surg

2000;69:680–91.

[19] Ghali WA, Rothwell DM, Quan H, et al. A Cana-

dian comparison of data sources for coronary by-

pass surgery outcome ‘‘report cards.’’ Am Heart

J 2000;140:402–8.

[20] Hannan EL, Kilburn H, Racz M, et al. Improving

the outcomes of coronary artery bypass surgery in

New York State. JAMA 1994;271:761–6.

[21] O’Connor GT, Plume SK, Olmstead EM, et al. The

Northern New England Cardiovascular Disease

Study Group. A regional intervention to improve

the hospital mortality associated with coronary ar-

tery bypass graft surgery. JAMA 1996;275:841–6.

http://www.cms.hhs.gov/mcd/viewdecisionmemo.asp?id=160



http://www.ctsymposium.org

http://www.ABTS.org/sections/Maintenance_of_certi/index.html

http://www.ABTS.org/sections/Maintenance_of_certi/index.html


Minimally Invasive Open Surgery Approachfor the Surgical Resection of Thoracic Malignancies

Hisao Asamura, MDDivision of Thoracic Surgery, National Cancer Center Hospital, 1-1, Tsukiji 5-chome,

Chuo-ku, Tokyo 104-0045, Japan

For resection of intrapulmonary malignancies,

lobectomy is still respected as the mainstay, themost appropriate surgical mode. Especially forlung cancer, the gold standard for surgical re-

section has been lobectomy with lymph nodesampling or dissection ever since the landmarkstudy by the Lung Cancer Study Group of NorthAmerica [1]. This has been the only randomized

phase III trial to compare lobectomy and sublo-bar resection for lung cancer. All other studieshave been based on retrospective case series.

Because of the increasing frequency of early-stage lung cancer, in the past decades the attemp-ted surgical resection is becoming increasingly

common in a minimally invasive setting. In1992, Lewis and colleagues [2] described the firstvideo-assisted thoracic surgery (VATS) lobectomy

for 40 patients. Although their technique, whichinvolved a simultaneous hilar stapling technique,has not been commonly used thereafter, it was ac-tually a landmark in thoracic surgery. Many stud-

ies have been reported subsequently, and newstudies emerged that have evaluated the use ofVATS procedure and clinical outcomes. Large

case series with more than 1,000 cases have beenpublished [3], and the indications, advantages, dis-advantages, morbidity or mortality, and socioeco-

nomic aspects are becoming increasingly clear.The definition of VATS lobectomy is some-

what ambiguous. This technique varies withregard to the number of incisions (2 to 5), length

of utility incisions (4 to 10 cm), degree of ribspreading, if any, and individual hilar ligationversus tourniquet lobectomy. Thoracic surgeons



doi:10.1016/j.thorsurg.2008.05.001

might use their own combinations of these

parameters in their technique. Thus, there mightbe considerably wide variation in VATS lobecto-mies performed today. In contrast to the enthu-

siasm with which VATS lobectomy is promoted,there are still many ‘‘conventional’’ lobectomieswith open thoracotomy, in which the type ofthoracotomy might vary among standard postero-

lateral thoracotomy, complete muscle-sparingthoracotomy, thoracotomy sparing only the ser-ratus muscle, anterolateral thoracotomy, and

sternotomy.This article describes minimally invasive open

surgery (MIOS). With this approach, which lies

between conventional and VATS lobectomy, thesurgery remains minimally invasive, but the weakpoints of VATS lobectomy are compensated for.

Present status of video-assisted thoracic surgery

lobectomy

Since the early 1990s, there have been manyreports on VATS lobectomy. These have included

a few small randomized trials, case-control series,and case series, and have focused on the feasibilityand advantage of the VATS procedure over the

conventional open procedure. Flores and Alam [4]reviewed the literature from 1996 in a systematicmanner, and summarized the results. They writethat few randomized trials have compared

VATS lobectomy and open lobectomy, whereasthere have been numerous case-control studiesand case series. Most of the procedures in the lit-

erature involved the use of mini-thoracotomy(utility thoracotomy) and different numbers ofports, with or without rib spreading. Many of

the reports mentioned that stage I peripheral

ts reserved.




Fig. 1. Skin incision in the MIOS approach. An 8- to

12-cm incision is made approximately on the ausculta-

tory triangle, 1 to 2 cm below the lower tip of the scapula.

270 ASAMURA

lung cancer was an indication for VATS lobec-tomy. There have been many comparisons incase-control series between VATS lobectomy

and open lobectomy with regard to postoperativepain, changes in pulmonary function tests, noctur-nal hypoxemia, and various markers of inflamma-tion. While they generally favored VATS

approaches, the inadequacy of the control groupwas noted. As a conclusion of this systematicreview, the investigators stated that VATS lobec-

tomy can be safely performed and is an adequateoperative procedure for early-stage non-small celllung cancer. However, they also addressed the

need for adequately poweredwell-balanced studies.The report from the Cancer and Leukemia

Group B is one of the few prospective, multi-insti-tutional studies on VATS lobectomy for early

non-small cell lung cancer [5]. In this study,VATS lobectomy was technically defined as a pro-cedure that involved one 4- to 8-cm access thora-

cotomy and two 0.5 cm port incisions without ribspreading. They mandated videoscopic guidanceand a traditional hilar dissection. VATS lobec-

tomy was successfully performed on 86.5% of127 patients. The operative indicators were a me-dian operative time of 130 minutes, a median

chest tube duration of three days, and a perioper-ative mortality rate of 2.7%. Data regarding thehospital stay were not given. The investigatorsconcluded that a standardized approach to

VATS lobectomy as specifically defined with theavoidance of rib spreading is feasible. The dataand the definition of VATS lobectomy should be

respected as the reference for this approach.Overall, VATS lobectomy is respected as

a technically feasible alternative to conventional

lobectomy by way of open thoracotomy with anacceptable range of morbidity or mortality. How-ever, as a precaution, the following points shouldbe carefully noted.

1. Indicators, such as operative time and bleed-ing volume, are usually taken from success-

fully accomplished surgeries. In contrast,the data for open thoracotomy have alwaysincluded those indicators with conversion

from VATS or those that are technically dif-ficult because of inflammatory adhesion andfusion. Therefore, the comparison of VATS

and open cases is sometimes unfair even incase-control series.

2. Although the definition of VATS lobectomyis being standardized, there are still con-

siderable technical variations. Some of the

techniques categorized as VATS lobectomymight be close to a small-thoracotomylobectomy.

3. In many studies, rib spreading is consideredto be an important factor which characterizesthe minimally invasive nature of VATS lo-bectomy, and it has been reported that ‘‘inva-

sive’’ VATS lobectomy can limit favorableeffects on perioperative pain and recovery[6,7]. However, the degree to which rib

spreading affects postoperative recovery hasnot been determined. In particular, the ad-vantage of rib spreading for instrumental

freedom has never been demonstrated.

The overall balance between downsized and

standard surgical approaches is important.

The minimally invasive open surgery technique

The concept of the MIOS approach can be

summarized as light-assisted lobectomy with di-rect vision through a small thoracotomy. The ribsare usually spread to enable direct access and an

adequate operative field. The goal of this ap-proach is to ensure direct manipulation for thewhole procedure and consequently less time for

the procedure.An incision of 8 to 12 cm in length, depending

on the size of the body, is made near theauscultatory triangle just 1 to 2 cm below the

scapula (posterolateral thoracotomy, Fig. 1). Be-cause of the need for complete hilar or mediastinallymph node dissection, the posterolateral inci-

sional location is usually preferred, since it ismore likely to provide easier access to the subcari-nal area than an anterolateral incisional location.

Fig. 3. Looped-knot devices can replace troublesome li-

gation for the small branches of pulmonary vessels in the

thorax. In the MIOS approach, ligation is instrumental

for most locations except for just below the incision.

271MIOS APPROACH

To supplement the limited operative view, thethoracoscope is used throughout the operativeprocedure, and the port for the thoracoscopecould be used for drainage afterward (Fig. 2).

Although room-fixed light and the videothoraco-scope are simultaneously available as a lightsource, the use of a head-mounted light is strongly

recommended to increase the brightness of the op-erative field. Although the ribs do not need to becut, two rib spreaders are used perpendicularly

(see Fig. 2). The intercostal space is usually ex-tended gently 3 to 6 cm to avoid fracturing theribs. Especially for the direction along the rib,

the incision can be well extended by anotherspreader. It is usually much more than expected.

In this incision, the vascular and bronchialstructures can be easily accessed under direct

vision. However, for the ligation of vascularstructures, especially the small branches of pul-monary arteries, instruments such as end staplers,

clips, and looped-knot devices (Endoloop) arebetter than direct ligation, and can save a greatdeal of time (Fig. 3). Endostaplers are usually

used to divide lobar or major segmental branchesof pulmonary arteries and veins, while knot de-vices or direct ligation are used for the ligation

of smaller branches of pulmonary arteries. Evenin direct ligation with threads, an instrumentalknotting fine forceps is often necessary. Surgeonsshould be familiar with this type of intrathoracic

maneuver (Fig. 4).

Fig. 2. A port for the thoracoscope and application of

two spreaders. Thoracoscopic assistance is maintained

throughout the procedure as a supplement to the small

operative field and as a light source. Two spreaders max-

imize the available operative field. The intercostal space

is widened to 3 to 5 cm, depending on the flexibility of

the chest wall. Another spreader applied along the rib

can extend the operative view.

Possible advantages and disadvantages

of the minimally invasive open surgery approach

over video-assisted thoracic surgery lobectomy

The MIOS approach offers several potentialadvantages over VATS lobectomy. First, based ondirect assessment of the lesion, including manual

palpation, the status of the cancer lesion might beevaluated more precisely. The chance of over-looking inoperable factors is minimized. In VATS

lobectomy, management of the vascular structurehas been a challenge, especially in cases withincomplete fissure or inflammatory change. To

ensure the safe maneuvering of vascular struc-tures, direct access to the vascular structure offersa significant advantage. Also, in the case of

Fig. 4. Instrumental knotting for small vessels. Smaller

Kelly-type forceps can be easily used.

272 ASAMURA

unexpected bleeding, the MIOS approach enablesa faster recovery. In VATS lobectomy, completehilar or mediastinal lymph node dissection has

been a technical challenge. For example, thesubcarinal space on the left side is hardly clearedin a VATS situation, because strong traction ofthe overlying aorta, esophagus, and left main

bronchus is indispensable for exposing the wholearea. In the MIOS approach, these lymph nodestations can be accessed as in conventional

posterolateral thoracotomy (Fig. 5). Thus, theMIOS approach ensures the complete lymphnode dissection for lung cancer. As a result of

the factors mentioned above, the operative timeis greatly reduced. Furthermore, this approachcan be applied to procedures that are more com-plex than lobectomy. Generally, in segmentec-

tomy, more precise, meticulous dissection of thehilum is needed. The hilar structure needs to bedissected and isolated at a more peripheral level

than in lobectomy. In the right upper lobectomy,isolation of the upper lobe bronchus is enough,while the anterior segmental bronchus must be

isolated in anterior segmentectomy. Recently,smaller and fainter nodules have been found oncomputed tomography (CT) imaging. This is

partly because of the markedly improved qualityof CT images and the increased likelihood of CTexaminations in screening programs. The trendin pulmonary resection is toward segmentectomy,

and this type of incisional approach is expected tobe increasingly important.

In comparison with VATS lobectomy, the

MIOS approach might be more invasive from

Fig. 5. Subcarinal node dissection in the MIOS ap-

proach. With a lever retractor and sponge stick, the sub-

carinal space is well exposed.

the viewpoint of incisional length. With regard tothe hospital stay, our anecdotal experience hasshown that patients can be dismissed on the same

postoperative day (usually postoperative day 4),and the length of the hospital stay is not pro-longed by this approach. The degree of post-operative pain is an issue, and this must be

assessed by a scientific comparison of the twoapproaches. Our impression is that, despite a slightincrease in postoperative pain, patients can well

tolerate this increased pain and achieve a quickpostoperative recovery.

The overall advantages and disadvantages of

VATS lobectomy and the MIOS approach need tobe evaluated fairly, and the surgeonapos;s envi-ronment and patientapos;s requests are otherimportant factors that must be determined when

approaching this choice.

Future perspectives of the minimally

invasive approach

Recently, there has been a growing likelihoodof encountering smaller, earlier lung cancers.

Some of these lesions are called ‘‘ground glassopacity,’’ and are characterized by a mild ormoderate focal increase in CT density with or

without a solid or cystic or linear componentwithin the nodule (Fig. 6). Pathologically, manyof them are atypical adenomatous hyperplasia,

Fig. 6. Typical presentation of a ground glass opacity le-

sion in the right upper lobe. This needs to be diagnosed

on high-resolution (thin-slice) CT with a scanning thick-

ness of less than 1 to 2 mm.

Segmentectomy bycompromised

approach

VATS lobectomy

Fig. 7. Overall comparison of the different combina-

tions in minimally invasive settings.

273MIOS APPROACH

bronchioloalveolar carcinoma (BAC), or mini-mally invasive BAC. For these tumors, the possi-bility of sublobar resection seems to be more andmore realistic because of the non- or minimally in-

vasive nature of the tumors [8,9], although lobec-tomy remains the gold standard in surgicalresection. Here, limited, sublobar resections in-

clude wide wedge resection and segmentectomy.The concern about lobectomy as the gold stan-dard even for tumors smaller than 2 cm in diame-

ter is promoting new studies. The definitiveanswer to this crucial question can only be ob-tained by a controlled randomized, phase III trial.

Although more than 1,000 patients need to be en-rolled in such studies to achieve sufficient statisti-cal power, the results might revise the standardsurgical care for tumors without nodal involve-

ment. Such studies are already open in NorthAmerica (CALGB) and will be launched soon inJapan.

In this trend toward sublobar resection forlung cancer, the VATS approach is being appliedto more complex procedures, such as segmentec-

tomy. One issue is the nonpalpable nature of theVATS technique. Surgeons do not directly accessthe tumor during the VATS procedure, especially

for tumors located deep in the lung parenchyma.When the nonpalpable approach by VATS is usedfor sublobar resections, the new technique may beneeded to ensure a safe surgical margin. This is an

important technical challenge. However, theMIOS, direct approach can easily enable handlingof the surgical margin, and ensures the safety of

complicated hilar dissection in segmentectomy.The technical merit of the MIOS approach mightbe even greater in the era of limited resection.

Another important feature must be addressed.Although VATS lobectomy is respected as a min-imally invasive technique, this is only true re-garding the incisional approach on the chest wall.

Regardless of whether VATS lobectomy or openlobectomy is used, the volume of resected lungparenchyma is essentially the same (lobe). How-

ever, in the future, lung parenchyma may matteras an indicator of minimal invasiveness. A com-parison of VATS lobectomy and segmentectomy

by the MIOS approach is being made in which theincisional approach on the chest and resected lungvolume are considered as the total surgical burden

(Fig. 7).While the trend toward a minimally invasive

approach will remain, greater flexibility in

selecting the appropriate technique based on the

nature of the tumor is needed. A dogmatic VATSapproach seems to diminish the advantage ofdirect access to the lung structures.

References

[1] Lung Cancer Study Group, Ginsberg RJ, Rubinstein

LV. Randomized trial of lobectomy versus limited re-

section for T1N0 non-small cell lung cancer. Ann

Thorac Surg 1995;60:615–23.

[2] Lewis RJ, Caccavale RJ, Bocage JP, et al. Video-

assisted thoracic surgical non-rib spreading simulta-

neously stapled lobectomy. Chest 1999;116:1119–24.

[3] McKenna RJ, Houck F, Fuller CB. Video-assisted

thoracic surgery lobectomy: experience with 1,100

cases. Ann Thorac Surg 2006;81:421–6.

[4] Flores RM, Alam N. Video-assisted thoracic surgery

lobectomy (VATS), open thoracotomy, and the robot

for lung cancer. Ann Thorac Surg 2008;85:s710–5.

[5] Swanson SJ, Herndon JE II, D’Amico TA, et al.

Video-assisted thoracic surgery lobectomy: report of

CALGB 39802. A prospective, multi-institution feasi-

bility study. J Clin Oncol 2007;25:4993–7.




lung cancer: a multi-institutional study. J Thorac Car-

diovasc Surg 2006;132:507–12.

[7] Demmy TL, Nwogu C. Is video-assisted thoracic sur-

gery lobectomy better? Quality of life considerations.

Ann Thorac Surg 2008;85:s719–28.

[8] Asamura H. Minimally invasive approach to early,

peripheral adenocarcinoma with ground-glass opac-

ity appearance. Ann Thorac Surg 2008;85:S701–4.

[9] Asamura H, Suzuki K, Matsuno Y, et al. A clinico-

pathological study of resected subcentimeter lung

cancers: a favorable prognosis for ground glass opac-

ity (GGO) lesions. Ann Thorac Surg 2003;76:

1016–22.


Complications and Learning Curves for Video-AssistedThoracic Surgery Lobectomy

Robert J. McKenna, Jr, MDThoracic Surgery, Cedars Sinai Medical Center, 8635 West Third,

Suite 975W, Los Angeles, CA 90048, USA

Surgery is a constantly evolving specialty.

Approximately 95% of what surgeons do is differ-ent from what they are trained to do. That evolu-tion requires education about the changes to be

introduced. Launching new techniques into a med-ical practice involves the educational process totrain surgeons about the new technique, a learningcurve for surgeons as they introduce the new proce-

dure to their patients, and comparison of the com-plications for the new and older techniques. Thisarticle addresses these issues. Major pulmonary re-

sections can be performed with minimally invasivesurgery, and many patients demand minimally in-vasive surgery. As such, this article also addresses

the issues of introducing these new techniquesinto the practice of thoracic surgery. Finally, thisarticle addresses the need for the surgeon to under-

stand the complications of any new procedure theyundertake, and how these new procedures comparewith the complications of the procedure performedin the traditional fashion.

Prerequisites to begin video-assisted thoracic

surgery lobectomy

There are many methods for the introductionof new technology into a thoracic surgery prac-tice. Surgeons can: read articles, atlases, and

books; observe surgeons who do the procedure;attend Society of Thoracic Surgeons (STS) Uni-versity; attend industry-supported courses; and

study in animal and cadaver laboratories. An indi-vidual surgeon must find the best method ormethods for that situation. A new stapler may

simply require education by the representative



doi:10.1016/j.thorsurg.2008.04.004

for the company that manufactures the stapler.

Introduction of new techniques, such as video-assisted thoracic surgery (VATS) lobectomy, aremuch more involved. The transition to new tech-

nology has always been challenging.There are many prerequisites for developing

a VATS lobectomy program. Before undertakinga VATS lobectomy, the individual surgeon should

have performed a substantial number of VATSprocedures (100 cases), such as wedge resection ortalc pleurodesis. Through these cases, the surgeon

acquires good basic video skills, including stapling,dissecting, and suturing.With this background, thesurgeon can then proceed with acquiring the skills

for advanced VATS procedures.There are also prerequisites to the thoracic

surgery practice for incorporating a VATS lobec-

tomy program. The surgeon should be realisticabout the possibility of developing a VATS lo-bectomy program: for example, it is not realisticfor a cardiac program to suddenly have a VATS

lobectomy program. The practice should includea minimal number of lobectomies per year (atleast 25 lobectomies per year) because the entire

surgical team (anesthesia, scrub nurse, circulatingnurse, and endotech) learns new tricks with eachVATS lobectomy. The whole team needs to

develop a rhythm and flow for the cases. Iflobectomies are infrequently performed, then thelessons of the last case will be forgotten.

Key points: prerequisites

The surgeon and the team need good VATS

capability.The program should be performing at least 25lobectomies per year.

ts reserved.




276 MCKENNA

Introduction of new technology into practice

If the surgeon and the program have thenecessary prerequisites, then development of

a VATS lobectomy program may proceed. Inthe early 1990s, the few surgeons who first beganto perform VATS lobectomies were breaking newground and had to develop the techniques for the

procedure. Today, the momentum for convertingopen lobectomies to VATS lobectomies is grow-ing, and there are many options for acquiring the

skills and knowledge for performing VATSlobectomies.

Some thoracic surgeons learn how to perform

a VATS lobectomy in their training program, andan increasing number of cardiothoracic residencyprograms have attending physicians who performVATS lobectomies. In some cases, the faculty has

gone through the learning curve to be a VATSsurgeon and to be a teacher for VATS lobectomy.If so, their trainees enter practice with the skills to

do the procedure. If the training is not adequate,there are 6 to 12 month fellowships that specializein advanced VATS procedures.

For practicing thoracic surgeons, othermethods are available to gain the skills to performVATS lobectomy (see previous section). Many

journal articles and book chapters have beenwritten about the technical details of how toperform the operation. Atlases filled with techni-cal details will be published soon.

Often, reading an article is not adequate, sothere are courses to learn the techniques. Theseare offered by professional societies (STS break-

fast sessions, STS University), industry (Ethicon,Covidian courses), and practicing surgeons. Thesecourses offer lectures, videos, and observation of

procedures (in the order of increasing benefit).The observation of procedures in an operatingroom is by far the most beneficial for thefollowing reasons: understanding proper place-

ment of the incisions, use of instruments, in depthunderstanding of real time details for performanceof the procedure (not just the highlights seen in

a video or lecture), and the ability to ask thesurgeon questions about the procedure. Outsidea formal course, it is also possible to visit hospitals

where surgeons regularly perform VATS lobecto-mies. To visit more than once helps because on thefirst visit, the surgeon learns the basics, such as

placement of the incisions. During subsequentvisits after trying some VATS lobectomies, thesurgeon gains a much more in-depth understand-ing of the procedure.

Key points: introducing the procedure

Observation of live VATS lobectomies is the

best learning tool.More than one visit for observation is usually

helpful.

Learning curve for video-assisted thoracic surgery

lobectomy

The learning curve for VATS lobectomy variesconsiderably. Basically, the surgeon needs topursue any or all of the aforementioned options

to gain the appropriate skills to perform theoperation safely for the patient. For some, thereis a natural transition from posterolateral thora-

cotomy to anterior thoracotomy and finally toVATS lobectomy. For the first step, the surgeonmoves from posteriorly to anteriorly. The ante-

rior, muscle-sparing thoracotomy starts at theanterior edge of the latissimus and goes anteriorly.The latissimus and the serratus are not mobilized.The incision is made through the fourth intercos-

tal space so it is directly over the hilum of thelung. Through this incision, the surgeon getscomfortable with operating from anterior to

posterior. That is a major change from theapproach for a lobectomy through a posterolateralthoracotomy. From that point, it is then a natural

transition to make the incision smaller and to viewthe operation on the monitor, rather than lookingthrough the incision [1].

When beginning to performVATS lobectomies,

the surgeon should proceed with plans to protectpatient safety. After gaining the proper education,the surgeon should not be afraid to convert to

a thoracotomy. A time limit for the VATS pro-cedure (eg, 3 hours) should be set before theoperation so that the general anesthesia is not too

long for the patient. If an incision is in the wrongplace, the surgeon should not be afraid to makeanother small incision to allow abetter angle for the

instruments to complete the operation.The length of the learning curve depends

upon many factors, such as the teaching skill ofthe surgeon’s faculty, the basic surgical skill of

the surgeon, and the VATS skill of the surgeon.Most surgeons feel that it takes about 50 VATSlobectomies to be comfortable with the procedure.

