Video-assisted thoracic surgery (VATS), also termed thoracoscopic surgery, refers to minimally invasive chest surgery that avoids rib spreading and rib resection and relies entirely on cameras and video technology for visualization. Thoracoscopic techniques may be applied to a variety of thoracic procedures, but thoracoscopic pulmonary resections are the most commonly performed. Despite the potential advantages of minimally invasive surgery, only approximately 30% of major pulmonary resections are currently completed using the thoracoscopic technique. The strategies and outcomes of thoracoscopic pulmonary resections are described, with a focus on anatomic procedures.

Thoracoscopic techniques may be applied to virtually all pulmonary resections, from wedge resection to pneumonectomy. The indications for thoracoscopic pulmonary resection are similar to those for resections performed using an open approach. The only absolute contraindication to thoracoscopic resections is the inability to achieve a complete resection or reconstruction. Relative contraindications include inability to maintain single-lung ventilation and tumor size, which may preclude a minimally invasive approach to extraction. Prior thoracic radiation, prior thoracotomy, prior resections, and adhesions are no longer considered absolute contraindications, and resection in these patients using minimally invasive techniques can be performed by experienced surgeons.

Several surgical strategies have been employed to perform an anatomic lobectomy, utilizing a variety of incisions to facilitate dissection. We believe that the thoracoscopic strategy described below provides for equivalent oncologic results compared to an open strategy and minimizes perioperative and postoperative complications.

Single-lung ventilation is required and may be achieved with a dual-lumen endotracheal tube or a bronchial blocker. The patient is placed in the lateral decubitus position. It is helpful to limit the tidal volume to increase the space within the thorax, and pressure-controlled ventilation is preferred. Most thoracoscopic anatomic resections may be performed via two or three incisions, and the overwhelming majority in our experience has been performed with only two incisions. Wedge resections should require no more than two incisions.

The placement of port incisions vary according to the preference and experience of the surgeon. In general, the port positions are the same whether an upper, lower, or middle lobectomy is performed, as this strategy places the access incision over the major fissure. The first port, placed in the 7th intercostal space in the midaxillary line, is used predominantly for camera placement and, ultimately, chest tube placement. The second incision (4 to 6 cm) is placed in the 5th or 6th intercostal space in the anterior axillary line. This site is chosen, in part, to allow easy access to hilar structures and to allow for extraction of the specimen (Fig. 11.1).

Instrumentation is important when performing thoracoscopic pulmonary resection, including the use of a 30-degree videoscope and long, curved instruments to improve retraction and dissection. High-definition video equipment improves visualization for difficult dissections. Linear staplers are used to control and divide lung parenchyma, vessels, and bronchus.

Once access to the chest has been achieved, thoracoscopic examination is undertaken. The lung parenchyma is assessed for presence of a mass, additional disease, metastatic disease, and adhesions. For most anatomic procedures (described in detail below), the specific pulmonary vein is the first structure to be divided, and complete hilar dissection usually performed prior to parenchymal division. Advantages of this hilar dissection technique include prevention of postoperative air leaks and minimization of back and forth retraction: dissection for an upper lobe, for example, begins anteriorly and progresses in the posterior direction only.

Most of the hilar dissection may be performed bluntly, with either a dissecting instrument or a thoracoscopic suction device, which also keeps the field dry during dissection. At the conclusion of the dissection, the fissure is completed with the stapling device and the specimen is removed using a protective bag. Mediastinal lymphadenectomy is subsequently performed, although this may be done prior to hilar dissection at the surgeon’s discretion.

In addition to the dissection strategy which varies according to the lobe being resected, the surgeon should have a planned strategy for conversion if bleeding is encountered or if there is failure to progress with the dissection thoracoscopically. Usually, conversion is best achieved by extending the anterior access incision to an anterior thoracotomy, as opposed to a separate posterolateral thoracotomy. It is important to note that most of the bleeding encountered can be controlled with direct pressure using a sponge stick, and that conversion need not be performed emergently.

