- Email: [email protected]
Video-Assisted Thoracic Surgery Lobectomy With Bronchoplasty for Lung Cancer: Initial Experience and Techniques
Kozo Nakanishi, MD, PhD Division of General Thoracic Surgery, Jikei University School of Medicine, Tokyo, Japan
Background. Many surgeons think video-assisted thoracic surgery is too complex to be applied to bronchoplasty; therefore, our institution tried to develop some safe and reliable techniques for video-assisted thoracic surgery bronchoplasty. Methods. One hundred thirty-four patients with lung cancer underwent curative video-assisted thoracic surgery lobectomy including mediastinal dissection at Iizuka hospital between October 2001 and September 2006. Five of these patients underwent radical lung lobectomy with bronchoplasty using video-assisted thoracic surgery. A minithoracotomy was performed at the lateral chest wall to place sutures around the bronchi. A continuous suture was placed at the median wall of the bronchi in cases of circumferential reconstruction, and shortened rubber tubes and silk suture lines were used for assisting with reconstruction.
Results. One patient with right lung carcinoma was treated with sleeve resection of the right main bronchus, whereas the others were treated with wedge resection. In one case, chylothorax was seen as a postoperative complication. There were no serious complications related to bronchoplasty. All cases are alive without any recurrence during follow-up. Conclusions. The importance of position of minithoracotomy and another access port, management of sutures, and the secure tightened method was assessed. There were no serious postoperative complications. Videoassisted thoracic surgery bronchoplasty is a complex procedure, but it can safely be performed using some additional techniques.
B
2006, 134 patients underwent curative VATS lobectomy, including mediastinal dissection, for lung carcinoma at Iizuka Hospital, Japan. Table 2 summarizes their characteristics. Five patients underwent VATS lobectomy with bronchoplasty (Table 3). All patients gave written informed consent, and the study was approved by the Institutional Ethics Committee.
ronchoplastic procedures for hilar lung cancer are performed widely as curative methods that preserve function [1]. Although video-assisted thoracic surgery (VATS) is regarded as a minimally invasive procedure [2– 6], many surgeons think that VATS is too complex and has too many technical limitations to be applied to bronchoplasty. Therefore, there are few reports in the literature of VATS bronchoplasty for lung carcinoma [7]. In this report, I describe a VATS bronchoplasty technique and several successfully treated cases.
Patients and Methods Patients Patients with primary lung cancer who were candidates for lobectomy with mediastinal lymphadenectomy and who satisfied the criteria in Table 1 were eligible for the VATS approach. Primary lesions and metastasis had been evaluated by using of roentgenography and enhanced computed tomography. Bronchofiberscopy, bone scintigraphy, and positron emission tomography were performed if necessary. Mediastinoscopy was not routinely performed. Between October 2001 and September Accepted for publication March 2, 2007. Address correspondence to Dr Nakanishi, Division of General Thoracic Surgery, Jikei University School of Medicine, 3-25-8 Nishi-shinbashi, Minato-ku, Tokyo, 105-8461, Japan; e-mail: [email protected].
© 2007 by The Society of Thoracic Surgeons Published by Elsevier Inc
(Ann Thorac Surg 2007;84:191– 6) © 2007 by The Society of Thoracic Surgeons
Operative Technique Patients were placed in the lateral decubitus position. The surgeon made a 7-cm incision in the fourth intercostal space as a utility thoracotomy, followed by three 1.5-cm incisions for access ports. A silicon rubber wound protector (LapDisk; Hakko Shoji, Tokyo, Japan) kept the utility thoracotomy opened (Fig 1A). The first port, on the posterior axillary line in the sixth intercostal space, was used primarily for thoracoscopy. The second, on the anterior axillary line in the sixth intercostal space, was for manipulation of the lung. The third port, on the anterior axillary line in the third intercostal space, was used for manipulation during dissection and, in particular, for the handling of a needle holder during bronchial anastomosis. Pulmonary vessels were resected as for standard lobectomy. Mediastinal lymph nodes, including the subcarinal nodes, were also dissected before bronchial reconstruction. The bronchus was cut wedgewise or circumferentially with an angledblade knife and scissors, and then the bronchial stump 0003-4975/07/$32.00 doi:10.1016/j.athoracsur.2007.03.008
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Table 1. Criteria for Video-Assisted Thoracoscopic Surgical Lobectomy for Primary Lung Carcinoma
GENERAL THORACIC
Minimum tumor size ⬍ 5 cm. No evidence of vessel invasion. No direct invasion to the surrounding organs requiring reconstruction. Patient and family agreed to procedure.