Key points: learning curve

Start with converting from a posterolateral

thoracotomy to a muscle sparing, anteriorthoracotomy.

277COMPLICATIONS AND LEARNING CURVES FOR VATS

Conversion from VATS to a thoracotomy isnot a sign of failure.

Complications after video-assisted thoracic

surgery lobectomy

Published series show thatVATS lobectomyhasgained international acceptance [1–4]; however,

less than 10% of lobectomies are currently per-formedwithVATS becausemost thoracic surgeonsare still not comfortablewith the technique.The au-

thor and colleagues’ experience with 1,100 VATSlobectomies, pneumonectomies, and segmentecto-mies over a 12-year period showed a mean length

of hospital stay at 4.78 days and median length ofhospital stay at 3 days. The mortality rate was0.8%, and no complications occurred in 84.7% ofpatients [1]. These results are better than published

results for lobectomy via thoracotomy.There are now many single institutional, ob-

servational series that report VATS lobectomy to

be a safe and reasonable procedure. In seriesinvolving 106 to 1,100 patients, the mortality ratesvaried from 0% to 2.6% [1–4]. Table 1 shows typ-

ical complications after a VATS lobectomy.

Key points: complications and acceptance

VATS lobectomy is slowly becoming a well-accepted procedure internationally.

Video-assisted thoracic surgery versus

thoracotomy for lobectomy

The evidence is mounting that a VATS lobec-tomy may have advantages over a lobectomy by

Table 1

Typical complications after video-assisted thoracic sur-

gery anatomic resections

Major complications Minor complications

Readmission 1%–2% Atrial fibrillation 3%–12%

Pneumonia 2% Air leak 5%

Myocardial

infarction

1% Transfusion !5

Empyema !1% Serous drainage !2%

Broncho pleural

fistula

!1% SQ emphysema 1%

Stroke !1% Gastrointestinal !1%

Somepatients experiencemore thanone complication.

Abbreviations: Air leak, air leak lasting more than

7 days; Gastrointestinal complications, Ogilvie’s syn-

drome, gastrointestinal bleed; Serous drainage, serous

drainage requiring chest tube drainage for more than

7 days; SQ emphysema, subcutaneous air requiring rein-

sertion of chest tube or subcutaneous catheters.

thoracotomy. Opponents believe that a VATSlobectomy is unsafe, an incomplete cancer oper-ation, and offers no advantage over a thoracotomyfor lobectomy. Proponents believe that VATS

lobectomy is a safe and effective treatment forlung cancer. The medical literature supports thelatter position, and the number of surgeons who

hold the negative belief is decreasing.As the literature shows benefit to the procedure

and as the public demands minimally invasive

operations, the momentum for VATS lobectomyis clearly growing. There are a few small, ran-domized studies. Two small randomized trials in

the 1990s showed a small advantage for the VATSapproach [5,6]; more recently, in a small random-ized, single institutional series, Hoksch and col-leagues [7] showed a complication rate of 50%

after thoracotomy versus 18% after VATS.Although there is no large, multi-institutional

randomized, prospective study to compare VATS

and thoracotomy approaches for lobectomy, ob-servational series with similar cohorts suggest thatthere is short-term benefit to a VATS approach,

without compromising the long-term survival[1–6]. Koizumi and colleagues [8] reported mortal-ity rates for patients aged 80 to 91 were 20% for

thoracotomy and 5.9% for VATS. A recentmeta-analysis and systematic review of controlledtrials showed considerable benefit during thehospital stay and recovery phase for VATS over

thoracotomy [9].

Hospital stay

During the hospital stay, there appear to be

many benefits for the VATS approach whencompared with a thoracotomy. The overall hospi-tal length of stay was reduced by 2.6 days for the

VATS approach [9]. This difference was particu-larly pronounced for elderly patients (length ofstay 5.3 � 3.7 versus 12.2 � 11.1 days, P ¼ .02

and duration of chest tubes 4.0 � 2.8 versus 8.3 �8.9 days, P ¼ .06). The charges for laboratoryexaminations, anesthesia, disposable equipment,and hospitalization were significantly higher in pa-

tients who underwent open thoracotomy, com-pared with the patients who underwent VATS [10].

Both randomized and controlled studies

showed a 48% reduction in overall risk ofcomplications [9]. Pulmonary complications, in-cluding respiratory dysfunction, pneumonia, atel-

ectasis, empyema, and prolonged air leak, werereduced [9]. Although the incidence of atrial fibril-lation in the author and colleagues’ series of 1,100

278 MCKENNA

patients was less than 3% [1], the meta-analysisfound no difference in the incidence of cardiaccomplications, including atrial fibrillation [9].

The incidence of blood loss greater than 500 mLin a case was no different, but the VATS patientsdid have a significant reduction in blood loss [9].The conversion rate from VATS to thoracotomy

was 6% [9]. In most cases, conversion wasnecessary for oncologic (eg, need for a sleeveresection and other procedures) or technical rea-

sons (eg, adhesion); this was rarely needed for in-tra-operative bleeding.

Recovery phase

The recovery phase is also better for patientsafter VATS, compared with thoracotomy. Thevital capacity was better initially and 1 year afterVATS than with a thoracotomy, although the

forced expiratory volume in one second, PaO2,and partial pressure of carbon dioxide were notdifferent [9,11]. The 6-minute walk was signifi-

cantly better after VATS. Thoracotomy produceda significant impairment of vital capacity from 1to 24 weeks after lobectomy (P!.05–0.001) [9].

Patients after a thoracotomy, compared withVATS, had significant impairment of the 6-minutewalk 1 week after surgery (P!.01-0.001) [12].

Independence after VATS was greater thanafter a thoracotomy [9]. Transfer to care facilitiesor home nursing support was needed for 63% ofopen patients and only 20% of VATS patients

(P ¼ .015). VATS patients needed less personalcare (10% versus 21%), wound or medical care(0% versus 13%), occupational or physical ther-

apy (5% versus 13%), or other home support(5% versus 18%) than open patients [13].

A randomized trial from Germany showed

fewer complications after VATS (14.2%) thanthoracotomy (50%) [7]. A Japanese study showedcost (anesthesia charges, laboratory charges, and

hospital charges) were less for the VATS approach[10]. Postoperative pain (visual pain scale, totaldose of narcotic, need for additional narcotic,need for intercostal blocks, and sleep disturbances)

is less after VATS than for thoracotomy [3].The postoperative recovery appears to be

better for the VATS approach than a thoracot-

omy. Demmy and Curtis [13] showed an earlier re-turn to full preoperative activities, (P!.01) for theVATS patients. They also had better short-term

and long-term quality of life (QOL) [14], less post-operative pain (P ¼ .014) [3], and less shoulderdysfunction [15].

Overall, the QOL scores did not significantlydiffer between VATS and thoracotomy, but thereare some QOL benefits to VATS [9]. Shoulder

strength and range of motion was better at 1week postoperatively, but the same at 3 months[15]. The incidence of limited activity at 3 monthswas greater after thoracotomy, and the return to

full activities was faster with VATS [9].VATS patients also had reduced postoperative

release of both proinflammatory and anti-

inflammatory cytokines. Although the postopera-tive release of tumor necrosis factor-a andinterleukin (IL)-1b were minimal for both groups,

the levels of IL-6, IL-8, and IL-10 were higher inthe open group [16,17]. The clinical significance ofthese findings remains to be fully elucidated. Forolder patients, Demmy and Curtis [13] showed

that VATS patients had less prolonged pain com-plaints (28% versus 56%, P ¼ .05).

Postoperative complications in older patients

undergoing anatomic pulmonary resection arecommon and contribute to prolonged hospitali-zation and associated health care costs. Compared

with standard thoracotomy, successful use ofa minimally invasive, non-rib spreading VATSapproach for resection of early stage broncho-

genic carcinoma is associated with reduced in-cidence and severity of postoperativecomplications in the elderly. A thoracoscopicapproach to anatomic resection of early stage

lung cancer may be preferred in these and possiblyother high-risk patients. This issue warrantsadditional investigation.

Concerns unique to video-assisted thoracic surgery

lobectomy

The biggest concerns regarding VATS lobec-

tomy center on three issues: risk and managementof intraoperative bleeding, tumor recurrence inthe incision, and the adequacy of the cancer

operation. The chances of these issues occurringappear to be small.

Some surgeons are concerned that dissectioncan be more difficult, so bleeding from the

pulmonary artery can occur more easily and bemore difficult to control by VATS than bythoracotomy [18]. However, several series have

demonstrated that bleeding occurred in less than1% of cases, so the risk of bleeding appears tobe low for skilled VATS surgeons [1–16].

The oncologic impact of VATS lobectomyhas been questioned with regards to recurrencein an incision, the completeness of the node

Table 2

Results of several reported series of video-assisted tho-

racic surgery lobectomy and pneumonectomy

VATS lobectomy/pneumonectomy

Reference No. Cancer Mortality LOS

Lewis [21] 200 171 0 3.07

Yim [22] 214 168 1 (0.4%) 6.8

Kasada [20] 145 103 1 (0.8%) NA

Walker [3] 159 131 3 (2%) 7.2

Roviaro [4] 169 142 1 (0.5%) NA

Solaini [12] 112 99 0 5.8

McKenna [1] 1,100 935 8 (0.5%) 4.6

Daniels [2] 108 108 4 (4%) 3

Watanabe [25] 185 172 2 (1.1%) N/A

Totals 2,390 2,029 22 (0.8%) 5.28

Abbreviations: LOS, length of stay in hospital; NA,

not available.

279COMPLICATIONS AND LEARNING CURVES FOR VATS

dissection, the possible spread of cancer cellsintraoperatively, and survival. Cancer rarely re-curs in a thoracotomy incision, but fatal tumorrecurrence in VATS incisions has been reported

[19]. However, this happens in only 3 out of1,321 (0.2%) cases [1–3]. Surgical technique isimportant to minimize this complication. Tho-

racic surgeons should not pull a tumor or an in-strument that has touched a tumor througha small, unprotected incision. The author and

colleagues have not experienced a trocar site re-currence in their VATS procedures for lung can-cer since switching to the Lapsack for removal

of the tumors [1]. As the skill of VATS surgeonshas advanced, studies have shown that the num-ber of lymph nodes removed by VATS was notinferior to that of thoracotomy. Systemic node

dissection by VATS is technically feasible andsafe, and seems acceptable for clinical stage Ilung cancer [18].

Ultimately, the measure of any cancer treat-ment is survival. Another concern is about theadequacy of VATS lobectomy as a cancer oper-

ation. The true measure of any cancer treatment issurvival. In a nonrandomized, prospective com-parison of VATS versus open lobectomy for stage

IA (T1N0) lung cancer, the 5-year survival was90% and 85% for the VATS and thoracotomygroups, respectively (P ¼ .74) [20]. Although somesurgeons have reported exceptional survival

(86%–94%) for stage I lung cancer after VATS lo-bectomy [21,22], others have reported the survivalthat is typically expected for surgical treatment of

lung cancer (Table 2) [1–3]. It certainly appearsthat a VATS approach does not compromise thesurvival for lung cancer patients. Yamashita and

colleagues [23] reported that carcinoembryonicantigen mRNA during video-assisted lobectomywas significantly higher than in subjects who un-derwent open lobectomy in a previous study (18

of 35 subjects; 51%; P!.001).

Key points: concerns

Bleeding can occur with VATS lobectomy, but

this appears to be rare and manageable.Recurrence in an incision can occur with

VATS lobectomy, but this appears to be

rare.Cure rates for a lobectomy by VATS and a tho-

racotomy appears to be the same.

An anatomic lobectomy should be performedwhether the procedure is performed byVATS or thoracotomy.

Consensus statement regarding video-assisted

thoracic surgery lobectomy

The consensus panel of the InternationalSociety of Minimally Invasive Cardiothoracic

Surgery (ISMICS) made the following statementsand recommendations regarding VATS for lobec-tomy in patients with clinical stage I non-small

lung cancer [24]:

VATS can be recommended to reduce the

overall postoperative complications (classIIa, level A evidence).

VATS can be recommended to reduce pain and

overall improved functionality over theshort term (class IIa, level B evidence).

VATS can be recommended to improve the de-

livery of adjuvant chemotherapy delivery(class IIa, level B evidence).

VATS can be recommended for lobectomy inclinical stage I and II non-small cell lung

cancer patients, with no proven difference instage specific survival, compared with openthoracotomy (class IIb, level B evidence).

Summary

Surgery remains the mainstay for the treatmentof lung cancer. While pulmonary resection hasbeen safe for years, there is a trend toward

minimally invasive (VATS) pulmonary resections.Studies have now shown that standard completecancer operations performed via VATS offer

patients a shorter hospital stay and quicker re-covery without compromising the cure rate for anoperation performed via a thoracotomy.

280 MCKENNA

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The VATS Lobectomist: Analysisof Costs and Alterations in the Traditional Surgical

Working Pattern in the Modern Surgical UnitWilliam S. Walker, MA, FRCS, FRCSE*,

Gianluca Casali, MDDepartment of Thoracic Surgery, Royal Infirmary of Edinburgh, University of Edinburgh,

Little France, Edinburgh EH16 4SA, Scotland, UK

Video-assisted thoracic surgery (VATS) lobec-

tomy remains an infrequently performed proce-dure. Despite a noticeable increase in interest inVATS resection in both the United States and

Japan, uptake in Europe has changed little ina decade. Various factors account for both thesedifferences and the slow growth in the field over-

all. Among these remain concerns as to oncologicvalidity, especially regarding adequacy of medias-tinal node management; safety; training; costissues; and the exact fit for VATS techniques

within the profile of a thoracic service. Theselatter two issues form the basis for this article.

Assessment of the comparative costs for VATS

and open lobectomy is complicated by severalissues. These include the differing medical andsocial conditions in various countries; the opera-

tive techniques used for both VATS and openresection; and the inability of current cost modelsto capture aspects of quality of life, particularly ina generally elderly patient group. To address this

question this article reviews the considerationlikely to arise from variations in VATS techniqueand geographic setting; considers actual costs

encountered within a Northern European modelof care; and, working from these data, determinesthe extent of any financial difference. Based on

these findings, also reviewed are the variationsthat might be anticipated within other caresystems and using different VATS techniques.



(W.S. Walker).


doi:10.1016/j.thorsurg.2008.06.003

Incorporation of a VATS major pulmonary

resection program within the structure of a generalthoracic surgery unit places significant emphasison selection, work-up, and integration. VATS

techniques are but one element in the armamen-tarium available to the thoracic surgeon. The skilllies as much in making the correct choice on

behalf of the patient as in the conduct of theprocedure itself.

Analysis of costs

Models of care

Across the world care delivery and cost attri-bution varies widely. Models of care tend to fallinto several different patterns (Table 1). All are

heavily interested in cost containment but thedrivers for this and the methods for achieving itvary widely. For example, in a charity or state-

funded program, restricting physician fees is notrelevant, whereas in a market-driven process thisis one of the more vulnerable areas within the

cost envelope. Conversely, non-business–orien-tated programs are very sensitive to disposableand equipment costs because there is no easymethod of passing these costs back to the funding

source by way of individualized patient charges oragreed care package prices.

Different care model environments focus on

different aspects of the overall cost and make itdifficult to generalize between systems regardingthe relative merits of one procedure over the

other. It is clear, however, that the level of patient

ts reserved.




Table 1

Variation in models of care

Funding agent Drivers for economy Major economy areas

Self payment Acceptable end user cost

Package deal envelope

Provider profit

Physician fees, procedure cost, bed stay

Insurer Premium competition

Provider profit

Physician fees, procedure cost, bed stay

National health program Budget compliance, meet service demand Equipment, disposables, bed stay

Charity or aid Maximize number of benefitted patients Equipment, disposables

282 WALKER & CASALI

choice is quite different within these modelsvarying from complete for self-funded patients

to effectively nil for those relying on charitablefunding. Such issues as cosmesis, pain, andfunctionality can be of importance in one group

but of little relevance to another group. Similarly,state-funded programs, although unsympatheticin general terms to innovation for fear of the costimplications, are sensitive to societal norms and

expectations regarding inpatient stay. Inpatientstay becomes an issue specific to the health careenvironment and not meaningfully comparable

between systems. For example, based on con-temporary reports, a postoperative stay of 7 to15 days following major pulmonary resection is

acceptable in Northern Europe and in Japan21 days is not unusual. In the United States,however, postoperative inpatient stay is typically

a matter of a few days. Or is it? Many institutions‘‘discharge’’ to adjacent hotels, sometimes evenphysically connected to the hospital. Is this reallydischarge or simply transfer of a portion of the

Table 2

Video-assisted thoracic surgery lobectomy techniques

Technique Outline Use

Simultaneously stapled

lobectomy [1]

Endoscopic procedure

Stapled division of fissures

Mass stapling of hilar pedicle

End

Ope

Minithorcotomy [2,6] Per-incisional surgery

Direct vision

Orthodox dissection

Supplementary light and vision

by videothoracoscope

Opt

Stap

Endoscopic

hilardissection

[3–5,18,21]

Endoscopic procedure

Anatomic hilar dissection

Individual structure division

End

d

cost burden? Furthermore, notions of fitness fordischarge vary widely. In general terms, within

a northern European environment, discharge witha Heimlich-type valve is relatively unusual andhome care issues often delay discharge while

domestic circumstances are assessed and, ifnecessary, modified to allow supported discharge.Conversely, in other care environments there maybe a strong financial imperative for the patient or

the family to accept a high level of ongoing carerequirement at home. Finally, the patient sub-strate is likely not directly comparable between

these systems. Quoted package deals, for example,require a higher degree of certainty than may beafforded by elderly or multiply comorbid patients.

Operative techniques

What is a ‘‘VATS’’ lobectomy? This question isaddressed elsewhere in this issue, but does requiresome consideration here to provide a background

for discussion. The three broad technique

of stapling devices

Special

instrumentation

o-stapler for fissure

n stapler for pedicle

Optional, not essential

ional, not essential

ler often used for bronchus

Optional, not essential

o-staplers and clip

evices used extensively

Endo-dissectors and

shears usually desirable

283VATS LOBECTOMYdCOSTS AND WORKING PATTERNS

groupings are described in Table 2. There areclearly multiple variations in the exact implemen-tation of these operative strategies and the simul-taneously stapled technique [1] is probably now

significantly less used than the other options. Ofthe other two, it can be observed that the mini-thoracotomy technique [2] could require the least

investment in endoscopic instrumentation and isan automatically cheaper approach. Whetherthis technique truly represents a VATS lobectomy

or the ultimate development of a muscle-sparingapproach is a matter for debate but it does repre-sent a minimally invasive approach and is widely

used, particularly in Asia, perhaps reflecting inpart the potential for minimal disposables costs.Endoscopic hilar dissection [3–5], a trueendoscopic analog of open resection, requires

the greatest investment in training and disposablesbut may be gaining in overall acceptance.

One might reasonably also ask, however, ‘‘what

is an open lobectomy,’’ for there are significantvariations among surgeons regarding incision size,rib division or resection or cartilage separation in

gaining entry, use of stapling devices, and lymphnode management, to list merely the obviousoperative issues. These differences potentially

impact on operative time, postoperative recovery,and discomfort. Despite the close scrutiny ofVATSprocedures both in terms of cost and long-termoutcome, knowledge of the outcomes associated

with various forms of thoracotomy and styles ofresection remains quite uncertain.

Cost analysis

Few authors [6–10] have specifically consideredthe economic aspects of VATS lobectomy,although such factors as inpatient stay have been

described in comparative series. Such analyseshave to be reviewed within the context of the healthcare system and region of origin, and one criticism

that may be leveled at almost all the availablestudies is that of inadequate sample sizes.

In an early study, Giudicelli and coworkers [6]noted a trend toward reduced mean in patient stay

in patients undergoing VATS lobectomy usinga minithoracotomy technique compared witha parallel control group undergoing muscle-

sparing thoracotomy (days: 12 VATS versus 15open). In an otherwise negative randomized studycomparing VATS lobectomy using an endoscopic

technique with open resection by a muscle-sparingthoracotomy, Kirkby and colleagues [7] founda reduced (but not significant) inpatient stay

with VATS lobectomy (7.1 versus 8.3 days) asso-ciated with significantly (P ! .05) fewer complica-tions in the VATS cases. Lewis and colleagues[8] in a retrospective cost comparison study

comparing 15 open and 15 VATS patients foundopen resection to cost almost twice as much asa VATS procedure using his simultaneously

stapled technique reflecting reduced advancedcare usage and shorter inpatient stay. These datawere not significant, however, because of the small

sample size. Sugi and colleagues [9], in a Japanesesetting, compared 10 VATS lobectomies with 20open thoracotomy controls. They found an in-

crease in surgical disposables of over $3000 witha VATS procedure and little benefit with regardto postoperative stay, which averaged 25.2 daysfor the VATS groups as opposed to 27.7 for

the open thoracotomy group. Nakajima andcolleagues [10] presented a mixed study, alsofrom Japan, involving early stage bronchogenic

carcinoma and metastases both resected by lobec-tomy or sublobar excision using both VATS andopen surgery. Included were 66 open thoracoto-

mies and 36 VATS procedures. Overall hospitalcharges were less with VATS resection andmean inpatient stay was significantly reduced at

17.3 days compared with 23.8 for open resection.Interestingly, Liu and colleagues [11] reporteda mixed VATS series of 2300 patients operatedon over a 7-year period and commented that

cost effectiveness was a vital consideration forthe survival of VATS techniques in an Asiansetting. Key to this was the use of conventional

instruments rather than expensive endoscopicdisposable devices.

The authors recently undertook a detailed

comparative analysis of costs associated withVATS and open resection in their unit. This studyclearly reflects United Kingdom costs and theeconomics of a nationalized health care system.

Nonetheless, there are some interesting findings.This analysis, reported in preliminary form [12]

and presented in outline here, reviewed cost

and outcome data for 346 patients undergoingpulmonary lobectomy between January 2004 andDecember 2006. Most resections were for early

stage lung cancer (stage I or II), with the remain-der a mix of metastatic disease and inflammatoryor benign conditions. A total of 93 VATS lobecto-

mies and 253 open thoracotomy resections wereperformed. In the VATS group 47% of patientshad an upper lobectomy versus 52% in the opengroup (P ¼ ns). Direct medical costs (ie, dispos-

ables, theater time, high dependency unit stay,

Fig. 1. Stylized flow sequence for oncologic assessment

and management of bronchogenic carcinoma.

284 WALKER & CASALI

and hospital) were determined and stratified bylobectomy type.

It was found that the mean theater cost for

a VATS lobectomy was significantly higher at2533� 230V versus 1280� 54V for a thoracotomylobectomy (P ¼ .00001). The mean high depen-dency unit cost, however, was reduced in VATS

cases at 1713 � 236V compared with 2571 �80V for a thoracotomy lobectomy (P ¼ .00001)reflecting reduced bed usage in the VATS group.

Similarly, the mean cost of the postoperative inpa-tient ward stay was less in the VATS lobectomygroup at 3776 � 281V as against 4325 � 154Vfor open resection (P ¼ .00001).

Overall, the cost of a VATS lobectomy wassimilar to that of an open lobectomy. Single-loberesection worked out at 155V cheaper by VATS

(8023 � 565V VATS versus 8178 � 167V open;P ¼ .0002) and bilobectomy was 47V more byVATS (8702 � 350V VATS versus 8655 � 466Vopen; P ¼ ns). Bed stay for VATS patients was5.54� 0.37 days and 6.87� 0.19 days for open tho-racotomy patients (P ¼ .001). The authors

reviewed a broad panel of postoperative complica-tions and found a consistent trend for events, nota-bly chest infection and lobar-sublobar collapse, to

be more frequent in the thoracotomy group than inthe VATS group (54.2% versus 46.2%; P ¼ 0.19).