Thoracoscopic wedge resections may be performed for various indications, both diagnostic and therapeutic. In general, wedge resections are technically straightforward, and the most difficult aspect of the procedure may be the localization of the nodule to be resected. Localization may
be particularly challenging when the tumor is less than 1 cm in diameter and not immediately subpleural, or when numerous wedge resections are required, such as for pulmonary metastasectomy. Tumor localization techniques include local injection of radiotracer, wire hook and coil markers, radiopaque markers using intraoperative fluoroscopy, and navigational bronchoscopy. However, other investigators have demonstrated that successful localization may be achieved in the majority of patients without these techniques.

Metastasectomy has become the standard of care for patients with secondary lung tumors. Complete macroscopic resection is the most important prognostic factor since patients with untreated metastatic disease having a median survival of less than 10 months and a 5-year survival rate of less than 5%. Although still controversial, thoracoscopic techniques are becoming more frequently utilized for the resection of pulmonary metastases, with equivalent efficacy and superior quality-of-life outcomes, as compared to thoracotomy.

Recently, single-and multiinstitutional studies have demonstrated that thoracoscopic lobectomy is an accepted oncologic procedure for patients with early stage lung cancer, and is recommended in treatment guidelines for nonsmall-cell lung cancer (NSCLC). Thoracoscopic lobectomy has been demonstrated to have better outcomes compared to conventional thoracotomy,
including shorter length of stay, shorter chest tube duration, decreased postoperative pain, improved preservation of pulmonary function, reduced inflammatory response, shorter recovery time, lower cost, and better compliance with adjuvant chemotherapy when required. In addition, it has been demonstrated that thoracoscopic lobectomy is a safer procedure than lobectomy by thoracotomy, as it is associated with fewer postoperative complications.

Using a prospective database, the outcomes of patients who underwent lobectomy at Duke from 1999 to 2009 were analyzed with respect to postoperative complications. 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% vs. 19%; P = 0.05), a lower incidence of atrial fibrillation (13% vs. 21%; P = 0.01), less atelectasis (5% vs. 12%; P = 0.006), fewer transfusions (4% vs. 13%; P = 0.002), less pneumonia (5% vs. 10%; P = 0.05), less renal failure (1.4% vs. 5%; P = 0.02), shorter chest tube duration (median 3 vs. 4 days; P < 0.0001), and shorter length of hospital stay (median 4 vs. 5 days; P < 0.0001).

Similar results were obtained when the Society of Thoracic Surgeons (STS) database was analyzed by Paul and colleagues. 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 thoracotomy and 1,281 thoracoscopy. 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%) who 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%] vs. 147 [11.5%]; P = 0.0004), reintubation (N = 18 [1.4%] vs. 40 [3.1%]; P = 0.0046), and blood transfusion (N = 31 [2.4%] vs. N = 60 [4.7%]; P = 0.0028), as well as a shorter length of stay (4.0 vs. 6.0 days; P < 0.0001) and chest tube duration (3.0 vs. 4.0 days; P < 0.0001). There was no difference in operative mortality between the two groups.

Finally, Berry and colleagues reported a recent analysis of high-risk patients over 70 years of age. During the study period, 338 patients older than 70 years (mean age 75.7 ± 0.2) underwent lobectomy (219 thoracoscopy, 119 thoracotomy). Operative mortality was 3.8% (13 patients) and morbidity was 47% (159 patients). Patients with at least one complication had increased length of stay (8.3 ± 0.6 vs. 3.8 ± 0.1 days; P < 0.0001) and mortality (6.9% [11 of 159] vs. 1.1% [2 of 179]; P = 0.008). Significant predictors of morbidity by multivariable analysis included age (odds ratio 1.09; P = 0.01) and thoracotomy as surgical approach (odds ratio 2.21; P = 0.004). Thoracotomy remained a significant predictor of morbidity when the propensity to undergo thoracoscopy was considered (odds ratio 4.9; P = 0.002).

As experience with thoracoscopic lobectomy increases, minimally invasive strategies are being more readily applied to more complex cases and surgical interventions, including segmentectomy. A recent review of the STS database demonstrates that segmentectomy is performed in approximately 5% of pulmonary resections at institutions contributing to the database. Thoracoscopic segmentectomy is defined as a sublobar resection of one or more anatomic pulmonary segments using a completely minimally invasive approach. As with thoracoscopic lobectomy, visualization is dependent on video monitors and rib spreading is avoided. Thoracoscopic segmentectomy employs anatomic resection, with individual vessel ligation. Hilar and mediastinal lymph node dissection are a standard part of the procedure.