The two-incision approach for video-assisted thoracoscopic lobectomy:an initial experience by SEPAR

European Journal of Cardio-thoracic Surgery 39 (2011) 120—126 www.elsevier.com/locate/ejcts

The two-incision approach for video-assisted thoracoscopic lobectomy: an initial experience Jose Maria Borro *, Diego Gonzalez, Marina Paradela, Mercedes de la Torre, Ricardo Fernandez, Maria Delgado, Jose Garcia, Eva Fieira ˜a, La Corun ˜a, Spain Hospital Universitario de La Corun Received 3 February 2010; received in revised form 18 April 2010; accepted 7 May 2010; Available online 16 June 2010

Abstract Objective: The video-assisted thoracoscopic approach (video-assisted thoracic surgery (VATS)) to lobectomy for non-small-cell lung cancer (NSCLC) is not standardised. Although three to four incisions are usually made, with the right surgical technique, the operation can be successfully carried out using only two incisions. We have analysed retrospectively, the characteristics and postoperative evolution of patients undergoing VATS lobectomies using two ports. Methods: From June 2007 to November 2009, we carried out 131 major pulmonary resections by VATS, of which 40 (February 2009 to November 2009) were realised using only two incisions: one 1-cm incision through the 7th/8th intercostal space in the mid-axillary line, and a 3—5-cm anterior utility incision in the 5th intercostal space. The patients’ mean age was 60.8 11.4 years (75% male, 25% female). Results: The conversion rate was 10% (four patients). Of the remaining 36 cases, the diagnosis in six patients was benign, and in four was metastatic disease. Of the 26 cases with NSCLC, the most frequent stage was that of interactive application (IA) (58%) and histology mostly revealed adenocarcinoma (33%). Mean duration of surgery in the 36 resections completed by VATS was 168.6 54.0 min (range 80—300 min). The median chest tube duration was 2.5 days and the median length of stay in hospital was 3 days. There was no perioperative mortality in completed VATS cases, and no patient needed to be re-operated. Those patients with chronic obstructive pulmonary disease (COPD) needed longer hospital stays ( p = 0.046). Similarly, extreme cases of adhesion during surgery needed more days of thoracic drainage ( p = 0.040) and longer hospital stays ( p = 0.011), as well as displaying a higher percentage of postoperative complications ( p = 0.008). If the group of patients is divided in two periods (February to July 2009 and August to November 2009), more extended lymphadenectomies are observed among those performed during the latter period. Conclusions: VATS lobectomy with two incisions is a safe and reliable procedure producing good postoperative results. As we obtain more experience over time, results improve, especially in the performance of more extended lymphadenectomies. # 2010 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved. Keywords: Thoracoscopy/VATS; Lobectomy; Approach; Lung cancer; Outcomes

1. Introduction Lobectomies have been carried out using thoracoscopy (video-assisted thoracic surgery (VATS)) since the beginning of the 1990s for the treatment of bronchogenic carcinoma. This treatment showed substantial advantages when compared with conventional open surgery, specifically in initial cancer stages. Among improvements observed, we can include those of reduced postoperative pain, shorter drainage time, shorter hospital stays, better conservation of pulmonary function and lower inflammatory rate, faster return to activities of daily living and a rapid commencement of chemotherapy, whenever this may be necessary [1]. * Corresponding author. Address: Department of Thoracic Surgery and Lung Transplantation, Hospital Universitario de La Corun ˜a, Xubias 84, 15006, La Corun ˜a, Spain. Tel.: +34 981178286; fax: +34 981178235. E-mail address: jbormat@sergas.es (J.M. Borro).

We began to perform VATS lobectomies in our department in June 2007. Until November 2009, we did a total of 131 major pulmonary resections by VATS. Many authors consider that, approximately, 50 surgical procedures are necessary to overcome the learning curve [2]. The first 80 cases were operated on using three incisions, but since February 2009, we have developed this technique further by eliminating the posterior port, and using only two incisions in almost all cases, according to the technique described by D’Amico [3]. Most surgeons use three to four incisions to perform a VATS lobectomy, as we used to do; however, it can be accomplished using only two ports. It has not been proved, but we believe that this approach, being less invasive, produces less pain and less immunologic response. We hope to prove this with a larger number of patients. In this article, we review our experience with this approach with regard to short-term postoperative evolution.