This study demonstrates that VATS lobectomydoes not present a financial challenge to the

parent institution. It does, however, offer reducedpostoperative complication rates and an easierrecovery path with a consequent decrease in bed

occupancy. The authors did not model the poten-tial for income generation provided by the liber-ated bed days because this would not be of direct

relevance within a nationalized health care system,but this reduced bed stay should have an oppor-tunity value for more treated patients withina more market-sensitive environment.

Such studies are confounded by various factors:the lack of randomized data; sample volumes; and,above all, the enormous differences in medical and

social environments across the world. As observedby Van Schil [13], there is a definite need for high-quality prospective randomized studies in this area

as is true of most comparisons between VATS andopen surgery.Whether such an ideal is attainable isanother matter. Patients are understandably reluc-

tant to agree to a randomization process thatpotentially allocates them to a more invasive pro-cedure. Clinicians have to rely on parallel cohortdata, which generate major issues regarding bias.

Nonetheless, there seems little prospect of true

randomized studies and one must hope that theuse of large collaborative databases analyzed usingappropriate matching tools, such as propensity

scoring, will provide robust answers acceptable toall concerned.

Alterations in the traditional surgical working

pattern in the modern surgical unit

Where does VATS lobectomy fit within theprocedural base of a busy general thoracic surgeryunit? To answer this question one must first

consider fundamental principles and from thatdeduce where VATS may be relevant.

As a first observation, the use of VATS is, inpart, a function of the skill and aptitude of the

surgeon. It is a core consideration that any use ofVATS techniques should not be to the prejudiceof the patient simply to achieve a ‘‘modernist’’

approach. There are established pathways fordiagnosis, assessment, staging, and managementthat function perfectly well without the use of

VATS. Clinicians must aim to avoid compromiseand to look toward those areas where the use ofVATS techniques may enhance the standard of

care delivery to their patients. VATS lobectomy issimply the apex of a pyramid of VATS interven-tions. In the authors’ unit, the philosophy is oneof integration (Fig. 1), so that VATS plays

a greater or lesser role in the various stages ofpatient management. It is also the case that justas VATS is but one of the available tools, so the

possibility must always be considered whether itis better to select a different approach, integrateboth open and VATS techniques, or indeed

change to an open procedure.

Staging and assessment

Before considering VATS lobectomy in detail

it is important to recognize the major contribution


to patient welfare afforded by VATS staging andassessment. In the United Kingdom approxi-mately 6% of thoracotomies are in the ‘‘openand shut’’ category. It may be argued that this is

an acceptable figure if all patients are to be giventhe potential advantage of resection where pre-operative data are in the balance. In the authors’

experience, however, the use of preliminary VATSinspection before any intended resection has cutthe rate of no resection thoracotomy to less than

1% consistent with the findings of others [2,14,15].They advocate routine insertion of a videothoraco-scope in all potential major pulmonary resection

cases. This takes but a few minutes and can helpin several important ways. Pleural or other unex-pected metastatic disease can be excluded. Obvi-ous invasion of structures that makes surgery

impossible can be identified. On occasion, irresect-ability implied on preoperative scans can be re-futed providing the opposing pathway. Also,

and often not considered, VATS assessment pro-vides the best opportunity to make a patient-based judgment of relative resectability. Consider,

for example, the patient with marginal pulmonaryfunction in whom a lobectomy is feasible buta pneumonectomy ill advised. VATS assessment

can confirm the situation before the surgeon com-mits to thoracotomy. Similarly, chest wall or aor-tic invasion might be operable in a good-riskcandidate but inappropriate in other cases.

Whether the adverse finding negating thoracot-omy is absolute or relative, the option to proceedto alternative oncologic therapies is hugely en-

hanced by avoiding the major trauma of an un-necessary thoracotomy. Recent work suggeststhat in some instances a single-port approach

can provide adequate assessment [16]. As a finalconsideration, routine assessment of cancer casesprovides familiarity for the surgeon and team inthis field and consequently a sound basis for judg-

ment in undertaking a VATS lobectomy. Betterthis gradated approach than the abrupt transitionfrom relatively minor VATS interventions to

a major endoscopic resection.

Video-assisted thoracic surgery lobectomy

The role of VATS lobectomy in a thoracic unit

is subject to several interdependent issues. Theseinclude surgical (and other operating room teammember) competencies; unit case volume; core

surgical philosophy; and the staging strategy used.Beyond these considerations program size mayalso be governed by economic considerations.

Program size

It is relatively easy to calculate the maximumreasonable percentage of VATS resections withina unit. Specimen extraction limits tumor size

in any practical sense to about 5 cm and therequirement for a clean hilar dissection areamakes selection of more peripheral lesions desir-able. T1 and T2 nonhilar lesions are preferred.

Lymph node management is a matter for debate.In the authors’ experience, using the endoscopicVATS lobectomy technique complete hilar dissec-

tion is routine and mediastinal adenectomy on theright is perfectly feasible but it is difficult to clearstations 7 and L2 and L4 on the left. This may be

easier to undertake using a minithoracotomytechnique. Arising from these considerations, theauthors have opted for extensive preoperativemediastinal assessment, which currently includes

CT, CT with positron emission tomography, androutine mediastinoscopy in all cases with inspec-tion and sampling of ipsilateral stations 2 and 4,

station 7, and contralateral 4 [17]. The intent is tolimit VATS resection to stage I and II disease. Intheir practice more advanced cases are the appro-

priate candidates for open surgery. On this basis,approximately 30% to 40% of resections under-taken could be candidates for VATS lobectomy.

Clearly, if a unit had a particular interest in resec-tion of advanced-stage cases, the proportion isreduced. It is perfectly possible to advance intoN2 category cases subject to the previously men-

tioned considerations and into hilar disease orlarger tumors. In these instances there may beissues regarding the required size of the utility

port and of rib retraction being required. None-theless, there can be a strong argument forproceeding in this direction on the basis that these

patients can progress to adjuvant therapy moreeasily than after standard thoracotomy [18].Where to draw the line in this process is a valuejudgment for the unit concerned but likely only

a high-volume program generates the necessaryskills to support resection of advanced cancer byVATS lobectomy.

Competency

As with all forms of surgery, maintenance of

skill requires that a certain minimum number ofVATS lobectomy should be undertaken each year.In the authors’ opinion, a minimum of 20 cases

per year should be undertaken by a VATS lobec-tomist, ideally more. Logically, unit structureshould provide for two surgeons in a group to

286 WALKER & CASALI

have this subspecialization, whereas the othersfocus on different aspects. A program of 40 to 50VATS lobectomies supports two surgeons within

a likely total case volume of 130 to 150 resectionsper year.

There are as yet no specific credentialing inVATS lobectomy, with some arguing that this is

another skill that the contemporary traineeacquires in due course. This is not the case.Data [19] suggest that a learning curve of 50 cases

is required to reach full competence. It followsthat units wishing to develop this aspect ofthoracic surgery require investing in individuals

with a proved track record in the field and devel-oping talent within their own group. A fullytrained surgeon is necessary to ensure that patientcare is not compromised with respect to open

surgery.Where specific training is not a possibility, the

option to develop a de novo program exists but is

a long and responsible road. In this circumstanceone advises a background of good endoscopicskills, considerable experience with open resec-

tion, and a willingness to progress in a slow andincremental manner. Accordingly, initial VATSassessment might progress to limited preliminary

mobilization followed in later cases by mobiliza-tion of structures until at some point favorablefissures and clear anatomy facilitate a successfullobectomy. In some instances, it may be found

helpful to start with a minithoracotomy approachand to migrate from that to an endoscopic pro-cedure. Whichever strategy is adopted, however,

one should be aware that this is a difficult wayforward and it is better to learn from theexperience of others. To paraphrase Sir William

Osler, learning in such a manner ‘‘is to sail anuncharted sea.’’

Competency issues are not restricted to thesurgeon. It is pointless embarking on a VATS

program unless nursing and anesthesia colleaguesare prepared to support this process and to acceptthe additional requirements of VATS lobectomy

and increased operating time necessary. Timepressure makes for bad surgery.

Summary

It is beyond the scope of this article to reviewthe advantages of VATS lobectomy, but the datain support of this technique are increasing pro-

gressively. There is excellent evidence to supportthe oncologic equivalence and safety profile ascompared with open thoracotomy [4,5,20,21], and

data that demonstrate the reduced pain associatedwith VATS resection [22,23]. Also, reduction inimmune disturbance provides a tantalizing

glimpse of one additional potential modality ofbenefit for less traumatic surgery [24]. Unfor-tunately, in the economic world, equivalence,preferably with less cost, is the test applied.

Whatever the societal benefit of improved qualityof life following surgery, this has no cost benefitattached. From the foregoing discussion one can

conclude that VATS lobectomy is no more costlythan open resection and does generate additionalhospital beds. The authors remain uncertain as

to the preferred form of VATS lobectomy but itseems that the reduced trauma of the endoscopicprocedure is associated with more benefit in termsof shorter hospitalization albeit at the cost of

some increase in operating time [25]. VATS tech-niques and lobectomy sit comfortably within thestructure of any thoracic unit requiring little

adjustment to established process. It is likelythat ultimately 30% or thereabouts of majorpulmonary resection will be undertaken using

this technique and that VATS interventions willaid patient assessment regardless of stage or ulti-mate intended therapy. Competency and responsi-

ble use remain paramount considerations.

References

[1] Lewis RJ, Caccavale RJ, Sisler GE, et al. One hun-

dred video-assisted thoracic surgical simultaneously

stapled lobectomies without rib spreading. Ann

Thorac Surg 1997;63:1415–21.

[2] Giudicelli R, Thomas P, Lonjohn T, et al. Major

pulmonary resection by video assisted mini-thora-

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[3] Roviaro G, Varoli F, Nucca O, et al. Long term

outcomes after videothoracoscopic resection for




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[5] McKenna RJ Jr, Houck W, Fuller CB. Video-assis-

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1,100 cases. Ann Thorac Surg 2006;81(2):421–5

[discussion 425–6].

[6] Giudicelli R, Thomas P, LonjonT, et al. Video-

assisted minithoracotomy versus muscle-sparing

thoracotomy for performing lobectomy. Ann

Thorac Surg 1994;58(3):712–7 [discussion 717–8].

[7] Kirkby TJ, Mack MJ, Landreneau RJ, et al. Lobec-

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[8] Lewis RJ, Caccavale RJ, Sisler GE, et al. Is video-

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lung cancer: a multi-institutional study. J Thorac



Robotically Assisted Lobectomy: Learning Curveand Complications

Franca M.A. Melfi, MD*, Alfredo Mussi, MDCardiac and Thoracic Department, University of Pisa, Via Paradisa\2, 56100 Pisa, Italy

There are different types of robotic devices,

some as simple as camera voice-control [1,2].Today, the da Vinci Robotic System (Surgical In-tuitive, Mountain View, California) is the onlycomplete surgical system applied in surgical prac-

tice. This system includes a master remote con-sole, a computer controller, and a three to fourarm surgical manipulator with fixed remote center

kinematics connected by electrical cables andoptic fibers (Fig. 1).

The master console is connected to a surgical

manipulator with two to three instrument armsand a central arm to guide the endoscope. Twomaster handles at the surgeon’s console aremanipulated by the user. The position and the

orientation of the surgeon’s hands on the handlestrigger highly sensitive motion sensors, whichtransfer the surgeon’s movements to the tip of

the instrument at a remote location.The surgical arm cart provides three degrees of

freedom: (1) pitch, (2) yaw, and (3) insertion.

Attached to the robot arm is the surgical in-strument, the tip of which is provided witha mechanical cable-driven wrist. This adds four

more degrees of freedom: (1) internal pitch, (2) in-ternal yaw, (3) rotation, and (4) grip. To increaseprecision, the system uses downscaling from themotion of the handles to that of the surgical arms.

In addition, unintended movements caused byhuman tremor are filtered by a 6-Hz motion filter.

This system overcomes many of the obstacles

of thoracoscopic surgery (Table 1). It increasesdexterity, restores proper hand-eye coordinationand ergonomic position, and improves



(F.M.A. Melfi).


doi:10.1016/j.thorsurg.2008.06.001

visualization. In addition, it renders now feasible

surgical operations that were technically difficultor even impossible. Instruments with increased de-grees of freedom greatly enhance the surgeon’sability to manipulate the tissues. The system is de-

signed so that the surgeon’s tremor can be com-pensated on the end-effector motion throughappropriate hardware and software filters. More-

over, this robotic system eliminates the fulcrum ef-fect, making instrument manipulation moreintuitive. By most accounts, the enhanced vision

afforded by these systems is remarkable. Thethree-dimensional view with depth perception isa marked improvement over the conventionalthoracoscopic camera views. A further advantage

is the surgeon’s ability directly to control a stablevisual field with increased magnification and ma-neuverability. All of this creates images with in-

creased resolution that, combined with theincreased degrees of freedom and enhanced dex-terity, greatly enhances the surgeon’s ability to

identify and dissect anatomic structures and toconstruct microanastomoses.

Nevertheless, there are several disadvantages

to the da Vinci Systems. Robotic surgery is a newtechnology and its uses and efficacy have not yetbeen well established. Another disadvantage is thesize of this system. This is an important disad-

vantage in today’s already crowded operatingrooms. Moreover, one of the potential disadvan-tages identified is a lack of compatible instruments

and equipment. Lack of certain instrumentsincreases reliance on tableside assistants toperform part of the surgical operation. This,

however, is a transient disadvantage becausenew technologies have been and will continue tobe developed to address these shortcomings. Mostof these disadvantages will be remedied with time

and improvements in technology.

ts reserved.




Fig. 1. (A) The surgical team. (B) The surgeon at master remote console.

290 MELFI & MUSSI

Training of surgical team: learning curve

To perform robotic surgery in a safe andstraightforward manner, it is necessary to stan-dardize procedures and establish operative

schemes. This robotic device requires meticulouspreparation in terms of set-up of the system andits placement at the operating table.

The main body of the machine (surgical cart)and the robotic arms must be placed in relation tothe side of the lesion. Only when the robotic carthas been positioned appropriately and the patient

placed in the chosen position, can the roboticarms be brought into the operative field. Thetransition from traditional surgery to advanced

totally robotic surgery is not immediate. Just as inthe passage from open surgery to minimallyinvasive technique, here too certain precise orga-

nizational and didactic routes must be followed.Advanced training on robotic systems provides

Table 1

Advantages and disadvantages of videothoracoscopic surgery

Videothoracoscopic surgery

Advantages Well-developed technology

Affordable and ubiquitous

Proved efficacy

Disadvantages Loss of touch sensation

Compromised dexterity

Limited degrees of motion

Fulcrum effect

Amplification of physiologic

the surgeon and scrub nurses (surgical team)

confidence when operating in tiny intracavitaryspaces. This allows the surgical team to activateand maintain the entire operative system, recog-

nize and correct errors, and take charge ofhandling all materials and instruments. Approxi-mately, 20 days are necessary to complete ade-

quate training.To expand these new capabilities, robotic

surgical procedures were developed and objec-tive-based curriculum levels were designed to

optimize surgeon and team training, which isnecessary to obtain the best early clinical results(Box 1).

Binocular and three-dimensional vision,restricted operative field, handling of joysticks,robotic surgical instruments, movements of

robotic arms and surgical instruments, andabsence of tactile feedback are important aspectsthat the surgeon needs to become familiar with

versus robotic surgery

Robotic surgery

Three-dimensional imaging

Dexterity

Seven degrees of freedom

No fulcrum effect

No physiologic tremors

Scale motions

Ergonomic position

tremors

No tactile feedback

Expensive

Unproved benefit

Box 1. The scheme for the learningcurve

Nurse team1. Setup robotic system

Connection of the console to therobotic cart (electric cables andoptic fibers)

Self-test (3 minutes): the test systemundergoes an automatic check-up

Draping the robotic arms in sterilenylon covers

2. Setup optic systemFrontal or inclined position of the

scope (0 degrees or 30 degrees)White balancingSetting of two- or three-dimensional

Surgeon’s team1. Trocar placement

The best positioning of the trocars isestablished in relation to the side ofthe lesion to have an excellent,unobstructed view of the chestcavity without arm impingementand interference

2. Patient positioning3. Robot cart positioning4. Surgical procedure (pneumothorax,

mediastinum lesions)

291ROBOTICALLY ASSISTED LOBECTOMY

during the learning curve. After an initial theo-retic phase, training at the console represents the

surgeon’s first real impact with robotic surgery.This can be performed using either mechanical oranimal models: in this regard, it is auspicable to

have a special robot available that can be usedexclusively for teaching purposes. The most fre-quent procedure used in the initial phase of thelearning curve is the treatment of pneumothorax

and mediastinum lesions (neurinoma, pericardialcystis). These procedures represent an ideal train-ing model, because they provide the means for

learning basic procedures combined with a rela-tively simple technique. As surgical experiencegrows, indications for robotic technique can be

extended to include an increasing number ofprocedures while obtaining results that conformto specific standards. Improvements in the quality

of surgery and reductions in operative timescorrespond to standardization of procedure interms of patient positioning, trocar placement,

and consequent reduction time of the surgical cartand mechanical arms placement in the surgicalfield. A minimum of 20 procedures is necessaryfor the learning curve for both teams. In addition,

the active cooperation with anesthesiologists isauspicious, mostly with regards to patient andsystem positioning so as not to hamper patient

monitoring.

Robotic lobectomy: technical aspects

Many of the robotic procedures can be per-formed by a single operator. This is true ofprocedures that require few accurate maneuvers

(dissection or coagulation) in a restricted andwell-defined field: enucleation of condroma, exci-sions of mediastinal masses, thymectomies. Dur-ing major resections, such as lobectomies,

however, some maneuvers must necessarily beperformed by the assistant surgeon, given theneed of a fourth arm. Maintaining a correct

position with appropriate tension of the lungparenchyma is top priority for identifying anddissecting the hilum structures (vessels and bron-

chus), as is suction, passing the sutures in the chestcavity, and appropriate positioning of the stapler.To perform these maneuvers the role of the

assistant surgeon is mandatory, and they mustalways be at hand at the operating table. The newda Vinci System (da Vinci S), however, overcamemost of these technical difficulties, thanks to

multiquadrant access of a fourth arm (the roboticarms have greater range of motion and theEndoWrist instruments are two inches longer;

together, these two features facilitate multiqua-drant access), and high-definition video technolo-gies, high-speed networking, and image-guidance

systems.In addition a new feature, called TilePro,

allows surgeons to import and view a variety of

video images without leaving the console. Allthese new features, fully integrated into the daVinci System, transcend the limitations of bothopen surgery and thoracoscopy, expanding the

surgeon’s capabilities and offering a minimallyinvasive option for many complex procedures,such as major lung resections.

A critical point of the robotic lobectomy is theplacement of the trocars and the surgical cart inthe right position to obtain the best performance

of the operation. In video-assisted thoracic sur-gery (VATS) the baseball-diamond principle isgenerally accepted as the concept guiding trocar

292 MELFI & MUSSI

placement. In robotic lobectomy a differentplanimetry is required with the trocars positionedat a greater distance from each other than they

normally are in standard thoracoscopic proce-dures. VATS exploration before the operation canyield important information that would markedlyalter the treatment strategy. This strategy is

particularly helpful when the fourth arm is used(to evaluate spatial relationship of the lobes andthe location of the lesion) for the physical

orientation and the optimal working angles be-tween instruments, lesions plane, and the angle ofthe vision. The best positioning of the system and

the robot arms is established to obtain an excel-lent view of the chest cavity without arm impinge-ment and interference. Patients are prepared anddraped for a posterior lateral thoracotomy so that

they can be converted in the event of intraoper-ative complications or in case a video robotlobectomy is not feasible. In addition to robotic-

thoracoscopic instruments, a full thoracotomyinstrument-set is available at the operating table.

Robotic lobectomy: surgical sequences

Video robotic lobectomy follows the standardsurgical steps of open thoracic surgery and impliesthe isolation and resection of the vascular and

bronchial hilar elements. Usually the artery isdealt with before the vein and eventually thebronchus is resected; however, priorities are not

strictly set. Like other thoracic procedures single-lung anesthesia is achieved by a double-lumenendotracheal tube. The patient is placed in

a maximally flexed lateral decubitus position.The standard layout is as follows:

� 1st incision (camera port): 7th–8th intercostalspace (ICS) at the mid-posterior axillary line.� 2nd incision (arm port 2): 6th–7th ICS at the

posterior axillary line; above the diaphragmposteriorly to the scapula tip.� 3rd incision (arm port 1) (utility incision, 3 cmlength): 4th–5th ICS anterior axillary line.

The utility incision location varies dependingon the lobe of interest and the hilar structures.For the upper lobectomy it is at the level of

the superior vein in the midaxillary line (usu-ally 4th ICS). For middle and lower lobecto-mies, the incision is placed one intercostal

space lower.� 4th incision (arm port 3): 5th–6th ICS inferiorto ausculatory triangle.

When the fourth arm is not suitable anadditional small incision is made (between theservice entrance and the three-dimensional scope)

for the assistant surgeon to insert conventionalendoscopic instruments.

Once the incisions have been made, the daVinci (surgical cart) is positioned at posterior, and

the patient’s head is brought into position fromthe posterior aspect of the patient, with the centercolumn at an approximately 45-degree angle with

respect to the longitudinal axis of the patient.A 30-degree scope angled down (generally pre-ferred) is introduced through a 12-mm trocar and

secured to the camera arm. The positioning of theinstrument arms and the remaining accessincisions are accomplished under direct vision.

Hilum dissection

The dissection is performed by using 1 or2 Cadiere forceps and the permanent spatula or

hook (preferably) attached to the electrocautery.Individual isolation of the hilar structures pro-ceeds with dissection around the hilar vessels andbronchi performed through a combination of

cautery and sharp and blunt dissection.

Arterial step

When the fourth arm is available, a Cadiereforcep–EndoWrist for lung retraction (throughport 2), a Bi-polar fenestrated forcep–EndoWrist(through port 3), and a monopolar hook or

Spatula-Endowers (through the utility incision)are used for the artery dissection. If the interlobarfissure is complete or nearly complete, the incision

of the visceral pleura with electrocautery or bluntdissection with a pledget mounted on the Cadiereforceps allows the pulmonary artery to be easily

identified. When the vessels are sufficiently dis-sected, two blunt-tipped Cadiere forceps are usedto isolate the pulmonary artery. Then, a sling is

passed. The dissection begins after vein isolationfor upper and middle lobectomies; the arteries areisolated and often taken separately, for lowerlobectomies. Thanks to the wrist instruments,

the suture may be performed by using double-tielinen 2.5 or by vascular stapler introducedthrough the posterior access incision, when an

upper or middle lobectomy is performed orthrough the anterior utility incision for the lowerlobectomy. Innovative robotic clips are now

available for pulmonary vessels (Hem-o-lok,WECK, TFX Medical, High Wycomb, UnitedKingdom). These clips may be delicately applied


by the surgeon who can position the vascular clipwith a safe and precise maneuver.

