MULTIMEDIA MANUAL OF
MMCTS
doi:10.1093/mmcts/mmv014 published online 14 July 2015.
CARDIO-THORACIC SURGERY
Video-assisted thoracoscopic lobectomy: operative technique Marco Scarcia,*, Alessandro Pardolesib, Edward Joseph Caruanaa, Francesco Petrellab and Piergiorgio Sollia Department of Thoracic Surgery, Papworth Hospital NHS Foundation Trust, Cambridge, UK Division of Thoracic Surgery, European Institute of Oncology, Milan, Italy
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b
* Corresponding author. Department of Thoracic Surgery, Papworth Hospital NHS Foundation Trust, Ermine Street South Papworth Everard, Cambridge CB23 3RE, UK. Tel: +44-1480-364474; fax: +44-1480-364740; e-mail:
[email protected] (M. Scarci). Received 8 January 2015; received in revised form 6 May 2015; accepted 17 June 2015
Summary In this study, we present our technique for performing video-assisted lobectomy. This is presented in clear, easy-to-follow, sequential steps, noting variations on the most established technique and the rationale for this divergence. We also provide an instrument preference card, some operative tips and high-quality videos. Keywords: Humans • Lobectomy • Video-assisted surgery
INTRODUCTION Definition Video-assisted thoracoscopic surgery (VATS) lobectomy was initially described in 1993 [1, 2]. Its use is now widespread, even if there is a huge variation in the definition of this type of operation. We use the Cancer and Leukemia Group B definition of VATS lobectomy as follows [3]: (i) A utility incision to a maximum length of 5 cm, and two further ports. (ii) Avoidance of rib spreading or resection, while using a soft tissue retractor (Alexis®) to facilitate the introduction of instruments. (iii) Consistent, systematic sampling of Station 7 and two lobe-dependent lymph nodes. Whilst some authors routinely use mediastinoscopy in the same session, we believe that this is unnecessary and that lymphadenectomy can be safely performed through the VATS approach. (iv) All the anatomical structures are identified and individually divided. (v) All operative steps are visualized through the monitor and not through the utility incision [4].
Indications and contraindications We do not believe that tumour size is per se a contraindication to VATS. It is true, though, that for large tumours, the manipulation of the lobe is more difficult and potentially more hazardous, because of the risk of tearing small arterial branches in an attempt to gain visualization.
In the past, chest wall involvement was also considered a relative contraindication to VATS. We feel that it is possible to perform an extrapleural stripping or limited chest wall resection through a VATS approach. While some might dispute the potential advantages of this approach in such cases, we believe that avoiding rib spreading is beneficial, especially in patients with limited pulmonary reserve. We feel that previous chemotherapy is not a contraindication to VATS. While it is true that one may encounter strong periadventitial inflammatory reaction, this is not the norm, and it remains possible to perform a safe dissection of vessels. Similarly, we have also successfully performed VATS in patients with previous thoracotomies. Provided there is a small space for the thoracoscope at the beginning of the dissection, it is possible to mobilize the lung once the correct plane is entered; although this procedure is occasionally quite timeconsuming. In our opinion, the only contraindications to VATS are large hilar tumours and bulky lymphadenopathy. Several important factors should be considered before starting a VATS lobectomy procedure. One of the most important points is that the entire operating room team (nurses, scrub, technicians and assistants) needs to be familiar with VATS procedures and instrumentation. The surgeon who is performing VATS lobectomy should have done a relatively large number of smaller VATS procedures (i.e. wedge resection, lymph node biopsies, etc.) and should have observed several ‘live’ VATS lobectomies. Small tumour (cT1a/b) with no hilar lymph node involvement (cN0) should be considered an ideal case for a beginner to start training with the VATS lobectomy procedure; the N1 nodal dissection can be challenging for both the instructor and the learner. A
© The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
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careful preoperative examination of chest computer tomography scan is strongly suggested to identify the presence of vascular anomalies or calcified lymph nodes avoiding unexpected and tricky intraoperative findings.
SURGICAL TECHNIQUE Patient positioning Unlike access via thoracotomy, correct patient positioning is essential to facilitate VATS. The patient’s hip should be placed at the level of the table break, so as to permit maximum separation of the ribs. The chest should be orientated parallel to the floor. Some authors advocate placing the upper arm on a gutter; however, we believe that such a device, while contributing to patient stability, greatly limits the movement of the thoracoscope. For that reason we suggest to keep the arms together between two normal pillows (Fig. 1).
