, Jun Wang2, Fengwei Li1 and Teng Mu2
(1)
Department of Thoracic Surgery, Beijing Aerospace General Hospital, No.7, Wanyuan North Street, Fengtai District, Beijing, 100076, China
(2)
Department of Thoracic Surgery, Peking University People’s Hospital, No.11, Xizhimen South Street, Beijing, 100044, China
7.1 General Considerations on VATS Pneumonectomy for Lung Cancer
Ying Tai Chen3 and Fengwei Li3
(3)
Department of Thoracic Surgery, Beijing Aerospace General Hospital, No.7, Wanyuan North Street, Fengtai District, Beijing, 100076, China
In 1933 Graham and Singer successfully performed the first pneumonectomy for a patient with lung cancer who survived for 33 years after the operation. Since then, pneumonectomy has gradually become one of the important thoracic surgical procedures. In recent years, 20–25 % of thoracic surgical procedures performed for lung cancer were pneumonectomy. However, as more and more lung cancer was detected in early stage and thoracic surgical skills improved, the proportion of pneumonectomy had been declining year by year. There were studies suggesting that pneumonectomy proportion was linked to postoperative complications and mortality (the complications rate was 11–49 %, and the mortality rate was 2.9–12 %), but this surgical procedure didn’t reduce the long-term survival rate of lung cancer. However, for patients with cancer indications, pneumonectomy is irreplaceable. With the constant development of thoracoscopic technology and instrument, pneumonectomy has been operated by video-assisted thoracoscope, which can reduce the surgical trauma while achieve the same therapeutic effect as compared with traditional procedures. Although video-assisted thoracoscopic pneumonectomy is rather difficult, as long as the operator is able to expertly processed pulmonary vessels and bronchi under thoracoscope, and properly handles the intraoperative severe tissue adhesion, special anatomical variation, and excessive bleeding, video-assisted thoracoscopic pneumonectomy is still worthy of promotion.
7.1.1 Operation Indication
Pneumonectomy has a greater influence on the circulation and respiratory function, so we need strictly comply with the operation indication, which can mainly be considered from the following two aspects:
7.1.1.1 Scope of Lesion
- 1.
The tumor locates in lobar bronchus and infiltrates to the plane of adjacent lobar bronchus.
- 2.
The tumor is limited within the lobe and metastasis lymph node encroaches to adjacent lobar bronchus wall.
- 3.
The tumor is located in hilus of lung and we can’t dissect fissurae interlobaris.
- 4.
Peripheral lung cancer has infiltrated to the whole lung.
7.1.1.2 Cardio-pulmonary Function
Routine examinations include pulmonary function test, blood gas analysis before and after exercise, and pulmonary perfusion imaging for patients prepared to receive pneumonectomy. The results are used to comprehensively evaluate the pulmonary function. It is generally believed that pulmonary function should satisfy the following conditions: forced expiratory volume in 1 s (FEV1) is greater than 2.0 L and forced expiratory volume in 1 s/forced vital capacity (FEV1/VC) is greater than 50 %. Pulmonary perfusion imaging should be used to predict postoperative residual pulmonary function, and the predicted value of FEV1 needs to be greater than 0.8 L. In addition, blocking the pulmonary artery trunk can determine the tolerance of pneumonectomy in the condition of one lung ventilation. If the fluctuation of systolic pressure is within 2.9 kPa and the heart rate change is within 20 times per minute after blocking the pulmonary artery trunk, patients should generally tolerate pneumonectomy. Meanwhile, it should be kept in mind that satisfactory cardiac function is also a major contributing factor to a safe and successful pneumonectomy.
7.1.2 The Preoperative Preparation
The preoperative preparation is almost similar to an ordinary thoracic surgery, but some aspects need special attention.
7.1.2.1 Chest CT Examination
Chest CT is very important for the safety assessment of video-assisted thoracoscopic pneumonectomy: First, the chest CT scan can help us understand the mediastinum, especially detect if there are calcifications in hilar lymph node. Generally, calcified lymph nodes indicate that pneumonectomy surgery is very troublesome because the possibility of intraoperative bleeding increases and the possibility of thoracotomy is higher. Second, chest-enhanced CT could help us understand the relationship between the tumor and the surrounding vessels, particularly the anatomical variation of the vessels. Thus chest CT is a very important method to evaluate the safety of pneumonectomy.
7.1.2.2 Preoperative Preparation for Elderly Patients
The hilar lymph nodes of elderly patients are susceptible to hyperplastic changes, therefore, surgeons should pay higher attention to their preoperative chest scan and enhanced CT examination results, and evaluate the risk of pneumonectomy sufficiently. Furthermore, elderly patients usually have many underlying diseases such as hypertension, diabetes, coronary heart disease, and thromboembolic diseases. These health conditions increase the incidence of postoperative complications in various systems of the body. Consequently, preoperative UCG and lower limb vascular ultrasound examinations are essential. At the same time, surgeons should actively control the patients’ basic diseases, and render them rational training and guidance. Only in this way could them achieve the best cardiopulmonary function and psychological state.
7.1.3 Surgical Instrument
Thoracoscopic surgical instruments are listed in Table 7.1
Table 7.1
Thoracoscopic surgical instruments
Surgical unit |
Thoracoscope |
Illuminant |
Image acquisition system |
Image display system |
Ordinary thoracoscopic surgical instruments |
Drive pipe |
Electrocoagulation |
Endoscopic separation pliers and scissor |
Endoscopic acutenaculum |
Knot pusher |
Oval forceps |
Extended tangential clamp |
Extended long curved forceps |
Video–assisted thoracoscopic pneumonectomy special surgical instruments |
Thoracoscopic suction |
Thoracoscopic long curved tangential vessel forceps |
Thoracoscopic side curved vessel forceps |
Thoracoscopic lymph node forceps |
Long acutenaculum (Z-type,S-type) |
Mechanical suture instruments |
Endoscopic section and suture instruments |
Multi-fire clipapplier |
Hem-o-lock |
Operation Energy platform (LigaSure、ultrasound scalpe) |
7.1.4 Key Points of Operation
Thoracoscopic pneumonectomy intraoperative considerations are basically the same as the video-assisted thoracic lobectomy. The key points that require special attention are:
7.1.4.1 Dissection of Pulmonary Artery
Dissection of pulmonary artery is an important step in the process of thoracoscopic pneumonectomy. Most patients who need pneumonectomy are central-type lung cancers which may be accompanied by enlarged lymph nodes. This makes handling the pulmonary artery very difficult. Flexible approaches should be chosen by surgeons according to specific situations. For example, when the tumor invades the root of pulmonary artery, the first branch of the pulmonary artery should be manipulated first in order to reveal a longer pulmonary artery trunk for use, or the pulmonary artery trunk should be manipulated inside the pericardium.
7.1.4.2 Manipulation of Auto SutureTA Stapler
Due to the disturbance of the descending aorta in the rear of the left bronchus, incision angle through the front operation incision using common Endo GIA Universal Straight or Endo GIA Universal Roticulator may be restricted, resulting in long bronchial stump. Using Auto Suture DST Series TA3048S can avoid the descending aorta, ensuring the bronchial stump fit.
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