was confirmed by frozen sectioning to be pathologically free of cancer. After pathologic examination, bronchial anastomosis was initiated by viewing and handling through the thoracotomy. In wedge plasty, the bronchial anastomosis was performed using several interrupted 3-0 absorbable monofilament sutures (Fig 1B). Interrupted sutures were first placed on the cartilaginous portions of the bronchial orifices, then on the membranous portions. Two ends of each suture were passed together through serially numbered rubber tubes shortened into 2-cm lengths. Furthermore, the ends were fastened with pieces of tape labeled in the same sequence as the rubber tubes. Along the sutures, the rubber tubes were moved into the pleural cavity around the anastomotic site. During suturing, all sutures were held together in the pleural cavity by a grasper inserted through the other access port (Fig 2). After placing all sutures, knot tying was started with a forceps-type tying instrument at the suture placed at the deepest position. All sutures were tied, and then the bronchoplasty was finally completed. End-to-end anastomosis was performed by dividing the bronchi into two portions: a medial portion that was also a posterior wall from the surgeon’s viewpoint, and a posterolateral portion. The anastomosis was first initiated at the medial portion of the bronchial cartilage by using a continuous 3-0 absorbable monofilament suture (Fig 3A). Every time the needle of the continuous suture came in from outside the bronchial lumen, the continuous suture was hooked by another silk suture, before the next stitch, to the outside of the lumen. The continuous suture was raised by these silk sutures until it was tied. Each silk was passed through a numbered rubber tube. Silk sutures were held together by a grasper inserted through a port. Handling the grasper in the pleural cavity can move half of the continuous-sutured line out of the surgeon’s visual field; therefore, the surgeon simply needs to stay focused on the other half, which runs outside the bronchial lumen, while suturing. Moreover, these silk sutures avoided entanglement of the continuous suture and prevented against too much tightening of the anastomotic sites (Fig 1C). After all stitches of the continuous suture were positioned, silk sutures were lifted sequentially, one by one (Fig 3B). By this method, the continuous suture could be tightened, and two anastomotic orifices were closed. However, the suture was still not completely tightened at this time, nor were the silk sutures removed. An interrupted suture was placed and tied near the end of the continuous suture (Fig 3C). The knotted suture was tied again to the end of the continuous suture (Fig 3D). At this
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time, one of two ends of the continuous suture was fixed. After that, another interrupted suture was placed near the free end of the continuous suture and tied (Fig 3E). The continuous suture was steadily tightened by lifting the silk sutures (Fig 3F). After the continuous suture was securely tightened, all silk sutures were removed. The free end of the continuous suture was tied to the knotted interrupted suture by using a sliding-knot method (Fig 3G), called “hitch and bend.” A two half-hitch knot was made by entwining a strand of another interrupted suture around the last free end of the continuous suture, outside the pleural cavity, by using a one-handed tying technique, similar to that used to tie a granny knot. Then, the hitch knot was slid to the anastomosis in the pleural cavity with a pusher-type tying instrument, keeping its “pretzel” shape. After tightening this knot, an additional square knot, which is a type of bend knot, was tied several times with a forceps-type tying instrument. The square knots were repeated several times to complete the knot. These were the procedures for the median portion. The remaining portions of the anastomosis, the other lateral portion of the bronchial cartilage, and the membranous portion of the bronchus, were anastomosed by placing interrupted sutures and tying them in the same way as for wedge plasty (Fig 3H). In all cases, no covering techniques or releasing procedures were required. A sealing test was performed to confirm that there was no leakage after completion of the anastomosis, and bronchoscopy was performed to confirm that there was no stenosis after the operation.
Results The characteristics of the 5 patients who underwent VATS bronchoplasty are summarized in Table 3. The mean percent expected forced expiratory volume in 1 second in these 5 patients was 47.7% ⫾ 14.3%. One patient with right lung carcinoma was treated with sleeve resection of the right main bronchus, and 4 patients were treated with wedge resection. Mean duration for bronchoplasty was 55.6 ⫾ 8.1 minutes. The postoperative complication chylothorax was only observed in patient 4. All patients were extubated at the end of the operation, and never used mechanical ventilation after Table 2. Lung Cancer Patients Successfully Treated by Video-Assisted Thoracoscopic Surgical Lobectomy With Mediastinal Lymph Node Dissection Age (y) Body height (cm) Body weight (kg) Operation time (min) Blood loss (g) Maximum tumor size (cm) Percentage vital capacity (%) FEV1 (%) Postoperative hospital stay (days) FEV1 ⫽ forced expiratory volume in 1 second.
