Acs0410 Video Assisted Thoracic Surgery


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Acs0410 Video Assisted Thoracic Surgery

  1. 1. © 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 4 THORAX 10 VIDEO-ASSISTED THORACIC SURGERY — 1 10 VIDEO-ASSISTED THORACIC SURGERY Raja M.Flores, M.D., Bernard Park, M.D., andValerieW.Rusch, M.D., F.A.C.S. The technique of thoracoscopy was first described in 1910 by Ja- has not been fully established, within the context of well-designed cobeus, a Swedish physician who used a cystoscope to examine the clinical trials. pleural space.1 Although thoracoscopy was initially performed for In particular, questions remain about the oncologic soundness of diagnostic purposes, it later evolved into a therapeutic procedure. some VATS procedures. It appears that levels of cytokines and other During the 1930s and 1940s, it was used to lyse intrapleural adhe- acute-phase reactants are lower with minimally invasive procedures sions after collapse therapy for tuberculosis. During the 1950s, when than with the corresponding open procedures.13,14 However, it re- effective antituberculous chemotherapy became available, thora- mains to be determined whether this decrease will ultimately result coscopy fell into disuse in the United States2; however, it remained in decreased tumor growth or reduced recurrence rates. Rigorous popular in Europe, where it was employed in diagnosing and treat- evaluation is needed to determine how VATS may be most appro- ing problems such as pleural effusion, empyema, traumatic hemo- priately and safely employed in cancer patients. thorax, persistent air leak after pulmonary resection, and sponta- neous pneumothorax.3-5 During the 1970s and 1980s, a few North American surgeons revived the practice of thoracoscopy, both to Operative Planning manage pleural disease and to perform small peripheral lung biop- POSITIONING AND PORT PLACEMENT sies in patients with diffuse pneumonitis. In the first stages of its revival, thoracoscopy was often per- Patient preparation and positioning are much the same for formed with open endoscopes that were originally designed for most VATS procedures. As a rule, the lateral decubitus position other procedures (e.g., mediastinoscopes).6,7 As optics and light- offers the best exposure, and it permits easy conversion to a tho- ing systems improved, smaller-caliber endoscopes were created racotomy if necessary.There are occasional exceptions to this rule, specifically for thoracoscopic applications8; however, these instru- however, and in such cases the choice of position is dictated by the ments were limited, in that only one person could visualize the procedure planned. For instance, if a cervical mediastinoscopy or operative field at a given time. In 1991, the application of video a Chamberlain procedure is being performed for lung cancer stag- technology to thoracoscopy revolutionized the procedure because ing and the pleura must be examined to rule out the presence of it allowed several persons to see the operative field simultaneous- metastases, the patient can be left in the supine position and the ly and to operate together as they would during an open proce- videothoracoscope introduced through the parasternal incision or dure. In addition, the development of endoscopic instruments, a separate inferior incision.15 particularly endoscopic staplers, enabled surgeons to perform Port placement, the use of so-called access incisions (utility tho- major operations using minimally invasive techniques.The impact racotomies), and instrumentation may vary from one procedure of this new technology was so profound that within a 2-year peri- to the next. In approximately 20% of patients undergoing VATS, od, traditional thoracoscopic techniques were abandoned in favor intraoperative conversion to a standard thoracotomy will be nec- of video-assisted thoracic surgery (VATS).9,10 essary for any of several reasons, including extensive pleural adhe- In what follows, therefore, we focus on current VATS proce- sions and pulmonary lesions that cannot be located thoracoscop- dures rather than on traditional thoracoscopic techniques. There ically or that necessitate a more extensive resection than can be are numerous accepted diagnostic and therapeutic indications for accomplished endosurgically. With experience, one can learn to VATS [see Table 1]. Accordingly, there are numerous operations predict the likelihood of such conversion in a given case. It is that can be performed by VATS; we describe the most important important to discuss this possibility with the patient before oper- of these, with the exception of esophageal myotomy and fundo- ation and to obtain informed consent to conversion. Any patient plication, which are covered elsewhere [see 4:8 Minimally Invasive who is likely to require conversion to a thoracotomy or who may Esophageal Procedures]. In addition, we describe the application of be undergoing lobectomy or pneumonectomy should receive the telerobotics to VATS lobectomy. cardiopulmonary evaluation that is usual for such procedures A major force that drives surgeons to perform VATS proce- before VATS is performed. dures has been patient demand. Unfortunately, the application of ANESTHESIA AND MONITORING VATS has not always been accompanied by careful evaluation of outcomes. Feasibility has sometimes been confused with success. VATS procedures are performed with the patient under general Although VATS appears to have beneficial effects in terms of anesthesia. Very limited operations (e.g., pleural biopsies) can be cosmesis and postoperative pain in the short term, it has not yet done with a single-lumen endotracheal tube in place, but most pro- been proved to have beneficial effects on pulmonary function and cedures should be performed with single-lung ventilation using a a return to normal activity in the long term.11,12 It is therefore the double-lumen endotracheal tube or a bronchial blocker.The degree responsibility of thoracic surgeons to perform these procedures of intraoperative monitoring needed depends on the extent of the selectively rather than indiscriminately, either in settings where the planned procedure and on the patient’s general medical condition. effectiveness of VATS is clearly proved or, where the role of VATS Standard monitoring techniques (including pulse oximetry) are al-
  2. 2. © 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 4 THORAX 10 VIDEO-ASSISTED THORACIC SURGERY — 2 ways used, but arterial lines are placed selectively. A central venous catheter or a Swan-Ganz catheter is inserted only when the patient’s Table 1—Indications and Contraindications baseline cardiac status demands precise hemodynamic monitoring. A Foley catheter is inserted at the beginning of all VATS procedures for VATS Procedures to monitor urine output because it is not always possible to predict Diagnostic indications how long the operation will take or whether conversion to thoracoto- Undiagnosed pleural effusion my will prove necessary. Indeterminate pulmonary nodule Undiagnosed interstitial lung disease INSTRUMENTATION Pulmonary infection in the immunosuppressed patient Instrumentation for VATS comprises (1) video equipment, (2) To define cell type in known thoracic malignancy To define extent of a primary thoracic tumor endoscopes and thoracoports, (3) staplers, (4) thoracic instru- Nodal staging of a primary thoracic tumor ments (e.g., lung clamps and retractors) modified for endoscopic Diagnosis of intrathoracic pathology to stage a primary extrathoracic use, and (5) various devices for tissue cauterization, including tumor lasers. Because immediate conversion to thoracotomy is occasion- Evaluation of intrapleural infection ally necessary, a basic set of thoracotomy instruments should be Therapeutic indications an integral part of a VATS instrument tray.16 Lung Spontaneous pneumothorax Video Equipment Bullous disease Minor variations in lighting and optics aside, the basic compo- Lung volume reduction nents of all video systems used for thoracoscopy are similar: a Persistent parenchymal air leak Benign