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2. Materials and methods

2.2. Surgical technique

A retrospective descriptive prevalence study was performed on patients undergoing lobectomy by VATS using two incisions, in the Thoracic Surgery Department of the Hospital Universitario de la Corun ˜a between February and November 2009. The study was approved by the Institutional Review Board at the Corun ˜a University Hospital. We established a two-port VATS programme for all thoracoscopic lobectomies, starting with lower lobectomies, as these presented less difficulty. Forty surgical interventions were performed using this technique during the period of study. Variables studied in each patient were age, sex, smoking habits, with or without chronic obstructive pulmonary disease (COPD), pulmonary function (forced expiratory volume in 1 s (FEV1) and forced vital capacity (FVC)), the presence of associated co-morbidity, the way the lesion is presented, tumour type and position, type and duration of surgical intervention, surgeryassociated adhesions, pre- and post-surgical stage, histologic type, tumour size, lymph node affectation (number of lymph nodes retrieved and number of nodal stations explored), duration of chest tube, length of hospital stay (also in days), postoperative complications and 30-day mortality. SPSS 17 for Windows was used for statistical analysis. A descriptive analysis of the variables studied was carried out. The quantitative variables are expressed as mean standard deviation, median and range. Qualitative variables are expressed by means of frequencies and the corresponding percentages. To study the link between qualitative variables, the chi-square test or Fisher’s-exact test were used. For the comparison of numerical variables between groups, the Mann—Whitney test was used. All tests were carried out with a bilateral approach and values of p < 0.05 were considered significant.

Video-assisted thoracoscopic lobectomy, using two incisions, follows the oncological principles of major pulmonary resections by VATS: individual dissection of veins, arteries and lobar bronchus; so does, complete mediastinal lymphadenectomy with a VATS approach, without visual access through the incision and without rib spreading. The patient is placed in the lateral decubitus position, the same position as for thoracotomy. It is essential that selective intubation and lung collapse are carried out correctly. The first incision is performed in the 7th—8th intercostal space, in the mid-axillary line, and is used mainly for introducing a 10mm 308 thoracoscope. The second incision, about 4—5 cm long, is performed at the 5th anterior interspace, just below the breast and the pectoralis major muscle. This position is chosen due to the greater width of the intercostal spaces in this area, and due to the good access available for the dissection of hilar structures. We use no rib retractor and almost the whole of the dissection is performed through the utility port. The camera must be of 308, to enable us to make our observations with a panoramic view. Instruments must, preferably, be long and curved to allow the insertion of two or three instruments, simultaneously. We use conventional instruments, combined with thoracoscopic equipment. The first action is to visually inspect the pleural cavity to rule out the presence of pleural metastasis and hilar invasion, and to make an accurate assessment of the tumour. In the event of adhesions hindering the introduction of the camera, the process of detaching them can be begun from the orifice of the camera, until they are detached enough to enable the anterior incision to be made. We confirm the presence of the tumour by touch, retracting the lung using the utility port, and if there is no diagnosis of malignancy, we perform an atypical resection, while if it is deep or too large, we can perform a Tru-cut biopsy. If malignancy is confirmed by intra-operatory biopsy, we go on to perform the lobectomy or segmentectomy, depending on the characteristics of both the tumour and the patient. To make the anatomical resection through only two incisions, it is essential to learn the technique, whereby, the 308 camera and the endostaplers are exchanged from one incision to the other for the resection of hilar structures. In the lower and middle lobectomies, it is usually unnecessary to make this change, it being feasible to both dissect and staple using the utility port. In the lower lobes, if the artery is exposed in the fissure, the procedure will be similar to that in open surgery, but when the fissure is incomplete, the ideal procedure to avoid air leaks is to perform the lobectomy from below, working upwards in the following order: vein, bronchus, artery and fissure. For upper lobectomies, most endostaplers must be inserted from the camera port; thus, a proper execution of the above-mentioned port of access is essential (Fig. 1). After adequate exposure of the lung, we begin hilar dissection through the utility port, the pulmonary vein being the first structure dissected in any lobectomy. For an upper lobectomy, we must retract the lung down and backwards, while, for a lower lobectomy, there will be upward

