One of the most well-studied advantages of thoracoscopic lobectomy is a reduction in postoperative pain [8, 9, 33–35]. Nomori and colleagues compared a group of age- and sex-matched patients who underwent thoracoscopic lobectomy (n = 33) or limited anterior thoracotomy (n = 33) [33]. The patients who underwent thoracoscopic lobectomy experienced less pain between postoperative day (POD) 1 and POD 7 (p < 0.05–0.001) and had lower analgesic requirements up to POD 7 (p < 0.001). Demmy and colleagues reported on their results in a series of patients who underwent either thoracoscopic lobectomy or conventional thoracotomy [19]. In this series, the percentage of patients reporting severe pain was 6 % after thoracoscopic lobectomy and 65 % after thoracotomy. Moreover, the percentage of patients reporting minimal or no pain was 63 % after thoracoscopic lobectomy and 6 % after thoracotomy.

Chronic discomfort is also an important issue in postoperative recovery. Although more difficult to measure than acute pain, chronic pain and shoulder dysfunction have been studied. Stammberger and colleagues, in addressing long-term quality of life following VATS, reported that 53 % of 173 patients undergoing VATS had insignificant pain 2 weeks after the operation [34, 35]. At 6 months, 75 % had no complaints, and only 4 % had mild or moderate discomfort at 2 years.

Many have theorized that smaller incisions and absence of rib spreading may improve lung function in the postoperative period, and several studies have reported pulmonary function test (PFT) data after thoracoscopic resection. Two studies examined postoperative arterial oxygen tension (PaO₂₎ after both VATS and muscle-sparing thoracotomy and found that VATS patients had better oxygenation during the first postoperative week [36, 37]. Others have demonstrated improvements in early postoperative forced expiratory volume in 1 s (FEV₁) and forced vital capacity in the first weeks and months after VATS [8, 19].

Minimally invasive procedures appear to produce less of a systemic insult than more conventional, invasive procedures [7, 8, 38–42]. Many groups have studied inflammatory mediators after VATS and open resection and have found lower levels of C-reactive protein and interleukins (IL) in those having undergone VATS. Yim and colleagues analyzed the cytokine responses in a series of 36 matched patients who underwent thoracoscopic lobectomy or conventional thoracotomy and lobectomy [7]. Analgesic requirements were significantly lower in the patients who underwent VATS lobectomy. In addition, the levels of IL-6 and IL-8 were lower in the VATS group than in the group that underwent thoracotomy. Leaver and coworkers examined immunosuppression due to systemic effects of surgery and found higher numbers of CD4 lymphocytes and natural killer cells and less suppression of lymphocyte oxidation in the VATS group [38]. These studies have shown that VATS lobectomy leads to a reduced inflammatory response, less postoperative reduction in immunosuppression, and less impairment of cellular cytotoxicity than open lobectomy. These findings could partially explain why perioperative outcomes of VATS lobectomy are superior to the perioperative outcomes of open lobectomy. Whether these trends toward more effective immune function after VATS resection lead to faster recovery or toward better long-term oncologic outcomes will be important endpoints of future studies, but is currently not known.

The ultimate acceptance of thoracoscopic lobectomy will be dependent on its oncologic effectiveness as compared with conventional lobectomy. To date, only one small prospective, randomized trial has compared oncologic results of VATS with open lobectomy [26]. In this study published in 2000, Sugi and colleagues reported that for 100 patients with stage IA non-small cell lung cancer undergoing either open (n = 52) or VATS (n = 48) lobectomy, there was no difference in 3- and 5-year survival rates. Though this trial is without sufficient power to assess differences between the operations, several additional retrospective studies performed are sufficient for limited analysis. Some analyses have further documented improved survival when VATS was used [4, 5, 43]. Reasons for the possible differences are unclear, but it has been postulated that preservation of immune function and less systemic release of inflammatory cytokines may be contributing factors [34]. In addition, the benefit of adjuvant treatment for resected stage II lung cancer necessitates attempts to maximize planned chemotherapy doses postoperatively. Thoracoscopic lobectomy, with its lower morbidity rates, allows a high proportion of patients to receive all intended doses [44, 45].

The assessment of cost-effectiveness is controversial because of the difficulty in identifying and including all costs. Clearly, VATS can be associated with high costs of disposables and with longer operative times in inexperienced hands. However, numerous disposable instruments essential to performing thoracoscopic lobectomies, such as linear endoscopic staplers, are also employed by many in performing either conventional or limited thoracotomies. Nakajima and colleagues published a study from Japan demonstrating that hospital charges were actually lower for the VATS approach [46]. One important variable in the assessment of cost-effectiveness is length of hospital stay. In most series of thoracoscopic lobectomy, the median length of stay was only 3 days [1–3, 6, 13, 14]. As surgeon experience increases with thoracoscopic lobectomy, the operative times will become comparable to that of conventional approaches. In fact, the mean operative time in the CALGB multi-institutional study was only 130 min [1].

A recent study by Swanson et al. used the Premier Perspective Database to compare hospital costs for VATS and open lobectomy procedures in the United States [47]. A total of 3,961 patients underwent either open lobectomy (n = 2,907) or VATS lobectomy (n = 1,054). Hospital costs took into account costs associated with the operation, length of stay, and with adverse events. Hospital costs were found to be significantly higher for open versus VATS lobectomy, though costs associated with VATS lobectomy were influenced by surgeon experience, whereas this was not the case with open lobectomy.