pulmonary nodule large-screen (21 in.) video monitor, a xenon light source, a video Resection of pulmonary metastases (in highly selected cases) recorder, and a printer for still photography, mounted together on Resection of primary lung tumor (in highly selected cases) a cart. A second video monitor, also mounted on a cart, is con- Mediastinum nected by cable to the main monitor and is placed across from it Drainage of pericardial effusion at the head of the operating table.Thus, both the surgeon and the Excision of bronchogenic or pericardial cyst first assistant are able to look directly at a video display without Resection of selected primary mediastinal tumors having to turn away from the surgical field. Alternatively, a single Esophageal myotomy monitor can be placed at the head of the operating table.The only Facilitation of transhiatal esophagectomy ? Resection of primary esophageal tumors additional item of equipment necessary for laparoscopy is an ? Thymic resection insufflator. Therefore, to maximize cost-efficiency, hospitals Ligation of thoracic duct acquiring video monitors and endoscopes should coordinate the Pleura choice of this expensive equipment among the specialties using it, Drainage of a multiloculated effusion including thoracic surgery, general surgery, gynecology, and urol- Drainage of an early empyema ogy. Hospitals performing many endoscopic procedures may find Pleurodesis it advisable to dedicate one or more rooms to video endoscopic Contraindications surgery and to mount video equipment on the ceilings or walls. Extensive intrapleural adhesions Inability to sustain single-lung ventilation Endoscopes and Thoracoports Extensive involvement of hilar structures Some procedures are performed with a forward-viewing (0º) rigid Preoperative induction chemotherapy or chemoradiotherapy scope; however, 30º angled scopes are useful for visualizing the sulci Severe coagulopathy and the superior and posterior mediastinum and provide better over- all visualization of the pleural space. In addition to the standard 10 mm thoracoscopes, there are 5 mm thoracoscopes whose resolution patients undergoing thoracoscopy are under general anesthesia is nearly as good.The scope is attached to the light source by a light and have a double-lumen endotracheal tube in place, the cannu- cable and is coupled to the video-monitor system by a camera cable las need not maintain an airtight seal, as they do in laparoscopy. [see Figure 1]. Although camera cables can be sterilized, it is best to Accordingly, thoracoports, which are shorter than laparoscopy cover the camera head and cable with a clear plastic bag so that the cannulas and have a corkscrew configuration on the outside that cable can remain in the OR at all times.Videoscopes are now avail- stabilizes them within the chest wall, are routinely used. The tro- able in which the camera chip is located at the tip of the scope rather car is simply a blunt-tip obturator that facilitates passage of the than in the connecting camera cable; these are replacing the endo- cannula through the chest wall [see Figure 2a]. Thoracoports are scopes previously used because they provide a sharper image. For available in several sizes (5, 10.5, 12, and 15 mm in diameter) to complex procedures (e.g.,VATS lobectomy), we currently use a 30° accommodate various instruments. rotating scope, which allows better orientation and visualization around structures such as the pulmonary artery and bronchus. Flex- Staplers ible thoracoscopes, which look like a short, heavy version of a flexible Endoscopic staplers that cut between two simultaneously bronchoscope but have a more rigid distal end, are also available. applied triple rows of staples (gastrointestinal anastomosis [GIA] Some surgeons feel that flexible thoracoscopes enhance their ability staplers) are available in lengths of 30 and 60 mm and in staple to visualize the entire pleural space, but these devices are very expen- depths of 2.0, 2.5, 3.5, and 4.8 mm [see Figure 2b]. Like their sive and continue to be premium purchases for most hospitals. counterparts designed for open procedures, they are disposable Originally, thoracoscopy made use of trocar cannulas designed multicartridge instruments. The endoscopic GIA stapler with 2.0 for laparoscopy to access the pleural space. However, these devices and 2.5 mm staples is designed for division of pulmonary vessels. are too long and have sharp ends that can injure the lung. Because Some surgeons are reluctant to use it on hilar vessels because if the
  3. 3. © 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 4 THORAX 10 VIDEO-ASSISTED THORACIC SURGERY — 3 0° Rigid Scope Detachable Camera Cable Figure 1 Shown is a forward-viewing (0º) rigid scope that can be used for either laparoscopy or thoracoscopy. A detachable camera cable is clipped onto the eyepiece of the scope for video endoscopy. The camera cable can be sterilized or enclosed within a plastic sheath if it is used frequently. stapler fails mechanically (e.g., cuts without applying both staple the staple line with prosthetic materials (e.g., Gore-Tex; W. L. lines properly), life-threatening hemorrhage can ensue. Endoscopic Gore, Boulder, Colorado) to reduce postoperative air leakage in staplers that do not cut (transverse anastomosis [TA] staplers) are patients with emphysematous lung tissue. also available. Although they have been largely supplanted by endoscopic GIA Some advocate using two applications of the endovascular sta- staplers, standard stapling instruments can also be used during pling device to minimize the risk of transecting the vessel as a con- some VATS procedures. They are unnecessary for most pul- sequence of a stapling misfire. In this approach, the stapler is first monary wedge resections but may be helpful for more complex fired proximally with the knife removed, leaving six rows of staples procedures (e.g., lobectomies). Standard GIA staplers and articu- in place. Next, the stapler is fired again more distally with the cut- lated rotating TA staplers (Roticulator; AutoSuture, Norwalk, ting mechanism intact to transect the vessel, leaving a total of nine Connecticut) are the most practical devices for VATS because they rows of staples on the patient side and three rows of staples on the can be inserted and positioned through an access incision. specimen side. Endoscopic GIA staplers have revolutionized surgeons’ ability Instruments to perform minimally invasive pulmonary resections. These Various types of Pennington and Duval clamps are available [see devices are highly reliable and provide excellent hemostasis and Figure 2c]. Sponge sticks modified by the introduction of various closure of air leaks. There are also stapler cartridges that buttress curves and a line of DeBakey-type teeth on the end can also be a b m 10 .5 m Endoscopic Gastrointestinal Anastomosis Stapler Thoracoscopic Port c Endoscopic Lung Clamp d Curved Sponge Stick Figure 2 Shown are instruments commonly used during VATS. Modified trocar cannulas, called thoracoports (a), facilitate access to the pleural space. They are shorter than the cannulas used in laparoscopy and have a corkscrew configuration on the outside that maintains their position on the chest wall. The trocar is a blunt- tipped plastic obturator that facilitates passage of the cannula through the chest wall. A thin plastic diaphragm stabilizes the position of the instruments or can be removed to facilitate access to the pleural space. Endoscopic GIA staplers that make incisions between two triple rows of staples (b) can be inserted through these ports. Like staplers designed for open procedures, endoscopic GIA staplers are disposable multifire instruments that hold three replacements of the staple cartridge. Another instrument that can be inserted through these ports is the nondisposable endoscopic lung clamp (c), which is available in various shapes with serrations at the end or along the full length of the clamp. Finally, the port allows insertion of curved sponge sticks (d), which have been modified for endoscopic use as lung clamps or lymph node holders.