2.1. Indications Indications are the same as those for VATS performed for most groups [4]. The utility incision must be large enough to remove the affected lobe without rib spreading. Contraindications have changed over time due to the technical improvements made and the surgeons’ own experience, so that advanced stage or post-chemotherapy can be performed providing oncological principles for complete resection. Absolute contraindications include the inability to perform a complete resection with lobectomy, invasive mediastinal or chest wall tumours, N2 or N3 disease or the impracticability of selective lobar lung collapse. Relative contraindications include tumours that have received chemo- or radiotherapy, endobronchial conditions requiring bronchoplasty, or lymph node affectation seriously hindering hilar dissection. This depends on the surgeon’s own experience and skill. There are publications reporting both sleeve resections by VATS and cases of post-chemotherapy with positive outcomes [5—7]. Tumour size ought not to be a contraindication, except in the case of large masses. We consider that the acceptable limit for performing a safe VATS lobectomy is 6 cm.

[(Fig._1)TD$IG]

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Table 2 Type of anatomic pulmonary resections (n = 40).

Right upper lobectomy Right middle lobectomy Right lower lobectomy Left upper lobectomy Left lower lobectomy Typical segmentectomy

Fig. 1. Introduction of stapler devices for upper lobectomies.

retraction. Normally, the vascular structures are tagged with surgical ligatures for retraction and to clear the way for the endostaplers. We prefer to staple the artery first and then the vein, whenever possible, to prevent vein congestion. Vascular dissection must be performed with care, taking advantage of good thoracoscopic vision. Once the lobectomy has been completed, the lobe is removed in a protective bag, and a complete mediastinal lymphadenectomy is performed. For right-side tumours, nodal stations 2, 4, 7, 8, 9 and 10—12 (or hilar) are studied, and for left-side tumours nodal stations 5—9, and 10—12 are dissected. We carry out a systematic nodal dissection, according to oncological criteria, proposed by Spanish Bronchogenic Carcinoma Cooperation Group of the Spanish Society of Pneumology and Chest Surgery [8]. A single chest tube is placed at the end of the surgery.

3. Results From February to November 2009, we performed 40 major pulmonary resections by VATS with only two incisions. Demographic characteristics, associated co-morbidity and pulmonary function tests are described in Table 1. Table 1 Patients’ demographic characteristics.

No.

8 5 7 10 9 1

20 12 18 25 22 3

Fifty-two percent of lesions were casual findings in routine chest X-ray. Bronchoscopy was performed in 100% of cases, as part of the protocol for the study of pulmonary lesions, with endobronchial lesions being revealed in five cases (12%). In 26 patients (65%), there was no diagnosis prior to surgery, while 72% of the patients had positive results in the positron emission tomography (PET) scan. Conversion to open surgery was required in four patients (10%), two of these for technical reasons and two due to bleeding. Conversion was performed by lengthening of the utility incision in a postero—lateral direction. The two instances of bleeding were presented because of the difficulty of vascular dissection, due to adenopathies (one of these following chemotherapy), and the other two, for technical reasons, due to tumour position. Type and frequency of lobectomy performed are shown in Table 2. The mean surgical time was 168 54.0 min (80—300 min) in the 36 cases completed using VATS and 240 49.0 min (180—300 min) in the four converted interventions. In all patients whose intervention by VATS was completed, a single chest tube was placed, while in the instances of surgical conversion, two drains were left. An analysis of the characteristics of patients with completed VATS resections (36 cases) was made, to observe postoperatory evolution. The most common histological type was primary lung adenocarcinoma (12 cases) (Table 3). Anatomical pathology confirmed tumour-free bronchial edges and free surgical margins in 100% of patients with diagnosis of malignancy (N = 30, 83%). Mean tumour size was 2.6 1.5 cm (0.2—8 cm). After anatomical resection, a complete mediastinal lymphadenectomy was performed in the 30 patients with diagnosis of malignancy, according to oncological criteria, as in open surgery.