Vein step

Usually the surgical time sequence impliestreating the vein as a second step. Vein isolationis generally performed with Cadiere forceps on the

left arm and hook or spatula on the right arm. Forlower lobectomies, the vein identification beginsfrom the pulmonary ligament that is incised. Forupper and middle lobectomies a good exposure of

the mediastinum is required to clear the vein fromthe surrounding tissues. Again, a sling is passedand a double tie (with linen 2.5 or silk) is placed to

close the vessel; when necessary, an additionaltransficted suture can be added. When the veinwall is particularly thick it is advisable to use

a mechanical stapler. Another way of handling thevein is to place a vascular curved clamp throughthe utility incision and stitch it by using the robot

Debakey forceps and a large needle holder (poly-propylene monofilament 4/0). This is more diffi-cult and not safe, considering that both the staplerand the clamp have to be placed by the assistant

surgeon whose hand-eye orientation (bidimen-sional vision) is less precise compared with thesurgeon who, at the console, has a different depth

perception and optical resolution. Consequently,poor coordination between the surgeon and theassistant can jeopardize the success of the

operation.

Bronchus step

The last step consists of dissecting the lobar

bronchus so that lobar bronchial nodes can becompletely removed with the specimen. A sling isused to encircle bronchus, which is subsequently

stapled (Endopath ATB45). This maneuver isnecessarily performed by the assistant surgeon.This is the only possible way to resect and suture

the bronchus. Although the robot wrists are ableto simulate even fine physiologic movements, thesurgeon cannot make a running stitch whendealing with the bronchus, because the robotic

instruments in current use are too small to handlesuch a thick structure.

When feasible, the completion of the fissure is

performed last, just before removing the speci-men. Ultimately, the specimen is placed in a sterileplastic bag and removed through the utility

incision without rib-spearing. The bronchialstump is then tested under water for air leakswith 20 cm of positive airway pressure.

Lymphadenectomy

Unlike the VATS approach, there are nolimitations regarding accurate lymph node dissec-tion given that this is performed at the end of the

operation when a part of the lung has beenremoved so that it is easier to reach all lymphnode stations to ensure proper staging of the lungcancer. At the end of the procedure, all the

accessible nodal stations are systematically sam-pled to ensure proper staging of the lung cancer.Currently, the lymph node samplings are made at

stations that are more likely involved for tumororiginating from a particular lobe, according tothe classification by Naruke and coworkers

[3]: right upper lobe (prevascular and retro tra-cheal N3 and lower paratracheal N4R); middlelobe (N3 and subcarinal N7); right lower lobe(N7); left upper lobe (sub aortic N5 and para-

aortic N6); and left lower lobe (N7).

The authors’ experience

Since February 2001, 201 patients wereselected for various surgical robotic procedures(da Vinci Robotic System) ranging from thesimplest operations, such as benign tumor enucle-

ations and excisions, to very complex procedures,such as major lung resections. Video roboticlobectomies were performed in 107 good-risk

patients with cardiopulmonary function demon-strating an adequate pulmonary reserve (forcedexpiratory volume in 1 second O1.5 L) and

arterial blood gases within normal limits. Thesepatients, 32 women and 75 men with mean age of64 years (range, 41–85), were referred to thoracicsurgery (Cardiac and Thoracic Department, Uni-

versity of Pisa) with a pulmonary opacity on chestradiographs and normal bronchoscopic appear-ances. In accordance with protocols at that time,

mediastinoscopy was not performed for smalllesions without mediastinal lymphadenopathyidentified on CT or PET scan. The patients were

judged to have clinical stage I (non–small cell lungcancer). In all patients, an anatomic major lungresection with lymphadenectomy was performed.

Specific consent was obtained to attempt a roboticresection.

Results

In this highly selected group of good-riskpatients, no technical operative mishaps relatedto maneuvers of the instrument arms occurred.

294 MELFI & MUSSI

None of the patients had problems related tooperative bleeding. Summarizing the results, theresected lobes were 22 lower left lobes, 26 lower

right, 10 middle lobes, 27 upper right, and22 upper left. A median of 22 lymph nodes wereremoved. Most of the series had adenocarcinoma(64 adenocarcinoma, 32 squamous cell carcinoma,

8 typical carcinoid, 1 small cell lung cancer, 1 largecell carcinoma, and 1 anaplastic cell carcinoma)and the most representative postoperative stage

was stage I (65 stage IA, 22 stage IB) in a highernumber of the cases (81.4%). The other post-operative stages were stage II in 10 patients (four

stage IIA and six stage IIB) and stage III in 10 (sixstage IIIA and four stage IIIB).

In 10 cases (9.4%) the procedure was con-verted to thoracotomy because of pleural adhe-

sions in two patients and because of fused fissurein six. In two cases the lobectomies were begun byisolating and stitching the transected lower vein

with the robot. The operations had to be com-pleted using the service entrance (enlarged byabout 2 cm) because of hilar calcified lymph

nodes, however, because these rendered the dis-secting of the pulmonary artery unsafe. Tenpatients had air leaks greater than 7 postoperative

days. In all patients, mechanical staplers wereused to complete the fissure. There was one deathon the twelfth postoperative day (not related tothe surgical technique) because of pulmonary

embolus. After an initial excellent postoperativerecovery the patient had acute kidney failure onthe fourth postoperative day, which led to a wors-

ening of the clinical condition.

� Chest tubes were removed in mean 3 postoper-

ative days (range, 2–28) and the patients weredischarged in mean 5 postoperative days.� Operative time (median operative time) was

220 minutes (range, between 130 and 250 min-utes), of which 60 minutes were used to do theself-test of the machine and instrument set-up.

This time was considerably longer than thatfor standard open surgery or VATS proce-dure, but it decreased with experience.� All patients were discharged in good condition

and returned to preoperative levels of physicalactivity within 10 days of the operation.

Comment

Robotic surgery was initially developed toperform cardiac surgery: the first internal mam-mary artery grafting was performed in 1999 [4],

and in 2000 Kapperet and coworkers [5] reportedthe preliminary results on 27 patients. Subse-quently, the undoubted advantages of a robotic

system were applied in many others disciplines,such as thoracic surgery. Movements in the gripof the console are naturally transmitted to the in-struments, and can reproduce the human wrist in-

side the chest cavity, thanks to the seven degreesof freedom. The three-dimensional vision andthe seven degrees of rotation of the robotic instru-

ments have made many procedures in a closed-chest setting feasible and safe. The da Vincirobotic system was found to be very useful in

the exeresis of mediastinal masses. Variousauthors reported encouraging results about medi-astinal masses exeresis: low conversion rate, lowor absent postoperative complications, and

acceptable operative times, which probably willbe reduced with increasing experience [6–8].Robotic technology has conferred certain advan-

tages in minimally invasive thoracic surgery, andfor anatomic lung resection, especially pulmonarylobectomy. The use of minimally invasive lobec-

tomy for early stage lung cancer is going to in-crease in clinical practice. In part this is becauseof detection of smaller size lung cancers thanks

to screening programs, and of recent advances inminimally invasive technology, in particular withthe development of a robotic system. In 2002,the encouraging results of five pulmonary lobecto-

mies performed with the aid of robotic technologywere reported [9]. Subsequently, Ashton and col-leagues [10] in 2003 and Bodner and colleagues

[11] in 2004 reported their experiences with theda Vinci robotic system, in performing right lowerlobectomies. Although the first experiences sug-

gested the feasibility and the safety of roboticVATS lobectomy, this type of approach requiredan increased operative time compared with con-ventional surgery, probably because of three dif-

ferent factors. First, there is no standardtechnique the surgeon can precisely follow, andeven very experienced VATS surgeons may have

very limited robotic experience. The sequence ofsurgical maneuvers needs to be well established.Secondly, the incorporation of any new device in

the surgical practice may affect performance inthe early period. Adequate training is requiredfor surgeons to acquire and master the new skills

to improve surgical performance. Thirdly, duringthe first period of clinical use of the robotic sys-tem, the instrumentation available for thoracicsurgery often was inadequate. Most of the robotic

instruments were designed for use on coronary


vessels, so each surgeon had to test the instrumen-tation to determine its safety and effectiveness.This fact has probably contributed to theincreased operative time.

During these last few years, new robotic clips forvessels (Hem-o-lok) were developed making someprocedures safer and more straightforward, above

all pulmonary lobectomies. It is desirable that moreroboticdevices, like the robotic stapler, bedevelopedtopermit the surgeonat the console toperformevery

phase of the procedure, increasing the safety of theprocedure and reducing the operative time.

This technique is still evolving and more

studies on a large population are necessary. Thecurrent literature showed, however, that this pro-cedure is feasible and safe [12,13]. Although thesestudies suffer from the limitations of being non-

randomized analysis, they revealed several keytechnical points that are essential for a successfulprocedure. First, the patient’s position and the

site of arm incisions are critical and have to bechosen to avoid arm impingement and interfer-ence. For this reason a minimum distance of

8 to 10 cm is advisable, especially for upper lobec-tomies. Secondly, the presence of a surgeon who isfamiliar with conventional VATS is highly pre-

ferred, because the assistant has to place the endo-scopic staplers under bidimensional vision and theoperating surgeon is seated at the console, awayfrom the patient. Thirdly, the robotic instrumen-

tation is still evolving and it is auspicable thatmore adequate instruments be available in thenear future to enable the surgeon to perform

robotic lobectomies on a routine basis.

References

[1] Miller DL, Allen MS. Set-up and present indica-

tions: video-assisted thoracic surgery. Semin Thorac


[2] Tsuboi M, Sakai H, Magata S, et al. The develop-

ment of a new setup for video-assisted thoracic

surgery. Diagn Ther Endosc 1999;6(1):43–6.

[3] Naruke T, Suemasu K, Ishikawa S. Lymph node

mapping and curability of various levels of metasta-

ses in resected lung cancer. J Thorac Cardiovasc

Surg 1978;76(6):832–9.

[4] Carpentier A, Louimel D, Aupacie B, et al. Com-

puter-assisted cardiac surgery. Lancet 1999;353:

379–80.

[5] Kappert U, Ciehon R, Guliemos V, et al. Robotic-

enhanced Dresden technique for minimally invasive

bilateral mammary artery grafining. Heart Surg

Forum 2000;3:319–21.

[6] Yoshino I, HashizumeM, Shimada M, et al. Thora-

coscopic thymomectomy with the da Vinci com-

puter-enhanced surgical system. J Thorac


[7] Bodner J, Wykypiel H, Greiner A, et al. Early expe-

rience with robot-assisted surgery for mediastinal

masses. Ann Thorac Surg 2004;78(1):259–65


[8] Rea F, Marulli G, Bortolotti L, et al. Experience

with the da Vinci robotic system for thymectomy

in patientswithmyasthenia gravis: report of 33 cases.

Ann Thorac Surg 2006;81(2):455–9.

[9] Melfi FM, Menconi GF, Mariani AM, et al. Early

experience with robotic technology for thoraco-

scopic surgery. Eur J Cardiothorac Surg 2002;

21(5):864–8.

[10] Ashton RC Jr, Connery CP, Swistel DG, et al.

Robot-assisted lobectomy. J Thorac Cardiovasc

Surg 2003;126(1):292–3.

[11] Bodner J, Wykypiel H,Wetscher G, et al. First expe-

riences with the da Vinci operating robot in thoracic

surgery. Eur J Cardiothorac Surg 2004;25(5):

844–51.

[12] Melfi FMA, Ambrogi MC, Mussi A, et al. Video

robotic lobectomy. Multimedia Manual of Cardio-

thoracic Surgery 2005;628:448.




2006;131(1):54–9.


Cost Comparison of Robotic, Video-assisted ThoracicSurgery and Thoracotomy Approaches

to Pulmonary LobectomyBernard J. Park, MD, Raja M. Flores, MD*

Department of Surgery, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10021, USA

The use of minimally invasive video-assisted

thoracic surgery (VATS) has been shown to havecertain advantages over conventional rib-spreading thoracotomy that is making it increas-ingly employed for anatomic pulmonary resections

[1–5]. One of the major advantages of VATS forlobectomy has been quicker recovery and shorterlength of stay [6]. Recently, there has been some

evidence to suggest that for patients with locallyadvanced lung cancer that initial resection byVATS can lead to greater tolerance and receipt of

adjuvant chemotherapy [7]. Despite this evidencein favor of the advantages of a VATS approach,there has been very little analysis of the compara-tive cost relative to standard thoracotomy. Fur-

thermore, there have been reported newapproaches to VATS lobectomy employingrecently developed, expensive telerobotic technol-

ogy [8], the financial implication of which has notbeen considered.

We evaluated the total hospital costs, direct

and indirect, associated with thoracotomy lobec-tomy as compared with VATS lobectomy androbotic VATS lobectomy.

Materials and methods

Approval for the study was obtained and the

need for individual patient consent was waived bythe Institutional Review Board. The financialdatabase (Decision Support System, Eclipsys

* Corresponding author. Department of Surgery,

Memorial Sloan-Kettering Cancer Center, 1275 York

Avenue, Room C-879, New York, NY 10021.

E-mail address: [email protected] (R.M. Flores).


doi:10.1016/j.thorsurg.2008.05.003

Corporation, Atlanta, GA) of a single institution

was queried retrospectively using CPT codes toidentify all patients undergoing thoracotomylobectomy (32480), VATS lobectomy (32663),and robotic VATS lobectomy (32663þ99997) in

the calendar year of 2007.The type of surgical resection was determined

by the individual surgeon’s recommendation

based on multiple factors that included patientpreference, expertise with a specific technique, andnature of the disease. Thoracotomy was a standard

posterolateral approach with partial division ofthe latissimus dorsi muscle and preservation of theserratus anterior muscle and rib spreading. VATSlobectomy was performed via a three-incision

technique with a 3- to 4-cm, non–rib-spreadingutility incision. Our technique for robotic VATSlobectomy has been previously described, employ-

ing the same three-incision approach and use ofthe three-arm da Vinci Surgical System (IntuitiveSurgical, Sunnyvale, California) [7]. Standard an-

esthesia techniques, including single-lung ventila-tion, were used in all cases. Individual hilardissection and ligation with endovascular stapling

devices and either systematic mediastinal lymphnode dissection or sampling were performed in ev-ery patient regardless of the surgical approach tolobectomy. Postoperative pain management in-

cluded patient-controlled analgesia via epiduralcatheter in the majority of patients.

Average costs for each group were generated

for each hospital day, which included all directand indirect costs with the exception of the cost ofthe surgeon’s professional fee, which was added

separately. The total average cost for each pro-cedure was calculated by adding the average dailycost over the mean number of hospital days.

ts reserved.




298 PARK & FLORES

Comparisons were made among thoracotomy, allVATS cases, VATS-only cases, and robotic-assisted procedures. Because of an institutional

policy restricting publication of actual cost data,the results are presented as relative, rather thanabsolute costs.

Results

From January 1, 2007, through December 31,2007, 269 patients underwent thoracotomy lobec-tomy, and 99 patients underwent VATS lobec-

tomy with 87 having VATS alone and 12 patientshaving a robotic-assisted procedure. The operat-ing room times for each group were similar(thoracotomy: 3 hours, 43 minutes; VATS:

3 hours, 45 minutes; robotic: 3 hours, 37 minutes).The average length of stay of the thoracotomygroup was 6 days versus 4 days for all VATS

patients with no differences between length of staybetween the groups that underwent either VATSonly or robotic lobectomy.

Table 1 lists the average costs associated witheach surgical approach relative to one another,taking into account the average length of stay

and the cost of the surgeon’s fee for the procedure.Costs were highest at the beginning of the hospitalstay and trended downward during subsequentdays (data not shown). The overall VATS group

had a substantially less total average cost com-pared with the thoracotomy patients ($1479versus $8368, difference –$6889). This difference

was even more pronounced when the VATSonly group was analyzed (–$7969) relative tothoracotomy. Use of robotic technology during

VATS lobectomy was associated with increasedcost for the minimally invasive approach, addingon average $3981 compared with VATS alone.

Table 1

Comparative procedure costs

Factor

Thoracotomy

relative cost, $

Overall VATS

relative cost, $

Day 1 1259 901

Day 2 427 103

Day 3 496 413

Day 4 835 62

Day 5 2546 0

Day 6 2290 0

Feea 515 0

Total 8368 1479

a Average surgeon’s fee cost.

When analyzing the daily costs, it was clear thatthe increased cost of employing robotics wasincurred almost fully in the first hospital day

($3880). Despite the increased costs associatedwith employing the robot relative to the VATS-only technique, robotic lobectomy was still lesscostly than thoracotomy lobectomy (–$3988).

The exact explanation of the increased averagecost of robotics in the first day of hospitalization isnot known. In an effort to ascertain the factors

associated with this finding, the direct costs for thefirst hospital day were analyzed for thoracotomy,VATS-only, and robotic-assisted VATS lobec-

tomy. Only two items stood out. The first wasthat a much higher percentage of robotic patientsunderwent additional procedures at the time oflobectomy. For instance, in 92% of robotic cases

bronchoscopy was performed compared with only54% of nonrobotic cases (thoracotomy and VATSalone). Similarly, in the cohort of robotic patients

analyzed, 25% required extensive lysis of adhe-sions versus only 3.5% of nonrobotic lobectomypatients. The second factor was the expense of the

specialized instruments and certain disposablesrequired to use the robot. Table 2 lists the addi-tional items used during robotic VATS lobectomy

procedures as performed by the authors. Theseinclude a minimum of three instruments (twoCadiere forceps and one permanent spatula) andthe necessary drapes for a three-arm approach,

resulting in $730 of additional direct costs.

Comment

In this largest series of cases of lobectomy, by

either thoracotomy or VATS (both robotic andnonrobotic), subjected to a cost analysis, we haveshown that use of a minimally invasive VATS

VATS-only relative

cost, $

Robotic relative

cost, $

0 3880

0 339

399 0

0 161

0 0

0 0

0 0

399 4380

Table 2

Disposable costs per robotic case

Item Cost, $

Cadiere forceps � 2 400

Permanent Spatula 200

Drapes

Instrument arms � 2 70

Camera arm 35

Camera 25

Total 730

Table 3

Volume of robotic cases at Memorial Sloan-Kettering

Cancer Center

Year Cases

2002 14

2003 33

2004 17

2005 51

2006 61

2007 172

2008a 80

Total 428

All divisions.a Through March.

299COST COMPARISON

approach results in decreased cost of pulmonarylobectomy compared with standard thoracotomy.

Taking into consideration real cost data thatincluded all indirect, direct, and surgeon’s fees,we demonstrated that patients undergoing thora-

cotomy incurred costs that were much higher thanthose undergoing VATS by $7969. The majorityof this added cost was attributable to an increased

length of stay by 2 days, resulting in $5098 ofadditional cost. In addition, the cost of thesurgeon’s fee for employing a thoracotomy was$515 more than the minimally invasive approach,

even though the operation (anatomic pulmonarylobectomy) was essentially identical. The only twopreviously published studies reported conflicting

results when analyzing cost differences betweenVATS and thoracotomy in smaller, mixed pop-ulations of patients [9,10]. Sugi and colleagues [9]

compared 10 VATS lobectomies and 20 thoracot-omy lobectomies, finding that operative times anddisposable costs to be significantly higher in the

VATS group with a similar length of stay. How-ever, the lengths of stay for VATS and thoracot-omy were long (25.2 days and 27.7 days,respectively) making discerning a relevant differ-

ence difficult. Nakajima and co-authors [10]looked at a total of 102 patients with a mixtureof primary lung cancer and metastatic disease,

66 of whom had thoracotomy and 36 hadVATS. The authors reported lower charges oflab examinations, anesthesia, disposable autosu-

ture devices, and hospitalization in the VATSgroup. However, 64 of 66 thoracotomy patientsunderwent lobectomy, whereas only 8 of

36 VATS patients had lobectomy. This extremeselection bias undoubtedly favored the VATSgroup and explains the result of decreased costsand hospital stay in that cohort.

When comparing the subsets of patientsundergoing lobectomy by VATS alone versusrobotic-assisted VATS, this study found that use

of robotic technology resulted in increased costs

($3880), primarily in the first hospital day. Onfurther analysis this was attributable to two mainareas. The first and most obvious was the addi-tional disposable costs of the robotic instruments

and drapes. The second was perhaps a chanceresult that the robotic cases included a higherpercentage of additional procedural costs (bron-

choscopy, lysis of adhesions) compounded by thesmall number of robotic patients compared withstandard VATS cases. It is likely that by analyzing

a larger number of robotic patients or controllingfor the added procedural costs, this differencewould be less profound. Moreover, the average

total costs of robotic cases were still substantiallyless than by thoracotomy (–$3988). This finding issimilar to the only other comparative cost study ofrobotic-assisted versus conventional surgery.

Mouraviev and colleagues [11] analyzed the costassociated with various open prostatectomy tech-niques with robotic prostatectomy and cryoabla-

tion. The authors found that the grand totalhospital cost associated with a robotic approachwas significantly less with the open techniques,

despite higher surgery costs. Although they donot detail the components of the increased surgerycost, it is likely related to cost of the disposable

robotic materials and operating room time. Thiscost, however, as in our study, was substantiallyoffset by decreased other hospital costs and mostimportantly length of stay.

In the current study the cost of robotic tech-nology to the institution was not added to eachcase through amortization. Previous studies have

attempted to do this in the following manner:calculate the sum of the initial institutional cost ofthe robot plus the annual service contract fee over

the estimated life of the device and divide this sumby the total number of projected robotic cases doneover the estimated life of the device. For instance,

300 PARK & FLORES

Morgan and colleagues [12] evaluated cost ofrobotic versus conventional atrial septal defectand mitral valve repair. Before amortization they

discovered no difference in total hospital cost. Foramortization they assumed a 5-year life span ofthe robot with an average of 100 cases per year.With an initial price of $1,000,000 and yearly ser-

vice fee of $100,000, the authors calculated an addi-tional cost of $2800 per case. Similarly, Lotan andcolleagues [13] published a purely theoretic cost

analysis of open, laparoscopic and robotic prosta-tectomy. In it, the authors assumed a 7-year lifespan of the robot with an average of 300 cases per

year, resulting in an additional $857 cost per case.Table 3 demonstrates the yearly volume of

robot cases at our institution since obtaining theda Vinci robot in 2002. It is clear that the volume

of cases is variable, but continues to rise witheach passing year. With an initial capital costof $1,000,000 and annual service expenditure of

$100,000 if one were to assume a total life spanof the robot of 10 years and a projected volumeof cases for the next 4 years at the 2007 level (170

cases/year), the added amortized cost ofemploying the robot for each case would beapproximately $1715 per case. Is this the real cost

of using the robot? This is not clear, as the amor-tized cost is highly dependent on the number ofcases performed with decreasing cost associatedwith increasing use of the technology. Further-

more, such amortization for the cost of the VATStechnology (scopes, towers, video monitors, andso forth) was not in this study and has not been per-

formed in other comparable studies. Even includ-ing this additional amortized cost in the currentstudy, a robotic-assisted procedure is associated

with lower cost relative to a thoracotomy.We have shown that the actual cost associated

with a minimally invasive VATS approach tolobectomy is substantially lower than that resulting

from a thoracotomy. The bulk of the improvementis the direct result of a decreased length of hospitalstay afforded by use of VATS. Robotic assistance

increases cost relative to the nonrobotic VATSalternative secondary to specialized disposableequipment required and through the theoretic

cost of robotic technology to the institution.However, increased use over time will continuallyreduce this cost with each new case.