  4. 4. © 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 4 THORAX 10 VIDEO-ASSISTED THORACIC SURGERY — 4 a Figure 3 Shown are retractors used for VATS. Vein retractors are best suited for gentle retraction of hilar or mediastinal structures, such as the ves- Disposable Vein Retractor sels, bronchi, esophagus, and lymph nodes. The tip of the disposable vein retractor (a) can be extend- ed from or withdrawn into the shaft to allow inser- b tion of the retractor through a 12 mm port. The c most useful retractor for general purposes is the fan retractor (b). A knob on the end of the handle opens and closes the fan, allowing the retractor to be inserted through a port and opened for retrac- Disposable Fan Retractor tion in the pleural space. used as lung clamps or lymph node holders [see Figure 2d]. and pass a monofilament suture to the tip of the instrument. A Several retractors have been developed for endoscopic sur- polyp forceps is an excellent instrument for holding and retract- gery. One such device is a modified Finochietto retractor with ing lymph nodes during a mediastinal lymph node dissection long, narrow blades, which is particularly helpful for retracting (MLND). Because polyp forceps have a slightly curved configu- the chest wall soft tissues in an access incision. Others are the ration and a blunt tip, they can also be used to dissect around hilar disposable vein retractor [see Figure 3a], the tip of which can be vessels. withdrawn into the straight instrument shaft, and the fan retrac- Although biopsy forceps have been specifically created for tor, which can be opened and closed like a fan by turning a knob laparoscopy and thoracoscopy, those used for mediastinoscopy on the end of the retractor [see Figure 3b]. Of these, the fan are, in fact, well suited for thoracoscopy. Because laparoscopy retractor is the most useful general retractor for thoracoscopic instruments were developed before thoracoscopy instruments, procedures.Vein retractors are best suited for gentle retraction of many types of grasping forceps are available; however, most are hilar or mediastinal structures (e.g., vessels, bronchi, esophagus, too traumatizing for thoracic surgery. DeBakey forceps, modi- or lymph nodes). fied for endoscopic use, are the gentlest type available. Various In major VATS procedures (e.g.,VATS lobectomy), the soft tis- curved and right-angle dissecting clamps, needle holders, and sues of the access incision may be retracted by means of a cere- scissors have been developed [see Figure 4]. In addition, stan- bellar (or Weitlaner) retractor.This measure allows the surgeon to dard thoracotomy instruments can be inserted through a encircle the hilar vascular structures by using two instruments minithoracotomy incision and used just as they would be in an simultaneously through the same incision. A Harken clamp is use- open procedure. ful, in that it is long enough to reach behind a vascular structure Devices for Tissue Cauterization Most scissors have an electrocautery attachment that permits si- a multaneous cutting and cauterizing.The neodymium:yttrium-alu- minum-garnet (Nd:YAG) laser is sometimes applied to VATS resec- Angled Dissecting Clamp tion of pulmonary lesions. This is done by inserting the YAG laser-fiber through angled or straight handpieces [see Figure 5]. Laser-assisted pulmonary resection is helpful in removing lesions on the flat surface of the lung, where a stapler cannot be easily applied.17 The argon beam electrocoagulator (ABC) (ConMed Corpor- ation, Utica, New York) is a noncontact form of electrocautery that b provides superb hemostasis on raw surfaces (e.g., denuded pul- monary parenchyma or the chest wall after pleurectomy) and helps Curved Dissecting Clamp seal air leaks from the surface of the lung.18 The standard dispos- able ABC handpiece used for open procedures is narrow enough to pass through a thoracoport and thus may be used for VATS.The optional Bend-a-Beam handpiece is extremely useful in VATS c lobectomy because it allows the surgeon to shape the shaft of the instrument for easier coagulation of hard-to-reach areas. Scissors YAG Laser Fiber Figure 4 Various right-angle (a) and curved (b) dissecting Angled Hand Piece clamps are available. On the angled model shown (a), the knob close to the handle rotates the shaft of the clamp 360º. Many Figure 5 Shown is an angled handpiece through which an yttri- types of endoscopic scissors (c) are also available. Some scissors um-aluminum-garnet (YAG) laser can be placed during VATS. The incorporate an attachment for an electrocautery so that the sur- handpiece is narrow enough to be used during thoracoscopy as geon can cut and cauterize simultaneously. well as during open procedures.
  5. 5. © 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 4 THORAX 10 VIDEO-ASSISTED THORACIC SURGERY — 5 Instrumentation for videothoracoscopy continues to evolve, posterior axillary line at the seventh or eighth intercostal space. especially as minimally invasive cardiac surgical procedures Instruments are introduced through two thoracoports: one is become commonplace. Nevertheless, to put together the best set placed at approximately the fifth intercostal space in the anteri- of instruments, it still is necessary to combine disposable and or axillary line, and the other is placed at the fifth space, parallel nondisposable instruments from different manufacturers and to to and about 2 to 3 cm away from the posterior border of the borrow instruments originally designed for other procedures. scapula [see Figure 6a]. If the procedure is converted to a thora- Rather than create separate instrument trays for different VATS cotomy, the two upper incisions can be incorporated into the procedures, it is best to maintain a single standard tray that thoracotomy incision and the lower incision can be used as a includes the basic instruments required for most operations and to chest tube site. When a patient is being operated on for an api- add instruments as needed. Again, this tray should also include the cal lesion (e.g., bullae causing a spontaneous pneumothorax) instruments needed for conversion to thoracotomy. [see Figure 6b], the camera port can be placed at the fifth or sixth intercostal space, and the two instrument ports may also be moved higher, with one in the axilla and the other higher on the Basic Operative Technique posterior chest wall at approximately the third intercostal space. VATS procedures include both true videothoracoscopies and Depending on the location of the lesion being removed, a fourth video-assisted procedures that are really a cross between videotho- port incision may be helpful to permit the introduction of addi- racoscopies and standard thoracotomies. Because VATS proce- tional instruments. dures are still evolving, there is no firm consensus among surgeons When the lung must be palpated so that a small or deep-seated with respect to the number, size, and location of incisions. lesion can be located or when complex video-assisted procedures The basic videothoracoscopy techniques have been well are being performed, a small (4 cm) intercostal incision is added described.19 The primary strategy is to place the instruments and to the three port incisions.This utility thoracotomy, or access inci- the thoracoscope so that all are oriented in the same direction, fac- sion, is usually placed in the midaxillary line or in the auscultatory ing the target disease within a 180º arc [see Figure 6]; this posi- triangle. An infant Finochietto retractor or a Weitlaner retractor is tioning prevents mirror imaging. The incisions should also be used to retract the soft tissues without actually spreading the ribs placed widely distant from each other so that the instruments do [see Figure 7]. not crowd one another. These basic concepts regarding incision placement are modi- For most procedures, the videothoracoscope is inserted fied as necessary to accommodate the procedure being performed through a thoracoport placed between the midaxillary and the and the location of the lesion being removed (see below). a b Stapler Retractor Grasper Camera Camera Figure 6 Basic operative technique. Shown is the typical positioning of instruments and the video camera for patients undergoing VATS for a lesion in the superior segment of the left lower lobe of the lung. Instruments are introduced through two port incisions made anteriorly at approximately the fifth intercostal space in the anterior axillary line and posteriorly parallel to and 2 to 3 cm away from the border of the scapula (a). For patients undergoing thoracoscopy for apical bullous disease in the left upper lobe of the lung, the camera port can be placed at the fifth or sixth intercostal space; one instrument port can be inserted in the axilla and the other port inserted higher on the posterior chest wall at approximately the third intercostal space (b).
