Video-assisted thoracic surgery (VATS) in the management of lung cancer was first described in the early 1990s. Recent studies have shown that major lung resection by VATS has low perioperative morbidity and mortality rates and is associated with a good prognosis in patients with stage I non–small cell lung cancer (NSCLC).
Step 1
Surgical Anatomy
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Knowledge of thoracic anatomy is critical to VATS. Anatomic lung resection requires a dissection of the pulmonary hilum and ligation and division of the bronchus, pulmonary artery, and pulmonary vein to the involved pulmonary lobe. The rationale behind lung resection is a complete removal of tumor along with an en bloc resection of the lymph nodes from the mediastinum associated with the tumor.
Step 2
Preoperative Considerations
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All patients considered for VATS lung resection receive preoperative computed tomography (CT) scan of the thorax, bronchoscopy, and pulmonary function tests. Mediastinoscopy is performed if there is radiologic evidence of mediastinal lymphadenopathy (>1 cm) on preoperative CT scan of the thorax. Positron emission tomography is performed only when indicated. Patients with clinical stage I or II disease are considered for VATS lung resection. Patients with tumor size greater than 4 cm and bronchoscopic findings of endobronchial lesions are excluded.
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The standard setup for VATS consists of a videoscope, a light source, and a camera. A monitor is placed on each side of the operating table, near the head end of the patient. The cords and cables of the videoscope are passed toward the head of the table in a standard fashion to minimize cluttering.
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The tower that contains the video components generally consists of, from top to bottom, a video monitor, which can be slaved to a second video monitor placed on the opposite side of the operating table; a camera processing unit; a light source; a Super VHS recorder; and a color printer.
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For major VATS lung resections, we use a 10-mm 30-degree videoscope. We endeavor to minimize the use of specially designed endoscopic instruments, with the exception of endoscopic stapling devices. The instruments in a standard thoracotomy set would suffice without modification. The advantages of conventional instruments are that they are light, easy to use, familiar to all surgeons, universally available, and inexpensive. Further, these instruments allow tactile feedback through instrument palpation.
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For VATS major lung resection, the patient will require general anesthesia and double-lumen intubation to achieve selective one-lung ventilation so as to collapse the side of the operation. A single-lumen endotracheal tube can be used with an endobronchial blocker as an alternative if double-lumen intubation is not feasible. It is good practice for the operating surgeon to perform on-table flexible bronchoscopy at this point to rule out endobronchial anomalies, if this has not been already performed.
Step 3
Operative Steps
1
Positioning of the Patient
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The positioning of the patient is in the lateral decubitus position, as per a posterolateral thoracotomy, because the surgeon should always be prepared to convert the procedure from a minimally invasive operation to an open conventional one. The patient is appropriately padded with one roll placed on either side of the chest and secured with straps. The operating table is flexed to allow the intercostal spaces of interest to be further opened to achieve better access as well as to bring the pelvis out of the way of the instruments.
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Typically the operating surgeon stands facing the front of the patient, as does the assistant holding the camera, with the scrub nurse standing facing the back of the patient.
2
Vats Port Strategy
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Our standard VATS port-site strategy uses a three-port technique, which consists of an inferior port for insertion of the videoscope, an anterior port, and a posterior port for placement of instruments. The anterior port is modified into an anteriorly placed utility mini-thoracotomy.
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In general, the sixth or seventh intercostal space in the midaxillary line is the position of choice for placement of the inferior port for videoscope access into the pleural cavity. This is the first port to be made, so it can be created only in a “blind” fashion; this care is taken to avoid injury to lung parenchyma, especially if the likelihood of pleural adhesions is high, and if necessary some blunt dissection may be needed. Digital palpation is recommended to confirm absence of adhesions.
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The videoscope is protected by a camera port, which prevents smudging of the camera lens. An assessment of the pleural cavity is made once the videoscope is positioned, and in cases of known or suspected malignant pathology, a special effort is made to look for pleural deposits, which may represent pleural metastases.