Acknowledgment

The authors acknowledge and thank Nicole

M. Barrow, Donna Boccamazzo, and Suzanne

Kelson from Memorial Sloan-Kettering CancerCenter’s Clinical Systems and Hospital Adminis-tration who provided the financial data and

analysis. We also thank Derek Goldstein andIntuitive Surgical for their input and support.

References

[1] LandreneauRJ,Hazelrigg SR,MackMJ, et al. Post-

operative pain-related morbidity: video-assisted

thoracic surgery versus thoracotomy. Ann Thorac

Surg 1993;56:1285–9.


nary function and prognosis with video-assisted

thoracic surgery thanwith thoracotomy.AnnThorac

Surg 2000;70:1644–6.

[3] Jaklitsch MT, DeCamp MM Jr, Liptak MJ, et al.

Video-assisted thoracic surgery in the elderly. Chest

1996;110:751–8.



a case-control study. Ann Thorac Surg 1999;68:

194–200.

[5] Flores RM,AlamN.Video-assisted thoracic surgery

lobectomy (VATS), open thoracotomy, and the

robot for lung cancer. Ann Thorac Surg 2008;85:

S710–5.

[6] McKenna RJ Jr, Houck W, Fuller CB. Video-

assisted thoracic surgery lobectomy: experience

with 1,100 cases. Ann Thorac Surg 2006;81:421–6.

[7] PetersonRP, PhamD, BurfeindWR, et al. Thoraco-

scopic lobectomy facilitates the delivery of adjuvant

chemotherapy after resection of lung cancer. Ann

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and lobectomy. Surg Today 1998;28:41–5.




89:2497–501.

[11] Mouraviev V, Nosnik I, Sun L, et al. Financial com-

parative analysis of minimally invasive surgery to

open surgery for localized prostate cancer: a single-

institution experience. Urology 2007;69:311–4.

[12] Morgan JA, Thornton BA, Peacock JC, et al. Does

robotic technology make minimally invasive cardiac

surgery too expensive? A hospital cost analysis of ro-

botic and conventional techniques. J Card Surg

2005;20:246–51.

[13] Lotan Y, Cadeddu JA, Gettman MT. The new eco-

nomics of radical prostatectomy: cost comparison of

open, laparoscopic and robot assisted techniques.

J Urol 2004;172:1431–5.


Does Minimally Invasive Thoracic Surgery WarrantFast Tracking of Thoracic Surgical Patients?

Robert J. Cerfolio, MD, FACS, FCCPa,*,Ayesha S. Bryant, MSPH, MDa,b

aDivision of Cardiothoracic Surgery, Department of Surgery, University of Alabama at Birmingham,

703 19th Street S, ZRB 739, Birmingham, AL 35294, USAbDepartment of Epidemiology, UAB School of Public Health, Birmingham, AL, USA

Reasons to fast track patients after surgery

In a previous edition of Thoracic Surgical

Clinics we described the importance of fast-track-ing in detail [1]. The main thrust of fast-tracking isto allow delivery of a safe operation with high pa-

tient satisfaction and minimize cost. The cost ofany operation can be divided into several cate-gories: preoperative evaluation, intraoperative

costs (equipment, personnel, surgeonapos;s fees,anesthesiologistapos;s fees, and time in the oper-ating room) and postoperative care. The latter isaffected primarily by hospital length of stay

(LOS) which, in patients who undergo pulmonaryresection, is mainly determined by air leaks, chesttube removal, pain control, or other complica-

tions such as arrhythmias. Thus hospital LOSmay be the easiest parameter for the surgeon tounilaterally modify. This article evaluates the

advantages of fast-tracking the patient who hasundergone video-assisted thoracoscopic surgery(VATS) instead of open thoracotomy.

Key issues for fast tracking

Fast-tracking protocols for any thoracotomy

or VATS procedure should include the consistentmanagement of the main factors that delayhospital discharge after pulmonary resection.

These include: chest tube management, air leakmanagement, and pain control.


E-mail address: [email protected] (R.J. Cerfolio).


doi:10.1016/j.thorsurg.2008.05.002

Most patient discharges are contingent on theremoval of the chest tube(s); although more and

more surgeons are sending patients home withchest tubes in place. Removal of chest tubes isgoverned mainly by volume of drainage and the

presence or absence of an air leak. When VATSlobectomy is performed instead of open thoracot-omy the chest tube output is often less; however, if

a complete thoracic lymphadenectomy is per-formed the outputs should be relatively compara-ble. A majority of thoracic surgeons prefer toleave chest tubes in until the air leak has been

resolved and the output is less than 250 mL/day[2] and some even use 200 mL/day [3]. In a recentpoll taken at a national meeting of general tho-

racic surgeons, approximately 75% stated theyuse 250 mL/day as the cutoff value for the re-moval of chest tubes following lung resection.

Hospital LOS is often prolonged because ‘‘thedrainage is too high,’’ despite the patient beingotherwise ready for discharge. In our recently

published series [4] that examined chest tube re-moval in 2,077 patients, 16 (19%) patients wereable to go home early on postoperative day(POD) two, 199 (30%) on POD three, and 135

(15%) on POD four, using the threshold of 450mL/day instead of the standard 250 mL/day. Atotal of 364 patients (or 18%) of the 1,988 patients

in this series who were sent home without a chesttube enjoyed an early hospital discharge. In thisseries all patients underwent thoracotomy. Only

19 (5%) were readmitted and, in a few, readmis-sion was only secondary to an ipsilateral pleuraleffusion. This is a similar readmission rate for

ts reserved.




302 CERFOLIO & BRYANT

the entire patient population and the removal oftubes with high output does not seem to increasethe readmission rate. This provides more evidence

that the removal of chest tubes with drainage ashigh as 450 mL/day is safe. In that study wealso observed that patients who spent more timein the hospital (one standard deviation above

the average) were more likely to be readmitted.Perhaps these patients are not amenable to fast-tracking protocols.

Air-leak protocols can also expedite dischargeto enhance fast-tracking. Alveolar-pleural fistulas(air leaks) are a common clinical problem and

remain the most common complication afteropen and VATS procedures. Recently, severalprospective randomized trials studied air leaks[5]. An objective, reproducible classification

(RDC) system was designed, reported, and clini-cally validated to help study air leaks. This sys-tem and these studies show that water seal is

superior to wall suction to help stop most airleaks [6,7]. Even in a patient with a pneumothoraxand an air leak, water seal is safe and the most

effective. If, however, a patient has a large leak(greater than an expiratory 3 on the RDC system)or experiences subcutaneous emphysema or an

expanding pneumothorax that causes hypoxia,then some suction (�10 cm of water) should beapplied to the chest tube(s) [8]. This concept ofsome suction being the most effective for large

leaks or leaks that lead to an expanding pneumo-thorax has been driven home by the work of Bru-nelli and colleagues [9,10]. They have presented

excellent prospective randomized data that sug-gest that suction, at least at night, may helpseal air leaks by encouraging pleural-pleural

apposition, which is a critical component forhealing air leaks. In addition, Brunelli and col-leagues [11] have shown that if a pleural tent isperformed during upper lobectomy it may de-

crease the incidence of an air leak. This is an ex-ample of a proactive step that is applied toa select group of patients who are at high risk

for complications in an effort to help reducethis complication. Pleural tents can be performedusing VATS techniques so the data are probably

translatable from open thoracotomy to VATS.Hence, the knowledge of risk factors for air leakscan help identify other patients who are at risk

for the developing of chronic air leaks. Finally,the continuous and digital assessment of air leaksis now available. Studies have shown that thismay provide a more accurate, reproducible tech-

nique for the management of chest tubes and

the assessment of air leaks. These digital airleak assessment devices may lead to shorter hos-pital stays [12].

Patients with a history of chronic steroid use,males, and those with a large leak or a leak witha pneumothorax have been shown to be at greaterrisk for a persistent air leak [13]. Brunelli and col-

leagues [14] have also shown that a low, predicted,postoperative forced expiratory volume in onesecond, the presence of pleural adhesions, and

an upper lobectomy or bilobectomy are other fac-tors that portend a persistent air leak. In our expe-rience, patients with prolonged air leaks scoring

less than an expiratory 5 on the RDC systemmay be discharged home safely on a Heimlichvalve or an outpatient portable drainage device.Thirty-three patients were placed on a Heimlich

valve, and six patients developed a pneumothoraxor subcutaneous emphysema; all patients had anexpiratory 5 leak or larger (P!.001). Seventeen

patients had leaks that resolved by 1 week, sixby 2 weeks, and the remaining nine had their tubesremoved without problems. Once the patient is

home and on a valve or another outpatient drain-age device, most air leaks will seal in two weeks. Ifnot, chest tubes can still be safely removed regard-

less of the size of the leak or the presence ofa pneumothorax. Thus the careful use of variouschest tube settings and the liberal use of outpa-tient drainage devices will help patients go home

on POD 3 or 4 despite the presence of a leak orbeing at high risk to get one.13

Pain medicine protocols to fast-track patients

Uncontrolled pain can impede the fast trackand lengthen hospital stay. This is true for

patients who undergo thoracotomy or VATSprocedures. The best treatment of pain, like anypostoperative complication, is prevention. We

have presented several prospective studies ontechniques to reduce pain during a thoracotomysuch as rib sparing, nerve sparing (by way of theuse of an intercostal muscle flap), and muscle

sparing [15–18]. We also drill holes in the inferiorrib to avoid the lower intercostal nerve. In addi-tion, the use of preemptive analgesia before rib

spreading reduces the pain of thoracotomy [19].The main perceived advantages of VATS arethat it reduces pain, causes less soft tissue trauma,

and leads to quicker recovery.Despite the use of all of these techniques

shown by randomized trials to reduce pain and

303FAST TRACKING OF THORACIC SURGICAL PATIENTS

a functional epidural, some patients still complainof severe pain in the hospital. Identification of thepatients before surgery who are at the greatest riskof having severe pain enables one to help stay on

top of the issue. Patients who are likely to havepain control issues are those who are chronic usersof narcotics, sleeping pills, or anti-anxiolytics.

Also, young muscular men are at risk to havemore pain than elderly, thin men or women. Forpatients likely to have pain-control issues, we add

different classes of pain medicines (eg, Cox IIinhibitors, nonsteroidal agents, and narcotics) inthe immediate postoperative period and deliver

them by way of patient controlled analgesia units.

Fast-tracking video-assisted thoracic surgery

A VATS technique may lend itself to fast-

tracking even more than a thoracotomy. Thefactors that can be modified to allow for fast-tracking are already reduced in patients who

undergo VATS rather than open thoracotomy.These patients have smaller incisions and less softtissue trauma [20]. The psychologic aspect of hav-

ing a thoracoscopic procedure over an openprocedure may in and of itself result in the percep-tion of less pain. Chest tubes are often removed

sooner with VATS than with a thoracotomywhich contributes to earlier discharge and fast-tracking. Studies have shown that patients whohave undergone a VATS lobectomy have fewer

air leaks and less chest tube drainage than thosewho undergo the same operation using an opentechnique.

A few series have evaluated fast-tracking pro-tocols for VATS with successful reduction ofhospital LOS. In 2002, Preventza [21] showed 37

patients underwent VATS wedge resection andwere able to enjoy overnight admission with amorbidity rate of 8% (three patients). Addition-

ally, hospital charges were half of those ofopen thoracotomy patients. More recently, in2007, McKenna and colleagues [22] reported on282 patients who underwent VATS lobectomies

and were fast-tracked. They had an average LOSof 3.3 days which was significantly less than theusual 4 to 7 days LOS for patients who undergo

open thoracotomy. Even patients who underwentVATS sleeve resection had an average LOS of3 days [23]. However, we have used a fast-tracking

protocol for our new open thoracotomytechniques and have reported a similar LOS, 3 to4 days, as well as complete return to all activities

postoperatively at 3 weeks. Thus the teaching andphilosophy are probably more important than theactual type of pulmonary resection performed.

Summary

Fast-tracking protocols or postoperative carecomputerized algorithms have been shown toreduce hospital LOS and reduce costs for patients

who undergo both open and VATS procedures[24,25]. The ability to fast-track is not governedby the type of procedure (closed versus open),but rather by patient characteristics and the mind-

set of the operating surgeon and the postoperativecare team. While use of protocols enhance theability of many physicians to fast-track many dif-

ferent types of patients, it is a mistake to forcethese protocols on all patients because, if notmodified, they can lead to increased complica-

tions, readmissions, and low patient and familysatisfaction. By carefully analyzing surgical resultsusing accurate prospective databases, the types of

patients who fail fast-tracking and the reasonsthey fail can be identified [26]. Specific changesto the postoperative algorithms can be imple-mented and these alterations can lead to improved

outcomes. For example, we have shown that byusing pain pumps instead of epidurals in elderlypatients we can improve outcomes and still fast-

track octogenarians with minimal morbidity andhigh patient satisfaction. We have also shownthat the use of increased physical therapy and re-

spiratory treatments (important parts of the careof all patients after pulmonary resection, but a lim-ited resource in most hospitals) may also lead toimproved surgical results for those with low

FEV1% and DLCO%. Although fast-trackingprotocols cannot be applied to all, the vast major-ity of patients who undergo elective pulmonary re-

section, even those at high risk, can undergo safe,efficient and cost-saving care by way of presetpostoperative algorithms after VATS or thoracot-

omy procedures. When the typical daily events arecommunicated each morning and the planneddate of discharge is reinforced with the patient

and family before surgery and each day in the hos-pital on rounds, most patients can be safely fast-tracked with high satisfaction and outstandingresults.

References

[1] Bryant AS, Cerfolio RJ. The influence of pre-opera-

tive risk stratification on fast-tracking patients after

304 CERFOLIO & BRYANT

pulmonary resection. Thorac Surg Clin 2008;18:

113–8.

[2] Sadovsky R. When to remove a chest tube? A ran-

domized studywith subsequent prospective consecu-

tive validation. J Am Coll Surg 2002;195:658–62.

[3] BaumannMH.What size chest tube?What drainage

system is ideal? And other chest tube management

questions. Curr Opin Pulm Med 2003;9:276–81.

[4] Cerfolio RJ, Bryant AS. Results of a prospective

algorithm to remove chest tubes after pulmonary re-

section with high output. J Thorac Cardiovasc Surg

2008;135:269–73.

[5] Cerfolio RJ. Recent advances in the treatment of air

leaks. Curr Opin Pulm Med 2005;11:319–23.

[6] Cerfolio RJ, Bass CS, Katholi CR. Prospective ran-

domized trial compares suction versus water seal for

air leaks. Ann Thorac Surg 2001;71:1613–7.

[7] Marshall MB, Deeb ME, Bleier JI, et al. Suction vs

water seal after pulmonary resection: a randomized

prospective study. Chest 2002;121:831–5.

[8] Cerfolio RJ, Bryant AS, Singh S, et al. The manage-

ment of chest tubes in patients with a pneumothorax

and an air leak after pulmonary resection. Chest

2005;128(2):816–20.

[9] Brunelli A, Sabbatini A, Xiume’ F, et al. Alternate

suction reduces prolonged air leak after pulmonary

lobectomy: a randomized comparison versus water

seal. Ann Thorac Surg 2005;80(3):1052–5.

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2005;130:987–93.

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the use of preemptive analgesia of the skin before

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sutures decrease the pain of thoracotomy. Ann

Thorac Surg 2003;76:407–11.

[18] Cerfolio RJ, Bryant AS, Maniscalco LM, et al.

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pleural intercostal nerve block associated with mini-

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790–4.

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[21] Preventz O, Hui HZ, Hramiec J. Fast track video

assisted thoracic surgery. Am Surg 2002;68:309–11.

[22] McKenna RJ, Mahtabifard A, Pickens A, et al.

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gery lobectomy, segmentectomy, and pneumonec-

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[23] Mahtabifard A, Fuller CB, McKenna RJ. Video-

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resection. Abstract accepted for presentation at the

2008 AATS meeting. San Diego (CA), May 10–14,

2008.


Uniportal Video-Assisted ThoracicSurgery for Diagnosis and Treatment

of Intrathoracic ConditionsMichele Salati, MDa,*, Alessandro Brunelli, MDa,

Gaetano Rocco, MD, FRCS (Ed), FECTSbaUnit of Thoracic Surgery, ‘‘Umberto I’’ Regional Hospital, Via Conca 1, 60020, Ancona, Italy

bDivision of Thoracic Surgery, Department of Thoracic Surgery and Oncology,

National Cancer Institute, Pascale Foundation, Via M Semmola 81, 80131 Naples, Italy

In the context of minimally invasive thoracicsurgery, the uniportal video-assisted thoracic

surgery (VATS) represents one of the most recentevolutions. With video-assisted mediastinoscopy,uniportal VATS could be considered the least

invasive VATS approach in our specialty and maybe used to diagnose and treat several intrathoracicconditions. Uniportal VATS magnifies the advan-tages already achieved by the standard (three-

portal) VATS, with a further reduction of pain,paraesthesia, immunologic injury, hospital stay,time for return to work, and hospital costs.

The uniportal approach for video-assisted

thoracic surgery

In 2004, Rocco and colleagues [1] devised theoriginal technique and published the first articleabout using the uniportal video assisted thoracic

surgery to perform wedge pulmonary resections.The initial experience on 15 patients who under-went pulmonary resections for diagnostic pur-

poses (interstitial lung disease) or for treatmentof primary spontaneous pneumothorax wasreported, and the theoretic premises and the prac-tical aspects of the technique, showing the safety

* Corresponding author. via A. De Gasperi 17/c,

60020 Offagna, Ancona, Italy.


(M. Salati).


doi:10.1016/j.thorsurg.2008.04.005

and the effectiveness of this procedure, wasdescribed in detail.

As explained in the Multimedia Manual ofCardio-thoracic Surgery [2], the uniportal VATSapproach consists of using a single port incision

(2.0-cm to 2.5-cm long) to perform video-assistedthoracic procedures. This single port representsthe access site for all the operative instrumentsand the optical source.

This concept implies a radical change of theperspective from the traditional three-portaltechnique. In fact, to perform an uniportal

VATS procedure it is necessary to hit the targetlesion arranging the instruments in a sagittalplane that is the same as where the lesion lies

(Fig. 1). Taking into account this new perspec-tive, it is intuitive that the wider the mobilityof the instruments on this imaginary plane, the

simpler the surgical procedure. To this purpose,it is extremely important to use 5-mm roticulat-ing instruments that reduce at a minimum mu-tual instrument interference, and offer the

operator a great liberty of action in being ableto change their position on multiple planes withmultiple angles.

A fundamental step in this procedure is thechoice of the intercostal space, where the portincision should be placed, particularly in light of

the impossibility of modifying the position of the5-mm 0� thoracoscope and operative instrumentsby switching their position to different ports [1–3].This choice will depend on the target lesion and an

error during this preoperative planning could lead

ts reserved.




Fig. 1. Diagram representing the different geometric

approach to the pulmonary lesion by (A) standard

three-port VATS compared with (B) uniportal VATS

(From Rocco G, Martin-Ucar A, Passera E. Uniportal

VATS wedge pulmonary resections. Ann Thorac Surg

2004;77:726; with permission.)

306 SALATI et al

to a conversion to traditional VATS or to an openapproach (Table 1).

Other technical tips that should be taken intoaccount when using this technique deserve to be

mentioned. First, it is possible to avoid crowdingof instrumentation through the port incision byretracting the trocar sleeve along the stem of the

thoracoscope [1,2] and avoiding the use of

Table 1

Position of the port incision for operative uniportal video-assi

Procedure

Intercostal

space

Bullectomy 5th

Lung biopsy

or lung resection

Upper lobes 5th

Middle lobe–Lingula 5th–6th

Lower lobes 4th

Mediastinal

nodes biopsy

Middle mediastinum 5th

Posterior

mediastinum

5th

Sympathectomy 3rd

Pericardial window 5th

supplementary trocars for the operative instru-ments. This allows an increase of the operativearea with a consequent reduction of the instru-

ments’ interference. If any, leverage should be ex-erted on the uppermost margin of the rib. Second,it can be useful to enlarge the intercostal spacecorrespondent to the skin incision by 1 cm to

1.5 cm, to further enlarge the working space andto avoid injuries to the intercostal neuro-vascularbundle. Finally, using a 2.7-mm or a 5-mm 30�

video-thoracoscope, a greater visual field may beobtained by just rotating the stem without chang-ing the relative position of the instruments [1–5].

The uniportal video-assisted thoracic surgery

for diagnosis

The uniportal VATS technique should be

considered as a potential procedure to obtaina pathologic diagnosis of lesions from virtually allintra-thoracic organs or tissues, as shown in recent

reports about diagnostic approaches for interstitiallung, pleural, and nodal diseases [1,2,6,7].

In 2004, Rocco and colleagues [6] published

their institutional experience on wedge lung biop-sies in 20 patients with suspected interstitial lungdisease. The uniportal procedure appeared safe

(neither mortality nor major morbidity) and effec-tive, inasmuch as it was possible to retrieve a me-dian of two wedge lung biopsies for each patientfrom one lobe or more, obtaining a pathologic

diagnosis for all cases. As described in anotherarticle from the same group [2], this procedurerequires a careful evaluation of the preoperative

CT findings. This allows one to select the specific

sted thoracic surgery procedures

Line Decubitus References

Posterior-median

axillary line

Lateral [3,6,11]

Median axillary line Lateral [2,4,6]

Posterior axillary–

scapular line

Lateral [1,2,4,9]

Median–posterior

axillary lane

Lateral [2,4]

Scapular line Lateral [5]

Posterior axillary line Supine [5]

Axillary hair line Lateral [7]

Axillary line Supine–

semilateral

[8]

307UNIPORTAL VATS

target area of the lung to be reached, and as a con-sequence, the most appropriate site for the singleskin incision.

An interesting development related to this

minimally invasive approach for diagnostic pur-poses may be that this operation can be performedat the bedside of the patient. This can be extremely

useful for planning the right therapeutic manage-ment in some intensive care unit patients with acuterespiratory distress syndrome of unknown origin

[2,6,8]. Furthermore, in selected patients, the op-portunity of offering a lung resection for diagnosticpurpose on an outpatient basis may be taken into

consideration with the purpose to optimize clinicalpathways. This could be made it easier with thisprocedure because of the minimal impact on thechest wall mechanics and the consequent reduced

negative influence on the postoperative pulmonaryresidual function, lowering the risk of postopera-tive respiratory complications [2,6].

Another main field of application of thistechnique is for mediastinal lymph node diagnosisand staging. In 2006, a multicentric study was

published that showed how this technique waseffective in achieving a pathologic diagnosis indifferent mediastinal node diseases [7]. The article

concluded that the uniportal approach may be su-perior in some circumstances to most traditionalapproaches used for this purpose. This is particu-larly true for patients previously operated on in

the mediastinum (complicated neck surgery, ster-notomy) or submitted to radiotherapy, in whomstandard surgical procedures such as mediastino-

scopy or anterior mediastinotomy may be imprac-tical or too risky. In these cases the uniportalVATS offers a wider surgical exposure and

increases the safety of the procedure. Moreover,the uniportal VATS allows the surgeon to easilyreach lymph node stations that are difficult tobiopsy with mediastinoscopy, such as the aorto-

pulmonary window, the paraesophageal, and thepulmonary ligament.

In lung cancer patients, the use of the uniportal

VATS for nodal sampling may be coupled witha more accurate staging of the T status, reducingthe risk of unnecessary exploratory thoracotomy.

