and Jun Wang6
(6)
Department of Thoracic Surgery, Peking University People’s Hospital, No.11 Xizhimen South Street, Beijing, 100044, China
11.1.1 Introduction
As the leader in developing Video-assisted thoracoscopic surgery (VATS) in China, we accomplished the first case in China in 1992. After 2005, we began regular VATS lobectomy and have completed more than 2500 VATS lobectomies till 2015. Chinese lung cancer patients have many special characteristics, such as more undeveloped interlobar fissures and more calcificatied hilar and mediastinal lymph nodes. This situation has caused us to develop more efficient and safer methods to undertake these difficult surgeries. We summarized and optimized our technique for the long-term minimally invasive thoracic surgical treatment for lung cancer (1). Here, we introduce our Wang’s technique to the readers, and wish it can be helpful when you encounter difficult cases.
11.1.2 Incisions
Operations were performed under general anesthesia with double-lumen endotracheal intubation. Patients are placed in the lateral decubitus position.
A total of three incisions are used. One 1.5-cm camera port is positioned in the seventh intercostal space, posterior axillary line. A 3–4 cm anterior incision is placed in the fourth or fifth intercostal space, anterior axillary line, without rib spreading. A wound protector was used to protect this incision. The posterior 1.5-cm port is then placed in the seventh intercostal space in the subscapular line. The resected lobe is retrieved through the anterior incision in a specimen retrieval bag.
11.1.3 Instruments
We believe that modified instruments and excellent teamwork contribute to the success in completely VATS lobectomy. We use several modified surgical instruments specially designed for VATS lobectomy, such as a double-curved suction with a threaded head (Fig. 11.1), a side-angled vessel-occlusion clamp, a lymphadenectomy clamp and some others. These instruments can be used flexibly to explore any area inside the chest. Two assistants cooperate with the surgeon in teamwork. The scope holder should apply the 30-degree thoracoscope nimbly to expose the complete surgical field for the surgeon and move the camera to just about 5 cm away from operational center when managing vessels or lymph-nodes. The close visual field will offer a clear view for accurate dissection. Another assistant should retract the lobe to protect normal tissue and be familiar with the surgeon’s techniques which will increase the operation efficiency.
Fig. 11.1
Double-curved suction with a threaded head
11.1.4 Technique
The main features of Wang’s technique are:
- (A)
A specially-made double-curved suction and an electrocautery hook are handled through a single incision concurrently and cross in the same direction (Figs. 11.2, and 11.3):
Fig. 11.2
Suction and electrocautery hook are crossed through a single incision simultaneously and thus point in the same direction once inside the chest (freehand sketching)
Fig. 11.3
Suction and electrocautery hook are crossed through a single incision simultaneously (intraoperative photograph)
The surgeon holds the suction in one hand and the electrocautery hook in the other hand. The two devices enter the thoracic cavity through the main incision simultaneously. Taking advantage of the double curved feature of the suction, the two devices cross at the chest wall incision and the operative region in thoracic cavity, respectively, so as to avoid interlocking of devices in the same incision, permitting a coordinated, fluid and precise operation. The suction can serve as blunt dissection, sucking blood, pushing normal tissue for exposure, preventing vessels and nerves from being injured by electrocautery hook, etc. Most procedures can be accomplished by the surgeon himself using the two devices, and the assistant just needs to retract the lobe to expose the visual field from the posterior port, preventing mutual interference between the two people.
- (B)
Creation of a perivascular tunnel for interlobar fissure division (Fig. 11.4):
Fig. 11.4
Create a perivascular tunnel for interlobar fissure division (oblique fissure of right lung)
Dissecting vessels after unfolding the interlobar fissure is more secure than fishing out the vessels within the pulmonary parenchyma. We set up a perivascular tunnel with close visual fields (Fig. 11.5) when dividing the interlobar fissure, contributing to locating the vessels accurately. Then we can divide the undeveloped fissure with an endoscopic stapler safely. Rather than fixing the sequence of operation, we prefer a multi-direction, flexible procedure. After interlobar fissure division, we can see vascular and bronchus distribution clearly and deal with any of them at our convenience.