  6. 6. © 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 4 THORAX 10 VIDEO-ASSISTED THORACIC SURGERY — 6 ated with a Yankauer or pool-tip suction device. Fibrinous debris can be removed by irrigating the pleural space with a pulsating water jet lavage device designed for debridement of orthopedic wounds.This technique is particularly useful for the debridement and drainage of loculated fibrinopurulent empyemas.22 At the end of the procedure, intercostal blocks are performed by using a mediastinoscopy aspiration needle, and talc can be insufflated for pleurodesis, if indicated. All of these instruments are introduced sequentially through the upper incision.23 An alternative approach is to make a single incision in the midaxillary line at the sixth or seventh intercostal space and to use an operating thoracoscope that incorporates a biopsy forceps.This approach has the advantage of requiring only one incision; how- ever, it does not allow as much latitude in draining or debriding the pleural space. Moreover, the biopsy forceps in an operating thoracoscope is of a smaller caliber than a mediastinoscopy biop- sy forceps and thus cannot obtain as large a biopsy specimen. TROUBLESHOOTING In patients with loculated effusion, thoracoport placement must sometimes be modified. The preoperative chest computed tomo- graphic scan and chest x-ray should help ensure that the ports are placed in areas where the lung is not adherent to the chest wall. In some cases, the pleural space is obliterated by adhesions or tumor.This event occurs most frequently in patients who have had severe inflammatory disease (e.g., pneumonia, empyema, or tu- berculosis) or extensive pleural malignancy (e.g., locally advanced Figure 7 Basic operative technique. Shown are the incisions used for common VATS procedures. The thoracoscope is inserted malignant mesothelioma). In these circumstances, the anterior through the bottom incision. Anterior and posterior incisions are thoracoport incision can be extended to a length of 5 to 6 cm, the used for the introduction of instruments. Only one additional low underlying rib section can be resected, and the parietal pleura can anterior incision (arrow) is needed for thoracoscopic pleural pro- undergo biopsy directly; a full thoracotomy is not required. If tho- cedures. If necessary, a so-called utility thoracotomy (dotted line) racotomy is subsequently warranted for therapeutic reasons (e.g, can be added at the fifth intercostal space. The tip of the scapula for pleurectomy, decortication, or extrapleural pneumonectomy is outlined. These incisions can be incorporated into a standard for mesothelioma), this small incision can be incorporated into the thoracotomy incision if the VATS procedure is converted to an thoracotomy incision. open procedure. VATS Pulmonary Wedge Resection VATS Procedures for Pleural Disease VATS pulmonary wedge resection has become a standard approach to diagnosing small indeterminate pulmonary nodules, OPERATIVE TECHNIQUE especially those not technically amenable to transthoracic needle A double-lumen endotracheal tube is inserted and the patient is biopsy.24,25 It is also an accepted method of diagnosing pulmon- placed in the lateral decubitus position. Two 1.5 cm incisions are ary infiltrates of uncertain origin, particularly in immunocom- made, one for the videothoracoscope and one for the instruments. promised patients in whom transbronchial biopsy is either unsafe The videothoracoscope is inserted through a 10.5 mm thoracoport or inappropriate.26,27 at the seventh or eighth intercostal space in the midaxillary line; the The role of VATS wedge resection is less well defined in the man- instruments are inserted through a port placed a couple of inter- agement of primary lung cancers. It is an appropriate compromise spaces higher in the anterior axillary line. If a talc poudrage is per- operation for primary lung cancers in patients with cardiac or pul- formed, both incisions are reused for placement of chest tubes, with monary function status that rules out lobectomy. However, it re- a right-angle tube inserted on the diaphragm through the lower inci- mains a highly controversial approach to the treatment of pulmonary sion and a straight tube advanced up to the apex of the pleural space metastases.28 In an often-quoted 1993 study,29 patients with CT - through the upper incision. The addition of a diaphragmatic chest documented pulmonary metastases underwent first thoracoscopic tube helps prevent loculated basilar fluid collections after a talc pleu- resection and then thoracotomy in the same setting. Many addition- rodesis. If a thoracotomy is subsequently performed, the upper port al lesions, both benign and malignant, were found at thoracotomy site is incorporated into the anterior aspect of the incision and the that had been missed by VATS.The study was terminated early be- lower site can be reused as a chest tube site. Proper placement of cause of the failure of thoracoscopy to identify these lesions. One port incisions is especially important in patients with suspected ma- criticism of the study is that the preoperative CT scans were not lignant mesothelioma because of the propensity of this tumor to im- comparable to the spiral (helical) CT scans currently available and plant in incisions and needle tracks.8,20,21 therefore probably missed many pulmonary nodules that modern Once the videothoracoscope has been inserted, pleural biopsies scanning methods would have identified. are obtained under direct vision by introducing a biopsy forceps A 2000 nonrandomized multicenter study of patients undergo- through a port placed in the upper incision. (The mediastinoscopy ing VATS metastasectomy for colon cancer suggested that mini- biopsy forceps are well suited to this task.) Pleural fluid is evacu- mal residual disease not identified by helical CT and not resected
  7. 7. © 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 4 THORAX 10 VIDEO-ASSISTED THORACIC SURGERY — 7 by VATS may not affect survival significantly.30 This conclusion, VATS database at the Memorial Sloan-Kettering Cancer Center however, is completely at odds with all of the previously published (MSKCC) found only one case of port-site recurrence.33 The surgical literature on pulmonary metastasectomy performed via authors concluded that the incidence of such recurrences can be thoracotomy. Improved survival in patients with pulmonary kept low if surgical oncologic principles are respected. At MSKCC, metastases appears to be directly linked to the ability to remove all these principles include (1) reserving VATS for lesions that can be gross tumor, and VATS does not allow the careful bimanual pal- widely excised; (2) conversion to an open thoracotomy for defini- pation that is critical to detecting pulmonary metastases that are tive or extensive operations; and (3) meticulous technique for too small or too deep to be visible endoscopically.30-32 Accordingly, extraction of specimens from the pleural space, with small speci- most centers reserve VATS for diagnosis rather than treatment of mens removed directly through a thoracoport and larger speci- pulmonary metastases. Until a well-designed prospective, ran- mens removed in specimen bags. domized trial is conducted with survival as an end point, the stan- OPERATIVE TECHNIQUE dard of care remains thoracotomy and metastasectomy. Anecdotal reports of port-site recurrence have also raised con- Once general anesthesia has been induced and a double-lumen cerns about VATS as a treatment method in patients with malig- endotracheal tube inserted, the patient is placed in the full lateral de- nancies. However, a 2001 study of 410 patients from a prospective cubitus position.Ventilation to the lung being operated on is stopped as soon as the patient is rotated into the lateral decubitus position, so that the lung will be thoroughly collapsed by the time the videotho- racoscope is inserted into the pleural space. Small subpleural pul- monary nodules are most easily identified in a fully atelectatic lung because they protrude from the surrounding collapsed pulmonary parenchyma, which is softer.19,20 Most pulmonary wedge resections are performed