Video-assisted thoracoscopic surgery (VATS) lobectomy is an approach to

lung cancer Lung cancer, also known as lung carcinoma (since about 98–99% of all lung cancers are carcinomas), is a malignant lung tumor characterized by uncontrolled cell growth in tissues of the lung. Lung carcinomas derive from transformed, mali ...

surgery.

Traditional approach to lung cancer surgery: thoracotomy

Anatomic lung resection, i.e. pulmonary

lobectomy Lobectomy means ''surgical excision of a lobe''. This may refer to a lobe of the lung (also simply called a lobectomy), a lobe of the thyroid ( hemithyroidectomy), a lobe of the brain (as in anterior temporal lobectomy), or a lobe of the liver ...

pneumonectomy A pneumonectomy (or pneumectomy) is a surgical procedure to remove a lung first successfully done in 1933 by Dr. Evarts Graham. This is not to be confused with a lobectomy or segmentectomy, which only removes one part of the lung. There are two ...

, in conjunction with removal of the

lymph nodes A lymph node, or lymph gland, is a kidney-shaped organ of the lymphatic system and the adaptive immune system. A large number of lymph nodes are linked throughout the body by the lymphatic vessels. They are major sites of lymphocytes that includ ...

from the

mediastinum The mediastinum (from ) is the central compartment of the thoracic cavity. Surrounded by loose connective tissue, it is an undelineated region that contains a group of structures within the thorax, namely the heart and its vessels, the esopha ...

is the treatment modality that provides the greatest chance of long-term survival in patients with early stage

non-small cell lung cancer Non-small-cell lung cancer (NSCLC) is any type of epithelial lung cancer other than small-cell lung carcinoma (SCLC). NSCLC accounts for about 85% of all lung cancers. As a class, NSCLCs are relatively insensitive to chemotherapy, compared to s ...

. Anatomic lung resections require a dissection of the pulmonary hilum with individual ligation and division of the

pulmonary artery A pulmonary artery is an artery in the pulmonary circulation that carries deoxygenated blood from the right side of the heart to the lungs. The largest pulmonary artery is the ''main pulmonary artery'' or ''pulmonary trunk'' from the heart, and ...

pulmonary vein The pulmonary veins are the veins that transfer oxygenated blood from the lungs to the heart. The largest pulmonary veins are the four ''main pulmonary veins'', two from each lung that drain into the left atrium of the heart. The pulmonary vei ...

, and the

bronchus A bronchus is a passage or airway in the lower respiratory tract that conducts air into the lungs. The first or primary bronchi pronounced (BRAN-KAI) to branch from the trachea at the carina are the right main bronchus and the left main bronchu ...

where these enter the lung. In the setting of

, the rationale for anatomic lung resection is a complete removal of a lung

tumor A neoplasm () is a type of abnormal and excessive growth of tissue. The process that occurs to form or produce a neoplasm is called neoplasia. The growth of a neoplasm is uncoordinated with that of the normal surrounding tissue, and persists ...

along with the

lymphatics The lymphatic vessels (or lymph vessels or lymphatics) are thin-walled vessels (tubes), structured like blood vessels, that carry lymph. As part of the lymphatic system, lymph vessels are complementary to the cardiovascular system. Lymph vessel ...

that drain that

to assure that any tumor cells present in the

will also be removed; lesser resections have been shown to be associated with a higher risk of local recurrence and diminished long-term survival. A cornerstone of surgical treatment of early stage lung cancer is aggressive removal of

from the mediastinum; this enhances the likelihood of removing all cancer cells (complete resection) and identifies patients who will require additional treatment (i.e.

adjuvant chemotherapy Adjuvant therapy, also known as adjunct therapy, adjuvant care, or augmentation therapy, is a therapy that is given in addition to the primary or initial therapy to maximize its effectiveness. The surgeries and complex treatment regimens used in ...