Fig. 11.5
Close visual field
- (C)
Control bronchial arteries as a priority (Fig. 11.6):
Fig. 11.6
Division of the bronchial artery by electrocautery hook as a priority
Due to air pollution and pulmonary tuberculosis, many Chinese lung cancer patients have calcified hilar and mediastinum lymph nodes. Since bronchial arteries surround these lymph nodes and supply blood to the bronchial wall, their injury may lead to serious bleeding or even converting to thoracotomy without prioritized handling of these arteries. Controlling bronchial arteries as a priority can decrease hemorrhage in the operative field when dissecting hilar structures.
- (D)
Dissect vessels in their subadventitial planes (Fig. 11.7):
Fig. 11.7
Freeing vessels in their subadventitial planes and skeletonizing exposed vessels
Dense adhesions between lymph-nodes and vessels is an indication for conversion to an open procedure. Since most of these adhesions are just outside the adventitial sheath, dissecting vessels within the adventitia will obviate this trouble. In addition, after blunt dissection of the connective tissue around the vessel with the suction device, the surgeon should dissect the vessel adventitia over a sufficient length until the vessel is skeletonized in order to permit an efficient and precise lymph node resection, which can increase the safety and also the beauty of an operation.
- (E)
Dissect the mediastinal pleura around the hilum of the lung (Fig. 11.8);
Fig. 11.8
Dissecting the mediastinal pleura around the hilum of the lung
Cut the inferior pulmonary ligament first, then retract the lung anteriorly, and dissect the posterior mediastinal pleura from inferior to superior. Then retract the lung posteriorly, and dissect the anterior mediastinal pleura in order to show the hilum anatomical structure clearly.
11.1.5 Summary
Through increasing experience, we summarized and optimized our Wang’s technique of VATS lobectomy. More than 90 % lobectomies were performed by VATS in our institution and the oncologic efficacy is similar to other studies (Table 11.1). Most previous studies comparing VATS with thoracotomy were limited to early-stage disease, in which the result of VATS for other stage patients was not clear. We believe with continued experience and optimized technique, VATS lobectomy can also be performed in patients that are more complicated without compromising the perioperative outcomes and oncologic efficacy, such as locoregionally advanced cases, patients with previous surgery or neo-adjuvant chemoradiotherapy. Randomized controlled trial should be performed to validate the potential benefits of VATS for these patients.
Table 11.1
Long-term survival after video-assisted thoracoscopic lobectomy for non-small cell lung cancer
Author | Date | Number | Stage | 3-year OS (%) | 5-year OS (%) |
|---|---|---|---|---|---|
Lee [2] | 2013 | 208 | I–III | 87.4 | 76.5 |
Cao [3] | 2013 | 1458 | I–III | 74 | 62 |
Hanna [4] | 2013 | 190 | I–II | / | 64 |
Whitson [5] | 2008 | 1634 | I | 87.2 | 80.1 |
Our institution | 2014 | 1131 | I–IV | 85.4 | 76.4 |
11.2 Preoperative Management
Xu Lin7
(7)
Department of Thoracic Surgery, Jiangsu Cancer Hospital, No. 42, Baiziting, Nanjing, China
11.2.1 History and Physical Examination
Although the field of thoracic surgery has been dramatically altered by the development of new technologies in both imaging and therapeutics, the history and physical examination remain the most important components of the preoperative evaluation. The following important components should be evaluated: presenting symptoms and circumstances of diagnosis, prior diagnosis of pulmonary or cardiac disease, comorbid conditions (diabetes mellitus, liver disease, renal disease…), prior experiences with general anaesthesia and surgery, cigarette smoking, medications and allergies, and alcohol use. A critical component of the preoperative evaluation is the assessment of a patient’s functional status. Functional status is an important component of the decision algorithm for both the pulmonary and cardiac elements of the preoperative evaluation. Patients should also be questioned about symptoms related to paraneoplastic syndromes. These can range from the relatively subtle symptoms of hypercalcemia to more dramatic neurologic symptoms.