as true videothoracoscopic procedures using just three port incisions placed in the triangulated manner already de- scribed [see Basic Operative Technique, above]. The pulmonary nodules to be removed are grasped with an endoscopic lung clamp (Pennington or Duval) inserted through one instrument port, and wedge resection is done with repeated applications of an endoscopic stapler inserted through the oppo- site port.24,34 As the resection is performed, it is often helpful to introduce the stapler through each of two instrument ports to obtain the correct angle for application to the lung [see Figure 8]. To prevent tumor implantation in the chest wall, small speci- mens (usually those resected with three or fewer stapler applica- tions) are removed via the thoracoport. Larger specimens are placed in a disposable plastic specimen retrieval bag, which is then brought out through a very slightly enlarged anterior tho- racoport incision. When the wedge resections have been completed, intercostal blocks are performed under direct vision with a mediastinoscopy aspiration needle, and a single chest tube is inserted through the inferior port after the videothoracoscope is withdrawn.35 The videothoracoscope can be placed through the anterior incision to check the position of the chest tube and to confirm reinflation of the lung after the double-lumen endotracheal tube is unclamped. The remaining incisions are then closed with sutures. TROUBLESHOOTING Four techniques may be used to locate pulmonary nodules that are either too deep or too small to be easily visible on simple inspection of the lung. All of these should be used in conjunction with a high-quality preoperative chest CT scan to identify the lung segment in which the nodule is located. First, an endoscopic lung clamp may be gently run across the surface of the lung as an extension of digital palpation.20,36 With some patience and experience, one can achieve considerable suc- cess with this technique. Second, ultrasonographic examination of the collapsed lung may be used to locate deep pulmonary nod- Figure 8 VATS pulmonary wedge resection. A double-lumen endotracheal tube is used to render the lung partially atelectatic. ules; at present, however, this approach appears to have lost The pulmonary nodule is lifted upward with a lung clamp, and an favor.37 Third, CT-guided needle localization may be used preop- endoscopic GIA stapler is applied to the lung underneath (top). eratively if a nodule is likely to be difficult to locate. Localization During the wedge resection, the lung clamp and the stapler are is accomplished by injecting methylene blue or by inserting a alternately inserted through opposite ports to obtain the correct barbed mammography localization needle, which is then cut off angle for performance of the wedge resection (bottom). at the skin exit site and later retrieved thoracoscopically.38 Needle
  8. 8. © 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 4 THORAX 10 VIDEO-ASSISTED THORACIC SURGERY — 8 localization techniques are effective, but they are also costly and VATS Procedures for Spontaneous Pneumothorax and time-consuming and hence are not used by most surgeons. Bullous Disease Finally, if careful endoscopic examination of the lung does not reveal the location of a nodule, an access incision is added to the OPERATIVE TECHNIQUE videothoracoscopy.24,39 Each lobe of the lung is sequentially rotat- VATS is now frequently performed for the management of ed up to this non–rib-spreading utility thoracotomy for direct dig- recurrent spontaneous pneumothorax and for bullous disease.41,42 ital palpation. This technique almost always allows identification The approach is similar to that followed in a wedge resection, with of a nodule when other techniques fail. As the endoscopist gains three or four port sites being utilized. The videothoracoscope is experience with these techniques, conversion to thoracotomy inserted at the fifth intercostal space in the midaxillary line, and solely for the purpose of locating a pulmonary nodule is rarely two other port sites are added at the fourth intercostal space in the necessary.40 anterior and posterior axillary lines. Pulmonary nodules located on the broad surface of the lung In patients with spontaneous pneumothorax, the responsible may not be amenable to a wedge resection with an endoscopic bulla (which is usually apical in location) is identified, and wedge stapler. Such nodules can be removed by means of electrocauter- resection is done with an endoscopic stapler.43,44 Bullae can be ization, just as in an open thoracotomy. An extension is placed on excised by applying the stapler across the base of the area of bul- the handle of the electrocautery, which is then introduced into lous disease. They can also be ablated with the ABC or the the pleural space through either a port or an access incision. Nd:YAG laser, then suture-plicated if necessary; however, this Another approach is to resect the pulmonary nodule with a laser approach may not be as successful over the long term.45,46 in either a contact or a noncontact mode. The potassium-titanyl- Taking note of the lower rate of recurrence, the shorter hospital phosphate (KTP)/YAG laser is particularly suited to this task stay, and the relative cost-effectiveness, some surgeons advocate because it is capable of both cutting and coagulation. To mini- performing VATS for the first episode of spontaneous pneumo- mize bleeding and air leakage, raw pulmonary surfaces can be thorax.47,48 To justify this approach in patients with primary spon- cauterized with either the Nd:YAG laser or the ABC.17 taneous pneumothorax, however, well-designed clinical trials Numerous types of absorbable sealant patches or materials are rather than retrospective reviews will be required. also available to control air leaks from areas of raw pulmonary parenchyma. TROUBLESHOOTING Occasionally, after a wedge resection, it is necessary to suture The placement of port incisions should be determined by the together the pleural edges over an area of raw pulmonary paren- location of the bullae. Because bullous disease is generally apical, chyma. The suturing can be done directly through a non–rib- port sites are correspondingly higher than for the average wedge spreading access incision or through port sites. In the latter case, resection (i.e., at the fourth and sixth intercostal spaces rather than the ports are removed and a 3-0 polypropylene suture is passed at the fifth or sixth and eighth spaces). The precise placement through the anterior port site with a standard needle holder. A sec- should, however, be determined by pinpointing the disease site or ond needle holder is introduced via the posterior port site and sites on the preoperative chest x-ray and CT scans. used in place of a forceps to pick up and reposition the needle as The main problem after resection for bullous disease is pro- it is passed through the lung. The surgeon and the first assistant longed leakage of air from the staple line. This problem can be work together to oversew the lung, in contrast with the normal minimized by applying commercially available sleeves made of practice for an open procedure, in which the surgeon uses a nee- bovine pericardium or Gore-Tex over the arms of the stapler to dle holder and a forceps to place the sutures. reinforce the staple line and by performing some form of pleu- a b c Pleura Resection Borderline Figure 9 VATS procedures for spontaneous pneumothorax and bullous disease. Limited apical pleurectomy is a useful alternative to chemical pleurodesis in young patients with spontaneous pneumothorax because these patients may need to undergo thoracotomy later in life. Shown is an outline of the pleural resection (a) performed in this procedure. The pleura is grasped at the inferior border with forceps and lifted in the avascular layer in a cranial or ventral direction (b). A T-shaped incision is made in the pleura at the level of the subclavian artery or the truncus brachiocephalicus. The dissection of the pleural flap thus created is extended in either the ventral or the parasternal direction and in either the apical or the mediastinal direction (c).