Port positions We start by performing the utility incision at the level of the fourth intercostal space, usually in front of the anterior edge of the latissimus dorsi along an imaginary line between the tip of the scapula and the nipple. Even if the creation of this port might seem a trivial procedure, particular care must be taken to avoid oozing from the muscle as, during a lengthy procedure, blood collecting into the chest will absorb the light and hinder the dissection of the hilar structures. At this point, the hemithorax is carefully examined for signs of pleural spread or other conditions that would preclude resectability or a VATS approach. The second port, which will be used for the camera, is usually two interspaces below the utility incision, in the anterior axillary line. Care must be taken not to place this port too low, since this may result in diaphragmatic interference with the manipulation of the thoracoscope (particularly in obese patients), and may result in difficulty in visualizing the right upper lobe bronchus. The third port is normally placed along the same line of the camera port along the posterior axillary line. We recommend making the port incision about 2 cm long, so as to facilitate the introduction of staplers and sponge sticks for retraction. Making a small incision in an attempt to make the procedure more cosmetic increases the risk of nerve injury with potential chronic pain (Figs 2 and 3).
Figure 2: Placement of the ports (right side).
Figure 3: Placement of the ports (left side).
Right upper lobectomy Step 1: pulmonary ligament
Figure 1: Patient positioning.
(i) Through the utility incision, the right lower lobe is retracted superiorly. (ii) The thoracoscope is aimed anteriorly with the 30° lens pointed posteriorly. (iii) We proceed with the incision of the pulmonary ligament and collecting any lymph nodes for histology (Stations 8 and 9).
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Step 2: right upper lobe vein (i) The lung is retracted by means of a long sponge stick inserted through the posterior port, so as to facilitate the exposure of the superior pulmonary vein (Video 1). If the horizontal fissure is grossly incomplete, it might be possible to run a stapler along the intended fissure line at this stage, thus allowing independent movement of the upper and middle lobes along the horizontal axis represented by the interlobar pulmonary artery. Note that the pulmonary artery branches to the upper lobe tend to be more vertical, and those to the middle lobe more horizontal. (ii) Care must be taken to ensure that the venous anatomy is normal and that an inferior pulmonary vein is present. (iii) Once the inferior border of the vein is dissected, we go on to create a separation between the upper and middle lobe branches until the underlying pulmonary artery is visualized. (iv) We then extend the dissection superiorly between the first branch of the pulmonary artery and the superior edge of the vein. A Station 11 lymph node is consistently present between these two vessels, and should be removed. (v) Once a plane is created, we use a silicone vessel loop to retract the vessel and insert a stapler through the posterior port.
Step 3: anterior trunk (i) Division of the upper lobe vein allows exposure of the interlobar pulmonary artery with its first branch (Video 2).
(ii) The anterior trunk is dissected and encircled with a silicone vessel loop. (iii) While it might be tempting to push a dissector across the vessel without dividing the adventitia of the pulmonary artery, we believe that taking the time to do so greatly facilitates further dissection. (iv) The anterior trunk is dissected and encircled with a silicone vessel loop.
Step 4: posterior ascending artery Once the pulmonary artery is divided, the next step is dependent on the patient’s anatomy, with two potential approaches outlined below. Step 4a (i) Exposure and dissection of the recurrent apical branch of the pulmonary artery prior to dividing the bronchus, if this is visible. This makes further dissection of the airway safer (Video 2). Step 4b (i) If the recurrent apical branch is not visible, we proceed directly with dissection of the upper lobe bronchus. Although classic teaching in VATS lobectomy is to move from anterior to posterior, we suggest opening the pleura posteriorly and identifying the junction between the upper lobe bronchus and the bronchus intermedius. This will facilitate further dissection from the front as only very little tissue usually remains (Fig. 4). (ii) We would recommend keeping close to the bronchial wall and avoiding undue force in attempting to pass instruments. Unintended consequences would include parenchymal laceration with lung congestion, bleeding or haemoptysis through the endobronchial tube, as well as tears to the membranous portion of the bronchus.