Mean SD (range), or No. (%) Age Sex Male Female Smoking history Yes No Co-morbidity COPD Cardiovascular risk factor Cardiac disease Previous cancer Previous surgery Other diseases Pulmonary function FEV1 Vital capacity

60.8 11.4 (37—82) 40 30 (75) 10 (25) 31 (77) 9 (23) 18 23 12 15 25 23

(45) (57) (30) (37) (62) (57)

84.6 21.3 (43—136) 90.2 17.3 (58—130)

Table 3 Histological diagnosis in the 36 cases completed with VATS.

Adenocarcinoma Squamous cell Bronchioloalveolar Ca Large cell Carcinoid Metastasis Benign - Inflammatory pseudotumour - Haemorrhagic infarct - Bullous disease - Endobronchial tumour - Chondroid hamartoma - Solitary fibrous tumour

No.

12 6 5 1 2 4 6 1 1 1 1 1 1

33 17 14 3 6 11 17 3 3 3 3 3 3

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Table 4 Characteristics of patients with postoperative complications and prolonged hospital stays.

Patient 1 75 years, Patient 2 65 years, Patient 3 49 years, Patient 4 44 years, Patient 5 82 years,

COPD

Adhesions

Stage

Surgical time

Type of lobectomy

Chest tube

Hospital stay

Complications

Yes

Strong

200

LUL

Yes

Strong

300

LUL

Yes

Strong

210

LUL

Mild

IIIA

120

RLL

Severe emphysema. Strong adhesions. Residual apical pneumothorax. New chest tube Need for tracheotomy. Pneumonia, atelectasis. 54 days in care intensive unit Previous thoracotomy (segmentectomy). Chemotherapy. Pulmonary relapse Prolonged air leak. Complex fissure

Yes

250

RUL

Chylothorax after radical lymph node dissection

male male female male male

LUL: left upper lobectomy; RLL: right lower lobectomy; and RUL: right upper lobectomy.

In patients diagnosed with non-small-cell lung cancer (NSCLC) (N = 26), the mean number of nodal stations explored was 3.9 1.1, with an average of 9.2 5.4 lymph node resections. There was no significant difference in the number of nodal stations and lymph node resections, according to the side operated on (median of four nodal stations and seven lymph nodes on the left and four and nine on the right side, respectively). Neo-adjuvant chemotherapy was administered to four patients (15%), who were diagnosed with NSCLC (one stageIIIA case, another stage-IV with cerebral metastasis and the other two by mediastinal size and contact). The case staged IIIA by N2 affection was a difficult case because he had intense pleural adhesions and needed a bronchoplastic procedure (sleeve resection), but no postoperative complications were found (duration of surgery 240 min, 2 days of chest tubes and 4 days of hospital stay). The stage-IV patient underwent a thoracotomy (segmentectomy and lymphadenectomy) in another centre, 4 years before. This patient presented cerebral metastasis, which had been treated, and had suffered relapse from a pulmonary lesion, which we operated on by VATS, completing a left upper lobectomy (Table 4). Pre-surgical staging and postoperatory histological results are described in Table 5. The rate of concordance of clinical stays with pathologies was 65%. In three cases, there was pathological lymph node affection, N2 (IIIA) making up 11%. No epidural catheter was inserted in 83% of patients. It was present in the 17% of patients who required it for an average of 0.2 0.4 (0—2) days. Median postoperative time in intensive care unit was 1 day (1—23) and the average number of days of morphine use 0.78 1.01 (0—4). There were no cases of postoperative mortality in completed VATS cases; however, there was one death in

Table 6 Postoperative complications.