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The remaining anterior and posterior instrument ports are created under videoscopic vision. The precise location of the ports depends on the pathology and takes into account the location of the fissure as seen via the videoscope as well as the presence of any pleural adhesion.
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A typical port strategy is as follows: The second incision is placed after inspection of the intrathoracic anatomy, avoiding areas of adhesions. The anterior utility incision, 2 cm long, is placed in the fifth intercostal space starting at the anterior axillary line. The posterior incision is placed one or two intercostal spaces below and posterior to the tip of the scapula.
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As a general principle, an adequate distance should exist between the ports to avoid “fencing” of instruments. The instruments and the videoscope should all face the direction of the target pathology because “mirroring” may cause awkward handling of the instruments.
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We frequently perform a segmental rib resection for the anterior utility port for cases of VATS major lung resection. The segmental rib resection technique is especially advantageous in redo cases, when tumor size is larger than 3 cm, and in cases in which bidigital palpation is desirable.
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The skin incision is up to 5 cm long. The incision is carried down to the rib, which is then resected subperiosteally for the length of the incision ( Fig. 4-1 ). With the use of a soft tissue retractor only (i.e., no rib spreading), a gap of up to 5 cm between ribs can be obtained underneath the wound to allow accurate bidigital palpation and retrieval of large specimens. At the time of wound closure, there is no need to reapproximate the ribs.
Figure 4-1
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The principles of VATS major lung resection will be illustrated with a right VATS pneumonectomy.
3
Right Pneumonectomy
Division of the Superior Pulmonary Vein
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The inferior pulmonary ligament is released to facilitate mobilization of the right lung. A sponge-holder clamp is passed via the posterior port to grasp the right lower lobe close to the inferior border to exert an upward traction. A rigid Yankauer sucker placed through the anterior port is used to depress the diaphragm, and a long-tipped diathermy is used to incise the inferior pulmonary ligament ( Fig. 4-2 ), which is then further released with blunt dissection using a mounted peanut swab ( Fig. 4-3 ).
Figure 4-2
Figure 4-3
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The right lung is then repositioned, with the posterior sponge-holder clamp grasping the right middle lobe close to its inferior border, giving it a posterior traction, which exposes the hilar structures.
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The superior pulmonary vein is exposed using a combination of sharp and blunt dissection. The upper and lower borders of the superior pulmonary vein are defined using a mounted peanut swab. The tip of a right-angled clamp is passed round the back of the superior pulmonary vein, and a silk tie is slung around the superior pulmonary vein ( Fig. 4-4 ). The space behind the superior pulmonary vein is further developed with a peanut swab mounted on a right-angled clamp.
Figure 4-4
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The videoscope is then repositioned through the anterior port, and an EndoGIA vascular stapler (Ethicon Endo Surgical Inc., Cincinnati, OH) is inserted through the inferior port. With slight tension on the silk tie, the flat blade of the vascular stapler is eased behind the superior pulmonary vein ( Fig. 4-5 ). To help keep the tip of the stapler from emerging behind the superior pulmonary vein, it might be necessary to use a mounted peanut or a right-angled clamp to push out of the way any structure that could cause obstruction. The superior pulmonary vein is then divided.
Figure 4-5
Division of the Right Pulmonary Artery
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The videoscope is returned to the inferior port position. Maintaining the same posterior traction using the posterior sponge-holder clamp, the right pulmonary artery is exposed with sharp and blunt dissection. Both upper and lower borders of the right pulmonary artery are defined using blunt dissection with a mounted peanut ( Fig. 4-6 ).
Figure 4-6
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A right-angled clamp is passed behind the right pulmonary artery and a silk tie is slung around the vessel ( Fig. 4-7 ). The space behind the right pulmonary artery is developed using a peanut mounted on a right-angled clamp.
