Video-assisted thoracic surgery (VATS) lobectomy has been used in the treatment of lung cancer since the early 1990s. While there is evidence that lobectomy is better than wedge resection in most patients, there are no large prospective, randomized studies favoring video-assisted lobectomy over conventional lobectomy by thoracotomy.¹ However, there are several series that support the use of VATS lobectomy technique. These include some small (n ≤ 100) prospective, randomized studies that compare VATS with lobectomy by thoracotomy (Table 74-1). From these data, as well as data from several exclusive VATS series, it is clear that VATS lobectomy is technically feasible and safe and even may provide better quality-of-life outcomes in patients with resectable lung cancer. Despite these efforts, VATS lobectomies represent about 25% to 30% of all lobectomies performed in the United States.⁶

The VATS cancer operation is specifically defined as an anatomic lobectomy (or segmentectomy, when indicated) and consists of individual hilar ligation by means of three or four small incisions and no rib spreading. This anatomic lobectomy should leave the patient with results identical to a cancer resection by thoracotomy. That is, the surgeon resects the tumor with negative margins, performing individual vascular and bronchial ligation and division and a complete hilar lymph node dissection. Furthermore, mediastinal lymph node dissection or sampling is performed as appropriate. Certain aspects of the technique, most notably avoidance of rib spreading or the use of a rib retractor, are emphasized, with the goal of improving the patient’s postoperative experience. Cosmetic aspects, such as smaller scars (largest incision is usually 5 cm), are also important. One variant, the video-assisted simultaneously stapled lobectomy, does not involve individual hilar ligation. In essence, it is a different operation and is not discussed in this chapter. Nevertheless, some surgeons have achieved excellent results with this technique.⁷

Oncologically, this surgery is equivalent to a lobectomy by thoracotomy. The ultimate measure of success in cancer surgery is long-term survival. Proving that VATS lobectomy is comparable with conventional lobectomy would require a large prospective, randomized multicenter trial. It is unlikely that this will ever occur for lack of sufficient patient accrual. Many patients prefer the minimally invasive technique, and the lack of data of the highest order (i.e., large prospective, randomized series) does not matter to them. Today’s patients are well informed, often using resources such as the Internet to choose the optimal technique or surgeon. Several meta-analyses show similar-to-possibly improved survival with VATS lobectomy compared with open lobectomy.^8,9

In lieu of ideal prospective, randomized data, the existing data demonstrate comparable and sometimes better long-term survival rates with VATS lobectomy (Table 74-2). Stage I 5-year VATS survivals can range from 63% to 97%.^12,14,15 Although direct comparison is precluded, indirect comparison of these data with two series of patients undergoing lobectomy by thoracotomy demonstrates a trend for improved survival with VATS lobectomy. Mountain¹⁶ reported 5-year survival in stage IA surgical patients of 61%. Martini et al.¹⁷ reported 5-year survival of 82% in stage IA surgical patients. Some hypothesize that the higher survival range observed with VATS is a result of the decreased presence of inflammatory mediators interleukin 6 and interleukin 8 in VATS patients compared with thoracotomy patients.^18–20 This theoretical decrease in postoperative inflammation may free the immune system to devote more effort to tumor cell surveillance and destruction.

The reported locoregional recurrence rates for VATS lobectomy are comparable with the published standards for lobectomy (Table 74-3). In general, locoregional disease is estimated to recur in 5% to 10% of all patients.^1,17 Port-site and incisional recurrence are extremely rare. Since the use of endoscopic bags for removing tumor became general practice, incisional or port-site recurrence has been reported to be in the low range of 0% to 0.57% of all cases.^6,22

Lymph node dissection can be accomplished adequately in VATS lobectomy. In fact, several studies have shown that thoracotomy may provide only minimal, if any, advantage in exposing lymph nodes and stations.^23–25 Sagawa et al. reported their experience with standard thoracotomy after VATS lobectomy. This group reported an average increased yield of 1.2 lymph nodes (2%–3%) at follow-up thoracotomy, but without effect as to clinical stage in a single patient. Lymph node sampling was very efficient, with 40 nodes sampled on the right and 37 on the left using the VATS technique alone.²⁵

The indications for VATS lobectomy are basically the same as those for conventional lobectomy, namely, non–small-cell lung cancer, metastasectomy, and carcinoid tumors. The ideal and typical patient has stage I non–small-cell lung cancer. Absolute contraindications to VATS lobectomy are becoming less frequent and still include the presence of T4 tumors that require a more direct approach to resection such as carinal resection and the presence of N3 disease. Relative contraindications include central hilar tumors, bulky mediastinal or hilar lymphadenopathy and a history of neoadjuvant chemotherapy or radiation. Although these issues can be managed by surgeons experienced in minimally invasive techniques. Incomplete or absent fissures rarely mandate conversion to thoracotomy. Furthermore, segmentectomy can be performed thoracoscopically.²⁶ Older or more frail patients even may tolerate lobectomy better by VATS than by thoracotomy.²⁷

The preoperative studies for VATS lobectomy are those typically performed for a lung cancer workup. These include chest radiograph, CT scan, bronchoscopy, pulmonary function studies, PET scan, and when necessary, other modalities for metastatic workup. In reviewing the CT scan, the surgeon should focus on whether there are any issues, such as bulky lymphadenopathy, that would render the hilar dissection more difficult with VATS.

It is important to perform a safe and effective surgery without compromising any established oncologic principles. Conversion to an open technique should be viewed as a sign of good judgment, not failure. The adequacy of resection should not be jeopardized by the predilection for a VATS approach.

A thoracotomy tray with vascular clamps and chest retractors always should be available in the room. Sponge-stick and dental pledgets also should be ready and available on the field for tamponade of major bleeding sites while a thoracotomy is expeditiously and carefully performed.

Once preoperative evaluation has deemed the patient to be a candidate for VATS lobectomy, the patient is brought to the OR. The patient is anesthetized and intubated. Bronchoscopy is performed to rule out endobronchial lesions that would preclude a VATS approach. Mediastinoscopy is performed when indicated. Lung isolation is obtained with a double-lumen endotracheal tube or bronchial blocker. Good lung isolation is an absolute need throughout the entire case. Once the position of the tube is confirmed, the patient is placed in the lateral decubitus position. The endotracheal tube is reconfirmed via bronchoscopy to ensure that it has not migrated out of position. The ipsilateral lung is immediately collapsed to permit ample time for atelectasis to occur before entering the chest. Suction also may be applied through a suction catheter or bronchoscope to aid in collapse of the isolated lung.

Several different approaches have been described in the literature. Two to four ports which include the incision used to extract the lobe within a bag which is typically about 3 to 5 cm are required to perform a VATS lobectomy. We prefer to use three incisions: an inferior camera port, a posterior working port, and an anterior incision (Fig. 74-1). Avoidance of rib spreading is the key element in VATS lobectomy for preventing postoperative pain and trauma to the intercostal nerve bundles, which are responsible for the postthoracotomy pain syndrome.