Video-Assisted Thoracic Surgical Non-Rib Spreading Simultaneously Stapled Lobectomy (VATS(n)SSL)

Video-Assisted Thoracic Surgical Non-Rib Spreading Simultaneously Stapled Lobectomy (VATS(n)SSL) Ralph j. Lewis and Robert j. Caccavale Two hundred consecutive patients underwent a video-assisted thoracic surgical non-rib spreading simultaneously stapled lobectomy (VATS(n)SSL). Ninety-three were males and 107 were females, ranging in age from 20 to 92 years. Lesions consisted of 171 primary lung carcinomas, 7 metastatic tumors, and 22 benign lesions. Resections included 47 right upper lobe, 18 right middle lobe, 46 right lower lobe, 52 left upper lobe, 26 left lower lobe and 11 bilobectomies, ie, 9 right upper and middle lobes and 2 right middle and lower lobes. Operating time averaged 79.5 minutes, and no patient received a transfusion. Tumors ranged from 1 cm to 9 cm, bronchial stumps were 4 to 5 mm, and length of hospitalization averaged 3.07 days. Complications were minimal, and there was no surgical mortality. No patient developed a bronchopleural fistula or neoplastic port implant. Twenty-four patients have died of metastases. At a median follow-up of 34 months for all stages of carcinoma, there is an overall survival rate of 86%. Survival rate is 92% for stage I. VATS(n)SSL is a new technique for lobectomy that has proven to be beneficial for patients needing resection. Copyright © 1998 by W.B. Saunders Company Key words: VATS non-rib spread simultaneously stapled lobectomy.

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uring the past 100 years, lobectomy has been performed for numerous pulmonary problems. A thoracotomy was always mandated to provide access and exposure of the lung, to facilitate maneuverability, and to allow an adequate work area to accomplish the planned resection. Even though thoracotomywas being used only as an access procedure, nevertheless, it contributed significantly to the morbidity, mortality, and prolonged, painful recovery of the patient. This was a very high price to pay merely for access. Through the years, various techniques were developed for the actual resection of a lobe, ie, isolationligation, mass ligation, exteriorization, and various combinations of these techniques. 1-3 However, since 1940, thoracotomy, using isolation-ligation (anatomic hilar dissection), has reigned supreme as the only technnique advocated for pulmonary lobectomy by all thoracic surgeons. 4 Because of recent technological advances, new and different surgical methods have become feasible From the University qf Medicine and Dentistry qf New Jersey, Robert WOod Jolmson Medical School, Universi~y Thoracic Surgical Service, St. Peter's Medical Center-Robert WoodJohnson Universi!}' Hospital, NJ. Address reprint requests to Ralph J. U I.IJis, MD, 185 Livingston Ave, New Brunswick, NJ 08901. Copyright © 1998 by WB. Saunders Compan)' 1043-0679/98/1004-0013$08.00/ 0

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and continue to evolve. 5- 7 One of these new techniques is video-assisted thoracic surgery (VATS) simultaneously stapled (SS) lobectomy which has been performed for 6\12 years. 8,g It has proven to be safe, efficient, less costly, oncological, and extremely beneficial for patients.

Technique After placement of a Mallinckrodt Broncho-Catheter tube (Critical Care, St. Louis, MO) and bronchoscopy using a pediatric scope, the patient is placed in a full lateral thoracotomy position. To widen the intercostal spaces on the operative side, the table is extended and a plastic bag is inflated beneath the down chest (Fig I). After prepping and draping, four incisions are made in quadrilateral fashion through the intercostal spaces of the lateral chest wall. They average 2 to 3 cm in length except for the anterior, cephalic incision, which is 5 cm long and positioned where the intercostal space is widest. The skin and subcutaneous tissue are sharply incised, whereas the underlying muscles are only separated in the direction of their fibers. The thoracic scope is inserted, and the visceral and parietal pleura are examined. The lesion and lobe to be excised are identified (Fig 2). When the lower lobes are to be resected, the

Seminars ill Thoracic and Cardiovascular Surgery, VollO, No 4 (October), 1998: pp 332-339