  9. 9. © 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 4 THORAX 10 VIDEO-ASSISTED THORACIC SURGERY — 9 a b Figure 10 VATS lung volume reduction surgery. Thoracoscopic lung volume reduction can be accomplished through either (a) resection or (b) plication without cutting. rodesis. Mechanical pleurodesis is done with a small gauze sponge carefully assessed. If the leak is small, the other side is operated on passed through a port site. Some surgeons scarify the pleura by in the same setting; if the leak is large, the contralateral procedure cauterizing it with the ABC or the Nd:YAG laser, but this is not as is put off to a later date. The use of fibrin glue or another com- successful as mechanical pleurodesis. Chemical pleurodesis by talc mercially available pneumostatic sealant along the staple line should poudrage is an appropriate option for older patients with emphy- be considered to minimize postoperative air leakage. sema and bullous disease but is unwise in young patients with spontaneous pneumothorax, who might require a thoracotomy later in life.49 Another option in younger patients is a limited api- VATS Lobectomy and Pneumonectomy cal pleurectomy [see Figure 9]. Special angulated instruments and Although VATS lobectomy is much less frequently performed blunt dissectors have been designed for this procedure; however, a than VATS pulmonary wedge resection, standard techniques have parietal pleurectomy is also easily performed with combinations of been developed for it.52 VATS pneumonectomy, on the other standard blunt and sharp instruments.50 hand, is less well accepted. Both operations are done as video- assisted procedures using a utility thoracotomy, which facilitates insertion of standard thoracotomy instruments, extraction of the VATS Lung Volume Reduction Surgery resected specimen from the pleural space, and performance of the technically complex aspects of the procedure, including dissection OPERATIVE TECHNIQUE of the hilar vessels and the mediastinal lymph nodes. VATS may also be applied to the performance of lung volume A 1998 retrospective study addressing the adequacy of VATS reduction surgery (LVRS). If unilateral LVRS is planned, the lobectomy as an oncologic procedure reported on 298 patients patient is placed in the lateral decubitus position and port place- who underwent VATS lobectomy with MLND for primary ment is similar to that for a patient undergoing a wedge resection non–small cell lung cancer.53 On the basis of a 70% 4-year survival of the upper lobe. Most patients undergoing LVRS, however, ben- rate for stage I tumors, the investigators concluded that outcome efit from bilateral LVRS. For this procedure, the patient is placed after VATS lobectomy is comparable to that after open thoracoto- in the standard supine bilateral lung transplant position, with my. At 5 years, however, survival rates after VATS are inferior, shoulder rolls placed vertically in an I fashion behind the back and stage for stage, to the rates generally reported after thoracotomy. with the arms positioned above the head. The camera port is Such differences could reflect either inaccurate staging or true placed in the anterior axillary line at the sixth interspace. A lung oncologic differences between VATS and thoracotomy; additional compression clamp is placed on the area that will be resected. A prospective studies are needed to clarify these issues. Gore-Tex–reinforced stapler is then inserted into the chest and Although VATS lobectomy has not been proved to be oncolog- fired sequentially until the desired area is excised [see Figure 10a]. ically sound in the long term, there is good evidence that it is safe Another approach used to help buttress the tenuous staple line in acute settings.54 Therefore, it should certainly be performed to in emphysematous lung tissue is lung plication [see Figure 10b].51 treat benign diseases (e.g., bronchiectasis).55 As with all minimal- In this method, the defunctionalized, bullous lung tissue is stapled ly invasive procedures, conversion to open thoracotomy is indicat- to itself to form a plicated autologous buttress [see Figure 11]. ed if technical issues require it. Some authors advocate VATS Because the diseased bullous lung is not cut, the risk of postoper- lobectomy for low-grade malignancies (e.g., carcinoids) as well.56 ative air leakage is minimized. It must be recognized, however, that although carcinoids have a lower malignant potential than non–small cell lung cancer, they TROUBLESHOOTING are still malignancies and must be treated appropriately for opti- A major cause of morbidity and mortality with this procedure mal long-term outcome. is the occurrence of air leaks, which sometimes are large enough Two approaches to lobectomy have been developed. One involves to compromise ventilation significantly. Thus, once LVRS has sequential anatomic ligation of the hilar structures, much as in a been done on one side, the lung is reexpanded and any air leaks standard lobectomy,57,58 and the other involves mass ligation of the
  10. 10. © 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 4 THORAX 10 VIDEO-ASSISTED THORACIC SURGERY — 10 a b Modified d Lung Clamp Stapler c 1 3 2 4 Figure 11 VATS lung volume reduction surgery. Shown are the key steps in the plication method of LVRS. (a) The apex of the lung area selected for plication is drawn to one side over a lung plication clamp, and the retractable guidebar of the clamp is extended into position. (b) The clamp is rotated 180º to fold the lung over itself. (c) The guidebar is retracted, a stapler is positioned with its jaws around the folded lung (but not yet closed), and the plication clamp is removed. (d) Shown is a cross-section of the folded lung after the stapler has been positioned but before the clamp has been removed. The stapler is then fired to complete the plication. pulmonary vessels and the bronchus. Both approaches require at ation of single-lung ventilation, the camera port is placed at the least two port incisions in addition to the utility thoracotomy inci- eighth interspace in the anterior axillary line (for right-side lesions) sion. The sequential anatomic ligation approach has been well de- or in the posterior axillary line (for left-side lesions). The posterior scribed and follows sound surgical oncologic principles.57 Accord- port is then placed where the lower lobe edge touches the diaphragm ingly, it is our preferred method of performing VATS lobectomy. It (at the ninth or 10th interspace) along the anterior border of the must be remembered, however, that VATS lobectomy is a procedure paraspinous muscle. A retractor is placed through the posterior port, for which there is no accepted uniform definition. In a survey aimed and the upper lobe is retracted laterally to allow visualization of the at defining the criteria used by minimally invasive thoracic surgeons superior pulmonary vein.The utility incision (no longer than 4 cm) for VATS lobectomy,14 the length of the utility incision ranged from is placed directly over the superior pulmonary vein for upper lobec- 4 to 10 cm, the number of incisions ranged from three to five, and tomies (at approximately the third or fourth interspace) and one in- the use of rib spreading was variable. In an effort to standardize the terspace lower for middle and lower lobectomies. A Weitlaner (or approach at our own institution (MSKCC), we define a VATS cerebellar) retractor is used to retract the soft tissues, and there is no lobectomy as an anatomic dissection that is performed entirely un- need for rib spreading. A rotating 30º videothoracoscope is always der thoracoscopic visualization, proceeds in an anterior-to-posterior used for these procedures. fashion, employs a 4 cm utility incision, involves absolutely no rib spreading, and uses two thoracoscopy ports (one for the camera and Right-side resections Right upper lobe. The superior pul- one for retraction). Our definition also includes nodal evaluation (ei- monary vein is dissected from the overlying pleura via the access ther sampling or dissection) of levels 4, 7, and 9 on the right and lev- incision with long Metzenbaum scissors and DeBakey forceps, els 5, 6, 7, and 9 on the left. much as in an open lobectomy. A Harken clamp is passed behind the superior pulmonary vein after clear identification of the mid- OPERATIVE TECHNIQUE dle lobe vein. The superior pulmonary vein is encircled with a monofilament tie and retracted upward via the utility incision. An Lobectomy (Sequential Anatomic Ligation) empty sponge stick is then placed through the utility incision, and Positioning and port placement Correct positioning and the upper lobe is retracted posteriorly. An endovascular stapler is port placement are essential for a successful VATS lobectomy.The placed through the posterior port and, with the suture as a guide, patient is placed in the maximally flexed lateral decubitus position to passed behind the superior pulmonary vein. prevent the hip from impeding downward movement of the thoraco- Once the pulmonary vein has been divided, the anterior and scope.Tilting the hip posteriorly, especially in obese patients, greatly apical segmental branches of the pulmonary artery are visualized. increases the range of movement of the thoracoscope. After the initi- The level 10 lymph nodes are removed. A Harken clamp is passed
