Innovations: Technology & Techniques in Cardiothoracic & Vascular Surgery:
Yendamuri, Sai MBBS; Nwogu, Chukwumere E. MD; Demmy, Todd L. MD
From the Department of Thoracic Surgery, Roswell Park Cancer Institute, Buffalo, NY.
Accepted for publication: November 24, 2008.
Presented at the 11th Annual Meeting of the International Society for minimally Invasive Cardiothoracic Surgery, June 11–14, 2008, Boston, MA.
Address correspondence and reprints requests to Sai Yendamuri, MD, Department of Thoracic Surgery, Roswell Park Cancer Institute, Elm and Carlton Streets, Buffalo, NY 14263; E-mail: Sai.Yendamuri@roswellpark.org.
Chest wall involvement from lung malignancy presents technical challenges for a minimally invasive surgical approach. Recently, new thoracoscopic rib cutting instrumentation has been developed and may offer a safe and efficient resection. Compared with thoracotomy, thoracoscopic lung and chest wall resection may potentially lower the morbidity associated with chest wall resection by thoracotomy. We present a case of thoracoscopic lobectomy with an en bloc chest wall resection.
The patient is a 69-year-old white male who underwent chest computed tomographic (CT) imaging for unresolving pneumonia. A right upper lobe mass with chest wall invasion (Fig. 1) underwent percutaneous biopsy demonstrating non-small cell lung cancer. There was no evidence of mediastinal or distant spread of disease by integrated positron emission tomography/CT. After multidisciplinary team planning, the patient received radiation therapy with 50.4 Gy with three cycles of concurrent carboplatin and taxol followed by new imaging. This revealed a <50% response and no evidence of mediastinal or distant metastases. The preoperative forced expiratory volume in the first second was 54% of predicted and the preoperative diffusing capacity of the lung for carbon monoxide was 75% of predicted. Radiation therapy was not provided to the mediastinum.
Flexible bronchoscopy revealed normal bronchial anatomy and mediastinoscopy excluded lymph node involvement. The patient was then placed in a left lateral decubitus position. A thoracoscopic port was inserted in the ninth intercostal space in the midaxillary line. After introduction of the thoracoscope through this port, an anterior sixth intercostal space incision was made in line with the oblique fissure. A 4 cm fourth intercostal space access incision was made just anterior to the involved chest wall (Fig. 2). This location was close to our preferred access incision for thoracoscopic lobectomy. Some adhesions were seen in the chest and these were lysed. A combination of palpation of the tumor through the access incision and visualization using a flexible thoracoscope (Olympus America Inc., Melville, NY) was used to determine the involved ribs. The pleura was scored to mark the involved area. The fourth and fifth intercostal neurovascular bundles were divided using a 5 mm Ligasure device (Valley Laboratory Inc., Boulder, CO) as were the intervening intercostal muscles(Fig. 3A). As the medial aspect of each rib needed to be divided was accessible through the access incision, a regular open rib cutter was used to divide the ribs. The lateral aspects of the ribs were divided using an endoscopic rib cutter (Medtronic Sofamor Danek Inc., Memphis, TN) (Fig. 3B, D). Portions of the third, fourth, and fifth ribs were thus excised along with the lung mass (Fig. 3C). Once this was done, the thoracoscopic right upper lobectomy was completed as usual. Briefly, the right superior pulmonary vein was divided sparing the middle lobe vein. The truncus anterior branch was then dissected out and divided. A plane along the anterior surface of the interlobar pulmonary artery was dissected and used to complete the horizontal fissure. The middle lobe was adherent to the tumor and, therefore, part of it was wedged along with the tumor as the horizontal fissure was completed. The posterior portion of the oblique fissure was then divided with a stapler followed by division of the posterior ascending branch of the upper lobe. To enhance the dissection of the upper lobe bronchus and to move around the bulky tumor, a laparoscopic liver retractor was used as described by us previously.1 This enabled clear visualization of the upper lobe bronchus and facilitated its division. The specimen was then retrieved in a nylon Lap-sac. Hemostasis was achieved. As the resected chest wall area was small and behind the scapula, no reconstruction was performed. Total duration of anesthesia was 146 minutes.