The examination of the patient includes an assessment of general overall appearance, including signs of wasting. Respiratory rate and the use of accessory muscles of respiration are noted. The pulmonary examination includes an assessment of diaphragmatic motion (by percussion) and notes any paradoxical respiratory pattern in the recumbent position. The relative duration of exhalation as well as the presence or absence of wheezing should be noted. The presence of rales should raise the possibility of pneumonia, heart failure, or pulmonary fibrosis. The cardiac examination includes assessment of a third heart sound to suggest left ventricular failure, murmurs to suggest valvular lesions, and an accentuated pulmonic component of the second heart sound suggestive of pulmonary hypertension. The heart rhythm and the absence or presence of any irregular heartbeats should be noted.
11.2.2 Pulmonary Function Assessment
Ageing and obesity are risk factors for pulmonary infection after thoracotomy. Age greater than 60 years old is a predisposing factor for postoperative pulmonary complications. The incidence of postoperative pulmonary complications of the patients whose weight exceeds 30 % of the standard weight is two times than the standard. The special attention should be paid to the chest X-ray on the basis of comprehensive investigation. Pulmonary function test and total amount of lung function should be performed on the patients undergoing lung surgery, which are important indicators.
Although a variety of pulmonary function tests have been examined in this setting, the two that have emerged as being predictive of postoperative complications are the forced expiratory volume in 1 s (FEV1) measured during spirometry and the diffusing capacity for carbon monoxide (DLco). Both of these values can be used to provide a rough estimate of the risk of operative morbidity and mortality. In addition, they are used to calculate the predicted postoperative values for FEV1 and DLco (ppo-FEV1 and ppo-DLco, respectively). The postoperative lung function could be predicted by simple calculation. Simple calculation is based on the assumption of homogeneously distributed lung function and requires knowledge of the number of segments to be resected and the preoperative value. For FEV1, the formula is ![$$ \mathrm{ppo}-\mathrm{FEV}1=\mathrm{FEV}1\ \left[1-\left(\mathrm{number}\ \mathrm{of}\ \mathrm{segments}\ \mathrm{resected}\times .0526\right)\right]. $$](https://i0.wp.com/thoracickey.com/wp-content/uploads/2017/09/A329363_1_En_11_Chapter_IEq1.gif?w=960)
A similar calculation is done for DLco.
A similar calculation is done for DLco.11.2.3 Assessment of Cardiac Function
Thoracic surgery operation has a very significant effect on the respiratory and circulatory function. And two thirds complications are heart and lung problems and there is a gradual increase in the rate of cardiac complications which is one of the main reasons for mortality in the preoperative period. Cardiac assessment is very important for rational control of surgical indications, prevention and reduction of complications and mortality. Therefore, preoperative cardiac function should be evaluated thoroughly.
11.2.3.1 Cardiac Disease History
Cardiovascular risk factors of patients should be full assessed, such as obesity, smoking, hyperlipidemia, history of hypertension, primary or secondary hypertension and blood pressure levels.
11.2.3.2 Heart Function Classification of NYHA
According to the New York Heart Association (NYHA) standard, heart function is divided into four levels. Patients with cardiac function I, II grade can tolerate general surgery. However, patients with III, IV grade tolerates surgery badly and have a high probability of complications.
11.2.3.3 Ladder-Climbing Test and 6 min Walking Test
The two tests are simple and easy approaches for the comprehensive assessment of the state of heart and lung function of patients, but they are not suitable for serious patients.
Respiration and pulse rate of the patients are recorded first in the ladder-climbing test. Then the patients are asked to speed up and down three floors flat. Respiration and pulse frequency and the time required for recovery should be recorded again. Recovery time within 15 min is in the normal range. The extending time of recovery indicates the poor heart function and thoracic surgery should be carefully considered. For 6 min walking test, if the distance traveled is less than 300–375 m, patient have poor cardiopulmonary function.
11.2.3.4 Goldman Cardiac Risk Index
In 1983, Goldman et al. proposed nine risk factors for preoperative cardiac complications and established a cardiac risk index (CRI) of patients with non-cardiac surgery. Goldman non-cardiac surgery cardiac risk index distributes as follows: <5 scores I grade, 6–12 scores II grade, 13–25 scores III grade, >26 scores IV grade.