69.5 ⫾ 8.5 158.4 ⫾ 8.5 57.0 ⫾ 8.6 340 ⫾ 92 167 ⫾ 174 2.96 ⫾ 1.6 107.8 ⫾ 16.5 69.8 ⫾ 11.6 8.46 ⫾ 3.5
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Table 3. Video-Assisted Thoracoscopic Surgical Bronchoplasty
Age (y) Complaint Atelectasis or obstructive pneumonia VC/%VC (L, %) %FEV1 (%) Pao2/Paco2 in room air (mm Hg) Histologic type Tumor location
Patient 1
Patient 2
44
Patient 3
⫹
⫹
2.95/98.6 63.5 86.6/41.1
3.59/102.3 63 97.2/38.4
2.81/87.6 38.2 69.3/37.9
3.48/106.7 35 78.0/39.3
2.91/86.2 38.9 85.3/40.5
SCC Right main bronchus 1.7 ⫻ 1.3 ⫻ 1.3 T3 N0 M0, IIB
SCC Right upper lobe
SCC Left upper lobe
5.5 ⫻ 3.5 ⫻ 4.2 T2 N0 M0, IB
5.5 ⫻ 3.2 ⫻ 4.8 T3 N2 M0, IIIA
None
None
None
Sleeve Right upper T3 N0 M0, IIB 68 702 1,118 None 2
Wedge Right upper T2 N0 M0, IB 56 600 265 Chylothorax 1
Wedge Left upper T3 N2 M0, IIIA 47 390 130 None 1
Cough
Carcinosarcoma Right upper lobe
SCC Right upper lobe
Tumor size (cm) Clinical TNM, stage on admission Preoperative work up
2.8 ⫻ 1.0 ⫻ 1.0 T2 N2 M0, IIIA
0⫻0⫻0 T3 N2 M0, IIIA
None
Type of plasty Lobectomy Pathologic TNM, stage Anastomosis time (min) Operation time (min) Blood loss (g) Postoperative complications Duration of postoperative oxygen therapy (POD) Postoperative hospital stay (days) Follow-up duration (days) Outcome
Wedge Right upper T2 N0 M0, IB 50 330 260 None 1
GEM, VNR ⫻ 4; NC CDDP, DOC ⫻ 4; PR Wedge Right upper T0 N0 M0, 0 57 740 750 None 1
9
8
1,793 Alive
11
1,430 Alive
62 Cough ⫺
13
981 Alive
CDDP ⫽ cisplatin; DOC ⫽ docetaxel; FEV1 ⫽ forced expiratory volume in 1 second; arterial partial pressure of oxygen; Paco2 ⫽ arterial partial pressure of carbon dioxide; SCC ⫽ squamous cell carcinoma; VC ⫽ vital capacity; VNR ⫽ vinorelbine.
that time. Mean postoperative hospital stay was 9.6 ⫾ 2.4 days. Mean follow-up was 1,125 ⫾ 490 days. All patients are presently alive without recurrence. On admission, patient 2 was T3 N2 M0, stage IIIA. He received eight courses of platinum-based chemotherapy. Although the tumor decreased in size markedly, the tumor never disappeared completely in roentgenographic images. Hence, he underwent the operation. Pathologic examination showed no malignant cells in the
73 Dyspnea ⫹
Patient 5
76 Hemosputum ⫹
Cough
58
Patient 4
7
878 Alive
541 Alive
GEM ⫽ gemcitabine; NC ⫽ no change; Pao2 ⫽ POD ⫽ postoperative day; PR ⫽ partial response;
surgical specimens. His pathologic stage was finally T0 N0 M0, stage 0. In patients 2 and 3, pleural adhesion was so severe that dissection took longer and more blood was lost than for the other cases. Patient 4 had the lowest percent expected forced expiratory volume in 1 second. This patient required supplemental oxygen therapy because of increasing dyspnea after discharge.
Fig 1. Photographs showing the surgical procedure. (A) Minithoracotomy with a silicon rubber wound protector; (B) interrupted suturing in wedge-shaped bronchoplasty; and (C) continuous suturing in circumferential reconstruction.
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Variable
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GENERAL THORACIC Fig 2. Cross-sectional view of the chest cavity. Note the difference in direction of the two instruments inserted through the minithoracotomy and the access port (dotted arrows).
Comment To apply VATS to bronchoplasty, it is necessary to ensure that the technique is both safe and reliable. Therefore, some technical issues are discussed and some solutions are presented.
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Minithoracotomy plays an important role in performing safe and reliable VATS bronchoplasty. Minithoracotomy provides a stereoscopic view of the operative field and a broader space in which to handle the surgical instruments than is available for pure VATS. Bronchoplasty is always performed after removal of the lung parenchyma; therefore, a minithoracotomy is already in place when VATS bronchoplasty is commenced. The minithoracotomy was made around a position nearest the hilar bronchi, and all vessels were in the visual field. Through the thoracotomy, the surgeon can view the hilum anteriorly (Fig 2). In most reconstruction operations, the operating site is viewed and the instruments are handled mainly through a 7-cm thoracotomy opened with a silicon wound protector and two access ports (Fig 1A). However, it is very difficult to reliably complete bronchoplasty only through a minithoracotomy. Therefore, thoracoscopy and another access port improve the weakness of this restricted surgical approach. If a closer view or a clearer view is needed because the field has been obscured by instruments inserted through the minithoracotomy, thoracoscopy provides another angled view on a monitor screen. The additional port assists with handling a needle holder, in particular, when sutures are placed at the lateral walls of the bronchi. The bronchial lateral walls are almost at a right angle to the direction of the needle
Fig 3. Management of sutures in end-to-end anastomosis; thick black lines and black and white lines are absorbable sutures, and thin black lines are silk sutures. (A) The anastomosis was first initiated at the medial portion of the bronchial cartilage by using a continuous 3-0 absorbable monofilament suture; (B) silk sutures were lifted sequentially, one by one; (C) an interrupted suture was placed and tied near the end of the continuous suture; (D) the knotted suture was tied again to the end of the continuous suture; (E) another interrupted suture was placed near the free end of the continuous suture, and tied; (F) the continuous suture was steadily tightened by lifting the silk sutures; (G) the free end of the continuous suture was tied to the knotted interrupted suture by using a sliding-knot method called “hitch and bend;” (H) the remaining portions of the anastomosis, the other lateral portion of the bronchial cartilage, and the membranous portion of the bronchus, were anastomosed by placing interrupted sutures and tying them in the same way as for wedge plasty.