). An important consideration when performing anatomic lung resection is to spare as much lung tissue as possible; while lobectomy and pneumonectomy are equivalent cancer operations, the risk of complications and

morbidity A disease is a particular abnormal condition that negatively affects the structure or function of all or part of an organism, and that is not immediately due to any external injury. Diseases are often known to be medical conditions that a ...

is considerably less with lobectomy. Traditionally, pulmonary

is performed through a poster-lateral

thoracotomy A thoracotomy is a surgical procedure to gain access into the pleural space of the chest. It is performed by surgeons (emergency physicians or paramedics under certain circumstances) to gain access to the thoracic organs, most commonly the hea ...

incision; over decades, thoracotomy has demonstrated its effectiveness in providing access to structures in the thorax and is in general tolerated by patients. Thoracotomy, as most commonly performed, requires cutting through one or more major muscles of the chest wall including the

latissimus dorsi The latissimus dorsi () is a large, flat muscle on the back that stretches to the sides, behind the arm, and is partly covered by the trapezius on the back near the midline. The word latissimus dorsi (plural: ''latissimi dorsorum'') comes from ...

, pectoralis or

serratus Serratus may refer to any of several muscles in the thorax (trunk). See: *Serratus anterior muscle *Serratus posterior superior muscle *Serratus posterior inferior muscle The serratus posterior inferior muscle, also known as the posterior serr ...

muscles, and spreading of the

ribs The rib cage, as an enclosure that comprises the ribs, vertebral column and sternum in the thorax of most vertebrates, protects vital organs such as the heart, lungs and great vessels. The sternum, together known as the thoracic cage, is a semi- ...

with a rib spreader. Because the joints of the ribs with the

vertebral bodies The spinal column, a defining synapomorphy shared by nearly all vertebrates,Hagfish are believed to have secondarily lost their spinal column is a moderately flexible series of vertebrae (singular vertebra), each constituting a characteristic i ...

have only limited flexibility, the use of a rib spreader usually results in rib fracture in the process of rendering the interspace between the ribs wide enough to perform a pulmonary lobectomy. Because of this,

thoracic The thorax or chest is a part of the anatomy of humans, mammals, and other tetrapod animals located between the neck and the abdomen. In insects, crustaceans, and the extinct trilobites, the thorax is one of the three main divisions of the crea ...

surgeons generally intentionally remove a section of one or more ribs in an effort to prevent splintered rib fracture associated with the use of the rib spreader. There is wide consensus that

is one of the most painful incisions that patients can undergo. In the initial post-operative setting after

, the use of

epidural Epidural administration (from Ancient Greek ἐπί, , upon" + ''dura mater'') is a method of medication administration in which a medicine is injected into the epidural space around the spinal cord. The epidural route is used by physicians an ...

catheters In medicine, a catheter (/ˈkæθətər/) is a thin tube made from medical grade materials serving a broad range of functions. Catheters are medical devices that can be inserted in the body to treat diseases or perform a surgical procedure. Cat ...

patient-controlled analgesia Patient-controlled analgesia (PCA) is any method of allowing a person in pain to administer their own pain relief. The infusion is programmable by the prescriber. If it is programmed and functioning as intended, the machine is unlikely to deliver ...

pumps for

intravenous Intravenous therapy (abbreviated as IV therapy) is a medical technique that administers fluids, medications and nutrients directly into a person's vein. The intravenous route of administration is commonly used for rehydration or to provide nutrie ...

narcotic The term narcotic (, from ancient Greek ναρκῶ ''narkō'', "to make numb") originally referred medically to any psychoactive compound with numbing or paralyzing properties. In the United States, it has since become associated with opiates ...

administration, and

ketorolac Ketorolac, sold under the brand names Toradol, and Biorolac among others, is a nonsteroidal anti-inflammatory drug (NSAID) used to treat pain. Specifically it is recommended for moderate to severe pain. Recommended duration of treatment is less ...

are commonplace and patients generally require a 7- to 10-day hospital stay before their pain is adequately controlled with oral

opioid Opioids are substances that act on opioid receptors to produce morphine-like effects. Medically they are primarily used for pain relief, including anesthesia. Other medical uses include suppression of diarrhea, replacement therapy for opioid use ...

analgesics An analgesic drug, also called simply an analgesic (American English), analgaesic (British English), pain reliever, or painkiller, is any member of the group of drugs used to achieve relief from pain (that is, analgesia or pain management). It ...