Table 5 Non-small-cell lung cancer stages (n = 26).

IA IB IIA IIB IIIA IIIB IV

Clinical (n, %)

Pathological (n, %)

15 7 1 0 2 0 1

15 6 0 1 3 0 1

(58) (27) (4) (0) (8) (0) (4)

the conversion cases. This was an 80-year-old male patient converted due to bleeding, who died 31 days after the surgery in the intensive care unit because of associated comorbidity (acute renal failure, contralateral pneumonia and sepsis). No patient required re-operation in the postoperatory period. A total of 83% (30 patients) presented no postoperative complications and 75% (27 patients) presented no postoperatory air leaks. The median chest tube duration and hospital stay was 2.5 (1—26) and 3 (3—76) days, respectively, with normal results for X-chest ray on discharge in 86% (31 patients) of cases. Fifty-five percent of patients were discharged within the first 72 h. In five cases, the hospital stay was prolonged for more than 10 days, these being complicated surgical cases. Characteristics of these patients are described in Table 4. Seventy five percent (27) of patients presented no postoperatory air leakage during the postoperatory period, while in three cases (8%), there was prolonged air leakage. Most common complications in the postoperative period and their frequencies are described in Table 6. We found that in COPD patients, both the mean time of surgery and the drainage period were longer than in non-COPD patients, although the results were not statistically significant. Hospital stay was significantly longer than those for nonCOPD patients ( p = 0.046) (Table 7). Similarly, those patients who presented with intense adhesions during surgery needed more days of thoracic chest tube (median 6 vs 2; p = 0.040), days of hospitalisation (median 7 vs 3; p = 0.011) as well as a larger percentage of postoperative complications, which was statistically significant (57% vs 7%; p = 0.008) (Table 7). On anatomical analysis of the lobectomies performed, dividing them into upper and lower, we found that the

(58) (32) (0) (4) (11) (0) (4)

Prolonged air leak (>5 days) Atelectasis Chylothorax Sepsis Pneumonia Atrial fibrillation Renal insufficiency Reinsertion of chest tube

3 2 1 1 1 1 1 1

8 6 3 3 3 3 3 3

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Table 7 Comparative table of several variables with outcomes.

COPD Yes No Adhesions Yes No Stage I Yes No NSCLC Yes No

Operative time median (range)

Chest tubes median (range)

Hospital stay median (range)

Complications %

180 (80—300) 150 (80—240) p = 0.18

4 (1—26) 2 (1—11) p = 0.10

5 (2—76) 3 (1—12) p = 0.046

27 9 p = 0.21

200 (130—300) 160 (80—250) p = 0.15

6 (2—26) 2 (1—13) p = 0.040

7 (2—76) 3 (1—17) p = 0.011

57 7 p = 0.008

160 (100—300) 195 (120—240) p = 0.76

2 (1—26) 4 (2—16) p = 0.29

3 (1—76) 4 (3—16) p = 0.24

19 33 p = 0.59

160 (100—300) 155 (80—240) p = 0.26

3 (1—26) 2 (2—4) p = 0.43

3.5 (1—76) 3 (2—5) p = 0.14

23 0 p = 0.16

duration of surgical procedure is significantly longer in upper lobectomies (199.4 43.3 vs 153.7 49.2; p = 0.007). If we divide patients operated on into two periods (February—July 2009 and August—November 2009), we found some differences. While total surgical time, days of chest tube and hospitalisation were similar, we saw differences in lymphadenectomy: a larger number of nodal stations explored in the second half (median 4 vs 3, p = 0.059) and a larger number of resected lymph nodes (median 9.5 vs 5.5, p = 0.018).