Step 5: right upper lobe bronchus (i) The upper lobe is retracted posteriorly (Video 3).
Video 1: Upper lobe vein isolation and division.
Video 2: Division of the pulmonary artery branches.
Figure 4: Posterior identification and dissection of the junction between the upper and intermedius bronchus.
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Video 3: Right upper lobe bronchus isolation and division. Fissure division.
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Video 4: Middle pulmonary vein isolation and division.
(ii) We remove the lobar nodes that hide the surface of the right upper lobe bronchus. (iii) The right upper lobe bronchus is dissected and encircled with a silicone vessel loop and transected with a stapler introduced through the posterior incision.
Step 6: fissure (i) Once the right upper lobe bronchus is divided, it is usually easy to complete the fissure front to back, for which we recommend long thick stapler reloads. (ii) The first stapler goes through the utility port and is directed towards the hilum while taking care to remain above the middle lobe vein. (iii) The second stapler is more horizontal and must always be positioned above the interlobar pulmonary artery. After these two firings, it is easy to divide the remaining fissure (Video 3). The lobe is then extracted through a specimen retrieval bag.
Right middle lobectomy A middle lobectomy is performed mostly anteriorly, dividing in order: the vein, the bronchus and the artery. Each step allows exposure of the next structure.
Step 1: middle lobe vein (i) The lung is retracted from the posterior port with a long sponge stick (Video 4). This manoeuvre facilitates the exposure of the superior pulmonary vein. (Occasionally, if the horizontal fissure is grossly incomplete, it is possible to run a stapler along the intended fissure line. Such a manoeuvre will allow independent movement of the upper and middle lobe along the horizontal axis represented by the interlobar pulmonary artery.) (ii) The branches to the upper lobe tend to be more vertical, whereas those to the middle lobe more horizontal. With a combination of blunt and diathermy dissection, it is possible to isolate the branches to the middle lobe. Care must be taken to ensure that the venous anatomy is normal and an inferior pulmonary vein is present. Occasionally, the middle lobe vein arises from the inferior pulmonary vein (Fig. 5). (iii) We always incise the pulmonary ligament and remove Stations 8 and 9 lymph nodes, if present, during this manoeuvre. At the beginning of our experience, we used a
Figure 5: Middle and upper lobe vein exposure.
hook diathermy. While this is useful in certain cases, we believe that the use of an endodissector allows better control during the dissection and avoids poking with a very hot diathermy on the delicate vessel surface. (iv) Once the inferior border of the vein is dissected, we create a separation between the upper and middle lobe branches until the underlying pulmonary artery is visualized. Similarly, the dissection is carried out to identify the inferior border of the middle lobe vein. (v) Once a plane is created, we use a silicone vessel loop to retract the vessel and insert a staple from the posterior port.
Step 2: middle lobe bronchus (i) The middle lobe bronchus is first felt with a cloth dissector and then dissected with diathermy to mobilise the lymph nodes towards the specimen (Fig. 6 and Video 5). Once the bronchus is clearly visualized, it is divided with a 30- or 45-mm stapler from the posterior port. Sometimes, there is a certain resistance in passing the stapler through the bronchus because of the soft tissue around the bronchus. Our suggestion is to keep the stapler parallel to the pericardium and to retract the lobe upwards so as to make the bronchus more vertical.
Step 3: middle lobe pulmonary artery (i) Once the bronchus is divided, the next step depends on the patient’s anatomy (Video 6). There are two options: (a) Exposure of the middle lobe pulmonary artery from the anterior hilum.
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Figure 6: Middle bronchus exposure. Video 6: Middle pulmonary artery isolation and division and fissure division.
(ii) According to the anatomy, the stapler can be inserted either through the utility incision or the posterior port. (iii) The inferior pulmonary vein is a rather robust structure, away from other major hilar structures. The only thing to keep in mind is that during VATS procedures, it is possible to dissect too much into the lung and divide only few branches of the inferior pulmonary vein, rather than the whole vein. Failing to realize that might lead to catastrophic bleeding when removing the specimen from unidentified venous vessels.
Step 3: once the vein is divided, there are two possibilities: Video 5: Middle bronchus isolation and division.