holder, which is inserted into the pleural cavity through the minithoracotomy. Therefore, it is difficult to place sutures at the lateral walls, even with a good view (Fig 2, dotted arrow). Through an additional port placed anterior to the bronchi, a needle holder can be inserted almost parallel to the lateral walls of the bronchi, resulting in easier handling of the sutures (Fig 2, sparsely dashed line). The next technical issue is management of the sutures. Clumsy management results in sutures that easily tangle themselves. This is more important in VATS than in open surgery. There are some surgical devices that prevent tangling of sutures, such as cardiac valve ring organizers. However, they are not useful in VATS because these devices have been developed for open surgical procedures. These devices and sutures must be placed outside the pleural cavity. This results in sutures being placed at the anastomotic sites, and running outside the pleural cavity across the narrow visual field and surgical working area. Sutures passed through rubber tubes are able to be shifted posteriorly in the cavity, resulting in the surgeon achieving a broad space around the hilum, and a good view from the anterior position (Figs 1B, 1C, and 2). This method also helps to release the anastomotic tension. This method is an extremely valuable way to prevent suture tangling, and it can be used in VATS and open thoracotomy, especially in sleeve reconstruction, which uses many sutures. The final technical tissue concerns secure suture tying. Although the continuous suture should be tied with some instruments during VATS, it is actually difficult to adjust the tying strength. Tying strength can be adjusted by using a sliding knot in endoscopic surgery. However, most sliding knots are very complex in practice. Therefore, an easy sliding-knot technique combining hitch and bend knots was used. A hitch is a type of knot used for tying a rope to a part of a ship or another object. Two half-hitches, which is one of the best-known hitch knots, can be tied in the same manner as a granny knot. This hitch knot is easy to slip, so that the strength of the knot can be controlled. Endoscopic surgical procedures are regarded as being less invasive [5, 6, 8]. Controversy still surrounds the long-term benefit of VATS [9]. However, the invasiveness, at least within the first 2 weeks postoperatively, is certainly less than that of open surgery [10 –13]. Even if VATS only has short-term merits, it is extremely beneficial in patients requiring considerable postoperative management. Many major complications develop in the immediate postoperative period. Hence, surgical treatment for high-risk patients should be less invasive. In my opinion, VATS technology should be applied to high-risk patients [3, 4]. It is not clear whether vascular reconstruction can safely be performed with the present VATS technique; therefore, VATS is contraindicated in patients requiring pulmonary angioplasty. Independent of bronchoplasty, bulky tumors are not suitable for VATS procedures.
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Hence, VATS bronchoplasty should be applied to patients with hilar tumors that have no vascular invasion. Bronchoplasty is usually performed in a small area at the pulmonary hilum; therefore, it does not require the large operative field created by posterolateral thoracotomy. This study demonstrates success in safely and reliably performing VATS bronchoplasty with minithoracotomy, and offers some solutions to the problem of reconstruction in a narrow space. Most instruments that are used in VATS bronchoplasty are conventional and in daily use for open surgery. By using these techniques and these instruments, a skilled surgeon who can complete VATS lobectomy should be able to carry out VATS bronchoplasty without major difficulty. Surgeons need to pay attention to the long-term prognosis of our patients and try to improve our skills to shorten the operation time. Although VATS bronchoplasty is a technique in its infancy, it needs to be developed further before it can be applied more widely.