The observation that thoracoscopic lobectomy may have a lower complication profile has been supported in multiple studies analyzing outcomes of series including patients undergoing thoracoscopic lobectomy and patients undergoing open lobectomy. In one study, 122 patients undergoing thoracoscopic lobectomy and 122 patients undergoing thoracotomy were compared [48]. Overall, the incidence of postoperative complications was lower in the thoracoscopic group (17.2 % versus 27.9 %, p = 0.046); however, these patients were matched for age and sex only, and there was no significant difference in the incidence of any of the specific complications reported. Whitson and colleagues analyzed the outcomes of 147 (unmatched) patients who underwent lobectomy, including 88 by thoracotomy and 59 by thoracoscopy. Thoracoscopic lobectomy was associated with a lower incidence of pneumonia but with no difference in other complications, including blood loss, atrial fibrillation, or number of ventilator days.

Using a prospective database, the outcomes of patients who underwent lobectomy at Duke from 1999 to 2009 were analyzed with respect to postoperative complications [49]. Propensity-matched groups were analyzed, based on preoperative variables and stage. Of the 1,079 patients in the study, 697 underwent thoracoscopic lobectomy and 382 underwent lobectomy by thoracotomy. In the overall analysis, thoracoscopic lobectomy was associated with a lower incidence of prolonged air leak (p = 0.0004), atrial fibrillation (p = 0.01), atelectasis (p = 0.0001), transfusion (p = 0.0001), pneumonia (p = 0.001), sepsis (p = 0.008), renal failure (p = 0.003), and death (p = 0.003). In the propensity-matched analysis based on preoperative variables comparing 284 patients in each group, 196 patients (69 %) who underwent thoracoscopic lobectomy had no complications, versus 144 patients (51 %) who underwent thoracotomy (p = 0.0001). In addition, thoracoscopic lobectomy was associated with fewer prolonged air leaks (13 % versus 19 %; p = 0.05), a lower incidence of atrial fibrillation (13 % versus 21 %; p = 0.01), less atelectasis (5 % versus 12 %; p = 0.006), fewer transfusions (4 % versus 13 %; p = 0.002), less pneumonia (5 % versus 10 %; p = 0.05), less renal failure (1.4 % versus 5 %; p = 0.02), shorter chest tube duration (median 3 versus 4 days; p < 0.0001) and shorter length of hospital stay (median 4 vs 5 days; p < 0.0001) [3].

Similar results were obtained when the STS database was analyzed by Paul and colleagues [6]. All patients undergoing lobectomy as the primary procedure via thoracoscopy or thoracotomy were identified in the STS database from 2002 to 2007. After exclusions, 6,323 patients were identified: 5,042 underwent thoracotomy, 1,281 underwent VATS. A propensity analysis was performed, incorporating preoperative variables, and the incidence of postoperative complications was compared. Matching based on propensity scores produced 1,281 patients in each group for analysis of postoperative outcomes. After VATS lobectomy, 945 patients (73.8 %) had no complications, compared to 847 patients (65.3 %) that had lobectomy via thoracotomy (p < 0.0001). Compared to open lobectomy, VATS lobectomy was associated with a lower incidence of arrhythmias [n = 93 (7.3 %) versus = 147 (11.5 %); p = 0.0004], re-intubation [n = 18 (1.4 %) versus n = 40 (3.1 %); p = 0.0046], and blood transfusion [n = 31 (2.4 %) versus n = 60 (4.7 %); p = 0.0028], as well as a shorter length of stay (4.0 versus 6.0 days; p < 0.0001) and chest tube duration (3.0 versus 4.0 days; p < 0.0001). There was no difference in operative mortality between the two groups [4].

Finally, two important meta-analyses have been done to assess the advantages of the thoracoscopic approach. In the first, analyzing the outcomes of 21 studies comparing VATS and open approaches, Yan and colleagues demonstrated that there were no significant difference in locoregional recurrence, but that VATS lobectomy was associated with a reduced systemic recurrence rate (p = 0.03) and improved 5-year mortality rate (p = 0.04) [4]. Cao and colleagues performed a similar analysis, focusing on studies that included propensity matching [5]. In this meta-analysis, VATS was associated with a lower risk of perioperative morbidity (p = 0.0004), confirming the single and multiple institution series in the literature [6, 16].

The right upper lobectomy is a difficult endoscopic procedure in all VATS lobectomies. Right upper lobe has many arterial branches, especially some thin branches, so the bleeding risk is relatively high during dissection. Besides, the operative field is large, so the scope has to switch from the anterior to the posterior mediastinum and from the apex to the diaphragm. In addition, the following difficulties may be faced:

Two different approaches can be used: (1) a classic anterior approach in which the truncus arteriosus and the superior pulmonary vein are controlled first and (2) a posterior approach in which the bronchus is divided first. If necessary, these two approaches can be combined.

The right middle lobe is as small as one-fifth to the total volume of the right lung. It is anatomically parallel to the lingular segment of the left upper lobe. The whole lobe is located in the anterior part of the lung, so that lobectomy could be done by only dissecting the front pulmonary hilum. Tumor located in this lobe is relatively rare, and the procedure of right middle lobectomy is therefore unfamiliar to many surgeons.

A right lower lobectomy is a slightly more complex procedure than a left lower lobectomy owing to the presence of the right middle lobe. Positive identification and exclusion of the hilar structures to the middle lobe is necessary in order to complete the lower lobectomy. Our usual practice entails division of the hilar structures in the following order: pulmonary vein, pulmonary artery, and bronchus. We routinely use a double-lumen endotracheal tube for lung isolation. Epidural catheters, arterial lines, and foleycatheters may be utilized at the surgeon’s discretion as needed.

Figure 4.16