(b) Alternatively, if the fissure is relatively complete, then it is possible to find the artery in the fissure. We recommend avoiding large fissure dissection, as it is the main cause of prolonged air leak. Once the hilar structures are divided, the fissures are divided with staplers keeping them above the underlying interlobar pulmonary artery. The lobe is then extracted through a specimen retrieval bag.
Right lower lobectomy Step 1: pulmonary ligament (i) The lung is retracted from the posterior port with a short sponge stick or lung grasper. This manoeuvre facilitates the exposure of the inferior pulmonary ligament. The ligament is incised with the hook diathermy up to the inferior edge of the inferior pulmonary vein. Care must be taken to apply the diathermy at the junction between the pleural reflection and the lung. Carrying out the dissection through some of the lung parenchyma will result in annoying bleeding throughout the procedure.
Step 2: right lower vein (i) Once the inferior pulmonary vein is visualized, we continue the dissection anteriorly to identify the superior pulmonary vein. After confirming normal venous anatomy, the inferior pulmonary vein is dissected, encircled with a vessel loop and divided with a 30-mm vascular stapler.
(i) Fissure-less technique: next structure to be divided is the bronchus which lies just superiorly to the vein. It is important to identify the middle lobe bronchus and avoid narrowing it with the stapler. Also, particular care must be taken to avoid injuring the interlobar pulmonary artery that lies just superiorly to the bronchus. (a) Once the bronchus has been divided, the artery lies just superiorly and it is easily visualized. The anterior portion of the fissure is completed with staplers, keeping the interlobar pulmonary artery under direct view. Then, it is easy to divide the pulmonary artery and the posterior fissure with a series of staplers run front to back. (ii) If the fissure is relatively complete, it is possible to dissect it to identify the interlobar pulmonary artery. (a) We suggest using two peanuts simultaneously to bluntly open the fissure plane and then the endodissector to open the adventitia of the pulmonary artery. (b) Once the pulmonary artery (PA) is visualized, before division, it is useful to divide the anterior portion of the oblique fissure. In order to do that, we use a right-angled dissector place inferiorly on the pericardium between the superior and inferior pulmonary veins; dissection is then carried out maintaining the tip of the dissector anterior to the previously identified pulmonary artery. (c) Once the tunnel is created, the fissure is divided with a stapler inserted from the posterior port. This manoeuvre allows a better visualization of the interlobar artery. Care must be taken during dissection not to injure the superior segmental artery. Sometimes, it is advisable to take the common basal trunk first and then divide the superior segmental artery.
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(d) Once the artery is divided, it is easy to complete the fissure front to back with a stapler inserted through the utility incision. The lobe is then extracted through a specimen retrieval bag (Video 7).
Left upper lobectomy Step 1: pulmonary ligament (i) We start the dissection incising the inferior pulmonary ligament with hook diathermy. Care must be taken not to injure the descending aorta, which lies immediately behind. (ii) The dissection then proceeds anteriorly to identify the superior pulmonary vein and the truncus anterior. There is usually a Station 10 lymph node, which needs to be removed to facilitate the subsequent division of the vessel.
Step 2: upper pulmonary vein (i) Once the inferior and superior border of the upper lobe vein is visible, a dissector is passed behind the vein and then the vein is encircled with a silicone vessel loop. (ii) To facilitate the retraction of the lung, it is possible to divide, if grossly incomplete, the fissure between the upper and lower lobe.
Step 3: pulmonary artery branches (truncus anterior/ lingular branch) (i) Once the vein has been divided, the first portion of the pulmonary artery becomes more visible. At this point, if the fissure is easy to dissect, we prefer to expose the lingula branch and divide it with a stapler. (ii) Further to that, we divide the truncus anterior. The division of the lingula and the truncus allows extra mobility of the pulmonary artery, which reduces the risk of accidental injury during dissection of the bronchus.
Step 4: left upper bronchus (i) Division of the upper lobe bronchus is the most dangerous manoeuvre in a left upper lobectomy as it is done partially blindly, dissecting behind the interlobar pulmonary artery.
Video 7: Right lower lobectomy.
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(ii) Care must be taken to dissect along the bronchial wall, without being too harsh as there is a risk of injuring the membranous part of the bronchus. Lymph nodes, if present, are swiped towards the specimen. (iii) The bronchus is eventually encircled and divided with a stapler. (iv) Retraction on the bronchial stump facilitates exposure of the remaining vessels of the pulmonary artery. We prefer to dissect them individually and use the stapler to divide them.