References 1. Tsuchiya R. Bronchoplastic techniques. In: Pearson FG, Cooper JD, Deslauriers J, et al, eds. Thoracic surgery, 2nd ed. Philadelphia: Churchill Livingstone, 2002:1005–13. 2. End A, Hollaus P, Pentsch A, et al. Bronchoplastic procedures in malignant and nonmalignant disease. Multivariable analysis of 144 cases. J Thorac Cardiovasc Surg 2000;120:119 –27. 3. Demmy TL, Curtis JJ. Minimally invasive lobectomy directed toward frail and high-risk patients: a case-control study. Ann Thorac Surg 1999;68:194 –200. 4. Garzon JC, Nga CS, Sihoe AD, et al. Video-assisted thoracic surgery pulmonary resection for lung cancer in patients with poor lung function. Ann Thorac Surg 2006;81:1996 –2003. 5. Nakata M, Saeki H, Yokoyama N, Kurita A, Takiyama W, Takashima S. Pulmonary function after lobectomy: videoassisted thoracic surgery versus thoracotomy. Ann Thorac Surg 2000;70:938 – 41. 6. Kaseda S, Aoki T, Hangai N, Shimizu K. Better pulmonary function and prognosis with video-assisted thoracic surgery than with thoracotomy. Ann Thorac Surg 2000;70:1644 – 6. 7. Santambrogio L, Cioffi U, Simone MD, Rosso L, Ferrero S, Giunta A. Video-assisted sleeve lobectomy for mucoepidermoid carcinoma of the left lower lobar bronchus: a case report. Chest 2002;121:635– 6. 8. Shigemura N, Akashi A, Funaki S, et al. Long-term outcomes after a variety of video-assisted thoracoscopic lobectomy approaches for clinical stage IA lung cancer: a multi-institutional study. J Thorac Cardiovasc Surg 2006;132:507–12. 9. Yim AP. VATS major pulmonary resection revisited— controversies, techniques, and results. Ann Thorac Surg 2002;74:615–23. 10. Nagahiro I, Andou A, Aoe M, Sano Y, Date H, Shimizu N. Pulmonary function, postoperative pain, and serum cytokine level after lobectomy: a comparison of VATS and conventional procedure. Ann Thorac Surg 2001;72:362–5. 11. Lia WW, Leeb RL, Leea TW, et al. The impact of thoracic surgical access on early shoulder function: video-assisted thoracic surgery versus posterolateral thoracotomy. Eur J Cardiothorac Surg 2003;23:390 – 6. 12. McKenna RJ Jr, Houck W, Fuller CB. Video-assisted thoracic surgery lobectomy: experience with 1,100 cases. Ann Thorac Surg 2006;81:421–5. 13. Ohtsuka T, Nomori H, Horio H, Naruke T, Suemasu K. Is major pulmonary resection by video-assisted thoracic surgery an adequate procedure in clinical stage I lung cancer? Chest 2004;125:1742– 6.
GENERAL THORACIC
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Background. Many surgeons think video-assisted thoracic surgery is too complex to be applied to bronchoplasty; therefore, our institution tried to develop some safe and reliable techniques for video-assisted thoracic surgery bronchoplasty. Methods. One hundred thirty-four patients with lung cancer underwent curative video-assisted thoracic surgery lobectomy including mediastinal dissection at Iizuka hospital between October 2001 and September 2006. Five of these patients underwent radical lung lobectomy with bronchoplasty using video-assisted thoracic surgery. A minithoracotomy was performed at the lateral chest wall to place sutures around the bronchi. A continuous suture was placed at the median wall of the bronchi in cases of circumferential reconstruction, and shortened rubber tubes and silk suture lines were used for assisting with reconstruction.
Results. One patient with right lung carcinoma was treated with sleeve resection of the right main bronchus, whereas the others were treated with wedge resection. In one case, chylothorax was seen as a postoperative complication. There were no serious complications related to bronchoplasty. All cases are alive without any recurrence during follow-up. Conclusions. The importance of position of minithoracotomy and another access port, management of sutures, and the secure tightened method was assessed. There were no serious postoperative complications. Videoassisted thoracic surgery bronchoplasty is a complex procedure, but it can safely be performed using some additional techniques.
B
2006, 134 patients underwent curative VATS lobectomy, including mediastinal dissection, for lung carcinoma at Iizuka Hospital, Japan. Table 2 summarizes their characteristics. Five patients underwent VATS lobectomy with bronchoplasty (Table 3). All patients gave written informed consent, and the study was approved by the Institutional Ethics Committee.
ronchoplastic procedures for hilar lung cancer are performed widely as curative methods that preserve function [1]. Although video-assisted thoracic surgery (VATS) is regarded as a minimally invasive procedure [2– 6], many surgeons think that VATS is too complex and has too many technical limitations to be applied to bronchoplasty. Therefore, there are few reports in the literature of VATS bronchoplasty for lung carcinoma [7]. In this report, I describe a VATS bronchoplasty technique and several successfully treated cases.
Patients and Methods Patients Patients with primary lung cancer who were candidates for lobectomy with mediastinal lymphadenectomy and who satisfied the criteria in Table 1 were eligible for the VATS approach. Primary lesions and metastasis had been evaluated by using of roentgenography and enhanced computed tomography. Bronchofiberscopy, bone scintigraphy, and positron emission tomography were performed if necessary. Mediastinoscopy was not routinely performed. Between October 2001 and September Accepted for publication March 2, 2007. Address correspondence to Dr Nakanishi, Division of General Thoracic Surgery, Jikei University School of Medicine, 3-25-8 Nishi-shinbashi, Minato-ku, Tokyo, 105-8461, Japan; e-mail: [email protected].