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Figure 1. Table extended and bag inflated to widen rib interspaces on operative side. (Reprinted with permission. S) inferior pulmonary ligament is opened and the inferior pulmonary vein is identified. Next, the posterior mediastinum is opened and dissected exposing the upper third of the trachea. Lymph nodes from stations 2, 3, 4,7,8,9, 10, 11, and 12 can be excised. The superior segment of the lower lobe is identified, and the posterior portion of the major fissure is completed using the Endopath EZ 45 stapler (Ethicon Endosurgery, Cincinnati, OR). At this time, the anterior mediastinum is dissected identifying the pulmonary artery, superior pulmonary vein, and inferior pulmonary vein. In the left thorax, stations 5 and 6 can be explored and nodes excised. The anterior portion of the fissure is completed by placing the anvil of the EZ 45 stapler between the superior and inferior pulmonary veins, pointing it in the direction of the fissure, and firing. When a right lower lobectomy is performed, as shown in the accompanying illustrations, a no. 18 red rubber catheter is brought in through the anterior, cephalic incision and looped around the base of the right lower lobe. Its flared end is pushed onto the anvil of a TL 60 stapler (Ethicon Endosurgery). The stapler is guided

Figure 2. Four incisions in quadrilateral fashion provide better access and visualization. (Reprinted with permission. g)

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around the base of the right lower lobe using the rubber catheter (Fig 3). When all structures are in their normal anatomic position, the stapler is fired to obtain a tight bronchial closure (Fig 4). The first row of staples are for bronchial closure. They may not be tight enough for complete hemostasis, but, more importantly, the staples should not crush the bronchus. The stapler is removed and reloaded as the integrity of the first staple line is examined. In similar fashion, a second staple line is placed 2 to 3 mm distal to the first one. This staple line is closed tighter to ensure hemostasis. The lobe is excised from the stapler, and the stapler is opened and removed (Fig 5). The lobar stump is examined for bleeding. If the staples are properly applied, this should not occur; however, if it does, the bronchial stump can be grasped easily with a clamp and re-stapled. The lobe is placed in a protective plastic

Figure 3. A no. 18 red rubber catheter, attached to a TL 60 stapler, facilitates positioning of the right lower lobe hilar structures within the jaws of the stapler. (Reprinted with permission. g)

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Figure 4. The stapler pin is down. All hilar structures of the right lower lobe are confined, in their normal, anatomic configuration, within the jaws of the stapler.

bag and removed through the anterior cephalic incision where the ribs are widest. The ribs are not spread. If the tumor is large, it can be sectioned into smaller segments within the plastic bag. This will facilitate removal between the ribs. The chest cavity is filled with warm saline, and the lung expanded to test the bronchus for an air leak. A similar approach is used for the upper lobes and the left lower lobe. If the minor fissure is incomplete on the right, it must be completely developed. The smaller jaw of the EZ 45 stapler is placed within the bifurcation of the superior pulmonary vein that demarcates the veins supplying the upper lobe from those supplying the middle lobe (Fig 6). The lung is pulled between the jaws of the EZ 45 stapler, and

Figure 5. Four separate rows of staples seal the short proximal stump. The right lower lobe has been resected. (Reprinted with permission.g)

Figure 6. The smaller jaw of the EZ 45 linear stapler is positioned within the birfurcation of the superior pulmonary vein that demarcates the middle lobe veins from the upper lobe veins.

with the smaller jaw still residing in the bifurcation, the larger jaw is pointed in the direction of any vestigial remnant of the minor fissure (Fig 7). The stapler is fired once or twice to develop the minor fissure. The bronchi and pulmonary arteries and veins to the middle and lower lobes are situated posteriorly to the small jaw of the stapler. They are protected and remain outside the field to be cut and stapled. The red rubber catheter and TL 60 staplers

Figure 7. The smaller jaw of the stapler r emains in the bifurcation, and the lung is pulled within the jaws of the stapler. The larger jaw is pointed toward any vestigial remnant of the minor fissure.

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limited time span were reviewed to allow a more valid follow-up period for pulmonary malignancies. Every planned and attempted VATS lobectomy has been performed using simultaneous stapling to seal the bronchus.