Step 5: fissure division (i) Once all the branches have been divided, the fissure is complete front to back with multiple stapler loads. (ii) Care must be taken to stay always above the interlobar pulmonary artery. (iii) It is advisable to pull the lung into the stapler rather than push the stapler through, to avoid the risk of accidental damage to the PA. The lobe is then extracted with an endobag (Video 8).
Left lower lobectomy Step 1: pulmonary ligament (i) We start the dissection incising the inferior pulmonary ligament with diathermy.
Step 2: lower pulmonary vein (i) The inferior pulmonary vein is then dissected and encircled with a vessel loop. (ii) Before division, we check that the venous drainage of the upper lobe is present. (iii) The inferior vein is then divided with the stapler.
Step 3: at this point, there are two options: (i) If the fissure is relatively complete, we expose the PA and divide it with the stapler after dissection and encircling with a vessel loop. (a) There are several ways to expose the PA, but we think that the safest and most effective is the ‘kissing peanuts’
Video 8: Left upper lobectomy.
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technique. Basically, two peanuts are used in conjunction and the thin lung tissue above the PA is gently separated. (b) Once the PA is seen, the fascia is opened with an endodissector and the PA dissected. Some surgeons use a hook diathermy. While this is certainly a possibility, we feel that the endodissector offers the advantage of no poking with the hot tip of the diathermy onto the PA in trying to lift the fascia. (c) Care must be taken when passing the stapler as the superior segmental branch is often separate from the main basal trunk and not always immediately visible. (ii) If the fissure is grossly incomplete, then we retract the lung upwards and encircle the bronchus. This manoeuvre offers the advantage of leaving the fissure intact, but is potentially quite dangerous as the PA is barely visible. (a) Once the PA is divided as in the previous option, the bronchus becomes visible. All lymph nodes are swiped towards the specimen and the bronchus divided with a stapler. (b) Care should be taken not to leave the bronchus too long as, especially in patients with chronic obstructive pulmonary disease (COPD), there could be dehiscence of the stump due to infective reasons. The fissure is then completed front to back with staplers and the lung extracted with an endobag (Video 9).
Preference cards (i) A 30° scope with a 2D high-definition camera. Having trialled several 3D visualization systems, we fail to note any subjective benefit in VATS. (ii) Specifically designed VATS instruments. (iii) Ligasure™ (Covidien) instruments for sealing of small vessels. (iv) Endo GIA™ 30 mm Curved Tip Articulating Vascular/ Medium Reload with Tri-Staple™ Technology (Covidien) for named vessels. (v) Alexis™ (Applied Medical) soft tissue retractor. (vi) Silicone vessel loops.
Tips/discussion points (i) A sponge on a stick should be mounted at all times during the procedure. This offers a means of applying direct pressure in case of sudden bleeding (see Video 1 at the 00:59 mark). (ii) There is controversy with regard to whether it is better to use a silk tie or a vessel loop to retract vessels before transection. Advocates of using a silk tie believe that it does not need to be removed before staple firing. We would argue that having a string attached to a vessel stump could create a point for inadvertent traction during surgery with subsequent bleeding. If removed before firing, we would be concerned that the harsh material might saw through the back wall of the delicate vessels. There are also surgeons who prefer to pass the stapler directly. While this is often possible, we believe that using a vessel loop provides further visualization and control, potentially reducing the incidence of vascular injuries. (iii) When performing open surgery, emphasis is rarely placed on removal of N1 nodes prior to obtaining vascular or bronchial control. As these nodes are often included within the specimen, they are typically not taken out separately in planned lobectomy. In VATS lobectomy, performance of regional lymphadenectomy often facilitates dissection. Arterial branch points and lobar bronchial origins are often signalled by clusters of lymph nodes. Removal of these lymph nodes creates obvious anatomical pathways for circumferential dissection and subsequent surgical control. This is particularly true with regard to the upper lobe bronchus on the right. One or two nodes are typically present at the angle created by the inferior aspect of the upper lobe origin and the bronchus intermedius.