© 2007 by The Society of Thoracic Surgeons Published by Elsevier Inc
(Ann Thorac Surg 2007;84:191– 6) © 2007 by The Society of Thoracic Surgeons
Operative Technique Patients were placed in the lateral decubitus position. The surgeon made a 7-cm incision in the fourth intercostal space as a utility thoracotomy, followed by three 1.5-cm incisions for access ports. A silicon rubber wound protector (LapDisk; Hakko Shoji, Tokyo, Japan) kept the utility thoracotomy opened (Fig 1A). The first port, on the posterior axillary line in the sixth intercostal space, was used primarily for thoracoscopy. The second, on the anterior axillary line in the sixth intercostal space, was for manipulation of the lung. The third port, on the anterior axillary line in the third intercostal space, was used for manipulation during dissection and, in particular, for the handling of a needle holder during bronchial anastomosis. Pulmonary vessels were resected as for standard lobectomy. Mediastinal lymph nodes, including the subcarinal nodes, were also dissected before bronchial reconstruction. The bronchus was cut wedgewise or circumferentially with an angledblade knife and scissors, and then the bronchial stump 0003-4975/07/$32.00 doi:10.1016/j.athoracsur.2007.03.008
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Table 1. Criteria for Video-Assisted Thoracoscopic Surgical Lobectomy for Primary Lung Carcinoma
GENERAL THORACIC
Minimum tumor size ⬍ 5 cm. No evidence of vessel invasion. No direct invasion to the surrounding organs requiring reconstruction. Patient and family agreed to procedure.
was confirmed by frozen sectioning to be pathologically free of cancer. After pathologic examination, bronchial anastomosis was initiated by viewing and handling through the thoracotomy. In wedge plasty, the bronchial anastomosis was performed using several interrupted 3-0 absorbable monofilament sutures (Fig 1B). Interrupted sutures were first placed on the cartilaginous portions of the bronchial orifices, then on the membranous portions. Two ends of each suture were passed together through serially numbered rubber tubes shortened into 2-cm lengths. Furthermore, the ends were fastened with pieces of tape labeled in the same sequence as the rubber tubes. Along the sutures, the rubber tubes were moved into the pleural cavity around the anastomotic site. During suturing, all sutures were held together in the pleural cavity by a grasper inserted through the other access port (Fig 2). After placing all sutures, knot tying was started with a forceps-type tying instrument at the suture placed at the deepest position. All sutures were tied, and then the bronchoplasty was finally completed. End-to-end anastomosis was performed by dividing the bronchi into two portions: a medial portion that was also a posterior wall from the surgeon’s viewpoint, and a posterolateral portion. The anastomosis was first initiated at the medial portion of the bronchial cartilage by using a continuous 3-0 absorbable monofilament suture (Fig 3A). Every time the needle of the continuous suture came in from outside the bronchial lumen, the continuous suture was hooked by another silk suture, before the next stitch, to the outside of the lumen. The continuous suture was raised by these silk sutures until it was tied. Each silk was passed through a numbered rubber tube. Silk sutures were held together by a grasper inserted through a port. Handling the grasper in the pleural cavity can move half of the continuous-sutured line out of the surgeon’s visual field; therefore, the surgeon simply needs to stay focused on the other half, which runs outside the bronchial lumen, while suturing. Moreover, these silk sutures avoided entanglement of the continuous suture and prevented against too much tightening of the anastomotic sites (Fig 1C). After all stitches of the continuous suture were positioned, silk sutures were lifted sequentially, one by one (Fig 3B). By this method, the continuous suture could be tightened, and two anastomotic orifices were closed. However, the suture was still not completely tightened at this time, nor were the silk sutures removed. An interrupted suture was placed and tied near the end of the continuous suture (Fig 3C). The knotted suture was tied again to the end of the continuous suture (Fig 3D). At this
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time, one of two ends of the continuous suture was fixed. After that, another interrupted suture was placed near the free end of the continuous suture and tied (Fig 3E). The continuous suture was steadily tightened by lifting the silk sutures (Fig 3F). After the continuous suture was securely tightened, all silk sutures were removed. The free end of the continuous suture was tied to the knotted interrupted suture by using a sliding-knot method (Fig 3G), called “hitch and bend.” A two half-hitch knot was made by entwining a strand of another interrupted suture around the last free end of the continuous suture, outside the pleural cavity, by using a one-handed tying technique, similar to that used to tie a granny knot. Then, the hitch knot was slid to the anastomosis in the pleural cavity with a pusher-type tying instrument, keeping its “pretzel” shape. After tightening this knot, an additional square knot, which is a type of bend knot, was tied several times with a forceps-type tying instrument. The square knots were repeated several times to complete the knot. These were the procedures for the median portion. The remaining portions of the anastomosis, the other lateral portion of the bronchial cartilage, and the membranous portion of the bronchus, were anastomosed by placing interrupted sutures and tying them in the same way as for wedge plasty (Fig 3H). In all cases, no covering techniques or releasing procedures were required. A sealing test was performed to confirm that there was no leakage after completion of the anastomosis, and bronchoscopy was performed to confirm that there was no stenosis after the operation.
Results The characteristics of the 5 patients who underwent VATS bronchoplasty are summarized in Table 3. The mean percent expected forced expiratory volume in 1 second in these 5 patients was 47.7% ⫾ 14.3%. One patient with right lung carcinoma was treated with sleeve resection of the right main bronchus, and 4 patients were treated with wedge resection. Mean duration for bronchoplasty was 55.6 ⫾ 8.1 minutes. The postoperative complication chylothorax was only observed in patient 4. All patients were extubated at the end of the operation, and never used mechanical ventilation after Table 2. Lung Cancer Patients Successfully Treated by Video-Assisted Thoracoscopic Surgical Lobectomy With Mediastinal Lymph Node Dissection Age (y) Body height (cm) Body weight (kg) Operation time (min) Blood loss (g) Maximum tumor size (cm) Percentage vital capacity (%) FEV1 (%) Postoperative hospital stay (days) FEV1 ⫽ forced expiratory volume in 1 second.