The postoperative course was complicated by a retained hemothorax for which the patient underwent its thoracoscopic evacuation on postoperative day 1. No surgical bleeding was found. The retained hemothorax was attributed to the early use of heparin and antiplatelet therapy. The patient was reintubated for respiratory compromise secondary to retained secretions on postoperative day 3. He was extubated on postoperative day 5 and discharged to home on postoperative day 9. Final pathology revealed a T3N0M0 lesion. At the first postoperative visit 3 weeks from his operative day, the patient reported having used only one narcotic pill in the preceding 5 days and a nearly normal activity level.
Thoracoscopic lobectomy is increasingly being accepted as an appropriate cancer operation for lung cancer. A CALGB feasibility trial recently reported confirmed the acceptable results of thoracoscopic anatomic pulmonary resection.2 Potential benefits of using a thoracoscopic approach are decreased perioperative pain, decreased perioperative complications, increased delivery of adjuvant chemotherapy, and overall increased postoperative functional status. There is also some evidence of decreased blunting of the postoperative immune response.3 Although there is a learning curve to performing these procedures safely, experienced surgeons have applied this technique to situations more complex than routine lobectomy. These include systematic lymph node dissections,4 pulmonary segmentectomies,5 pneumonectomies,6 and sleeve lobectomies.7 Increasing experience and improved thoracoscopic instruments help extend these indications.
The primary disadvantage with thoracoscopic surgery is twofold: the first is the absence of tactile feedback. The second is the compromised ability to obtain vascular control in the circumstance of intraoperative hemorrhage. In exchange for this, several advantages are gained. These include better visualization, particularly with the use of flexible thoracoscopes, both for the primary surgeon and significantly more for the assistant. The thoracoscope makes the visualization of the apex and the paravertebral gutters much more readily visually accessible than open surgery. The second major advantage is the ability to operate on patients who would be at prohibitive risk for open procedures, particularly older patients. In an era of increasing use of multimodality therapy where each added modality comes with a morbidity price, this advantage cannot be overlooked.
In this report, we present a case where an anatomic resection with an en bloc chest wall resection was performed thoracoscopically. Two instruments particularly help in this operation: the 5-mm Ligasure device and the endoscopic bone cutter. Proper placement of the access incision is also a key factor to use tactile feedback that further enables the surgeon to decide on surgical margins. We conclude that thoracoscopic chest wall resection can be performed safely in carefully selected patients with lung cancer invading the chest wall and deserves further study.
1. Demmy TL, Nwogu CE, Sussman MS. Triangular retractor facilitates minimally invasive lobectomy. J Thorac Cardiovasc Surg
2. Swanson SJ, Herndon JE II, D’Amico TA, et al. Video-assisted thoracic surgery lobectomy: report of CALGB 39802—a prospective, multi-institution feasibility study. J Clin Oncol
3. Ng CS, Wan S, Hui CW, et al. Video-assisted thoracic surgery for early stage lung cancer—can short-term immunological advantages improve long-term survival? Ann Thorac Cardiovasc Surg
4. Cadiere GB, Torres R, Dapri G, et al. Thoracoscopic and laparoscopic oesophagectomy improves the quality of extended lymphadenectomy. Surg Endosc
5. Atkins BZ, Harpole DH Jr, Mangum JH, et al. Pulmonary segmentectomy by thoracotomy or thoracoscopy: reduced hospital length of stay with a minimally-invasive approach. Ann Thorac Surg
. 2007;84:1107–1112; discussion 1112–1113.
6. Nwogu CE, Glinianski M, Demmy TL, Minimally invasive pneumonectomy. Ann Thorac Surg
7. Nakanishi K. Video-assisted thoracic surgery lobectomy with bronchoplasty for lung cancer: initial experience and techniques. Ann Thorac Surg
The role of the small incision endoscopic lobectomy is continuing to evolve; the equipment is improving providing greater opportunities for performing extensive thoracic surgery. These authors illustrate our ability to resect a lobe and the adjacent chest wall even after induction chemoradiotherapy, a concern for increased postoperative complications. As was demonstrated in this case, the continued evolution of equipment and techniques will provide us ways in which we can treat patients to reduce the encumbrances of standard thoracotomy procedures.
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