Lymph node dissection Left side (i) On the left side, Stations 5 and 6 are removed by pulling up the mediastinal pleura from the utility incision and moving the Ligasure through both the mini-thoracotomy and the posterior port. (ii) Stations 9 and 8 are removed usually during release of the ligament and dissection of the inferior vein. (iii) The subcarinal area (Station 7) requires the remaining lobe to be retracted anteriorly and superiorly to have a better exposure. Nodes are removed using both blunt dissection (ring curved forceps) and thermosealer.
Right side
Video 9: Left lower lobectomy.
(i) On the right side, Stations 7, 8 and 9 are cleaned in the same fashion as on the left side. (ii) The paratracheal area is approached starting under the azygos vein; subsequently, the pleura along the lateral profile of the superior vena cava is opened and the Stations #2R and #4R are removed en bloc, exposing the lateral wall of the trachea and the right vagus nerve (posterior limit of the dissection). (iii) Tip: procedure can be facilitated by rotating the table. For instance, for the subcarinal area, it is advantageous to move the table anteriorly and into the Trendelenburg position (Video 10).
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t raining courses are providing ample number of surgeons skilled in VATS lobectomy [6, 7]. The ‘Copenhagen approach’ [8] was preferred for several reasons: easy and natural movement from the habit of the lateral thoracotomy open approach, simple technique (direct view at the hilum and major vessels, the camera in the same position during the procedure, n = 3 incisions with possibility of triangulation, easy conversion in an emergency), but mostly for the quicker learning curve. This allowed us to shift almost one-third of the surgical cases per annum to VATS without significant changes in outcome and without mortality or major events.
CONCLUSION Video 10: Lymphadenectomy Station 7 (subcarinal) R2 and R4.
RESULTS During the period between March 2010 and May 2014, we performed 203 VATS lobectomies for lung cancer at the Department of Thoracic Surgery, European Institute of Oncology (IEO) in Milan, Italy. The percentage of cases done via a minimally invasive approach out of the overall annual number of lobectomies has increased progressively during the years: was less than 15% in 2010 and was about 35% before the completion of 2014. The most frequent resection was the right upper lobectomy (n = 74 cases), the least frequent the middle lobectomy (n = 19 cases). The most common histological types were adenocarcinoma (n = 105, 52%) and squamous cell carcinoma (n = 43, 21%). The mean surgical time was 155 min (range 95–305 min). There were n = 21 conversions (10.3%): due to anatomical anomalies, time constraints, or technical problems n = 7, adhesions n = 5, vascular injuries n = 4, unexpected advanced stage of the disease n = 2, inability to localize the nodule n = 2, and chest wall invasion n = 1. The median chest tube duration was 3 days (range 2–21) and the median length of hospital stay was 4 days (range 3–21). There was no 30-day mortality. We had 3 major complications: one vascular injury requiring emergency thoracotomy (1.5 L sudden blood loss due to a PA injury during a left upper lobectomy), and n = 2 cases with prolonged air leak requiring redo open surgery (both right lower lobectomy). The minor complications list includes: supraventricular arrhythmia (atrial fibrillation) n = 12, prolonged air leakage n = 9, chylothorax managed conservatively n = 1, residual space n = 3, atelectasis and sputum plugging requiring aspiration bronchoscopy n = 3 and haemotrasfusion n = 2.
DISCUSSION A recent study on Lancet by Goldstraw et al. [5] reported no difference in mortality or local recurrence between open resections or VATS, lower systemic recurrences and improved 5-year survival with VATS. The percentage of cases treated with minimally invasive surgery is increasing each year according to the main national databases worldwide, and current residency and fellowship
Despite being unable to predict which of the various techniques described in the literature, if any, will prove most successful over the coming years, one notes the following themes in contemporary VATS practice: the training of junior surgeons, the safe introduction of VATS in units with experience limited to conventional open approaches, the percentage of cases out of the overall annual volume of lung resections addressed by VATS, further clarification of indications, and eventually reduction in health management costs. Further development of the technology will supply us with more angulated robotic-assisted and ultra-thin staplers, innovative instruments for dissection, robotic single arms to assist VATS procedures and wireless cameras with super HD, possibly 3D, features, and probably VATS lobectomy regardless of the specific technique will become a standard approach even for complex cases. Conflict of interest: none declared.
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