4. Discussion Major pulmonary resection using VATS is a widely accepted and feasible procedure for the treatment of NSCLC and other lung pathologies. However, several concerns have been expressed regarding this procedure, particularly about the lack of absolute indications and a standardised surgical technique, with significant differences in technique between different centres. Technical variables such as size and position of port incisions, length of utility incision, the use of rib spreading and the amount of anatomical hilar and interlobar dissection are main topics of ongoing discussion [9]. VATS lobectomies must be performed with anatomical dissection of veins, arteries and lobar bronchi, as occurs in open surgery. Nevertheless, some authors, such as Lewis et al. published reports in 1992, where good outcomes are reported in the first 40 cases of VATS lobectomy through simultaneous stapled lobectomy [4]. We consider a complete VATS (c-VATS) endoscopic lobectomy to be that realised by 2—4 incisions, without rib spreading and viewing through a camera. It must be distinguished from assisted VATS (a-VATS), which uses rib retractors, enabling us to view the thoracic cavity directly. In one multi-institutional study comparing a-VATS with c-VATS, Shigemura et al. found that patients with c-VATS stayed for a shorter time in hospital and recovered faster [10]. After 80 thoracoscopic lobectomies, we began to perform VATS surgery eliminating the posterior incision, starting with lower lobectomies. According to Dr D’Amico’s technique [3],

we set up a two-incision port VATS programme in almost all thoracoscopic lobectomies. In the same way, our real conversion rate of 10% corresponds with published data [11]. There are few teams in the world that carry out this procedure. A review of the literature reveals that only three centres have published reports on series of patients operated on by VATS through two incisions. The largest series of this procedure is at Duke Medical Center (Durham, NC, USA). D’Amico’s group have published reports on an extensive series of 500 cases, with a conversion rate of 1.6%, an average period of hospitalisation of 3 days and a perioperatory mortality rate of 1% [12]. They have recently published a comprehensive review of 697 VATS lobectomies with excellent outcomes [13], and also a series of 48 thoracoscopic segmentectomies [14]. In our series, only one typical segmentectomy on segment VI of the left lower lobe was performed, in a case of pulmonary metastasis. Yim et al. published a report (1998) on a series of 214 patients (they fail to report whether the interventions are with two incisions) undergoing major VATS resections [15]. Mean operative time was 2.2 h and mean hospitalisation 6.8 days. In the same journal (1998), Kaseda et al. report on 128 cases, also failing to define whether or not they are twoincision approaches [16]. For the first 100 lobectomies, they used a RoticulatorTM 30—3.5 surgical stapler (USSC). Almost all of the articles described in the literature relating to major pulmonary resections by VATS elucidate the three-incision approach. Most of these studies come to the conclusion that the VATS approach reduces the length of hospital stay and the time for chest tubes [17], thus allowing for earlier return to full activity. Among 1100 patients reported by Mckenna et al. median length of stay was under 3 days, with 20% of patients discharged on postoperative day 1 or 2 [18]. The performance of two, three or four incisions in VATS lobectomies seems to have no influence on short-term postoperative outcomes. Two-incision lobectomies are a consequence of greater skills acquired with experience. Our present view is that it is convenient to make the optical and utility incisions, leaving the realisation of the posterior incision for those cases, where surgical difficulties make it