When CRI distributes in grade I or II, the operation risk is low and the incidence of severe complications is 0.7–5 %. The risk of cardiac death is 0.2–2 %. The surgical risk is high in grade III. The incidence of severe complications is 11 % while the cardiac death is 2 %. The operation is great danger in grade IV. The incidence of cardiac death is 56 % and the severe complications is 22 %. It can be operated only in the case of rescue.
11.2.3.5 ECG
ECG is the most common and basic diagnostic method of coronary heart disease and cardiac arrhythmias. Compared with other diagnostic methods, ECG is easy to use and spread. Dynamic ECG can improve detection rate of the non-persistent ectopic rhythm especially for transient cardiac arrhythmia as well as transient myocardial ischemia.
11.2.4 Exercise of Respiratory Function
Preoperative exercise of respiratory function can improve patients’ physical function and tolerance of surgery. Diaphragmatic breathing and shrinkage lip-abdominal breathing are two common training methods, and volumetric exerciser can also be used if available.
11.2.5 Active Cough Training
Respiratory secretions retention is one of the main reason which leads to the pulmonary atelectasis. Therefore, an effective way is needed to expel sputum. Active cough training is an efficient measure which can clear airway and improve the ventilator capacity. Active cough training also significantly decrease the infection rate. There are three routine active cough methods.
11.2.5.1 Cascade Cough
It is the most effective cough way. It can expel the sputum directly from the vertebrate trachea and bronchus. This method is applied in the patients with less pain or taking analgesic.
11.2.5.2 Cough Softly
Sputum moves from the deep parts of bronchia to tracheas by cough softly. This method is appropriate for the patients with severe pain. This method must cooperate with huff cough to expel the sputum.
11.2.5.3 Huff Cough
This approach can expel the sputum out of the tracheas. This method is applied to the patients with less sticky or less deep sputum.
11.3 Postoperative Management
Xu Lin8
(8)
Department of Thoracic Surgery, Jiangsu Cancer Hospital, No. 42, Baiziting, Nanjing, China
11.3.1 Postoperative Pain Management
Pain management is of paramount importance post operatively as it is essential for patients to comply for chest physiotherapy and ambulation and they will be unable to do so if they have severe pain. There are various ways by which pain is managed.
11.3.1.1 NASIDs
The NSAIDs usually used for postoperative pain management are diclofenac, ketorolac, lysine acetyl salicylate, indomethacin, piroxicam, and tenoxicam. Intramuscular diclofenac 75 mg/12 h (PMID: 1728708), rectally indomethacin 200 mg/24 h [6] (PMID: 2248838) or continuous intravenous lysine acetyl salicylate (7.2 g/24 h) [7] (PMID: 3919746) decrease the required quantities of morphine and the postoperative Visual Analogue Scale scores. Indeed, the i.v. lysine acetyl salicylate was comparable with i.v. infusion of morphine (40 mg/24 h).
11.3.1.2 Opioids
The traditional use of opioids for postoperative analgesia after thoracic surgery includes morphine, pethidine (meperidine), fentanyl or tramadol. The route of administration may be intravenous, intramuscular or subcutaneous. Usually, the use of opioids is almost always supplemental to other alternative analgesic approaches. The combination of i.v. opioids and NSAID i.v. has become popular, with satisfactory safety regarding anticoagulation and renal function.
11.3.1.3 Ketamine
Ketamine is a non-competitive antagonist which blocks the ion channel associated with NMDA receptor. After thoracic surgery, i.m. administration of ketamine 1 mg/kg resulted in similar pain scores and in weaker respiratory depression in comparison with i.m. pethidine 1 mg/kg (PMID: 1514347) [8].
11.3.1.4 Regional Analgesia
Regional techniques are very important tools in the treatment of postoperative pain after thoracotomy. Intercostal blockade, paravertebral blockade, epidural blockade and spinal blockade are commonly used for pain management.
Patient controlled analgesia (PCA) can approach the near optimal state of analgesia, maintained with minimum sedation and side effects. The patient adjusts the repetition of dose to the analgesic needs, outreaching the minimum effective analgesic concentration. PCA can be used for drug delivery via intravenous (most frequently) or epidural route. Before the initiation of PCA use, a sufficient analgesic state should be established.