Results

Figure 8. The appearance of the closed incisions and chest tube on completion of the lobectomy.

are used in the same manner as when performing a lower lobectomy. When necessary, bilobectomies can be accomplished by resecting the right upper-right middle lobe or right middle-right lower lobe together. The minor fissure must be fully developed to accomplish the right middle-right lower lobe resection. After completing the lobectomy, a single no. 20 Silas tic chest tube is placed in the thorax. All wounds are closed in layers using no. 2-0 vicryl to the muscle, no. 3-0 vicryl to the subcutaneous tissue and 4-0 vicryl subcuticularly (Ethicon, Somerville, l'{J) (Fig 8).

Materials and Methods After gaining experience with less complex VATS procedures during 1990, our first VATS lobectomy was performed on September 9, 1991. Initially, the isolation-ligation technique was used for lobectomy, and continued for 1 year, when it was changed to simultaneous stapling. However, some surgeons on our service, at that time, continued to favor the open thoracotomy with isolation-ligation for lobectomy, and they used that technique exclusively. Each surgeon acted independently when selecting a technique for lobectomy. Therefore, patients for VATS(n)SSL were not preselected upon the basis of chest wall configuration, anatomy, or physiology. The technique used depended on the preference and philosophy of the surgeon performing the operation. Currently, every surgeon on the University Thoracic Surgical Service performs VATS(n)SSL as the procedure of choice for lobectomy. Two hundred consecutive VATS(n)SSL have been performed between September 1992 and May 1997. Presently, 300 procedures have been performed; however, only the first 200 patients from the above

Two hundred consecutive patients, ranging in age from 20 years to 92 years, with an average age of 66.5 years, underwent a VATS(n)SSL. Ninety-three were males and 107 were females. Lesions comprised 171 primary lung malignancies, 7 metastatic tumors, and 22 benign lesions (Fig 9). One hundred thirty-one adenocarcinomas, 30 squamous cell carcinomas, 5 giant cell carcinomas, 4 carcinoid tumors, and 1 lymphoma constituted the primary malignant tumors. The metastatic lesions consisted of 1 renal, 1 uterine, 1 melanoma, and 4 colon tumors. All of the benign lesions, ie, 12 granulomata, 5 giant bullae, 1 sequestration, 1 organizing pneumonia, 1 bronchogenic cyst, 1 aspergillus abscess and fungus ball and 1 hamartoma, mandated lobectomy because of size or location. Solid benign lesions averaged 4.6 cm in size. Bronchoscopy identified lesions in segmental bronchioles in 6 patients; however, in 194 patients, bronchoscopy results were negative. In all patients with malignancy, the postoperative bronchial margins were negative for tumor. Mediastinoscopy was performed when lymph nodes were greater than 1 cm on CT scan. In 58 patients, mediastinoscopy results were negative. When mediastinal lymph node biopsy results were positive, a pulmonary resection was not performed. Preceding VATS lobectomy, nodal stations 2, 3, 4, (5, 6 left), 7, 8, 9, 10, 11, and 12 were carefully examined and, usually, 7 to 18 lymph nodes could be excised. In patients with primary lung

METASTATIC

LARGE CELL

4 CARCINOID 1 LYMPHOMA

Figure 9. Composition of lesions resected by lobectomy. (Reprinted with permission. B)

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cancer, 154 of them had negative nodes, whereas 13 had Nl and 4 N2 nodes (Fig 10). Operating times ranged from 40 to 150 minutes with an average of79.5 minutes. The average operating time decreased to 68 minutes for the second cohort of 100 patients. Average estimated blood loss was less than 100 mL, and no patient received a transfusion. Simultaneous stapling was used to resect 47 right upper, 18 right middle, 46 right lower, 52 left upper, 26 left lower, 9 right upper and middle, and 2 right middle and lower lobes. Postoperative bronchoscopies confirmed bronchial stumps of 4 to 5 mm. Tumors ranged from 1 cm to 9 cm and had an average size of 3.44 cm. The average hospitalization for all 200 patients was 3.07 days; however, this decreased to 2.63 days for the second group of 100 patients. Complications occurred in 13% of patients; however, all of them made a complete recovery. There were 14 minor air leaks, 2 mild subcutaneous emphysemas, 1 inflamed chest tube site, 3 pneumonias, 2 cardiac arrythmias, 1 minor chest wall bleed, and 3 transient cerebral vascular ischemic episodes. The average length of stay of the patients with minor air leaks was 3.05 days. These patients were discharged with Heimlich valves attached to their chest tubes. After hospital discharge, the average period of time before chest tube removal was 4 days. There was no surgical mortality, and no neoplastic implantation has occurred at any port site. No patient developed a bronchopleural or bronchovascular fistula (Table 1). Preoperative staging for patients with primary lung cancer was 85 in stage I, 86 in stage IT, and I in stage IITa. Postoperatively, this was changed to 73 in stage I, 85 in stage IT, 7 in stage rna, and 6 in stage IV. The International Staging System was used. IO Follow-up ranges from 12 to 72 months with a mean of 34 months. After curative surgical resection,

