My name is Jules Lin, one of the thoracic surgeons. And would like to talk today about thoracotomy versus minimally invasive approaches for lung cancer resection. The objectives of today's talk is to discuss the benefits of minimally invasive lung resection and review the indications for a thoracotomy versus thoracoscopy for lung resection. After today's talk, we hope you can answer this question, which of the following are reported benefits of a thoracoscopic approach to lung resection? A.Improved lymph node dissection due to better visualization. B.Decreased air leaks due to dissection of the fissure using cautery. C.Improved pain due to the use of a smaller rib retractor. Or D.Improved long-term survival due to decreased inflammation and immune response. Video-assisted thoracoscopy or VATS has been around since 1910 when Jacobaeus first used it. It's increased in popularity since 1990's, and is reported to improve postoperative pain and lead to shorter hospital stays. It's the procedure of choice in stage I and II lung carcinomas. But it's important to remember that you need to achieve the same oncologic results. So there's a learning curve and it's recommended that 25 to 50 VATS lobectomies be performed as part of the learning curve. It requires different technical skills and you need to have a low threshold to convert to an open thoracotomy. Let's review a case, this is a 65 year old woman who's had pneumonia with a prolonged recovery. The chest x-ray shows a 2.7 by 2.8 cm mass in the left upper lobe. Here on the chest CT, you can see this is a peripheral, solid lobular, left upper lobe nodule. And a PET scan shows us the metabolic function of the nodule. And here you can see that it's intensely metabolically active, left upper lobe nodule and when we perform a VATS resection you do need a double-lumen tube for lung isolation. The patient is placed in right lateral decubitus position here with the left chest up. And we start with three thoracoscopic ports, this is a left upper lobe blood resection here you can see the three ports and a frozen section showed a lung adenocarcinoma. So the port placement is important. In the anterior working port is placed in the 6th intercostal space along the major fissure. There's a camera port here in the 8th intercostal space and then the posterior port here in the 6th intercostal space. If you're proceeding to a lobectomy we make an additional utility incision in the 4th intercostal space. The one important difference between VATS and open thoracotomy is that there is no rib spreading in the VATS. This hopefully leads to less post operative pain. We do perform intercostal nerve blocks and we use an angled camera so a 30 degree camera and careful not to torque on the ribs with the camera. We also use roticulating staplers to divide the structures and this helps so you don't torque as much on the ribs. And we perform an anterior to posterior approach, so we start by dividing the pulmonary veins and then move posteriorly. The fissure stapled without a fissuredized section and hopefully this leads to less air leaks. Specimen is placed in a collection bag and this is to help prevent any port site recurrence. And due to learning curve, it's important that programs perform more than 25 lobectomies per year. This is the second case, this is a 43 year-old gentleman that has a history of a cough and he has obstruction of the left lower lobe bronchus. And here you can see atelectasis of the entire left lower lobe. In considering a thoracotomy for lung cancer resection, we often consider the size of the tumor, if it's greater than five centimeters. The distance from the hilar structures, central tumors being ones that will consider more for thoracotomy. If there are extensive pleural adhesions or a previous history of chest surgery, previous neoadjuvant chemoradiation, inability to collapse a lung, and if the patients are unable to tolerate single lung ventilation. Again we need to have a low threshold to convert to thoracotomy. Patient safety is the most important, adhesions at the time of the thoracoscopy, if these are dense adhesions then thoracotomy may be indicated. If there's a vascular injury it's important to control this with a sponge stick and proceed to open thoracotomy. If there are any bronchial stump leaks, again, you should consider converting it to a thoracotomy to repair the bronchial stump. And minor leaks from the lung can be controlled with a wedge resection or even sealants. The initial reports are difficult to compare, there were different definitions for VATS lobotomy but generally VATS lobotomy does not involve any rib spreading. Grogan, et al, reviewed case series and case-control studies from 2000-2008. And you can see here that the mortality for VATS resections ranged from 0.6% to 2.7%. The morbidity ranged from 7.4% to 30%, and the conversion rate to open thoracotomy was 1.6% to 13%. When we look at complications, the most common complications were arrhythmia at 5.5%, air