11.3.2 Fluid Management
Fluid administration for lung resection patients must be determined on an individual basis. Post thoracic surgery especially in resections intravenous fluids are given in reduced amounts to prevent pulmonary insufficiency. Care is taken not to overhydrate the patient and oral feeding is encouraged as soon as possible. In a review of published reports, Slinger (PMID: 7579118) [9] gives guidelines regarding postoperative fluid management: (1) a maximum of 20 mL/kg fluid to be given intravenously for the first 24 postoperative hours, (2) acceptance of average urine output of 0.5 mL/kg/h the first 24 h, and (3) use of vasopressors if tissue perfusion is inadequate and the 20 mL/kg maximum of fluid has already been administered.
11.3.3 Deep Venous Thrombosis Prophylaxis
The prophylaxis should start when the patients are admitted in the hospital. Everyone should be given a prophylactic dose of heparin subcutaneously if not contraindicated at a dose 5000 IU twice daily and this is continued in the postoperative period till discharge. All patients should have stockings and the high-risk patients should be on compression stockings. If there are signs of DVT then a Doppler in arranged and patients put in treatment dose of heparin infusion and an IVC filter put in if necessary.
11.3.4 Management of Drainage Tubes
Placement and removal of chest tubes should be standardized by protocol after lung resection. If the postoperative chest X-ray shows expanded lung fields the no suction is applied even if there is bubbling. If there is airspace the suction is applied. It is preferable to use a balanced drainage system in all patients. Fluid drainage of 300–400 mL or less per 24 h is acceptable for chest tube removal after lung resection. Chest tube removal after drainage must be tailored to the particular patient’s course. When there is any concern about anastomotic leak in the chest or mediastinum after tracheal reconstruction, tubes should be left until resolution of the leakage.
11.3.5 Respiratory Therapy
The most common complications after thoracic surgery are related to the pulmonary system. Vigilant postoperative pulmonary care decreases the incidence of complications. Incentive spirometry and chest physiotherapy, including clapping, postural drainage, and vibratory therapy, aid in mobilizing mucous secretions and allowing patients to clear their own secretions. Ambulation is an excellent method of decreasing atelectasis. Nebulized albuterol is very helpful in curtailing or preventing bronchospastic episodes. If a patient has had multiple manipulations of the upper airway and there is concern about edema and stridor, intravenous and aerosolized steroids and aerosolized racemic epinephrine are effective in reducing edema.
11.4 Uniportal Video-Assisted Thoracoscopic Anatomic Lung Resections
Diego Gonzalez-Rivas9 , Yang Yang10 and Gening Jiang10
(9)
Department of thoracic surgery, Coruña University Hospital and Minimally Invasive Thoracic Surgery Unit (UCTMI), Xubias 84, 15006 Coruña, Spain
(10)
Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, 200433, China
11.4.1 Introduction
Uniportal video-assisted thoracic surgery (VATS) has a history spanning over more than 10 years and has recently become an increasingly popular approach to manage most of the thoracic surgical diseases [10]. Less invasiveness, protential reduction of pain, and a better cosmesis are some of the advantages that have stimulated the spread of the uniportal technique around the world [11]. Thanks to the experience gained since its origins in 2010, as well as the improvement of surgical instruments and other technology, the technique has evolved to become a feasible and safe approach for increased indications for VATS major pulmonary resections. [12–15].
11.4.1.1 Material
The adoption of conventional surgical instruments to a thoracoscopic design (long curved or angled instruments with both proximal and distal articulation) is one of the key requirements in order to accomplish a successful single-incision lobectomy (Fig. 11.9a). In addition, the evolution of HD cameras and curved vascular clip appliers as well as more narrow and angulated staplers have contributed to the improvement of this approach by making it safer for a broad range of indications. The use of videolaparoscope with the distally mounted CCD design facilitates the instrumentation (Fig. 11.9b).
Fig. 11.9
Instrumentation of uniportal VATS lung resections
11.4.1.2 General Aspects
The surgeon and the assistant must be positioned in front of the patient in order to have the same thoracoscopic vision throughout the procedure (Fig. 11.9a). Despite this anterior positioning of the view, thanks to the 30° scope and combined movements along the incision enable different angles of vision. The advantage of using the thoracoscope in coordination with the instruments is that the vision is directed to the target tissue. By doing this, we are lining up the instruments to address the target lesion from a direct, sagittal perspective [16]. An optimal exposure of the hilum is vital in order to facilitate dissection of the structures as well as preventing interference with instrumentation.