69.5 ⫾ 8.5 158.4 ⫾ 8.5 57.0 ⫾ 8.6 340 ⫾ 92 167 ⫾ 174 2.96 ⫾ 1.6 107.8 ⫾ 16.5 69.8 ⫾ 11.6 8.46 ⫾ 3.5
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Table 3. Video-Assisted Thoracoscopic Surgical Bronchoplasty
Age (y) Complaint Atelectasis or obstructive pneumonia VC/%VC (L, %) %FEV1 (%) Pao2/Paco2 in room air (mm Hg) Histologic type Tumor location
Patient 1
Patient 2
44
Patient 3
⫹
⫹
2.95/98.6 63.5 86.6/41.1
3.59/102.3 63 97.2/38.4
2.81/87.6 38.2 69.3/37.9
3.48/106.7 35 78.0/39.3
2.91/86.2 38.9 85.3/40.5
SCC Right main bronchus 1.7 ⫻ 1.3 ⫻ 1.3 T3 N0 M0, IIB
SCC Right upper lobe
SCC Left upper lobe
5.5 ⫻ 3.5 ⫻ 4.2 T2 N0 M0, IB
5.5 ⫻ 3.2 ⫻ 4.8 T3 N2 M0, IIIA
None
None
None
Sleeve Right upper T3 N0 M0, IIB 68 702 1,118 None 2
Wedge Right upper T2 N0 M0, IB 56 600 265 Chylothorax 1
Wedge Left upper T3 N2 M0, IIIA 47 390 130 None 1
Cough
Carcinosarcoma Right upper lobe
SCC Right upper lobe
Tumor size (cm) Clinical TNM, stage on admission Preoperative work up
2.8 ⫻ 1.0 ⫻ 1.0 T2 N2 M0, IIIA
0⫻0⫻0 T3 N2 M0, IIIA
None
Type of plasty Lobectomy Pathologic TNM, stage Anastomosis time (min) Operation time (min) Blood loss (g) Postoperative complications Duration of postoperative oxygen therapy (POD) Postoperative hospital stay (days) Follow-up duration (days) Outcome
Wedge Right upper T2 N0 M0, IB 50 330 260 None 1
GEM, VNR ⫻ 4; NC CDDP, DOC ⫻ 4; PR Wedge Right upper T0 N0 M0, 0 57 740 750 None 1
9
8
1,793 Alive
11
1,430 Alive
62 Cough ⫺
13
981 Alive
CDDP ⫽ cisplatin; DOC ⫽ docetaxel; FEV1 ⫽ forced expiratory volume in 1 second; arterial partial pressure of oxygen; Paco2 ⫽ arterial partial pressure of carbon dioxide; SCC ⫽ squamous cell carcinoma; VC ⫽ vital capacity; VNR ⫽ vinorelbine.
that time. Mean postoperative hospital stay was 9.6 ⫾ 2.4 days. Mean follow-up was 1,125 ⫾ 490 days. All patients are presently alive without recurrence. On admission, patient 2 was T3 N2 M0, stage IIIA. He received eight courses of platinum-based chemotherapy. Although the tumor decreased in size markedly, the tumor never disappeared completely in roentgenographic images. Hence, he underwent the operation. Pathologic examination showed no malignant cells in the
73 Dyspnea ⫹
Patient 5
76 Hemosputum ⫹
Cough
58
Patient 4
7
878 Alive
541 Alive
GEM ⫽ gemcitabine; NC ⫽ no change; Pao2 ⫽ POD ⫽ postoperative day; PR ⫽ partial response;
surgical specimens. His pathologic stage was finally T0 N0 M0, stage 0. In patients 2 and 3, pleural adhesion was so severe that dissection took longer and more blood was lost than for the other cases. Patient 4 had the lowest percent expected forced expiratory volume in 1 second. This patient required supplemental oxygen therapy because of increasing dyspnea after discharge.
Fig 1. Photographs showing the surgical procedure. (A) Minithoracotomy with a silicon rubber wound protector; (B) interrupted suturing in wedge-shaped bronchoplasty; and (C) continuous suturing in circumferential reconstruction.
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GENERAL THORACIC Fig 2. Cross-sectional view of the chest cavity. Note the difference in direction of the two instruments inserted through the minithoracotomy and the access port (dotted arrows).
Comment To apply VATS to bronchoplasty, it is necessary to ensure that the technique is both safe and reliable. Therefore, some technical issues are discussed and some solutions are presented.