In the above mentioned article [7], the investi-gators described 13 uniportal VATS proceduresfor diagnosis of mediastinal adenopathy. In all

cases, the surgical material was deemed sufficientfor pathologic examination and no conversionto open thoracotomy or mediastinoscopy wasneeded. No morbidity or mortality was observed

and the median postoperative stay was only 1 day.

These data suggest that this technique shouldbe rightly considered as a new tool in the surgicalarmamentarium for the diagnosis and staging ofmediastinal nodal disease and, in some circum-

stances, it could represent the first choiceapproach.

The operative uniportal video-assisted thoracic

surgery

The uniportal VATS has been proven safe andeffective for the treatment of numerous intratho-

racic diseases and since 2004 six articles have beenpublished about the use of this technique forcurative purposes [4,5,7,9–11].

The best evidence seems to be in favor ofperforming the uniportal VATS for the treatmentof primary spontaneous pneumothorax. Aftera first series of five patients presented in 2004

[6], Jutley and colleagues [9] published in anotherarticle the results obtained by comparing twogroups of subjects affected by spontaneous pneu-

mothorax and treated by uniportal (16 subjects)or three-portal (19 subjects) VATS. The investiga-tors showed that this procedure was safe (not

correlated with major cardiorespiratory complica-tions) and effective in preventing recurrences frompneumothorax. One of the most important find-

ings of this study was the one related to the occur-rence of postoperative neurologic symptoms.Despite the small sample size and the relativelyshort follow-up period, the study clearly showed

a lower incidence of chronic postoperative painand paraesthesia in the uniportal group whencompared with the three-port group. This benefi-

cial effect can be partly explained by the decreasedrisk of traumatizing the intercostal nerves byreducing the number of ports used and by using

smaller instruments without trocars.More recently, Salati and colleagues [4] cor-

roborated these conclusions by analyzing the clin-

ical and economic impact of this new approach inpatients with primary spontaneous pneumotho-rax, compared with the traditional three-porttechnique (Table 2). The investigators confirmed

the safety and effectiveness of the uniportalVATS approach, as well as the reduction of par-aesthesia, after a mean postoperative follow-up

period of 24 months (mean follow-up in theuniportal group, 13 months; mean follow-up inthe three-portal group, 39 months). At the same

time, this study demonstrated that the uniportalVATS yielded better results in terms of postoper-ative stay, hospital costs, and time to return to

Table 2

Differences between the uniportal and three-portal approach

Category Variables

Comparison between uniport and

threeport technique (p values)

Intraoperative variables Operation time 0.67

Operating room occupancy costs 0.67

Postoperative variables Postoperative stay 0.03

Recurrence rates 0.62

Prolonged air-leak 0.09

Recovery variables Pain 0.24

Paraesthesia !0.0001

Normal activity 0.069

Cost variables Surgical material costs 0.69

Postoperative stay costs 0.03

308 SALATI et al

complete physical activity after the operation.Most importantly, surgical costs were not in-creased because of the use of reusable materials

for all the procedures. Although the mean fol-low-up in the uniportal group was shorter thanin the three-portal group and these results need

to be interpreted with caution and confirmed byother studies, the recurrence rates were similar inthe two groups.

Curative resection of pulmonary lesions by theuniportal VATS is feasible, but the possibility oftreating lung diseases using this approach is

limited by two main factors: the lesion shouldbe easily reachable without palpating the lungand the disease should be radically treated by oneor multiple wedge resections. Taking into account

these considerations, Brunelli and colleagues [5]published a 2006 a case report describing bilat-eral staged uniportal VATS pulmonary resections

for synchronous early stage lung cancers ina patient with compromised respiratory function.The minimal invasiveness of this technique

proved a valuable option to treating lung cancerpatients with poor cardio-respiratory function,which could preclude more aggressive accesses.Interestingly, the investigators showed the mini-

mal changes of pulmonary function tests, inspira-tory and expiratory pressures, and VAS painscore before and after the two operations, which

confirmed the minimal impact of this procedureon chest wall mechanics and residual pulmonaryfunction.

In recent years, several articles were publishedshowing the efficacy of uniportal VATS to per-form an endoscopic sympathectomy for hyperhi-

drosis or facial blushing [10,12–18]. A review ofthese articles in the Multimedia Manual of Cardio-thoracic Surgery [10] presents in detail the

technical aspects and the key points in identifyingthe sympathetic chain, dividing the relevant gan-glia, and interrupting the aberrant accessory sym-

pathetic nerve fibers using the uniportal VATStechnique. Moreover, a comparison of clinical re-sults and complications between the uniportal and

the common three-portal approach is clearlyshown, supporting a wider use of the uniportaltechnique.

This technique has been reported also forperforming a pericardial window in five patientswith malignant pleuro-pericardial effusions [11].

The procedures had no morbidity nor mortalityand all patients were discharged home or trans-ferred to a chemotherapy unit the day aftersurgery. Moreover, no recurrences of pericardial

effusion were observed (median follow-up,7 months). The investigators emphasized theimportance of using a technique that allows per-

forming additional diagnostic procedures inpatients with metastatic cancer (nodal or pleuralbiopsies, lung resections, talc pleurodesis) creat-

ing, at the same time, a pericardial window.

Advantages and limitations of the uniportal

video-assisted thoracic surgery

Several studies have demonstrated that thetraditional three-portal VATS offers substantial

clinical and economic advantages when comparedwith thoracotomy [19–23]. In addition, the VATSapproach has been shown to cause a lower immu-

nologic stress and this may have a potential influ-ence on long-term survival when used for curativepurposes in oncologic patients [24–27].

The uniportal approach has the potential toconfirm and possibly further reduce the minimalimmunologic disturbances, compared with the

309UNIPORTAL VATS

three-portal VATS. Future studies are needed toinvestigate this issue. For the time being, thefirst published evidence underlines the favorableresults of this technique in terms of residual

postoperative neurologic symptoms, time torestore normal working and physical activities,and costs related to this procedure.

In this era of the managed care system, in whichclinical pathways of care are required for optimi-zation and resources need to be appropriately

allocated in a context of financial restraint, the useof this technique appears cost-effective and in linewith fast-tracking policies. Preliminary concerns of

increased surgical costs derived by the use of specificdisposable endoscopic roticulating instrumentswere not confirmed by most recent evidence [4],showing that surgical costs can be abated by the

use of reusable ad-hoc instrumentation.In addition, the reduction of postoperative

costs because of a shorter hospital stay and the

lower incidence of chronic paraesthesia [4,9], lead-ing to a faster return to normal daily life activities,contributes to cut the total economic burden on

the health care and social systems.In spite of these beneficial effects of uniportal

VATS, several issues still remain to be clarified

by future clinical and experimental evaluations.The role of this technique in radically treatingpatients with primary or secondary malignanciesof the chest requires further investigation. On

one side, the reduced immunologic depressionconsequent to its minimal aggressiveness can bea favorable factor in using this technique;

however, on the other side, to obtain a radicalresection with systematic lymph node dissectioncan be technically challenging to achieve from

one single port and with current instruments.The current interest toward sublobar resectionsfor stage I ground glass opacities or pulmonaryadenocarcinomas less than 1 cm may concentrate

the attention on the uniportal approach. As tosecondary lesions, concerns of radicality are thesame as with traditional VATS in cases of lung

metastasectomy because of the lack of a biman-ual palpation of the parenchyma. With respectto traditional VATS, uniportal VATS is even

more dependent on CT scan findings for select-ing the site of the single port, and exploration ofthe entire parenchyma, albeit technically possi-

ble, is at times cumbersome. The future de-velopment of methods for the intraoperativelocalization of small pulmonary nodules mayassist in implementing this approach in a larger

set of patients.

The learning curve depends on previousindividual and institutional experience withtraditional VATS. The impact of this techniqueon the surgical training of young residents needs

to be assessed, taking into consideration thatVATS exploration of the chest cavity througha single approach is often performed before both

open and VATS segmental or lobar resection. Inthis setting, traditional three-portal VATS, in-stead of thoracotomy, can function as the imme-

diate back-up option of uniportal VATS, thusenabling a smoother learning experience of VATSin its full range of applications. In addition,

uniportal VATS may be the preferential techniquefor peripheral lung resections to be used in theawake patient (see the article on awake operativeVATS pulmonary resections by Pompeo and

Mineo in this issue).

References

[1] Rocco G, Martin-Ucar A, Passera E. Uniportal

VATS wedge pulmonary resections. Ann Thorac

Surg 2004;77:726–8.

[2] Rocco G. VATS lung biopsy: the uniportal tech-

nique. Multimedia Manual of Cariothoracic Sur-

gery. Martigny (Switzerland): EACTS; 2005.

[3] Ng S, Rocco G, Yim A. Video-assisted thoraco-

scopic surgery (VATS) pleurodesis for pneumotho-

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Martigny (Switzerland): EACTS; 2005.

[4] Salati M, Brunelli A, Xiume F, et al. Uniportal

video-assisted thoracic surgery for primary sponta-

neous pneumothorax: clinical and economic analysis

in comparison to the traditional approach. Interact

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[5] Brunelli A, Xiume F, Refai M, et al. Bilateral staged

uniportal VATS for synchronous lung cancers.

Interact Cardiovasc Thorac Surg 2006;5:658–9.

[6] Rocco G, Khalil M, Jutley R. Uniportal video-assis-

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[7] Rocco G, Brunelli A, Jutley R, et al. Uniportal

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[8] Brunelli A. Invited commentary. Ann Thorac Surg

2006;82:267.

[9] Jutley RS, Khalil MW, Rocco G. Uniportal vs stan-

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and residual paraesthesia. Eur J Cardiothorac Surg

2005;28:43–6.

[10] Rocco G. Endoscopic VATS sympathectomy: the

uniportal technique. MMCTS; 2007. doi:10.1510/

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[11] RoccoG, La RoccaA, LaManna C, et al. Uniportal

video-assisted thoracoscopic surgery pericardial

window. J Thorac Cardiovasc Surg 2006;131:921–2.

[12] Yim AP, Liu HP, Lee TW, et al. ‘Needlescopic’

video-assisted thoracic surgery for palmar hy-

perhidrosis. Eur J Cardiothorac Surg 2000;17:

697–701.

[13] Lee DY, Yoon YH, Shin HK, et al. Needle thoracic

sympathectomy for essential hyperhidrosis: interme-

diate-term follow-up. Ann Thorac Surg 2000;69:

251–3.

[14] Yamamoto H, Kanehira A, Kawamura M, et al.

Needlescopic surgery for palmar hyperhidrosis.


[15] Goh P, Keat Cheah W, De Costa M, et al. Needle-

scopic thoracic sympathectomy: treatment for

palmar hyperhidrosis. Ann Thorac Surg 2000;70:

240–2.

[16] Lardinois D, Ris HB. Minimally invasive video-

endoscopic sympathectomy by use of a transaxillary

single port approach. Eur J Cardiothorac Surg 2002;

21:67–70.

[17] De Giacomo T, Rendina EA, Venuta F, et al. Thor-

acoscopic sympathectomy for symptomatic arterial

obstruction of the upper extremities. Ann Thorac

Surg 2002;74:885–8.

[18] Lin TS, Kuo SJ, Chou MC. Uniportal endoscopic

thoracic sympathectomy for treatment of palmar

and axillary hyperhidrosis: analysis of 2000 cases.

Neurosurgery 2002;51:84–7.

[19] Garzon JC, Ng CS, Sihoe AD, et al. Video-assisted

thoracic surgery pulmonary resection for lung can-

cer in patients with poor lung function. Ann Thorac

Surg 2006;81:1996–2003.

[20] Nagahiro I, AndouA,AoeM, et al. Pulmonary func-

tion, postoperative pain, and serum cytokine level

after lobectomy: a comparison of VATS and conven-

tional procedure. Ann Thorac Surg 2001;72:362–5.

[21] Yim AP. VATS major pulmonary resection revi-

siteddcontroversies, techniques, and results. Ann

Thorac Surg 2002;74:615–23.

[22] Hazelrigg SR, Nunchuck SK, Landreneau RJ, et al.

Cost analysis for thoracoscopy: thoracoscopic

wedge resection. Ann Thorac Surg 1993;56:633–5.

[23] Van Schil P. Cost analysis of video-assisted thoracic

surgery versus thoracotomy: critical review. Eur

Respir J 2003;22:735–8.

[24] Walker WS, Leaver HA. Immunologic and stress

responses following video-assisted thoracic surgery

and open pulmonary lobectomy. Thorac Surg Clin

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reduces cytokine responses compared with conven-

tional surgery. Ann Thorac Surg 2000;70:243–7.


Awake Operative VideothoracoscopicPulmonary Resections

Eugenio Pompeo, MD*, Tommaso C. Mineo, MDDepartment of Thoracic Surgery, Policlinico Tor Vergata University, V.le Oxford, 81, 00133 Rome, Italy

Historical steps

In the early nineteenth century, Sauerbruch [1]hypothesized that general anesthesia only couldavoid the fatal events triggered by a surgical pneu-

mothorax. Main concerns were related to thecollapse of the nondependent lung and the shiftof the mediastinum against the contralateral

lung, which was considered invariably fatal. Toavoid this adverse effect, various tricks andmethods have been attempted. The so-called

‘‘Mueller maneuver’’ entailed the surgeon graspingthe lung and making traction on the hilum duringthe operation to avoid shifting of the mediastinum[2].

Other ingenious but unreliable ideas includedSauerbruch’s negative-pressure operating cham-ber [3] and Brauer’s positive-pressure ventilating

chamber [4]. These methods were directed atkeeping the operated lung expanded during thora-cotomy through respectively creating a negative-

pressure environment within a closed operatingchamber, or maintaining a positive pressurewithin the airway through placing the patient’shead into a positive-pressure closed box [5].

Surprisingly enough, despite the enormousadvance in physiology knowledge of the modernera, this exquisitely empiric thought has accom-

panied the history of thoracic surgery up to now.One-lung ventilation through double-lumen

endobronchial intubation, introduced by Zavod

[6] in 1940 and refined by Bjork and Carlens [7] in1949 proved a revolutionary advance and is



(E. Pompeo).


doi:10.1016/j.thorsurg.2008.04.006

currently considered mandatory in open and vid-

eothoracoscopic operative procedures. However,general anesthesia and single-lung ventilationcan be associated with several adverse effects

that can increase the procedure-related mortalityand morbidity, particularly in patients who haveassociated comorbidities [8–10].

To avoid these adverse effects, the authorshypothesized that several simple videothoraco-scopic procedures could be performed using sole

thoracic epidural anesthesia in spontaneouslyventilating awake patients [10].

Recent reports on awake pulmonary resectionshave included videothoracoscopic resection of

undetermined pulmonary nodules [11], solitarylung metastases [12], and even anatomic resectionof non-small cell lung cancer (NSCLC) [13]. In

these early series, results have been encouraging,although awake videothoracoscopic pulmonaryresections must still be considered investigational,

because indications and many pathophysiologicaspects remain to be elucidated.

Physiopathology

One-lung ventilation under general anesthesiaassures an immobile operative field and allows forsafe and easy surgical manipulation of the lung.

However, with the patient in lateral decubitus, thecost of having the nondependent lung perfusedbut nonventilating is a net increase in the overall

rate of venous admixture from approximately10% to more than 27% [14]. This condition mayimpair oxygenation, particularly in patients whohave compromised respiratory function [15].

Other adverse effects deriving from use ofgeneral anesthesia with single-lung ventilation

ts reserved.




312 POMPEO & MINEO

are listed in Box 1 and include an increased riskfor pneumonia, an impaired cardiac performance[16], neuromuscular problems, and injury related

to mechanical ventilation, such as barotrauma,volutrauma, and atelectrauma [8], which hasshown to increase as occlusion time rises [17]. Fur-thermore, general anesthesia with instrumentation

of the airways can elicit bronchospasm and life-threatening complications. Most of these adverseeffects could be avoided using epidural anesthesia

in awake patients [18].Nonetheless, theoretic concerns arise from use

of sole thoracic epidural anesthesia in awake

patients. Firstly, the need to operate on a ventilat-ing lung may render the surgical procedure moretechnically demanding because of limited visuali-zation of the operative field, leading to higher

operative risks. These concerns are even increasedin patients who have compromised respiratoryfunction because of the risk for respiratory failure

induced by the epidural anesthesia–related motorblockade and increased bronchial tone and airwayhyperreactivity caused by sympathetic blockade.

Finally an open pneumothorax could lead tocompression of the dependent lung, eventuallyresulting in further deterioration of patient’s

functional compromise [18].

Box 1. Adverse effects of generalanesthesia with one-lung ventilation

Increased risk for pneumoniaImpaired cardiac performanceNeuromuscular impairment related to

sedation and muscle relaxantsPressure-induced lung injury

(barotrauma)Lung inflation-induced injury

(volutrauma)Lung injury caused by cyclic opening

and closing of small airways/lung units(atelectrauma)

Release of proinflammatory mediators(biotrauma)

Atelectasis in the dependent lungfavored by muscle paralysis

Atelectasis in the nondependent lungfavored by exclusion from ventilation

Bronchospasm and airway traumatismelicited by instrumental trachealintubation

The authors’ preliminary experience withawake video-assisted thoracoscopic surgery(VATS) suggests that most of these concerns are

unfounded, because in patients who have normalor nearly normal lung elastic recoil, the surgicalpneumothorax that follows insertion of the cam-era port leads to a nearly complete collapse of the

nondependent lung, allowing easy and safe surgi-cal maneuvering.

Additional difficulties can arise in patients who

have severe emphysema-associated lung hyperin-flation, in whom positive end-expiratory pressurein the airways can prevent a satisfactory lung

collapse despite the presence of atmosphericpressure in the pleural cavity.

Regarding perioperative oxygenation, simpleadministration of oxygen through a Venturi mask

prevents hypoxemia, whereas an acceptablehypercapnia develops only in patients who hassevere emphysema and particularly when opera-

tive time is prolonged because of pleural adhe-sions or more technically demanding procedures[19]. The authors’ findings seem to be supported

by the fact that, given an adequate flow of oxygenthrough patent airways, oxygenation can be main-tained for more than 40 minutes even in complete

apneic lungs (apneic oxygenation) [20].The pathophysiology of permissive hypercap-

nia development in awake thoracic surgery are notyet completely elucidated, although hypoventila-

tion caused by partial collapse of the operatedlung and a rebreathing effect seem reasonablehypotheses. However, perioperative raise in car-

bon dioxide is well tolerated by these patients andresolves more rapidly than in those who undergosurgery under general anesthesia.

The authors hypothesize that the bettersynchronization of rib cage–abdominal motion,which is immediately evident after awake thoracicsurgery procedures, might explain this feature.

The authors have also reasoned that satisfactoryrespiratory function may be sustained throughoutthe procedure through the maintained diaphrag-

matic motion, which might decrease the detrimen-tal effect of the abdominal pressure, leading theparalyzed diaphragm to compress the dependent

lung during general anesthesia [19,21].

Patient selection

All candidates suitable for videothoracoscopic

resection of a pulmonary nodule, who have nocontraindications for thoracic epidural anesthesia,are theoretically eligible for an awake approach.

Fig. 2. Subcentimetric solitary colorectal lung metasta-

sis of the posterior basal segment of the right lower

lobe, which is easily removed through the awake video-

thoracoscopic approach.

313AWAKE VATS PULMONARY RESECTIONS

However, this newly developed surgical modalityrequires extra attention to some particularaspects, including the absence of severe anxietyor depression and written patient consent for the

awake procedure after being informed that con-version to general anesthesia and thoracotomymay be required because of intraoperative

complications or other unexpected findings. Theproposed criteria for eligibility for awake pulmo-nary resection are as follows:

Radiologic evidence of newly discovered,peripheral, undetermined pulmonary nodule

!3 cm in maximal sizeNo previous thoracic surgery on the involved

hemithorax

No radiologic evidence of pleural adhesionswith pleural scarring or calcifications onthe involved hemithorax

Acceptance of awake VATS with writteninformed consent

No evidence of advanced interstitial lungdisease with restrictive ventilatory pattern

Arterial carbon dioxide tension less than55 mm Hg

No severe anxiety or depression

No coagulation disorders

The indications the authors propose for awake

pulmonary resection currently entail nonanatomicwedge resection of peripheral lung lesions, in-cluding undetermined pulmonary nodules (Fig. 1),

solitary pulmonary metastases (Fig. 2), and

Fig. 1. According to the radiologic classification

proposed by Suzuki and colleagues [28], this recently

developed undetermined left lower lobe lung nodule in

a patient who has severe chronic obstructive pulmonary

disease will prove to be a type 3 adenocarcinoma.

NSCLC in high-risk patients (Fig. 3). However,even anatomic resection, such as lobectomy and

pneumonectomy, have been performed in awakepatients in one recent series [13].

In patients who have undetermined pulmonary

nodules, the main criteria for resection includea positive positron emission tomography (PET)scan (Fig. 4) and the finding of a recently devel-oped lung nodule documented using sequential ra-

diographic controls, independent of the PET scan.

Fig. 3. Right lower lobe undetermined nodule highly

suggestive of lung cancer in a patient who has upper-

lobe predominant severe emphysema. Semiperipheral

nodules distant about 2 cm from visceral pleura can be

easily resected through the awake approach particularly

if lung density is reduced because of emphysematous

destruction.

Fig. 4. Fusion CT-PET image showing elevated fluoro-

deoxyglucose uptake of a peripheral 3-cm non-small cell

lung cancer lesion in an 83-year-old lady who underwent

successful awake pulmonary resection.

314 POMPEO & MINEO

In patients who have pulmonary metastases,eligibility criteria include complete control of theprimary tumor and absence of extrapulmonarymetastases, a newly discovered solitary pulmonary

nodule localized in the peripheral one third of thelung and measuring less than 3 cm at CT.Exclusion criteria include the presence of multiple

metastases and lesions located at more than 2 cmfrom the visceral pleura, radiologic evidence ofpleural scarring, or a history of previous thoracic

surgery on the side targeted for metastasectomy.Proposed inclusion criteria for patients who havelung cancer are as follows (satisfaction of the firstcondition is the main prerequisite, whereas at least

one other condition is necessary for eligibility):

Peripheral, stage I lung cancer less than 3 cm inmaximal size amenable of thoracoscopicwedge resection

Age O80 years

Severe emphysema documented at high-resolution CT

Forced expiratory volume in 1 second less than

40% predictedArterial oxygen tension less than 65 mm HgDiffusion capacity for carbon monoxide less

than 40% predictedExercise oxygen consumption less than 50%predicted

American Society of Anesthesiology (ASA)

score: 3

The main indication is represented by periph-eral stage I lesions in patients who have severeemphysema and impaired pulmonary function,

particularly when lobectomy is contraindicatedbecause the tumor is localized in the functionallybetter-preserved lung lobe [5].

Contraindications for thoracic epidural anes-thesia include unfavorable anatomy, previoussurgery of the cervical or upper thoracic spine,compromised coagulation with thromboplastin

time less than 80%, prothrombin time greaterthan 40 seconds or platelets less than 100/nL, andbleeding disorders [22].