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imperative. Of the cases intervened between February and November 2009, only 17 required three incisions for them to be completed. The realisation of two incisions should neither prolong estimated operative time nor hinder cleaning of the lymph nodes, nor increase the likelihood of surgical or postoperative complications. We currently routinely perform complete lymph node dissections in patients undergoing lobectomy for NSCLC. In the thoracic surgical practice for the treatment of lung cancer, 66% of the surgeons do not take any sample of the mediastinal lymph nodes [19]. It has not been possible either to clarify what is the mean number on each side of the mediastinum and in the stations, according to the map from the American College of Chest Physicians [20]. It has not been possible either, such as in other cancers, to know what are the minimum number of lymph nodes necessary to consider a radical lymph node dissection [21]. Thoracoscopy provides optimal access to nodal stations 5—9 for both sides and paratracheal nodes on the right side. Even in the left subcarinal space, we can do a complete lymphadenectomy by using the two-incision approach with the correct retraction of aorta and oesophagus and the appropriate instruments placed in the upper part of the utility incision. In our study, we can see that as we treated more cases, we achieved more extensive lymphadenectomies with results similar to those reported by some authors [22]. Thus, we see how, if the second period (August to November 2009) is analysed, during which more experience has been obtained with this technique, a larger number of nodal stations are explored in relation to the first period (a mean of 4 against 3, p = 0.059) and a greater number of adenopathies are resected (a mean of 9.5 against 5.5, p = 0.018). This would indicate an improvement in surgical technique through two incisions, obtaining more extensive lymphadenectomies as more experience is gained. Another important consideration is the surgery time. In our series, the mean duration of surgery was globally similar with either two or three ports (168.6 min in the two-ports group vs 163.39 min in the three-ports group). However, differences were observed on analysing the results, according to whether upper or lower lobectomies are involved. By obviating the posterior incision, we must assume some learning curve component not comparable to that of the start of a VATS programme. On dividing into two periods (February—July 2009 and August—November 2009), no significant differences were found in the mean duration of upper lobectomy in the second period using the double-port approach versus the triple-port approach (198.7 vs 169.0 min). This seems to indicate that, as more procedures are performed and surgeon experience with the double-port procedure increases, times are shortened and become similar to those recorded with the triple-port approach. Many articles in the literature suggest that VATS lung resection is associated with reduced postoperative pain when compared with conventional thoracotomy [23]. Further studies will be required to identify any quantifiable advantage of VATS, when it is carried out with fewer incisions. If adjuvant therapy is required, improved tolerance of chemotherapy is another potential benefit of the VATS lobectomy [7,24]. However, no randomised prospective data are available to support this. The future growth of indications for VATS resection for lung cancer includes those patients who

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are at high risk, for example, older patients and those with poor pulmonary function [25]. In conclusion, we have learned that the 3rd incision is not necessary in the majority of cases for VATS lobectomies using the two-incision technique. Our study provides good results with a less invasive procedure, obtaining results similar to the conventional VATS approach. Like any surgical procedure, there is a certain learning curve.