171 PATIENTS

/"-.. 17 ( pos.) /"-..

154 ( neg.)

4 N2

13 N1

Figure 10. Lymph nodes resected from patients with primary neoplasms.

Table 1. Comparison and Averages Between the First and Second 100 Patients Undergoing VATS (n) SSL

O.R. time (minutes) Length of stay (days) Fistula (BPF) Transfusion Port implant Surgical mortality

1st 100 Patients

2nd 100 Patients

Average

90.9 3.50

68.0 2.63

79.5 3.07

o o o o

o o o o

o o o o

24 patients have died from causes related to their neoplasms. Their average period of survival was 16.8 months ranging from 5 to 38 months. Histopathology consisted of 16 adenocarcinomas and 8 squamous cell carcinomas. Positive lymph nodes were found in 9 patients, ie, 6 N1 and 3 N2 nodes. Microscopically, the vascular system of the resected lobe contained malignant cells in 12 patients. Two patients had multifocal lesions. Preoperative staging for patients who died from neoplasm was 13 in stage I, 10 in stage II, and 1 in stage rna. Postoperatively, this was changed to 7 in stage I, 12 in stage II, 3 in stage IlIa, and 2 in stage IV. Metastases were the cause of death in all patients, ie, 5 brain metastases, 2 contralateral lung, 3 liver, 1 bone, and 13 multiorgan (Table 2). Non-neoplastic deaths occurred in 7 patients reTable 2. Findings in 24 Patients With Resected Primary Lung Carcinoma Who Died of Their Malignancy 11M 13F 54 yr to 92 yr Avg 72 yr 5 RUL 1 RML 8 RLL 9 LUL 1 LLL 0 Bilobectomy Tumor size 1.5 cm --+ 9 cm AVG. 3.8 cm Pathology 16 Adenocarcinoma 8 Squamous cancer Nodes 15 Negative 9 Positive (6N, 3N2) Vascular V(-)12 V(+)12 Bronchial margin 24 Negative Stage Preoperative Postoperative I 13 I 7 II 10 II 12 IlIa I IlIa 3 (N2) N 2 (multifocal) Survival 5 mo. --+ 38 mo. Avg. 16.8 mo. Death 5 Brain 1 Bone 3 Liver 13 Multiorgan 2 Bilateral pulmonary Critical findings (2 visc PL ulcer, 2 multifocal) (1 Preop adjuvant, 1 lung cancer and breast cancer) Gender Age Lobes resected

Abbreviations: RUL, right upper lobe; RML, right middle lobe; RLL, right lower lobe; LVL, left upper lobe; LLL, left lower lobe.

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sulting from 4 myocardial infarctions, 1 renal failure, 1 cerebrovascular bleed, and 1 alcoholic aspiration pneumonia. Clinical tumor is known to be present in 6 patients, ie, 3 bone, 1 brain, and 2 disseminated metastases. The initial tissue type for these patients was 4 adenocarcinoma, 1 squamous cell carcinoma, and 1 lymphoma; these tumors varied in size from 1.5 cm to 5 cm. Two patients had histologically confirmed Nl and 1 patient N2 nodes. Four patients had neoplastic cells identified in their pulmonary vascular system postoperatively. Of 171 patients who had a primary carcinoma resected, 147 patients are alive and well.