that they can take at home. A great deal of emphasis is placed on post-operative

pulmonary toilet Pulmonary hygiene, formerly referred to as pulmonary toilet, is a set of methods used to clear mucus and secretions from the airways. The word ''pulmonary'' refers to the lungs. The word ''toilet'', related to the French ''toilette'', refers ...

because the incisional pain associated with

leads to a decreased ability of patients to cough and clear

bronchial A bronchus is a passage or airway in the lower respiratory tract that conducts air into the lungs. The first or primary bronchi pronounced (BRAN-KAI) to branch from the trachea at the carina are the right main bronchus and the left main bronchus ...

secretions, which in turn leads to an increased risk of persistent

atelectasis Atelectasis is the collapse or closure of a lung resulting in reduced or absent gas exchange. It is usually unilateral, affecting part or all of one lung. It is a condition where the alveoli are deflated down to little or no volume, as distinct ...

(collapsed areas of lung) or

pneumonia Pneumonia is an inflammatory condition of the lung primarily affecting the small air sacs known as alveoli. Symptoms typically include some combination of productive or dry cough, chest pain, fever, and difficulty breathing. The severit ...

. Finally, to allow time for the divided muscles and bone fractures to heal, patients must refrain from strenuous activity or lifting greater than 5 lbs for 6 weeks after surgery.

The advent of VATS (video-assisted thoracoscopic surgery)

Video-assisted thoracoscopic surgery Video-assisted thoracoscopic surgery (VATS) is a type of minimally invasive thoracic surgery performed using a small video camera mounted to a fiberoptic thoracoscope (either 5 mm or 10 mm caliber), with or without angulated visualiza ...

, or VATS, came into widespread use in the 1990s and early on in its development practitioners began to perform

via VATS incisions. The advantage of VATS over

is that major chest wall muscles are not divided and ribs are not spread. This leads to reductions in the intensity and duration of post-operative pain and allows patients to return to full activity more quickly.

VATS for lung cancer surgery

VATS lobectomy is the same as lobectomy performed via thoracotomy in that the

, and

to the involved pulmonary lobe are individually dissected, ligated and divided. Generally,

endoscopic An endoscopy is a procedure used in medicine to look inside the body. The endoscopy procedure uses an endoscope to examine the interior of a hollow organ or cavity of the body. Unlike many other medical imaging techniques, endoscopes are inse ...

stapling devices are used to ligate and divide the vessels and the

however conventional

suture Suture, literally meaning "seam", may refer to: Arts, entertainment, and media * ''Suture'' (album), a 2000 album by American Industrial rock band Chemlab * ''Suture'' (film), a 1993 film directed by Scott McGehee and David Siegel * Suture (ban ...

material can also be used. During VATS lobectomy, the structures being operated on are not directly visualized with the naked eye but are visualized solely with a rigid thoracoscope. A

camera A camera is an optical instrument that can capture an image. Most cameras can capture 2D images, with some more advanced models being able to capture 3D images. At a basic level, most cameras consist of sealed boxes (the camera body), with ...

attached to the thoracoscope transmits the image to a video screen, which allows surgeons and assistants to observe the flow of the operation. Surgical specimens are placed into a water-tight bag and removed from the chest without morcellization (i.e. breaking up the specimen into small pieces before removal); this prevents seeding of the VATS incisions with tumor cells and allows for an intact specimen for

pathology Pathology is the study of the causes and effects of disease or injury. The word ''pathology'' also refers to the study of disease in general, incorporating a wide range of biology research fields and medical practices. However, when used in ...

examination and

cancer staging Cancer staging is the process of determining the extent to which a cancer has developed by growing and spreading. Contemporary practice is to assign a number from I to IV to a cancer, with I being an isolated cancer and IV being a cancer that ha ...

. Removal of

from the

is not compromised by VATS and remains a cornerstone of the surgical therapy of lung cancer. Visualization is enhanced due to the magnification afforded by the fiberoptic thoracoscope and a 30-degree angle of visualization aids in looking around corners. However, because the incisions are too small to allow passage of the surgeon's hands into the

thorax The thorax or chest is a part of the anatomy of humans, mammals, and other tetrapod animals located between the neck and the abdomen. In insects, crustaceans, and the extinct trilobites, the thorax is one of the three main divisions of the c ...

