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Technical aspects of single-port thoracoscopic surgery for lobectomy
© Chen et al.; licensee BioMed Central Ltd. 2012
Received: 22 October 2011
Accepted: 16 May 2012
Published: 6 June 2012
Thoracoscopic Surgery is in common use in routine surgical practice. With the advancement of the various techniques and instruments required, mini wounds and fewer thoracoports become practical in recent years. Here, we report our experience of performing lobectomy with radical lymph node dissection in 3 patients using regular straight endoscopic instruments. We demonstrate the feasibility of such techniques and discuss the key points of effectively performing the procedures. Because of the favorable outcomes, we encourage such procedures to be widely applied in surgical operations of various types.
Video assisted thoracoscopic surgery (VATS) is indicated for any thoracic procedure that would be aided by the use of a thoracoscope. At present, there is no clear definition of how small an effective endoscopic procedure may be. In the past, thoracic procedures have usually been performed through multiple port wounds, especially in complicated cases of cancer resection. Single- incision thoracoscopic surgery is also known as single-port thoracoscopic surgery or uni-portal thoracoscopic surgery. Single- incision thoracoscopic surgery grown increasingly popular in recent years. A variety of general thoracic surgery procedures can be accomplished by a single port wound instead of the multiple port wounds used previously. Certain modified tools are very helpful in the execution of single-port endoscopic surgery, such as reticulating instruments [1, 2]. However, such a procedure is infrequently required in cancer surgery . In general, a port wound is typically 1.5 to 2.5 cm. In certain circumstances, up to 3.5 cm may be necessary to pull a large specimen out, such as in the case of one or two lobes of lung tissues. Here, we report 3 cases of lung cancer. The three patients were treated with a single-incision approach for lobectomy and radical lymph node dissection. The technical aspects are discussed.
A 70-year-old woman complained of chest tightness. During her annual heath examination, a chest radiograph revealed an irregular opacity in the left lower lung field. She was then admitted for cancer screening. A CT scan uncovered a tumor in the superior segment of the left lower lobe of mediastinal lymphadenopathy, especially in the aortopulmonary window. Further investigation, including sputum cytology and percutaneous needle biopsy, failed to obtain a clear histology. She was then prepared for surgery in order to both obtain a diagnosis and identify the treatment course. During the operation, a 2.5-cm wound was initially made after the induction of general anesthesia. Using straight instruments to identify the tumor in the left lower lobe, a linear stapler was employed for wedge resection. The frozen section displayed adenocarcinoma. Because of the tumor’s malignant nature, we then proceeded to lobectomy and radical lymph node dissection. Before the procedure, we slightly extended the wound to 4 cm. The wound was protected with a plastic wound protector. The procedure took approximately 3 hours to complete. The estimated blood loss was 300 ml. After observation for 2 days, the chest tube was removed. Three days after the operation, the patient was discharged. The tumor was 2.5 cm in its greatest dimension. The station 5 (AP window) lymph nodes and hilar lymph nodes were positive for malignancy. She is currently on adjuvant chemo-radiation due to this pIIIA adenocarcinoma.
A 47-year-old man complained of productive cough for several months. He indicated that he had no past history of disease. He sought medical attention in the outpatient department. After a series of work-ups, he was found to have multiple small nodules in the bilateral lungs and mediastinal lymphadenopathy. Bronchoscopic findings were normal and washing cytology was also negative for malignancy. He was then treated surgically to confirm the diagnosis. Because the larger lesion was easily approached in the right middle lobe, we performed thoracoscopic surgery on the right side. Due to the more centralized location of the lesion, lobectomy of right middle lobe was performed. The final wound size was 3.5 cm in length. The estimated blood loss was less than 30 ml. The operative procedure elapsed time was 90 minutes. The endotracheal tube was removed immediately after the procedure. His chest tube was removed 2 days later and he was discharged one day after that. The final pathology report indicated adenocarcinoma in situ. Due to this in situ multiple focal adenocarcinoma, he is currently on chemotherapy.
Video-assisted thoracoscopic surgery through a single incision is a challenging technique for most thoracic surgeons. The transition from conventional thoracotomy to thoracoscopic surgery took a longer time than might have been expected. Currently, the transition from multi-portal thoracoscopic surgery to uni-portal thoracoscopic surgery is also taking a fair amount of time. It is reasonable that thoracic surgeons would want to know whether such a procedure is feasible, safe and has at least an equivalent oncological outcome as the previous procedures. This brief paper reports the feasibility and safety only. The long-term oncological outcome remains to be determined after more patients have undergone such procedures.
Conventional endoscopic multiport procedures
Localization of neoplasm
A potential problem in the diagnostic procedure is the lack of tactile sensation. Especially in the setting of bronchoalveolar carcinoma with air-bronchogram, it may sometimes be difficult to definitely confirm the location of the neoplasm in the absence of pleural dimpling or if the solid component is tiny. A CT–guided needle localization by the radiologist may help in such an event. In our case, we did not perform needle localization because the neoplasm was identified. Delicate tactile exploration to find a tiny or soft neoplasm using a variety of instruments is sometimes possible for experienced surgeons. In fact, at times, the index finger is used to palpate the tumor through the small wound in order to avoid uncertainty. Whatever the techniques applied, it is crucial to confirm the tumor location prior to the procedure. Without an accurate preoperative localization, there will be uncertainty during the course of the endoscopic procedure.
Adequate position of the single port wound
The necessity of the trocar
Division of fissures, branches of pulmonary vessels and bronchus
The minimum effective wound size
The hospital stay was 3 days. The stay in the intensive care unit was 12 hours for 2 patients and the third patient was brought to the general ward. Postoperative pain was only minimal without the need of an epidural or intravenous patient-controlled anesthesia. The maximal visual analogue score for pain was 4, 4, and 5 for the three patients. Refraining from the use of a rib retractor during the operation is thought be an important means of decreasing the acute pain which can occur after thoracic surgery. The patients described here experienced only minimal intercostal neuralgia. In addition to not using a rib retractor, a smaller wound size also helps to alleviate acute wound pain. A shorter stay in both hospital and ICU is the expected outcome.
Single-port thoracoscopic lobectomy with radical lymph node dissection is an alternative approach to conventional thoracoscopic lobectomy in lung cancer treatment. Although technically plausible and feasible, the issues of patient acceptability, the cosmetic and oncologic results, and ultimately cost-effectiveness, remain to be determined in the future using randomized-controlled trials and long-term follow-up.
Written informed consent was obtained from the patient for publication of this report and any accompanying images.
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