Discussion The evolution, creditability, and scientific justification for VATS(n)SSL have all been discussed and documented in previous publications.B,g Although only our first 200 consecutive patients have been reviewed, presently 300 patients have undergone this technique. In every case, the procedure was successfully accomplished, and there were no unanticipated conversions to a thoracotomy. VATS(n)SSL has been applicable to patients with dense adhesions or a frozen chest, large lesions (9 cm), anatomic variations, and absence of lobar fissures. In this entire series, there has been no conversion related to hemorrhage, adhesions, or unfavorable intrathoracic anatomic findings. Initially, all of our patients are explored using VATS.ll If a malignancy is suspected, every ipsilateral nodal station is dissected and every identifiable node is excised and sent for frozen section when suspicious for tumor. If unsuspected neoplastic, parietal pleural implants or positive N2 nodes are discovered, this would contraindicate any planned radical resection by our criteria. We believe a cure is unattainable for these patients. 12 ,13 In these particular patients, a parietal pleurectomy and talc insuffiation will be performed to prevent a future debilitating, malignant, pleural effusion. Usually, they make a very uneventful recovery from this procedure, and some patients can be discharged the same day. This type of exploratory approach to the thorax using VATS, in cases such as these, when metastatic carcinoma cannot be diagnosed by invasive or imaged preoperative interventions, will avoid the morbidity and mortality that can occur from using the traditional open thoracotomy to confirm incurability. H When a solitary primary neoplasm is present,

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VATS(n)SSL has been our method of choice for curative resection. It permits a complete and valid oncological procedure to be safely and expeditiously achieved that complies with all current criteria for the curative removal of pulmonary neoplasms. Lesions can be completely resected and lymph nodes sampled or excised. Currently, our results for cancer survival using this technique are better than those found in the literature for the open traditional isolationligation lobectomy. 15,16 Using VATS(n)SSL, overall long-term survival after curative resection for primary carcinoma of the lung at a median follow-up of 34 months, for all stages, is 86%. It is 92% for stage I. Tissue injury caused by surgical procedures evokes an immediate reparative response by eliciting numerous humoral substances, ie, cytokines, growth factors, etc. This accelerates cellular division and repair of normal tissues. Unfortunately, there is evidence that this same response also accelerates and enhances growth and survival of malignant cells. In fact, the magnitude of the injury, such as a large thoracotomy incision, correlates with the magnitude of the reparative process. It is believed that metastases are most viable and occur most commonly during the intraperioperative period when injury and repair are most prominentY The small incisions of VATS, which require less of a reparative response for healing, could account for the improved long-term survivals after VATS lobectomy, by failing to provide an environment sufficiently conducive for survival of malignant cells. Also, transfusion of blood, with its adverse neoplastic effects, has not been needed for any patient, and VATS lobectomy is more of a "no touch" technique. Possibly, fewer malignant cells are released and shed into the blood stream, which could occur from palpation and compression so common to open techniques. Evidence is beginning to accumulate supporting these factors and others as possible explanations for the improved survivals being reported by VATS surgeons. Elderly, debilitated, comorbid patients have all done exceedingly well after VATS(n)SSL. Thirtyseven of our patients were between the ages of 75 and 91 years. Twelve patients were 80 years or older. Seven of them were considered such poor candidates that other institutions rejected them for a traditional open thoracotomy and lobectomy. Each underwent a VATS(n)SSL, and each of them made a benign and uneventful recovery. Elderly patients usually have atrophic chest wall muscles, osteoporotic ribs, and persistent distention of the lungs from emphysema