The patient is positioned as in a conventional VATS, in a lateral decubitus position. The incision is preferably placed in the fifth intercostal space, a bit anteriorly and is about 3–4 cm long. The location of the incision provides better angles for hilar dissection and insertion of staplers. In order to help with the exposure of the hilum, it is recommended to rotate the surgical table away from the surgeon during the dissection and division of structures. The opposite movement of the table would be advisable for the subcarinal lymph node dissection. We always recommend inserting the staplers through the anterior part of the incision with angulation (Fig. 11.9d). The use of curved-tip stapler technology allows for improved placement around superior pulmonary vein and bronchus through a single incision, which are the most difficult structures to divide through a single port. It is important to dissect the vessel as distal as possible in order to achieve better angles for the stapler insertion. When the angle is difficult for the insertion of the stapler the use of new improved vascular clips (click aV plus,) is recommended (anti sliding system). Alternatively, ligation of the vessels by using sutures can also be done.
It is crucial that the thoracoscope remains positioned at the posterior part of the incision at all times, as it works with the instruments in the anterior part (Fig. 11.9c). The only step where we place the camera below the stapler insertion (anterior part) is for the division of the anterior part of the minor fissure.
When doing upper lobectomies, the pulmonary artery is normally divided first, followed by vein (Fig. 11.10). When the lobectomy is completed, the lobe is removed in a protective bag and a systematic lymph node dissection is performed. At the end of the surgery, the intercostal spaces are infiltrated with bupivacaine under thoracoscopic view. Only one chest-tube is placed in the posterior side of the incision.
Fig. 11.10
Uniportal VATS left upper lobectomy
11.4.1.3 Surgical Technique
Lower Lobectomy
The technique of the lobectomy may be different depending on whether the fissure is complete or not. If the fissure is complete, the dissection of the artery in the fissure is attempted. There are some cases where the arterial branches of the superior and basilar segments are easier to be divided. The vein is dissected and divided. Then, the lower lobe bronchus is exposed, dissected, and stapled as done with the vein. The last step is to staple the fissure.
In the presence on an incomplete fissure or if there is no visible artery, the technique may change. In order to avoid postoperative air leaks, the preferred method does not involve dissection within the fissure. In this case, the lobectomy must be performed from caudal to cranial, leaving for last, the stapling of the fissure (fissureless technique). The sequence of the dissection should be as follows: inferior pulmonary ligament; inferior vein; inferior bronchus. Subsequently, a plane is created between the bronchus and the artery and the artery is taken, leaving the fissure to be developed last.
When performing a right lower lobectomy, care must be taken in order to identify the bronchus or artery of the middle lobe. Once the inferior pulmonary vein has been stapled, the lower lobe bronchus is exposed, dissected, and divided from its inferior side to its bifurcation with the middle lobe bronchus. After this, the bronchus is dissected and the plane between the bronchus and the artery is developed and further dissected. This exposes the artery. The removal of the peribronchial lymph nodes is recommended to better define the anatomy. Once identified, the segmental arterial branches to the lower lobe (basilar artery and superior segmental artery) are divided, leaving the fissure to be stapled at the end.
Upper Lobectomy
The uniportal view aids in the dissection and division of upper anterior and apical segmental trunks, which are normally hidden by the superior vein when using a conventional thoracoscopic view. We first recommend dividing the upper anterior and apical segmental trunk (Fig. 11.10a, b), in order to facilitate the insertion of the staplers in the upper lobe vein. Once this arterial branch has been stapled, the vein will be easily transected (Fig. 11.10c, d). It is important to dissect the vein as distal as possible to allow for an optimal stapler insertion. Another interesting option for management of the upper lobe vein is to open the fissure as the first step, from a hilar view, and then create a tunnel between upper and lower vein with identification of the bronchus and artery (Fig. 11.11a). The anvil of the stapler is placed over the artery, dividing the anterior portion of the fissure (Fig. 11.11b) and allowing for the mobilization of the lobe (to allow the stapling of the vein from a different angle).