  11. 11. © 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 4 THORAX 10 VIDEO-ASSISTED THORACIC SURGERY — 11 around the anterior and apical pulmonary arterial branches, and a endoscopic GIA stapler introduced via the access incision.The bi- monofilament suture is passed around them and brought out furcation of the left upper and left lower lobe bronchi is identified, through the utility incision. The endovascular stapler is passed and the left upper lobe bronchus is transected with an endoscopic though the posterior port and used to transect the vessels. GIA stapler with 4.8 mm staples introduced via the posterior port. Transection of the truncus artery branch exposes the right upper An empty sponge stick is then used to retract the stump of the lobe bronchus. Dissection is performed to separate the ongoing bronchus laterally, which facilitates exposure of several branches of pulmonary artery from the bronchus. A monofilament suture is the pulmonary artery, including the lingular artery.These branches passed around the bronchus and brought out through the utility are transected individually via the posterior port.The fissure is then incision. An endoscopic GIA stapler with 4.8 mm staples is placed completed by passing an endoscopic GIA stapler with 4.8 mm sta- through the posterior port, and the right upper lobe bronchus is ples via the posterior port. transected. This step exposes the branch of the pulmonary artery to the posterior segment of the right upper lobe, which is tran- Left lower lobe. The lower lobe is retracted superiorly, the infe- sected in the same manner through the posterior port. rior pulmonary ligament is transected, and level 9 lymph nodes Once all the structures to the upper lobe have been divided, the are removed. Once the inferior pulmonary vein has been dissect- fissure is assessed. A lung clamp placed through the posterior port is ed free, an endoscopic GIA vascular stapler is placed via the utili- used to retract the middle and lower lobes inferiorly, and a second ty incision to transect the vessel. The lower lobe bronchus is lung clamp placed through the utility incision is used to retract the exposed from its inferior aspect to its bifurcation with the upper upper lobe superiorly. Once the fissure is exposed, a long curved lobe bronchus. The bronchus is left intact until the pulmonary sponge stick is used to elevate the right upper lobe, and an endo- scopic GIA stapler with 4.8 mm staples is passed through the utility artery to the lower lobe is exposed medially and superiorly from incision to complete both minor and major fissures.The lobe is then the overlying fissure. After the pulmonary artery has been ade- placed in a large surgical tissue pouch and removed via the utility quately exposed, the bronchus is transected with an endoscopic incision. GIA stapler with 4.8 mm staples placed via the utility incision.The Certain basic surgical concepts—dissection of hilar structures, pulmonary artery is then transected via the utility incision, and the passage of a monofilament suture around the structure, and tran- fissure is completed via the posterior port. In cases with a very section with a stapler—are similar for all lobectomies. However, thick incomplete fissure, the fissure between the lingula and lower the order in which structures are transected and the ports through lobe should be opened before dissection of the pulmonary artery which staplers are passed differ. to facilitate subsequent arterial exposure. Lobectomy (Mass Ligation) Right lower lobe. The lower lobe is retracted superiorly, the inferior pulmonary ligament is transected, and the level 9 lymph The mass ligation method, or so-called SIS (simultaneous indi- nodes are removed. Once the entire inferior pulmonary vein has vidual stapling) lobectomy, has also been used for VATS lobecto- been dissected, a stapler is placed via the utility incision to transect my.59 Four incisions are made: an incision for the camera port at the vessel. The lower lobe bronchus is exposed from its inferior the seventh intercostal space, a 2 cm incision in the midaxillary aspect to its bifurcation with the middle lobe bronchus. The line at the sixth intercostal space for the insertion of staplers, and bronchus is left intact until the pulmonary artery to the right lower two 3 cm incisions at the fourth intercostal space in the anterior lobe is exposed medially and superiorly from the overlying fissure. and posterior axillary lines for the insertion of additional instru- Once the pulmonary artery has been adequately exposed, the ments. In the initial report of this technique, the bronchus and the bronchus is transected with a 4.8 mm universal stapler placed pulmonary vessels were ligated separately, but the vessels were sta- through the utility incision. The pulmonary artery is then tran- pled en masse.60 Subsequently, the technique was refined so that sected via the utility incision, followed by the fissure. the bronchus and the vessels were stapled simultaneously by applying the stapler twice, the first time loosely to obtain closure Right middle lobe. With the middle lobe retracted laterally, the of the bronchus and the second time more tightly to obtain hemo- pleura overlying the middle lobe vein is incised. Once dissection of static closure of the vessels. the vein is complete, the vessel is transected with an endovascular Although the early results of SIS lobectomy were satisfactory,61 stapler placed via the posterior port, and the middle lobe bronchus concerns arose about the long-term risks of bronchovascular or is exposed.The bronchus is encircled with a monofilament suture, arteriovenous fistula formation resulting from mass ligation of the and an endoscopic GIA stapler with 3.5 mm staples is placed via hilar structures. Consequently, this approach has not gained wide the posterior port to transect the bronchus. An empty sponge stick is then used to place traction on the middle lobe bronchus, expos- acceptance and is rarely used at present. ing the one or two branches of the middle lobe artery, which are Pneumonectomy then transected via the posterior port. On occasion, the angle is such that the middle lobe artery must be transected via the utility The approach to VATS pneumonectomy is similar to the sequen- incision. The minor fissure is then completed by passing staplers tial anatomic ligation approach to VATS lobectomy. The thoraco- via the utility incision. scope is inserted at the seventh intercostal space in the midaxillary line, and a utility thoracotomy is performed at the fourth intercostal Left-side resections Left upper lobe. The left upper lobe is space in the same line.Two port sites are then created at the sixth in- retracted laterally, and the superior pulmonary vein is dissected free tercostal space in the anterior and posterior axillary lines.The hilar and transected via the posterior port.The first apical branch of the vessels are sequentially isolated, ligated, and divided with endoscop- pulmonary artery is dissected free and transected with an endoscop- ic or standard staplers.The inferior pulmonary vein is done first, fol- ic GIA vascular stapler introduced via the posterior port.The anteri- lowed by the superior pulmonary vein and the pulmonary artery. or aspect of the fissure is opened with one or two applications of an The bronchus is stapled and divided last.62,63