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associated with decreased elasticity and compliance. All of these changes contribute to weaker forces of respiration. Because of the minimal trauma inflicted on their fragile chest walls by VATS(n)SSL, all of these patients were able to be extubated in the operating room, and all ventilated easily and spontaneously in the recovery room. IS Their rapid, uneventful recovery could be attributed to shorter operating times, lighter anesthesia, minimal chest wall trauma, and the avoidance of intensive services or narcotics. Because of VATS (n)SSL, these elderly patients had minimal interference with their respiratory mechanics and pulmonary physiology. Postoperatively, consultants have been needed very infrequently because complications that are known to occur commonly after open traditional surgery, ie, hypoxia, atelectasis, arrythmias, became very unusual after VATS. VATS(n)SSL has been exceptionally beneficial for patients with benign lesions. Entities such as sequestration, giant bullae replacing a lobe, large parenchymal granulomas, or deeply seated hamartomas have all been uneventfully resected using this technique. Many are usually younger patients who can make an exceptionally rapid recovery from this type of surgery. The average length of stay for this group was 2.07 days. Results for 194 bronchoscopies were negative; however, tumor was visualized or biopsied in 6 patients. Even with these findings, VATS(n)SSL can be accomplished. Every mediastinoscopy, in the series, was negative because patients with positive N2 disease would be excluded from a radical resection. During VATS, the four small incisions for access facilitate various approaches and angles to the intrathoracic pathology, allow better visualization because of more options for placement of the scope, and permit the surgeon to work with two hands. Each lobe can be approached and resected satisfactorily, and even a bilobectomy (right upper lobe-right middle lobe or right lower lobe-right middle lobe) can be accomplished by VATS(n)SSLwhen indicated. Bronchial stumps have ranged between 4 to 5 mm, which compares favorably to resections performed using the open isolation-ligation technique. Every bronchial margin was negative for malignancy. No patient has had a recurrence at the bronchial stump. Nine patients had undergone a previous, traditional, open, contralateral thoracotomy and resection. Each subsequently had undergone a VATS (n)SSL, and each has confirmed that a VATS (n) SSL is a less painful, more convenient, patient-friendly, and more humane operation. The bone-sparing operation of VATS, in our

experience, has been much less painful than the muscle-sparing operation. 19 Up to the present time, in our entire series, there has been no surgical mortality, only 26 minor complications, no transfusions, and no bronchopleural fistulas or empyemas. This compares favorably to reports for open traditional techniques. 20 ,21 There has been no port implantation. Neither acute nor chronic pain has been a problem, and usually only small doses of non-narcotic analgesics are offered postoperatively. Epidural or local anesthetic infiltration has not been used for any patient. After a brief period of time in the recovery room, the lobectomy patients are transferred to a regular surgical floor. No special monitoring is required, even for the elderly with comorbid problems, and they receive only routine nursing care. Intensive care unit or intensive services and monitoring have not been used or needed. The average length of stay is 3.07 days with a recovery period, ie, return to preoperative physical levels or return to work that ranges between 7 to 10 days. Early discharge, from the alien, intimidating environment of the hospital to the comfort and security of one's home, seems to enhance and expedite recovery especially for the elderly patients. Recent studies are beginning to confirm the numerous physiological benefits resulting from VATS when compared with the open thoracotomy. It is not just the small incisions and decreased pain of VATS which make it so attractive and beneficial for patients, but rather the avoidance of the cascade of pathophysiologic changes that occur after the open tradi tional thoracotomy.22 Over the years, we have learned that VATS requires different skills and attitudes. It is not for every thoracic surgeon, and some, for various reasons, will not make the transition to VATS. Also, results are best when it is approached with the same philosophy of team participation advocated by cardiac surgeons. A VATS operating room with appropriate VATS equipment, instruments and dedicated, enthusiastic, experienced surgeons and nurses with special skills and training will give the best clinical results. In fact, a trained experienced team will not only consistently produce superior clinical results, but will begin to perceive a marked reduction in costs. Our overall costs decreased by 51 % when VATS(n)SSL were compared with the cost of our traditional open lobectomies. 23 As experience is accumulated, contraindications to VATS(n)SSL are becoming fewer in number. A large lesion seated deep within the hilar area or

T'll.TS SS Lobectomy

visible within the proximal bronchus by bronchoscopy would usually require an open technique. A lesion exceeding 9 em could compromise intrathoracic maneuverability and would be better approached through an open thorax. However, tumors invading the chest wall can be more accurately demarcated intrathoracically using the endoscope and can be resected en bloc by VATS. Most other lesions or anatomic variations have not obviated the use of VATS (n)SSL. VATS(n)SSL has been performed for 6Y2 years and should no longer be considered an experimental technique. It has proven to have numerous significant advantages and, possibly, will improve longterm survival for patients with carcinoma of the lung resected by this method.

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11. 12.

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Conclusion VATS(n)SSL has been used successfully for all lobes including bilobectomies. It follows all current principles for oncological resections and has been beneficial for the fragile elderly, viable terminal, and debilitated patients. Pain, hospitalization, recovery time, and cost have all been markedly reduced. The incidence of complications, surgical mortality, transfusion, and bronchopleural fistula is exceedingly low to non-existent when compared with traditional open surgery. Survival after resection for neoplasms compares favorably with conventional surgery. Patient satisfaction is overwhelmingly positive and supportive. VATS(n)SSL could become an important technique in the thoracic surgeon's armamentarium in the near future.