, the surgeon's tactile input is compromised. VATS operations rely on a thorough understanding of pulmonary anatomy to allow for strategically placed incisions (usually 3–5 incisions total). The main advantages of VATS over thoracotomy are that major muscles of the chest wall are not divided and rib spreaders that can lead to rib fractures or

costovertebral joint The costovertebral joints are the joints that connect the ribs to the vertebral column. The articulation of the head of the rib connects the head of the rib to the bodies of the thoracic vertebrae. Structure The costotransverse joint connects th ...

pain are not used. This results in a hospital length of stay after VATS

generally reported to range from 3–5 days, or roughly half that for lobectomy via thoracotomy.

Candidates for VATS lobectomy

Not all patients are candidates for VATS lobectomy. The classic indication for a VATS approach to lobectomy is early stage

in which the primary

is 3 cm or less in diameter and located toward the periphery of the lung

parenchyma Parenchyma () is the bulk of functional substance in an animal organ or structure such as a tumour. In zoology it is the name for the tissue that fills the interior of flatworms. Etymology The term ''parenchyma'' is New Latin from the word � ...

. Tumors that are located close to the major blood vessels or airway where these enter the lung or larger tumors associated with tumor spread to

in the central regions of the lung may require the enhanced tactile input afforded by

to make sure the tumors are resected with a negative margin, i.e. that the tumor is surrounded completely by a margin of non-cancerous tissue, and that

arteries An artery (plural arteries) () is a blood vessel in humans and most animals that takes blood away from the heart to one or more parts of the body (tissues, lungs, brain etc.). Most arteries carry oxygenated blood; the two exceptions are the pu ...

and airways to portions of the lung that are not being removed are preserved intact. In addition, patients who have had pre-operative

chemotherapy Chemotherapy (often abbreviated to chemo and sometimes CTX or CTx) is a type of cancer treatment that uses one or more anti-cancer drugs (chemotherapeutic agents or alkylating agents) as part of a standardized chemotherapy regimen. Chemother ...

radiation In physics, radiation is the emission or transmission of energy in the form of waves or particles through space or through a material medium. This includes: * ''electromagnetic radiation'', such as radio waves, microwaves, infrared, visi ...

for

or previous chest surgeries may not be candidates for VATS due to scarring around the major blood vessels that makes dissection via VATS difficult. Cases in which a lung tumor invades the chest wall and an en bloc resection of ribs must be performed to achieve negative resection margins generally are felt to abrogate the value of VATS. Finally,

by VATS, though it has been reported, is generally not performed because the size of the specimen requires a large incision with or without rib spreading for removal, abrogating the value of VATS.

Published benefits of lobectomy performed by VATS versus thoracotomy

Because of the lesser chest wall trauma of VATS compared to

, elderly patients have been shown to tolerate

by VATS better than via thoracotomy. Patients who require

after surgery have been shown to be more likely to succeed in completing the prescribed course of

after VATS lobectomy compared to lobectomy via thoracotomy. Along with the lesser

chest wall The thoracic wall or chest wall is the boundary of the thoracic cavity. Structure The bony skeletal part of the thoracic wall is the rib cage, and the rest is made up of muscle, skin, and fasciae. The chest wall has 10 layers, namely (from s ...

trauma and improved pulmonary mechanics, a lesser level of

cytokine Cytokines are a broad and loose category of small proteins (~5–25 kDa) important in cell signaling. Cytokines are peptides and cannot cross the lipid bilayer of cells to enter the cytoplasm. Cytokines have been shown to be involved in au ...

disturbance has been reported after VATS lobectomy compared to thoracotomy. From the standpoint of medical economics, VATS lobectomy is less expensive than

performed via

because hospital

length of stay Length of stay (LOS) is the duration of a single episode of hospitalization. Inpatient days are calculated by subtracting day of admission from day of discharge. Analysis A common statistic associated with length of stay is the average length of ...

and number of days in the

intensive care unit 220px, Intensive care unit An intensive care unit (ICU), also known as an intensive therapy unit or intensive treatment unit (ITU) or critical care unit (CCU), is a special department of a hospital or health care facility that provides intensi ...

are significantly reduced.

References

External links

* {{Commonscatinline
What patients need to know, on YouTube
Surgical removal procedures Pulmonary thoracic surgery