Anesthesia

Thoracic epidural anesthesia is performed toachieve somatosensory and motor block from T1

to T8 level. The maximum permissible block levelis C6, which can be monitored through thedevelopment of Horner syndrome. One majorobjective is to achieve motor block of the

intercostal muscles while preserving diaphrag-matic motion. The thoracic epidural catheter isusually inserted at the T4 level after premedica-

tion with oral midazolam (7.5 mg).In the operating room, patients receive a con-

tinuous infusion of ropivacaine 0.5% and sufen-

tanil, 1.66 mg/mL, into the epidural space. Sensoryblock is achieved between the neck and theabdomen, including the arms. Sensory level

is tested every 5 minutes with warm–colddiscrimination.

During the procedure, a Venturi mask is used tokeep oxygen saturation greater than 90%. When-

ever patients indicate unsatisfactory somatosen-sory block, additive anesthesia can be performedthrough local injection of a 50% mixture of

ropivacaine (7.5%) and bupivacaine (2%).One possible complication is the occurrence of

a panic attack, which can be triggered by percep-

tion of some thoracic pain from unsatisfactoryefficacy of the epidural anesthesia, the occurrenceof fatigue and tachypnea from the increased

inspiratory effort induced by the atmosphericpressure in the opened pleural cavity, or thedevelopment of permissive hypercapnia in pa-tients who have chronic obstructive pulmonary

disease. In these instances, surgeons must reassurepatients about the causes of the increased venti-latory effort and can show their main vital

parameters, including oxygen saturation thatmostly remain within normal values and arecontinuously visualized in the anesthesiologist’s

monitor. Mild sedation with midazolam canbe useful to control the panic attack. If thediscomfort is not adequately controlled using


these measures, a deeper sedation with intrave-nous infusion of propofol while maintainingspontaneous breathing can allow the procedureto be completed without conversion to general

anesthesia and tracheal intubation.Whenever required, conversion to general

anesthesia and tracheal intubation can be rapidly

performed without changing the patient positionbut just rotating the table in a semisupine positionand taking care to insert the double-lumen tube

with the aid of a fiberoptic bronchoscope.During wound closure, the epidural anesthetic

regimen is changed to ropivacaine 0.16% and

sufentanil 1mg/mL at 2 to 5 mL/h for postopera-tive analgesia. All patients receive lactatedRinger’s solution at 12 mL Kg�1 h�1. The epidu-ral catheter is removed 24 hours after surgery.

Postoperatively, liquids infusion is stoppedimmediately and drinking, meal intake, andambulation can be started on the same day of

surgery.

Surgical technique

The procedure is performed with the patient

placed in lateral decubitus, and using a three-flexible-thoracoscopic-trocar access. Before per-forming the first trocar incision, a complete chest

drainage system should be prepared on the nursetable to allow immediate pleural drainage andsuture of trocar incisions, in case unexpectedproblems occur requiring interruption of the pro-

cedure and conversion to general anesthesia andsingle-lung ventilation.

Instrumentation for awake pulmonary resec-

tion does not differ from that routinely used fornonawake procedures. The authors usually usetwo-ring forceps for initial instrumental palpation

of the lung, and an endoscopic 35-mm or 45-mmstapler to accomplish the lung resection. Foradhesions, standard endoshears, endodissectors,

and 10-mm cotton swabs are used for sharp andblunt dissection.

To allow fine full-lung palpation for pulmo-nary metastases, the authors developed a new

mixed digital–instrumental palpation method.Identification of lung nodules is facilitated bythe partially deflated lung status induced by the

open pneumothorax, which reduces the averagelung tissue density, thus facilitating identificationof millimetric nodes. In this way, the entire lung

can be carefully explored and palpated betweenthe forefinger and the flat side of the modified ringforceps.

The nodules are excised through staple wedgeresection or precise lung excision (Fig. 5). Duringthe procedure, surgeons talk with the patients totest their overall wellness and the effectiveness of

the analgesia, while informing them about the on-going operation. Low-volume classical music isalso played in the operating room during the pro-

cedure to maximize patients comfort, because thisnonpharmacologic option was recently shown toperioperatively increase relaxation and reduce

anxiety and sedative requirements [23,24]. Theauthors also believe it important to reassure thepatient that although the induction of the surgical

pneumothorax may be associated with temporaryfatigue, oxygenation will not deteriorate and con-tinuous breathing at a normal rate can be easilyaccomplished.

During the operation, the anesthesiologist canalso invite the patient to follow the vital param-eters, including heart rate, arterial pressure, and

peripheral oxygen saturation, on the monitor.Some patients may also be allowed to follow theoperation on the operating video (Fig. 6). At the

completion of the procedure, a single 28F chesttube is inserted and connected to waterseal. Sub-sequently, while occluding the ports with their fin-

gers to aid immediate lung reexpansion, surgeonsask the patients to breathe deeply and coughrepeatedly. Finally, trocar incisions are suturedin a standard manner (Fig. 7).

Results

Resection of undetermined pulmonary nodules

In 2004, the authors reported results of a pro-spective study in which 60 patients who hadundetermined solitary pulmonary nodules were

randomized to undergo thoracoscopic wedge re-section using sole thoracic epidural anesthesia orgeneral anesthesia with double-lumen intubation

plus thoracic epidural anesthesia [11]. This studyassessed anesthesia time, operative time, globaloperating room time, patient satisfaction withthe anesthesia, technical feasibility, nursing care

need, 24-hour changes in arterial oxygenation(DPaO2), and hospital stay. No difference wasfound between the groups in technical feasibility,

although two patients in the awake group re-quired conversion to thoracotomy because ofsevere adhesions. Another two patients in each

group required conversion because of unexpectedlung cancer requiring lobectomy. Comparisons ofawake- versus general anesthesia–group results

Fig. 5. An awake patient who has chronic obstructive pulmonary disease is undergoing the wedge resection of a non-

small cell lung cancer (A). Intraoperative view showing the completion of the pulmonary resection with the ventilating

lung (B). Surgical specimen after resection (C).

Fig. 6. This awake patient is following his ongoing

operation in the operative monitor.

Fig. 7. Immediately after closure of the trocars incision,

this awake patient, still lying in lateral decubitus, can

comfortably ventilate without oxygen mask.

316 POMPEO & MINEO


showed that anesthesia satisfaction score, DPaO2

(�3 versus �6.5 mm Hg; P ¼ .002), nursing carecalls (2.5 calls per day versus 4 calls per day;P ¼ .0001), and median hospital stay (2 versus

3 days; P ¼ .02) were better in the awake group.After awake thoracoscopic resection of lung

nodules, arterial oxygenation worsened during

the first postoperative day, but this impairmentwas greater in patients who underwent surgeryunder general anesthesia. The authors hypothe-

size that operating under epidural anesthesiawith spontaneous breathing avoided generalanesthesia- and single-lung ventilation–related

adverse effects, resulting in a more physiologicpostoperative lung reexpansion and a fasterrecovery. In fact, avoidance of general anesthesiaallowed immediate resumption of many daily life

activities, including drinking, eating, andwalking. These advantages eventually resultedin short hospitalizations, with 50% of the

patients being discharged within the secondpostoperative day.

Among differences in general anesthesia sur-

gery, an important one relates to active patientparticipation to the surgical procedure. Psycho-logic inferences of this novel policy must still be

elucidated, although the authors hypothesize thatit might help reassure patients about the realeffectiveness and limited physiologic impact of theongoing operation.

Pulmonary metastasectomy

Videothoracoscopic pulmonary metastasec-tomy is accepted in the presence of single periph-

eral lung lesions [25], although the accuracy ofdigital and instrumental lung palpation with theclosed chest has been questioned [26]. Therefore,

the authors developed the transxiphoid approach,which allows bimanual lung palpation duringthoracoscopic surgery [27]. More recently [12],

they analyzed the results of an awake videothora-coscopic approach, including a new method ofdigital-instrumental palpation that allowedbimanual-like palpation of the lung.

In 14 operated patients, lung metastases werepresumed because of recently developed lungnodules with radiologic characteristics compatible

with metastatic lesions, which were discovered atchest roentgenogram or CT during oncologicfollow-up. After the lung lesions were discovered,

all patients underwent further examination toexclude primary or extrapulmonary recurrence.The lung lesions were also restaged immediately

before planned surgery using a helical chest CTscan.

Overall, the procedure was easily and safelyaccomplished under sole thoracic epidural anes-

thesia; no mortality or major morbidity occurred.Awake pulmonary metastasectomy resulted inoptimal patient acceptance and satisfaction, as

shown by the high anesthesia satisfaction score,which was rated as excellent to good in 12 patients,or 86% of the whole series.

Total operating room time and hospital staywere significantly shorter than those of a controlgroup who underwent surgery under general

anesthesia, whereas oncologic results and sur-vivals were comparable.

The rapidity of the procedure together withthe significantly reduced anesthesia time and lack

of weaning time improved patient turnoverin the operating theater, and offered the doubleadvantage of less risk for patients and less cost

for the institution within its new fast-trackpolicy.

In the authors’ series, nodules as small as 5 mm

were identified with this lung palpation method,and the low rate of ipsilateral lung recurrencesuggests that it was as effective as bimanual

palpation in detecting all palpable lesions. Fur-thermore, despite the use of helical CT scan, whichis currently the most accurate tool in detectingmetastases, direct lung palpation allowed the

authors to discover some radiologically undetectedlesions in the selected cohort, a finding that is inline with previous data [28].

Resection of non-small cell lung cancer

Resection of NSCLC represents the last chal-

lenge and probably the most provocative indica-tion for awake thoracoscopic surgery. Even openanatomic lung resections, including two pneumo-

nectomies, have been performed in 11 patientsthrough an awake approach in a recent series[13].

However, this field must still be considered

widely investigational, and several concerns existwith using awake thoracoscopic resection inoncologic patients. The authors also started to

perform thoracoscopic nonanatomic resection ofperipheral NSCLC in strictly selected patientswho were deemed at high-risk for both anatomic

resection and even sole general anesthesia (Fig. 8).Initial results have been encouraging, and no mor-tality or major morbidity and satisfactory 2-year

Fig. 8. Coronal CT-image showing a 20-mm non-small cell lung cancer lesion of the left lower lobe superior segment,

involving the parietal pleura in an 81–year-old patient who has chronic obstructive pulmonary disease (A) who under-

went successful awake pulmonary resection (B).

318 POMPEO & MINEO

results were seen in the first eight patients whounderwent surgery (Table 1).

A further indication might be considered

the resection of peripheral tumors alreadytreated with nonsurgical local therapies, such aspercutaneous radiofrequency ablation [29] or

stereotactic radioablation [30] in medically inoper-able patients who have early-stage lesions.

Summary

The authors’ initial experience with awakevideothoracoscopic lung resection suggests that

these procedures can be easily and safely per-formed under sole thoracic epidural anesthesiawith no mortality and negligible morbidity

[11,12]. One major concern was that operating ona ventilating lung would render surgical maneuversmore difficult because of the lung movements and

lack of a sufficient operating space. Instead, theopen pneumothorax created after trocar insertionproduces a satisfactory lung collapse that does

not hamper surgical maneuvers.These results contradict the accepted assump-

tion that the main prerequisite for allowingsuccessful thoracoscopic lung surgery is general

anesthesia with one-lung ventilation. No particu-lar training is necessary to accomplish an awakepulmonary resection for teams experienced in

thoracoscopic surgery, and conversions to generalanesthesia are mainly caused by the presence ofextensive fibrous pleural adhesions or the de-

velopment of intractable panic attacks. Overall,awake pulmonary resection is easily accepted andwell tolerated by patients, as confirmed by the

high anesthesia satisfaction score, which wasbetter than in nonawake control patients. None-theless, thoracic epidural anesthesia has potential

complications, including epidural hematoma, spi-nal cord injury, and phrenic nerve palsy caused byinadvertently high anesthetic level [12], but these

never occurred in the authors’ experience.Further concerns relate to patient participa-

tion in operating room conversations or risk for

development of perioperative panic attacks.However, the authors have found that reassuringthe patient during the procedure, explainingstep-by-step what is being performed, and even

showing the ongoing procedure on the operatingvideo can greatly improve the perioperativewellness and expectations of patients, particularly

if the procedure is performed for oncologicdiseases.

Panic attacks occurred in few patients and

could be usually managed through moderatelyincreasing the depth of sedation while maintainingspontaneous breathing. Finally, as long as thephysiologic impact of awake metastasectomy is

definitively elucidated, the authors believe thismodality should be used for unilateral procedures,while deserving a staged bilateral approach for

bilateral lung metastasectomy [12].Avoidance of general anesthesia results in

a faster recovery with immediate return to many

daily life activities, including drinking, eating, andwalking, and a reduction in hospital stay andprocedure-related costs.

If confirmed with future studies, these resultscould advocate earlier resection of peripheralsolitary pulmonary nodules, reducing the risk for

Table

1

Resultsofawakenon-smallcelllungcancerresectionin

eightpatients

Age/Gender

Site

Size(m

m)

Pleural

invasion

FEV1(%

predicted)

DCO

(%

predicted)

Comorbidity

Histology

Outcome(m

o)

77/M

ale

LUL

20

Yes

32

50

COPD

Diabetes

ADC

Alive(56)

83/Fem

ale

RUL

30

Yes

42

63

COPD

ADC

Dead(30)

78/M

ale

ML

15

No

38

45

COPD

Chronic

renalfailure

ADC

Alive(52)

80/M

ale

RUL

26

Yes

26

38

COPD

Squamous

Alive(49)

76/Fem

ale

LLL

23

No

35

28

COPD

ADC

Dead(45)

76/M

ale

RUL

17

No

62

37

Chronic

cardiacfailure

Largecell

Alive(45)

79/M

ale

RUL

15

No

40

45

COPD

ADC

Dead(24)

81/M

ale

LLL

20

Yes

28

66

COPD

ADC

Alive(43)

Abbreviations:ADC,adenocarcinoma;COPD,chronicobstructivepulm

onary

disease;DCO,diffusingcapacity

forcarbonmonoxide;FEV1,forced

expiratory

volumein

1second;LLL,left

lower

lobe;

LUL,left

upper

lobe;

LVEF,leftventricularejectionfraction;ML,medium

lobe;

RLL,rightlower

lobe;

RUL,rightupper

lobe.


delaying a diagnosis of unexpected pulmonarymalignancy. Furthermore, potential new frontiersof awake thoracoscopic surgery might includeassessment of feasibility and safety of anatomic

resections in properly selected instances.Ethical and economical concerns push

remorselessly for less frequent and less-invasive

surgery. Administrators advocate minimal hospi-talization and cost-saving treatments, whereaspatients ultimately ask for appropriate health

care.Thoracic surgeons of the third millennium

must accept the challenge of this dynamic and

rapidly evolving scenario without loosing the rightroot, which probably lays just between well-established conventional surgery techniques andnewly available advanced technology tools.

Awake thoracic surgery will benefit fromevidence-based data that are progressively accu-mulating. Findings will stimulate experts to con-

tinue an active clinical investigation in thisunpredictably evolving surgical field, which mightultimately lead to a better understanding of

cardiorespiratory physiology and effects of thesurgical pneumothorax and thoracic epiduralanesthesia on perioperative, respiratory function

in awake patients.As the Italian architect Renzo Piano recently

stated, ‘‘Recovering in the past can be reassuringbut the future is the only place where we can go.’’

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bieten der Medizin und Chirurgie 1904;13:399–482

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folgen mit hilfe des ueberdruckverfahrens. Mittei-

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Chirurgie 1904;13:483–500 [in Italian].

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tion. Chest Surg Clin N Am 2000;10(1):9–43.

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2004;78:1761–8.

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[26] Mineo TC, Pompeo E, Ambrogi V, et al. Transxi-

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Outpatient Thoracic SurgeryLaureano Molins, MD, PhDa,*, Juan J. Fibla, MD, PhDa,

Jose M. Mier, MDa, Ana Sierra, MDb

aThoracic Surgery Department, Sagrat Cor University Hospital, Viladomat 288, E-08029 Barcelona, SpainbAnaesthesiology Department, Sagrat Cor University Hospital, Viladomat 288, E-08029 Barcelona, Spain

Outpatient surgery includes the surgical pro-

cedures performedunder general, regional, sedationor local anesthesia, requiring neither intensive post-operative care nor overnight stay because the

patient is discharged a few hours after the pro-cedure. According to the International Associationfor Ambulatory Surgery, the procedure should not

be urgent, should be performed within a normalworking day, and should not exceed a duration of12 hours, including postsurgical recovery.

From the different alternatives to conventional

hospitalization developed in the last decades,outpatient surgery (also called ‘‘day surgery’’ or‘‘major ambulatory surgery’’) has been the one

experiencing the greatest growth. However, onlya few studies have been reported on thoracicsurgery since the first publication of Vallieres

and colleagues [1], concerning ambulatory media-stinoscopy, in 1991. In Spain, despite the fact thatthere are currently 139 ambulatory surgery cen-ters, only three thoracic surgery services have

communicated their experience in this field [2–6].The reduced referrals to outpatient thoracic

surgery in ambulatory surgical programs without

hospital admission can be attributed to a numberof reasons. From a strictly clinical standpoint, thepotential for anatomic complexity, prolonged

postoperative recovery, severe complications, sig-nificant postsurgical pain, and the need in manycases of a negative-pressure thoracic drainage,

indicate a formal hospital admission. Nonclinicalreasons include a lesser number of patients in thesurgical waiting list with respect to the other


E-mail address: [email protected] (L. Molins).


doi:10.1016/j.thorsurg.2008.04.003

specialties, the lack of incentives to sustain

a greater medical-legal responsibility, and a lowpatient demand because of the paucity of infor-mation that is generally provided to them. In fact,

Molnar and colleagues [7] state that if the legaland judicial system is strongly patient-oriented,even a minor out-of-hospital postoperative com-

plication could lead to a verdict of professionalnegligence.

Ambulatory surgery requires its own qualityindicators. Some advocate that the substitution

index and the unplanned admission index couldbe reliable and user-friendly indicators of thequality of care in ambulatory surgery units [8,9].

A difference could be established between earlyadmissions (not discharged patients) and late ad-missions (readmitted patients), and both seem to

be good indicators of stable quality of care in out-patient surgery. The substitution index (SI) is de-fined as the ratio of the number of outpatients tothe total number of procedures, and expressed as

a percentage. The admission rate (AR) is definedas the ratio of the number of unplanned admis-sions (because of any clinical or social reason) to

the total number of outpatient procedures, alsoexpressed as a percentage. The readmission rate(RR) is defined as the ratiodexpressed as a per-

centagedof the number of unplanned admissionsafter discharge (because of any clinical or socialreason related to the surgery performed) from

the total number of outpatient procedures.

Outpatient thoracic surgical program

The success of outpatient surgical programsrequires the receptiveness of all involved pro-

fessionalsdsurgeons, anesthesiologists, nursing,

ts reserved.




322 MOLINS et al

and administrative staffdand it requires furtherthat this receptiveness is transmitted to thepatients who are going to be included in the

program. To achieve good results, it is importantthat the outpatient thoracic surgical program(OTSP) is integrated into an already-functioningoutpatient surgical unit.

According to the authors’ experience [5], thesurgical risk for each patient must be evaluatedaccording to the classification of the American So-

ciety of Anesthesiologists (ASA). As a rule, ASA Iand ASA II patients with no age limitation are ac-cepted, but select ASA III patients can also be in-

cluded. The assistance by a family member orfriend is encouraged not only on the day and thenight of the operation, but also for the following24 hours. Specific inclusion criteria for lung

biopsy were ambulatory patients, absence of con-tinuous oxygen dependency, and pulmonaryfunction tests with forced expiratory volume in

the first second of expiration (FEV1) and carbonmonoxide diffusing capacity (DLCO) greaterthan 30%. An informed consent signed by the sur-

geon, anesthesiologist, and patient must be neces-sary to be scheduled for surgery. Patients areusually admitted to the dedicated day-surgery

unit 1 to 2 hours prior the procedure. Oral diaze-pam (5 mg–10 mg) is given for preoperative seda-tion and surgery is performed on the morning orearly afternoon operative list. The procedures

are usually performed under general anesthesia,but recently procedures were successfully per-formed on awake patients under local or epidural

anesthesia [10,11]. Al-Abdullatief and colleagues[11] reported 26 outpatients operated on underawake anesthesia out of 79 major surgical proce-

dures (33%).The authors consider anesthetic management

as crucial for the success of an outpatientthoracic surgical program. The objective is

a quick awakening and recovery, so thatpatients can be discharged a few hours afterthe intervention without pain or with moderate

pain that does not cause discomfort or anxietyat home. To this purpose, a combination ofanesthetic drugs is required, such as inhalation

agents (sevoflurane, nitrous oxide), intravenousanesthetic drugs (propofol), short-acting opioids(alfentanil, remifentanil), and short-acting re-

laxants (atracurium, succinylcholine). After sur-gery, the patient is observed in the recoveringroom for 20 to 40 minutes and transferredback to the short-stay facility. Later, postoper-

ative analgesia will be administered, taking care

at avoiding mepedirine and morphine, as theyslow down total conscience recovery greatly.The patient stays a few hours in the day

surgery unit until the criteria for discharge aremet. These criteria include stable vital signs,ambulation at preoperative level, minimal post-operative nausea and vomiting or pain, and

ability to tolerate oral fluids and void beforedismissal. The patient is discharged home onoral analgesics (mostly nonsteroidal anti-inflam-

matory drugs or NSAIDs) and prophylaxisagainst NSAID-induced gastric ulcers. Postop-erative chest X-rays are reviewed by a member

of the operating team, but the patient’s fitnessfor discharge is assessed after 4 to 6 hourspostoperatively, primarily by nursing staff. Pa-tients have a dedicated telephone number that

they can use in case of need; they are contactedin the morning following surgery and ques-tioned on their postoperative course [5].

After having logistically structured the tho-racic surgery program, the authors defined theeligible surgical procedures based on the scanty

experience published in the literature and on thecriteria previously used to select single-day ad-mission into hospital. In April 2001, the authors

started with outpatient mediastinoscopy, bilateralthoracic sympathectomy, and videothoracoscopiclung biopsy [5]. The inclusion of lung biopsy inambulatory surgery was possible because of the

implementation of the authors’ early chest drainremoval policy [12].

The authors’ experience, from April 2001 to

September 2007, showed the following results outof a total of 634 operations performed during thatperiod, with 480 patients who were operated on

as part of the outpatient thoracic surgical pro-gram (SI ¼ 75.7%). The mean age was 55.8 years(range, 15 to 85 years). The female-to-male ratioin the 480 patients was 154 to 326 (32.1% to

67.9%). There was no mortality. Concerning the154 patients not included in the OTSP, 108(70.3%) were operated on in an ‘‘afternoon

surgical program’’ and dismissed the morningafter surgery. Twenty-three patients were fromout of town and two had already been admitted to

hospital. None of the 133 patients (108 þ 23 þ 2)had any objective contraindication for ambula-tory surgery and therefore, excluding these pa-

tients without formal contraindication for OTSP,the ‘‘real’’ substitution index could have been95.8% (480 out of 501). Seven patients wereadmitted (AR ¼ 1.4%) and four patients read-

mitted after being discharged (RR ¼ 0.83%).

Table 1

Outpatient mediastinoscopy

Author N SI AR RR

Valleries et al [1] 158 21%

Bonadies et al [13] 65 54% 1,5% 4%

Cybulsky and Bennett [14] 1,015 96% 9,8% 0,9%

Souilamas et al [16] 20 40% 0% 2,5%

Molins et al, 2007

(present series)

297 83,4% 1,3% 0%

323OUTPATIENT THORACIC SURGERY

Outpatient mediastinoscopy

Mediastinoscopy as a method to stage bron-chogenic carcinoma was the first published in-dication of ambulatory surgery applied to

thoracic surgery, and today it is the one mostoften used [1]. The feasibility of outpatient media-stinoscopy has been proven by several studies with

a good degree of success [1,5,13–16], but it is stillwidely performed in an inpatient setting.