References 1. Heuer G: The development of lobectomy and pneumonectomy in man.J Thorac Cardiovasc Surg 3:560, 1934 2. Sarot I: Practical points in lobectomy. J Thorac Cardiovasc Surg 8:300-308, 1939 3. Berezovsky KK, Sabroda GS: On resection of lungs with the application ofUKL-60. Novy Khir Arkh 1:18-35, 1959 4. Blades B, Kent E: Individual ligation technique for lower lobe 10bectomy.J Thorac Cardiovasc Surg 10:84-10 I, 1940 5. Lewis RJ, Caccavale RJ, Sisler GE: Special report: Videoendoscopic thoracic surgery. NJ Med 88:473-475, 1991 6. Lewis RJ, Caccavale RJ, Sisler GE, Mackenzie JW: One

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hundred consecutive patients undergoing video-assisted thoracic operations. Ann Thorac Surg 54:421-426,1992 Landreneau RJ, Mack MJ, Keenan RJ, et al: Strategic planning for video-assisted thoracic surgery "VATS". Ann Thorac Surg 56:615-619,1993 Lewis RJ, Caccavale RJ, Sisler GE, et al: 100 video-assisted thoracic surgical simultaneously stapled lobectomies without rib spreading. Ann Thorac Surg 63:1415-1422,1997 Lewis RJ: Simultaneously stapled lobectomy: A safe technique for video-assisted thoracic surgery. J Thorac Cardiovasc Surg 109:619-625,1995 Mountain CF, Greenberg SD, Fraire AE: Tumor stage in non-small cell carcinoma of the lung. Chest 99:1258-1260, 1991 Vim APC: Routine video-assisted thoracoscopy prior to thoracotomy. Chest 109:1099-1100, 1996 Orringer MD: Editorial on "occult cervical nodal metastases in esophageal cancer: Preliminary results of three-field lymphadenectomy." J Thorac Cardiovasc Surg 113:538-539, 1996 McKneally NF: Im~ted comment: The importance of surgery to non-small cell carcinoma of lung with mediastinal lymph node metastases. Ann Thorac Surg 46:609-610, 1988 Goldstraw P, Manna MG, Kaplan D, et al: Surgical management of non-small cell lung cancer with ipsilateral mediastinal node metastasis (N2 disease). J Thorac Cardiovasc Surg 107: 19-28, 1994 Williams DE, Pairolero PC, Davis CS, et al: Survival of patients surgically treated for Stage I lung cancer. J Thorac Cardiovasc Surg 82:70-76, 1981 Humphrey EW, Smart CR, Winchester DP, et al: National survey of the patterns of care for carcinoma of the lung. J Thorac Cardiovasc Surg 100:837-843,1990 Reid S, Kaufman M, Murthy S, et al: Perioperative stimulation of residual cancer cells promotes local and distant recurrence of breast carcinoma.J Am Coll Surg 185:290-306, 1997 Vim APC, Ho JKS: Minimizing chest wall trauma in videoassisted thoracic surgery. J Thoracic Cardiovasc Surg 109: 1255-1256,1995 Landreneau RJ, Pigula F, Luketich JD, et al: Acute and chronic morbidity difference between muscle-sparing and standard lateral thoracotomies. J Thorac Cardiovasc Surg 112: 1246-1250, 1996 Samura H, Naruke T, Tsuchiya R, et al: Bronchopleural fistulas associated with lung cancer operations. J Thorac CardiovascSurg 104:1456-1464, 1992 Ginsberg R, Hill L, Eagan R, et al: Modern thirty-day operative mortality for surgical resections in lung cancer. J Thorac Cardiovasc Surg 86:654-658, 1983 Tschernko E, Hofer S, Bieg1mayer C, et al: Video-assisted wedge resection lobectomy vs. conventional axillary thoracotomy.Chest 109:1636-1642,1996 Lewis RJ, Caccavale RJ, Sisler GE, et al: Is video-assisted thoracic surgery cost -effective for major pulmonary resections? NJMed 93:35-41,1996