leaks at 4.7%, and pneumonia at 2.1%. In comparing open to VATS several of the studies, three of them showed significant decreases. And the total complication rate between VATS and open thoracotomy. In looking at operative time, intraoperative blood loss, the length of chest tube drainage and the length of hospital stay, there was significant difference in several of the studies. Here for operative time, the operating time was significantly loner for an open thoracotomy. For intraoperative blood loss, three of the studies showed a significant decrease with thoracoscopy. And chest tube drainage was also significantly less in three of the studies after a VATS lobectomy. The length of stay was significantly less in three of the studies after a VATS lobectomy. When we look at pain, pain control was better in the study by Grogan, et al at three weeks. And in addition looking at chronic pain at one year, chronic pain was significantly less after VATS lobectomy, here you see in black. Severe chest pain at one year, and open and here in VATS significantly less. We're looking pulmonary function, several study did find improvement and FEV1 and the final capacity in three months, several study founds quicker recovery in FEV1 and FVC at two weeks. And the Nomori et al looked at the six minute walk and found improvement we compare it to axillary thoracotomy. And in this final study there was an improvement in physical function at 12 months. When we look at mediastinal lymph node dissection, this study compared the number of lymph nodes removed, comparing that to open lumpectomy and found no significant difference. And there were approximately 31 lymph nodes removed regardless of the approach. And Sagawa, et al, performed VATS Mediastinal Lymph Node Dissection compared to open, and they performed VATS first and followed by an open Mediastinal Lymph Node Dissection, and found that there were only 1.2 lymph nodes that were left at the time of thoracotomy, and that these were negative on final pathology. When we look at survival, again it's important that you have the same oncologic outcomes after a minimum invasive approach. And several studies have shown that the outcomes are at least equivalent for long term survival and some have even shown an improve long term survival after using VATS approach. Now why would this be? So Yim, et al., found that there was a significant decrease in IL-6, IL-8 and IL-10. And Leaver, et al found that there were less effects on circulating T cells and natural killer cells. So some of these studies found an increased survival after VATS vs open lobectomy. And the thought is that this maybe because of there's decreased inflammation and the affects on the immune response after VATS lobectomy. The other thing that we consider is that after VATS lobectomy because of decrease pain and quicker recovery. That these patient can undergo agile therapy earlier and also have a higher chance of completing the complete course of chemotherapy. Petersen et al., found there were significant improvement in completing chemotherapy with 61% of VATS patients receiving 75% of the doses versus 40% after an open lobectomy. So for the final cases, a 63 year-old gentleman with an enlarging nodule on serial chest CTs. Here you can see this nodule being biopsied on a chest CT. And some of these nodules, especially now that we're performing more chest CTs and screening chest CTs. We're finding smaller and smaller nodules and some of these are not solid. Some of are ground-glass lesions and they're difficult to palpate on thoracoscopy. And newer technology is being used so that we can locate these nodules without performing a thoracotomy based on preoperative imaging. If they can not be palpated due to the depth, location or how solid the nodules are we can inject methalyne blue in these areas or place coils by navigational bronchoscopy or CT guidance. And after localizing these nodules interoperatively here you see the dye that we can perform on the wedge resection, we can perform on the frozen section. So which of the following are reported benefits of a thoracoscopic approach to lung resection? Is it A.lymph node dissection due to better visualization. B.Decreased air leaks due to dissection of the fissure using cautery. C.Improved pain due to use of a smaller rib retractor. Or D.Improved long-term survival due to decreased inflammation and immune response. The answer is D. So the take home points. VATS lobectomy results in decreased hospital stay and shorter recovery time. Postoperative pain after discharge is improved. And some studies have shown improved long-term survival possibly due to decreased inflammation and immune response. Thoracotomy should still be considered, and is an important approach, with hilar tumors, if there's severe adhesions, or after chemoradiation. Thank you for listening to today's talk. And I hope you learned something about the differences between a thoracoscopic lobectomy and an open lobectomy. Thank you.