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Minithoracotomy plays an important role in performing safe and reliable VATS bronchoplasty. Minithoracotomy provides a stereoscopic view of the operative field and a broader space in which to handle the surgical instruments than is available for pure VATS. Bronchoplasty is always performed after removal of the lung parenchyma; therefore, a minithoracotomy is already in place when VATS bronchoplasty is commenced. The minithoracotomy was made around a position nearest the hilar bronchi, and all vessels were in the visual field. Through the thoracotomy, the surgeon can view the hilum anteriorly (Fig 2). In most reconstruction operations, the operating site is viewed and the instruments are handled mainly through a 7-cm thoracotomy opened with a silicon wound protector and two access ports (Fig 1A). However, it is very difficult to reliably complete bronchoplasty only through a minithoracotomy. Therefore, thoracoscopy and another access port improve the weakness of this restricted surgical approach. If a closer view or a clearer view is needed because the field has been obscured by instruments inserted through the minithoracotomy, thoracoscopy provides another angled view on a monitor screen. The additional port assists with handling a needle holder, in particular, when sutures are placed at the lateral walls of the bronchi. The bronchial lateral walls are almost at a right angle to the direction of the needle
Fig 3. Management of sutures in end-to-end anastomosis; thick black lines and black and white lines are absorbable sutures, and thin black lines are silk sutures. (A) The anastomosis was first initiated at the medial portion of the bronchial cartilage by using a continuous 3-0 absorbable monofilament suture; (B) silk sutures were lifted sequentially, one by one; (C) an interrupted suture was placed and tied near the end of the continuous suture; (D) the knotted suture was tied again to the end of the continuous suture; (E) another interrupted suture was placed near the free end of the continuous suture, and tied; (F) the continuous suture was steadily tightened by lifting the silk sutures; (G) the free end of the continuous suture was tied to the knotted interrupted suture by using a sliding-knot method called “hitch and bend;” (H) the remaining portions of the anastomosis, the other lateral portion of the bronchial cartilage, and the membranous portion of the bronchus, were anastomosed by placing interrupted sutures and tying them in the same way as for wedge plasty.
holder, which is inserted into the pleural cavity through the minithoracotomy. Therefore, it is difficult to place sutures at the lateral walls, even with a good view (Fig 2, dotted arrow). Through an additional port placed anterior to the bronchi, a needle holder can be inserted almost parallel to the lateral walls of the bronchi, resulting in easier handling of the sutures (Fig 2, sparsely dashed line). The next technical issue is management of the sutures. Clumsy management results in sutures that easily tangle themselves. This is more important in VATS than in open surgery. There are some surgical devices that prevent tangling of sutures, such as cardiac valve ring organizers. However, they are not useful in VATS because these devices have been developed for open surgical procedures. These devices and sutures must be placed outside the pleural cavity. This results in sutures being placed at the anastomotic sites, and running outside the pleural cavity across the narrow visual field and surgical working area. Sutures passed through rubber tubes are able to be shifted posteriorly in the cavity, resulting in the surgeon achieving a broad space around the hilum, and a good view from the anterior position (Figs 1B, 1C, and 2). This method also helps to release the anastomotic tension. This method is an extremely valuable way to prevent suture tangling, and it can be used in VATS and open thoracotomy, especially in sleeve reconstruction, which uses many sutures. The final technical tissue concerns secure suture tying. Although the continuous suture should be tied with some instruments during VATS, it is actually difficult to adjust the tying strength. Tying strength can be adjusted by using a sliding knot in endoscopic surgery. However, most sliding knots are very complex in practice. Therefore, an easy sliding-knot technique combining hitch and bend knots was used. A hitch is a type of knot used for tying a rope to a part of a ship or another object. Two half-hitches, which is one of the best-known hitch knots, can be tied in the same manner as a granny knot. This hitch knot is easy to slip, so that the strength of the knot can be controlled. Endoscopic surgical procedures are regarded as being less invasive [5, 6, 8]. Controversy still surrounds the long-term benefit of VATS [9]. However, the invasiveness, at least within the first 2 weeks postoperatively, is certainly less than that of open surgery [10 –13]. Even if VATS only has short-term merits, it is extremely beneficial in patients requiring considerable postoperative management. Many major complications develop in the immediate postoperative period. Hence, surgical treatment for high-risk patients should be less invasive. In my opinion, VATS technology should be applied to high-risk patients [3, 4]. It is not clear whether vascular reconstruction can safely be performed with the present VATS technique; therefore, VATS is contraindicated in patients requiring pulmonary angioplasty. Independent of bronchoplasty, bulky tumors are not suitable for VATS procedures.
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Hence, VATS bronchoplasty should be applied to patients with hilar tumors that have no vascular invasion. Bronchoplasty is usually performed in a small area at the pulmonary hilum; therefore, it does not require the large operative field created by posterolateral thoracotomy. This study demonstrates success in safely and reliably performing VATS bronchoplasty with minithoracotomy, and offers some solutions to the problem of reconstruction in a narrow space. Most instruments that are used in VATS bronchoplasty are conventional and in daily use for open surgery. By using these techniques and these instruments, a skilled surgeon who can complete VATS lobectomy should be able to carry out VATS bronchoplasty without major difficulty. Surgeons need to pay attention to the long-term prognosis of our patients and try to improve our skills to shorten the operation time. Although VATS bronchoplasty is a technique in its infancy, it needs to be developed further before it can be applied more widely.
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