References [1] Ettinger DS, Bepler G, Bueno R, Chang A, Chang JY, Chirieac LR, D’Amico TA, Demmy TL, Feigenberg SJ, Grannis Jr FW, Jahan T, Jahanzeb M, Kessinger A, Komaki R, Kris MG, Langer CJ, Le QT, Martins R, Otterson GA, Robert F, Sugarbaker DJ, Wood DE. National Comprehensive Cancer Network (NCCN): non-small cell lung cancer clinical practice guidelines in oncology. J Natl Compr Canc Netw 2004;2:94—124. [2] Ferguson J, Walker W. Developing a VATS lobectomy programme—can VATS lobectomy be taught? Eur J Cardiothorac Surg 2006;29:806—9. [3] Burfeind WR, D’Amico TA. Thoracoscopic lobectomy-operative techniques in thoracic and cardiovascular surgery 2004;9:98—114. [4] Lewis RJ, Caccavale RJ. Video-assisted thoracic surgical non-rib spreading simultaneously stapled lobectomy (VATS(n)SSL). Semin Thorac Cardiovasc Surg 1998;10:332—9. [5] Mahtabifard A, Fuller CB, McKenna Jr RJ. Video-assisted thoracic surgery sleeve lobectomy: a case series. Ann Thorac Surg 2008;85(2):729—32. [6] Nakanishi K. Video-assisted thoracic surgery lobectomy with bronchoplasty for lung cancer: initial experience and techniques. Ann Thorac Surg 2007;84(1):191—5. [7] Petersen R, Pham D, Toloza E, Burfeind W, Harpole D, Hanish S, D’Amico T. Thoracoscopic lobectomy: a safe and effective strategy for patients receiving induction therapy for non-small cell lung cancer. Ann Thorac Surg 2006;82:214—9. [8] Spanish Bronchogenic Carcinoma Cooperation Group of the Spanish Society of Pneumology and Chest Surgery. Intraoperative lymph node staging in bronchogenic carcinoma. Consensus report. Arch Bronconeumol 2001;37(11):495—503. [9] Rocco G, Internullo E, Cassivi SD, Van Raemdonck D, Ferguson MK. The variability of practice in minimally invasive thoracic surgery for pulmonary resections. Thorac Surg Clin 2008;18(3):235—47. [10] Shigemura N, Akashi A, Funaki S, Nakagiri T, Inoue M, Sawabata N, Shiono H, Minami M, Takeuchi Y, Okumura M, Sawa Y. Long-term outcomes after a variety of videoassisted thoracoscopic approaches for clinical stage IA lung cancer: a multi-institutional study. J Thorac Cardiovasc Surg 2006; 132:507—12. [11] Solaini L, Prusciano F, Bagioni P, di FF, Solaini L, Poddie DB. Video-324 assisted thoracic surgery (VATS) of the lung: analysis of intraoperative 325 and postoperative complications over 15 years and review of the 326 literature. Surg Endosc 2008;22:298—310. [12] Onaitis MW, Petersen RP, Balderson SS, Toloza E, Burfeind WR, Harpole Jr DH, D’Amico TA. Thoracoscopic lobectomy is a safe and versatile procedure: experience with 500 consecutive patients. Ann Surg 2006;244:420—5. [13] Villamizar N, Darrabie M, Burfeind W, Petersen R, Onaitis M, Toloza E, Harpole D, D’Amico T. Thoracoscopic lobectomy is associated with lower morbidity compared with thoracotomy. J Thorac Cardiovasc Surg 2009;138:419—25. [14] Atkins B, Harpole D, Mangum J, Toloza E, D’Amico T, Burfeind W. Pulmonary segmentectomy by thoracotomy or thoracoscopy: reduced hospital length of stay with a minimally-invasive approach. Ann Thorac Surg 2007;84:1107—13. [15] Yim APC, Izza MB, Liu H, Ma C. Thoracoscopic major lung resections: an Asian perspective. Semin Thorac Cardiovasc Surg 1998;10:326—31. [16] Kaseda S, Aoki T, Hangai N. Video-assisted thoracic surgery (VATS) lobectomy: the Japanese experience. Semin Thorac Cardiovasc Surg 1998;10: 300—4. [17] 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. [18] McKenna Jr RJ, Houck W, Fuller CB. Video-assisted thoracic surgery lobectomy: experience with 1,100 cases. Ann Thorac Surg 2006; 81:421—5.

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J.M. Borro et al. / European Journal of Cardio-thoracic Surgery 39 (2011) 120—126

[19] Little A, Rusch V, Bonner J, Gaspar L, Green M, Webb R, Stewart A. Patterns of surgical care of lung cancer patients. Ann Thorac Surg 2005;80:2051—6. [20] Mountain C, Dresler C. Regional lymph node classification for lung cancer staging. Chest 1997;111:1718—23. [21] Wu Y, Jeff Lin C, Hsu W, Huang B, Huang M, Wang L. Long-term results of pathological stage I non-small cell lung cancer: validation of using the number of totally removed lymph nodes as staging control. Eur J Cardiothorac Surg 2003;24:994. [22] Whitson BA, Groth SS, Maddaus MA. Surgical assessment and intraoperative management of mediastinal lymph nodes in non-small cell lung cancer. Ann Thorac Surg 2007;84:1059—65.

[23] 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. [24] Nicastri DG, Wisnivesky JP, Litle VR, Yun J, Chin C, Dembitzer FR, Swanson SJ. Thoracoscopic lobectomy: report on safety, discharge independence, pain, and chemotherapy tolerance. J Thorac Cardiovasc Surg 2008; 135:642—7. [25] Cattaneo SM, Park BJ, Wilton AS, Seshan VE, Bains MS, Downey RJ, Flores RM, Rizk N, Rusch VW. Use of video-assisted thoracic surgery for lobectomy in the elderly results in fewer complications. Ann Thorac Surg 2008;85(1):231—5.