In their publication, Vallieres and colleagues

[1] described outpatient mediastinoscopy in 158patients (SI ¼ 21% over a 9-year period). Bona-dies and colleagues [13] reported 65 ambulatory

patients with a substitution index of 54% and anadmission and readmission rate of 1.5% and 4%respectively. Cybulsky and Bennett [14] report1,015 ambulatory mediastinoscopies, representing

96% of their total mediastinoscopy population,with 10 patients admitted (AR ¼ 9.8%) and onereadmission (RR ¼ 0.9%). Souilamas and col-

leagues [16] describe 20 video-mediastinoscopiesperformed on an outpatient basis (SI ¼ 40%);one patient required readmission because of pneu-

monia (RR ¼ 2.5%).In the authors’ experience, mediastinoscopy

was performed as outpatient procedure in 297

patients out of a total 356 mediastinoscopy (SI ¼83.4%), including five ‘‘extended’’ ones. The meanage was 64.7 years (range 25–85 years). Fourpatients were admitted (AR ¼ 1.3%) for obser-

vation of a minimal pneumothorax (the secondextended cervical mediastinoscopy), late durationof the operation, urinary retention, and an intra-

operative hemorrhage that required a sternotomyto control. There were no readmissions afteroutpatient mediastinoscopy (RR ¼ 0%). One

patient presented a subcutaneous infection. Ofthe 59 inpatient mediastinoscopies, 56 had noobjective contraindication for ambulatory sur-gery: 46 were scheduled in an ‘‘afternoon surgical

program,’’ 8 patients were from out of town, and2 had already been admitted. Therefore, excludingthese patients without formal contraindication for

OTSP, the ‘‘real’’ substitution index could havebeen 99% (297 out of 300) (Table 1).

Outpatient thoracic sympathectomy

In recent years thoracoscopic sympathectomy(TS) has become the most widely used approach

in the management of primary hyperhidrosis andfacial blushing [17]. Although the procedure isusually performed in young, otherwise healthy

patients, in the previous years, most of themended up staying one night because of pain, nau-sea, or vomiting. The key to including these pa-tients in the outpatient program is the anesthetic

technique and premedication with antiemeticagents and analgesia, including intercostal infiltra-tion with local anesthetic [18,19]. In recent years,

some investigators concluded that TS is a safeand effective outpatient procedure [10,18–24].

Grabham and colleagues [20] first reported

their experience with 20 day-cases of transthoracicunilateral endoscopic sympathectomies. Eighteenwere completed as a day case (AR ¼ 10%). In

two different articles, Hsia and colleagues [21] re-ported 47 patients with palmar hyperhidrosis and262 with axillary hyperhidrosis [22] operated onby outpatient thoracoscopic bilateral sympathec-

tomy. All operations were performed at an outpa-tient facility (AR ¼ 0%). Doolabh and colleagues[23] scheduled 180 patients to undergo video-

assisted TS on an outpatient basis. Of these, 177patients were completed as an outpatient proce-dure (AR ¼ 1.7%). More recently, Baumgartner

and Toh reported an admission rate of 0.3%and a readmission rate of 1.2% in a series of309 consecutive outpatient sympathectomies [24].

In the authors’ series, 117 patients were in-

cluded in the OTSP for bilateral thoracic sympa-thectomy out of a total 164 TS (SI ¼ 71.3%). Themean age was 26.8 years (range 15–57 years). The

procedure was performed with selective bronchialintubation and the patient placed in semi-Fowler’sposition. A uniportal operating 10-mm 0� thora-coscope was then introduced to divide the sym-pathetic trunk with a diathermy hook at thedesired level. Since 2007, following other investi-

gators’ good results with clipping of the sympa-thetic chain [25] and trying to preserve its integrityfor a possible reversibility of the procedure, theauthors have used the clipping technique. The

small-bore tubes were removed at the same surgi-cal theater or in the recovering room. Local anes-thetic (0.5% bupivacaine with adrenaline, or 0.2%

324 MOLINS et al

ropivacaine) was used to infiltrate the intercostalspaces. In all patients, routine chest X-rays wereperformed before discharge and reviewed by a sur-

geon. One patient was admitted, as an axillarythoracotomy was needed because of adhesions(AR ¼ 0.85%). Two patients were readmitted af-ter 9 and 3 days because of a hemothorax and

a pneumothorax respectively (RR ¼ 1.7%), bothsuccessfully resolved by chest tube thoracostomy.One patient presented a subcutaneous emphysema

without need of admission. Forty-three out of 47patients not included in the OTSP had no objec-tive contraindication for ambulatory surgery: 36

were scheduled in an ‘‘afternoon surgical pro-gram’’ and 7 patients were from out of town. Ofthe remaining 4 patients out of the 47 not includedin the OTSP, 3 of them were redo sympathecto-

mies and another was operated in the course ofa pectus excavatum repair, all considered as con-traindications for OTSP. Therefore, excluding

these four patients with formal contraindicationfor OTSP, the ‘‘real’’ substitution index couldhave been 96.7% (117 out of 121) (Table 2).

Recently, Elia and colleagues [10] reported tho-racic sympathectomy under local anesthesia (LA)and spontaneous breathing in 15 patients and com-

pared this group to 30 patients undergoing TS un-der general anesthesia (GA). The operating roomtime was 63.55 minutes versus 86.05 minutes forLA and GA patients, respectively. All awake pa-

tients were discharged the same day, while themean hospital stay of the GA patients was 1.38plus or minus 0.6 days. The quality of life was sim-

ilar in both groups and the overall rate of patientsatisfaction was greater in the awake group [10].

Outpatient lung biopsy

Videothoracoscopic lung biopsy (VATS-LB)has become an increasingly accepted approach forthe diagnosis of patients with both diffuse

Table 2

Outpatient thoracic sympathectomy

Author N SI AR RR

Grabham et al [20] 20 10%

Hsia et al [21] 47 0%

Baumgartner

and Toh [24]

309 0.3% 1.2%

Hsia et al [22] 262 0%

Doolabh et al [23] 180 1.7%

Molins et al 2007

(present series)

117 71,3% 0,85% 1,7%

interstitial lung disease [26,27] and pulmonarynodules [28] but, to date, very little has been pub-lished on outpatient lung biopsy [5,29,30].

In general practice, after a videothoracoscopiclung biopsy, the ‘‘need’’ for a postoperative chestdrainage is still the reason that hinders patientsfrom being discharged home. Russo and col-

leagues [31], in a prospective, nonrandomizedtrial, demonstrated that chest tube removal within90 minutes of VATS lung biopsy in selected pa-

tients could be accomplished safely. More re-cently, Luckraz and colleagues [32] conducteda prospective randomized controlled trial to assess

the need for intercostal chest drainage afterVATS-LB, concluding that there is no need foran intercostal chest drain in patients undergoingVATS-LB if no air leak is identified at the time

of surgery, raising the possibility of this procedurebeing performed in an outpatient setting [32].

Blewett and colleagues [29] did not use chest-

tube drainage after open lung biopsy for diagnosisof interstitial lung disease in 32 patients who un-derwent outpatient open lung biopsy; no compli-

cations occurred and no patients requiredovernight observation or hospital admission.Chang and colleagues [30] reported a series of 62

patients undergoing outpatient thoracoscopiclung biopsy; 72.5% were discharged home within8 hours of observation on the day of operationand one patient was readmitted for pneumothorax

(RR ¼ 1.6%). They concluded that outpatientthoracoscopic lung biopsy is safe and effectivefor diagnosis of either interstitial or focal lung dis-

ease [30]. The less invasive uniportal VATS lungbiopsy reported by Rocco and colleagues [33]could help to include more patients as an outpa-

tient procedure.The authors included 66 ambulatory patients

for lung biopsy out of a total 114 LB performedduring the same period (SI ¼ 57.9%). The mean

age was 62.5 years (range 33–81 years). Theprocedure was performed with double-lumenendotracheal tube or by selective bronchial in-

tubation using a single lumen tube. With thepatient in the lateral decubitus position, threeport sites were used and one or two stapled wedge

resections were performed. Local anesthetic (0.5%bupivacaine with adrenaline, or 0.2% ropiva-caine) was systematically infiltrated into the inter-

costal spaces. The chest drain was removed in therecovering room if no air leak or bleeding waspresent. In all patients, routine chest X-rayswere performed before discharge and reviewed

by a surgeon. Two patients were admitted because


of air leak observed after surgery (AR ¼ 3%) andrequired the chest tube during 1 and 6 days, re-spectively. Two patients were readmitted becauseof pneumothorax (RR ¼ 3%), only one requiring

drainage. Thirty-four out of 48 patients not in-cluded in the OTSP had no objective contra-indication for ambulatory surgery: 26 were

scheduled in an ‘‘afternoon surgical program’’and 8 patients were from out of town; 13 patientshad formal contraindication because of FEV1 or

DLCO less than 30%, and one because of a bilat-eral procedure. Therefore, excluding the patientswithout formal contraindication for OTSP, the

‘‘real’’ substitution index could have been 82.5%(66 out of 80).

Table 3 shows the experience on outpatientvideothoracoscopic lung biopsy in the main series

published.

Economic impact

Increasing the percentage of operations done

as outpatient surgery should save money to thehealth care system and allow us to care for morepatients with the same amount of resources. The

impact of the economic benefit depends on theprevious policy on hospital stay for the sameprocedures performed by conventionalhospitalization.

In the authors’ previous experience, the eco-nomic impact was applied to the reduction invariable hospital costs (bed, meals, energy, laun-

dry, and so on) over conventional hospitalization,as fixed hospital costs (personnel, and so on)remain unchanged. The authors calculated the

hospital total and per patient saving, as well asthat in other Spanish hospitals with similaractivity level, applying their median hospital

stay. The net saving in Sagrat Cor Hospital forthe first 300 outpatient thoracic surgical pro-cedures over conventional hospitalization (1 day)was 12,668 V, or 42.20 V per patient. Applying

the median hospital stay from other Spanishhospitals with similar activity level (4 days), the

Table 3

Outpatient lung biopsy

Author N SI AR RR

Blewett et al [29] 32 0%

Chang et al [30] 62 27.5% 1,6%

Molins et al 2007

(present series)

66 57,9% 3% 3%

hospital’s saving was 88,226 V or 294.10 V perpatient [5]. Recently, the authors have calculatedthe median cost of the outpatient VATS-LB tobe 1,257.78 V. The median cost with one day of

hospitalizationdwhich was the authors’ previousmedian staydwas 1,743.88 V, with a median sav-ing per outpatient procedure of 486.10 V. Apply-

ing the median hospital’s stay in other Spanishhospitals with similar activity level (2 days), thesaving per outpatient procedure could rise to al-

most 1,000 V. This calculation of the economicimpact does not include the real fact of includingadmission into hospital of a patient in the place of

the one being dealt with by means of ambulatorysurgery. This would indeed increase the real bene-fit of the outpatient surgical program.

Comments

Because of the underlying pathology of thepatients, the authors’ think that it will be difficultto improve the lung biopsy substitution index, but

the mediastinoscopy and thoracic sympathectomysubstitution indices could rise to nearly 99%. Inthe authors’ program, 108 out of 154 patients not

included in the OTSP (70.1%) were operated on inan ‘‘afternoon surgical program’’ and dismissedthe morning after surgery with no objective

contraindication for ambulatory surgery. Today,these patients are operated on early in theafternoon program and discharged the sameevening, so the SI will increase.

It is important for outpatient thoracic surgeryto be integrated into an already-working out-patient surgery unit to obtain good results. The

voluntary acceptance on the part of the patient,with a good capacity to understand the procedure,family support, and a telephonicdand later,

a personaldfollow-up are indeed necessary tominimize the risk of any possible complicationsthat could go unnoticed.

Despite a significant increase in ambulatorysurgery activity, there is still great potential for anincrease in outpatient thoracic surgery. Once theoutpatient thoracic surgery program has been

established, with thoracic drainage being thereason on which the decision hinges as to whethera patient can be discharged home or not, its

indications can be extended as soon as the pro-tocol for the early removal of drainages is applied.The use of a Heimlich valve [34] or other portable

chest tube systems [35] can even reduce the admis-sion index because of air leak. The diagnosis ofpleural effusion, the management of located

326 MOLINS et al

pleural and mediastinal diseases, the staging oflung and esophagus cancer, and the resection ofsolitary pulmonary nodules will gradually be in-

corporated into the indications currently laiddown, namely sympathectomy, mediastinoscopy,and videothoracoscopic lung biopsy. The resec-tion of peripheral solitary pulmonary nodules is

also included now in the authors’ outpatient tho-racic surgical program, with still scanty experienceto be presented here. In fact, the procedure is sim-

ilar to that of the videothoracoscopic lung biopsy,and the patient is usually in better respiratory con-dition, so a very good outcome is anticipated. The

problem of including these patients in the outpa-tient program is if the frozen section pathology re-port forces a surgeon to do something ‘‘more’’than the simple nodule resection. Tovar [36,37],

from the University of California, Irvine, has pub-lished a number of articles showing that it is pos-sible to contemplate ambulatory surgery even in

pulmonary resections. Although this is nota race toward a diminished stay, there is no doubtthat, if the thoracic surgeon has in mind the ben-

efits of outpatient thoracic surgery, it will extendits indications gradually.

Summary

In summary, from the different alternatives toconventional hospitalization developed in the lastdecades, outpatient surgery has been the one with

the greatest growth. However, only few studieshave been reported on thoracic surgery and thereis still great potential for an increase in outpatient

thoracic surgery. The aim of this article has beento evaluate the clinical aspects, results, andeconomical impact of an outpatient thoracicsurgery program (OTSP). Video-assisted media-

stinoscopy, lung biopsy, and bilateral thoracicsympathectomy can be accomplished safely ina significant percentage of cases as ambulatory

patients. The impact of the economical benefit ofoutpatient thoracic surgical program over theconventional hospitalization depends on the pre-

vious department’s policy on hospital stay. Fur-ther experience is needed to increase thesubstitution index and expand the OTSP to other

procedures.

Acknowledgments

The authors thank Antoni Tobella, PhD, forhis assistance in the revision of this article.

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Index

Note: Page numbers of article titles are in boldface type.

A E

Adjuvant chemotherapyand thoracoscopic lobectomy, 259–261in video-assisted lobectomy versus open

thoracotomy, 255and video-assisted thoracic surgery, 236, 255

Anesthesia

adverse effects of general, 312and awake operative videothoracoscopic

pulmonary resections, 314–315

Awake operative videothoracoscopic pulmonaryresections, 311–320anesthesia for, 314–315

and historical steps, 311and non-small cell lung cancer, 311, 317–318patient selection for, 312–314physiopathology of, 311–312

for pulmonary metastasectomy, 317for resection of pulmonary nodules, 315–317results of, 315–319

surgical technique for, 315

C

Complications and learning curves

for video-assisted thoracic surgery lobectomy,275–280

Cost comparison of robotic, video-assisted

thoracic surgery (VATS) and thoracotomyapproaches to pulmonary lobectomy, 297–300

Costs

of outpatient thoracic surgery, 325of video-assisted thoracic surgery, 254–255,

281–286, 297–300

D

Does minimally invasive thoracic surgery warrantfast tracking of thoracic surgical patients?,

301–304


doi:10.1016/S1547-4127(08)00061-3

European Society of Thoracic Surgeonsand survey on pulmonary resection, 237–247

F

Fast tracking of thoracic surgical patientsafter minimally invasive thoracic surgery,

301–303

key issues for, 301–302and pain medicine protocols, 302–303reasons for, 301

L

Lobectomyopen, 283

robotic, 255, 289–295thoracoscopic, 259–261video-assisted, 238–242, 244–245, 249–255,

263–268

Long-term outcomes of thoracoscopic lobectomy,259–262

Lung biopsyoutpatient, 324–325

Lung cancer

and video-assisted lobectomy, 263–268and video-assisted versus open thoracotomy,

249–255

Lung volume reduction surgery

and video-assisted lobectomy, 264–265

LVRS. See Lung volume reduction surgery.


in video-assisted lobectomy versus openthoracotomy, 251–252

M

Mediastinoscopyoutpatient, 323

ts reserved.



330 INDEX

Minimally invasive open surgery, 269–273

future perspectives of, 272–273technique of, 270–271and thoracic malignancies, 269–273

versus video-assisted lobectomy, 271–272

Minimally invasive open surgery approach for thesurgical resection of thoracic malignancies,269–273

Minimally invasive thoracic surgery, 235–247,301–303factors influencing choice of, 242, 244

and fast tracking of thoracic surgical patients,301–303

and hospital length of stay, 301–303

indications for, 238, 240

MIOS. See Minimally invasive open surgery.

MITS. See Minimally invasive thoracic surgery.

O

Open thoracic surgerydefinition of, 238–239

Open thoracotomy, 249–255

and biologic response versus video-assistedlobectomy, 253

and conversion rate versus video-assistedlobectomy, 251

and costs versus video-assisted lobectomy,254–255, 283–284, 297–300

and delivery of adjuvant chemotherapy versus

video-assisted lobectomy, 255and length of hospital stay versus

video-assisted lobectomy, 277–278

and lymph node dissection versusvideo-assisted lobectomy, 251–252

and morbidity rate versus video-assistedlobectomy, 250–251

and mortality rate versus video-assistedlobectomy, 250

and pain versus video-assisted lobectomy,

252–253and perioperative course versus video-assisted

lobectomy, 251

and pulmonary function versus video-assistedlobectomy, 253–254

and quality of life versus video-assisted

lobectomy, 254, 278and recovery phase versus video-assisted

lobectomy, 278and results in high-risk patients versus

video-assisted lobectomy, 254

and short-term results versus video-assisted

lobectomy, 250–255and stage of lung cancer versus video-assisted

lobectomy, 255

and survival rate versus video-assistedlobectomy, 255

versus video-assisted lobectomy, 249–255,277–278

Outpatient lung biopsy, 324–325

Outpatient mediastinoscopy, 323

Outpatient thoracic surgery, 321–327economic impact of, 325and readmission rate, 321

Outpatient thoracic sympathectomy, 323–324

P

Painin video-assisted lobectomy versus open

thoracotomy, 252–253and video-assisted thoracic surgery, 236, 241,

244, 252–253

Pulmonary metastasectomyand awake operative videothoracoscopic

pulmonary resections, 317

Pulmonary resection, 235–247

and survey of European Society of ThoracicSurgeons, 237–247

R

Rib spreadingand video-assisted thoracic surgery, 236,

238–240

Robotic lobectomy, 255, 289–295and arterial step, 292–293and bronchus step, 293costs of, 297–300

and da Vinci system, 289and hilum dissection, 292learning curve and complications of, 289–295

and lymphadenectomy, 293results of, 293–294surgical sequences of, 292–293

technical aspects of, 291–292and TilePro, 291and training, 290–291and vein step, 293

versus videothoracoscopic surgery, 290

331INDEX

Robotic thoracic surgery, 242–243, 245,

255, 289–295financial issues of, 243, 245, 289–295

Robotically assisted lobectomy: learning curve

and complications, 289–295

T

Thoracic malignancies

and minimally invasive open surgery, 269–273

Thoracic surgeryand preferred terminology, 238–239

robotic, 242–243, 245, 255, 289–295

Thoracic sympathectomyoutpatient, 323–324

Thoracoscopic lobectomy, 259–261and complete resection rate, 260and compliance with adjuvant chemotherapy,

260and local recurrence, 260long-term outcomes of, 259–261and lymph node dissection, 260

and morbidity and mortality rates, 261oncologic outcomes of, 259–260and quality of life, 259

and state-specific survival, 259–260

Thoracotomy, 238, 240, 244, 249–255versus video-assisted lobectomy, 249–255

U

Uniportal video-assisted thoracic surgery fordiagnosis and treatment of intrathoracic

conditions, 305–310

V

The variability of practice in minimally invasivethoracic surgery for pulmonary resections,

235–247

VATS. See Video-assisted thoracic surgery.

The VATS lobectomist: analysis of costs and

alterations in the traditional surgical workingpattern in the modern surgical unit, 281–287

VATS lobectomy is better than open

thoracotomy: what is the evidence forshort-term outcomes? 249–258

Video-assisted lobectomy, 238–242, 244–245,249–255, 263–268

and alterations in surgical units, 284–286and analysis of costs, 281–284

and biologic response versus open

thoracotomy, 253and competency, 285–286complications after, 277

complications and learning curves for,275–280

concerns unique to, 278–279consensus statement regarding, 279

and conversion rate versus open thoracotomy,251

costs of, 281–286, 297–300

and costs versus open thoracotomy, 254–255,297–300

and costs versus open thoractomy, 283–284,

297–300and credentialing, 267and dedicated surgical teams, 265

definitions of, 249–250and delivery of adjuvant chemotherapy versus

open thoracotomy, 255and introducing new technology into practice,

276learning curve for, 276–277and length of hospital stay versus open

thoracotomy, 277–278and lung cancer, 263–268and lung volume reduction surgery, 264–265

and lymph node dissection versus openthoracotomy, 251–252

and maintenance of training, 267versus minimally invasive open surgery,

271–272and models of care, 281–282and morbidity rate versus open thoracotomy,

250–251and mortality rate versus open thoracotomy,

250

and national database, 267versus open thoracotomy, 249–255, 277–278and operative techniques, 282–283

and pain versus open thoracotomy, 252–253and perioperative course versus open

thoracotomy, 251prerequisites to begin, 275

present status of, 269–270and program size, 285and pulmonary function versus open

thoracotomy, 253–254and quality assurance, 263–265and quality of life versus open thoracotomy,

254, 278and recovery phase versus open thoracotomy,

278

332 INDEX

Video-assisted (continued)and results in high-risk patients versus open

thoracotomy, 254short-term results versus open thoracotomy,

250–255and short-term results versus open

thoracotomy, 250–255and stage of lung cancer versus open

thoracotomy, 255and staging and assessment, 284–285and standardizing terminology, 263

and surgical simulators, 266and survival rate versus open thoracotomy, 255training for, 265–267

Video-assisted thoracic surgery, 235–247,249–255, 263–268and advantages and limitations of uniportal

approach, 308–309background and history of, 249and baseline prognosis, 236and blood loss, 236

and diagnosis via uniportal approach, 306–307and fast tracking of thoracic surgical patients,

303

and impairment of activities, 236

and length of hospital stay, 236, 241, 244and meta-analysis of International Society of

Minimally Invasive Cardiothoracic

Surgery, 236and mortality rate, 236and postoperative complications, 236and postoperative pain, 236, 241, 244,

252–253and postoperative vital capacity, 236and rib spreading, 236, 238–240

and time to adjuvant chemotherapy, 236training pathway for, 244–245uniportal approach for, 305–309

and uniportal versus three-portal approach,308

Video-assisted thoracic surgery lobectomy:

centers of excellence or excellence of centers?,263–268

Video-assisted thoracic surgery lobectomy. SeeVideo-assisted lobectomy.

Videothoracoscopic pulmonary resectionwhile awake, 311–319

Health & Medicine

Frontiers of minimally invasive thoracic surgery