  12. 12. © 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 4 THORAX 10 VIDEO-ASSISTED THORACIC SURGERY — 12 TROUBLESHOOTING tion that contains the computer, the three-dimensional imaging cen- If ambiguous anatomy or excessive bleeding is encountered at ter, and the master controls that govern the robot’s function. The any point during the procedure or if oncologic principles are vio- third part is the equipment tower, which holds the light source, the lated, conversion to a thoracotomy is mandatory to ensure patient camera, and additional necessary components (e.g., the electro- safety. A sponge on a stick, an open thoracotomy tray, and a cautery, the ultrasonic scalpel, and the insufflator). polypropylene suture should always be readily available for emer- For our purposes, the da Vinci robot has three signal advantages. gency control of hemorrhage. First, it offers a true three-dimensional imaging system with binocu- To prevent too-distal or too-proximal dissection (which can lar vision. The scope is 12 mm in diameter, with a separate 5 mm lead to bleeding and violation of oncologic principles), the surgeon scope for each eye.The left and right images remain separated from should alternate frequently between panoramic and close-up the telescopes to the surgeon’s eyes, so that the right eye sees the views. In addition, to ensure that the mainstem bronchus has not right image and the left eye sees the left image. Second, the instru- been inadvertently dissected, the remaining lobes may be reinflat- ment and camera arms are all controlled by the surgeon through the ed before bronchial transection. master controls and their interface with the computer; no voice or vi- sual activation is necessary. Third, all of the surgical instruments, with the exception of the SonoSurg (Olympus America, Melville, Robot-Assisted VATS Lobectomy New York), have seven degrees of freedom and two degrees of axial Current minimally invasive surgical technology has several rotation, which means that they can be articulated in a manner that notable weaknesses. First, the camera platform is unstable, which replicates the action of a human wrist. means that the operating surgeon must rely on an assistant with a OPERATIVE TECHNIQUE variable amount of experience and knowledge of the technical aspects of the procedure to provide the needed visualization. To date, there have been only two published reports of the use of Second, the straight instruments used are limited with respect to robotic technology during VATS lobectomy. One is a case report of a range of movement and degrees of freedom when placed through VATS left lower lobectomy done with robotic assistance,70 and the small incisions—a limitation that can be particularly significant other is a series of five patients, two of whom were converted to tho- with thoracic procedures in which incision size is further limited racotomy for technical reasons.71 It is clear from the lack of a sub- by the size of the intercostal space.Third, the cameras provide only stantial literature that a standardized approach has not yet been es- two-dimensional imaging. Finally, as a result of all of the preced- tablished. At MSKCC, however, we have developed a technique of ing factors, the ergonomics of these minimally invasive procedures robot-assisted VATS lobectomy that employs the da Vinci Surgical for the operating surgeon and the assistants are often very poor.64 System as an adjunct to our standard VATS lobectomy technique. These weaknesses provided the impetus for the application of This robot-assisted approach has proved to be safe and feasible in robotic techniques to minimally invasive surgery. more than 30 consecutive patients. The first generation of surgical robots focused primarily on the is- Step 1: Initial Exploration of Chest and Positioning of Robot sue of the unstable camera platform. In 1994, the Automated Endo- scopic System for Optimal Positioning (AESOP) (Computer Mo- The patient is placed in a maximally flexed lateral decubitus tion, Santa Barbara, California), a voice-activated robotic camera position after single-lung ventilation is established. Initial thoracic holder, was approved by the Food and Drug Administration for clin- exploration is conducted by means of conventional thoracoscopy ical use in abdominal surgery. Subsequently, the EndoAssist (Arm- to verify resectability and to establish the three standard VATS strong Healthcare Limited, High Wycombe, United Kingdom), lobectomy access incisions. As noted [see VATS Lobectomy and which allows the operating surgeon to control camera movement Pneumonectomy, Operative Technique, above], the location of the through natural head movement, was also approved by the FDA. main utility incision varies slightly, depending on the lobe of inter- The newest generation of surgical robots was designed to address est. Employing standard VATS lobectomy incisions has the bene- issues beyond the camera platform by employing telerobotic tech- fit of allowing conversion to a conventional VATS procedure if the nology to enable the operating surgeon to control the surgical robot need arises (e.g., as a result of minor bleeding, inadequate expo- and its instruments by using a remote computer console. At present, sure, or mechanical or technical problems with the robot). Once two FDA-approved systems are commercially available: the da Vinci the incisions have been made, the conventional VATS instruments Surgical System (Intuitive Surgical, Sunnyvale, California) and the are removed, and the robot is brought into position from the pos- ZEUS Surgical System (Computer Motion, Santa Barbara, Califor- terior aspect of the patient, with the center column at an angle of nia). Both were originally designed for closed-chest cardiac sur- approximately 45° with respect to the patient’s longitudinal axis. gery,65,66 and most of the published literature to date has been con- This positioning allows the field of dissection to include the hilar cerned with this application. Nevertheless, the published experience structures and most of the chest. with surgical telerobotics in minimally invasive surgery continues to A 12 mm trocar is placed through the anterior inferior access expand, ranging from laparoscopic cholecystectomy to laparoscopic incision, and the camera arm is attached to the trocar. The three- Nissen fundoplication to laparoscopic radical prostatectomy.67-69 dimensional 30° scope is introduced through the trocar and At MSKCC, we employ the da Vinci Surgical System, which con- secured to the camera arm. The remainder of the positioning is sists of three main parts.The first part is the basic robot.The robot accomplished under direct vision, both from outside the patient has three arms—two instrument arms with a camera arm between and from within the thorax. The trocars attached to the two them—all attached to a central column. Each instrument arm at- instrument arms are introduced into the two remaining access taches to an 8 mm trocar, and the whole unit is placed into the pa- incisions. Care must be taken to ensure that the instrument arms tient; surgical instruments are then introduced through the trocar for have full range of motion and do not collide with each other or intracorporeal use.The camera arm attaches to a 12 mm trocar that with any portion of the patient. is already positioned inside the patient.The second part of the sys- Once the camera and the instrument arms are in place, surgical tem is the surgeon’s console, an ergonomically comfortable worksta- instruments are inserted through the attached trocars under direct
  13. 13. © 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 4 THORAX 10 VIDEO-ASSISTED THORACIC SURGERY — 13 thoracoscopic vision. Our practice is to start the procedure with a the upper lobe bronchus is stapled and divided. The upper lobe is Cadiere forceps in the left instrument arm (placed in the main then retracted laterally and inferiorly. Additional hilar nodal tissue is utility incision) and a blunt permanent spatula hooked to an elec- resected, and the origins of the posterior ascending (or recurrent) trocautery in the right instrument arm.When all instruments have artery, middle lobe artery, and superior segment pulmonary artery been positioned optimally, the operating surgeon scrubs out and branches are defined.The recurrent artery branch is divided with an moves to the control console. endoscopic GIA vascular stapler with 2.5 mm staples. Once each of the hilar structures of the upper lobe has been Step 2: Robot-Assisted VATS Dissection divided, only the fissure remains. At this point, the robotic portion Two assistants are required: the first stands at the anterior of the procedure is terminated. The instruments and the instru- aspect of the patient and assists through the main utility incision ment arms are removed under direct vision, followed by the cam- by providing additional retraction of the lung and suction when era, the camera arm, and, finally, the robot. Conventional thora- necessary, and the second is positioned at the posterior inferior coscopy is reestablished, and the fissure between the upper lobe access incision. and the remaining middle and lower lobes is completed with mul- At MSKCC, we typically begin the procedure with MLND. All tiple firings of the 4.8 mm endoscopic GIA stapler.The specimen major nodal stations are explored with a combination of electro- is placed in a large laparotomy sac and brought out through the cauterization and blunt dissection, and all nodal tissue is removed anterior superior access incision. Hemostasis is confirmed, inter- and sent for frozen-section analysis to rule out occult stage III dis- costal nerve blocks are created with 0.5% bupivacaine, and a sin- ease in patients with non–small cell lung cancer. Currently, we use gle chest tube is placed under direct vision.The remaining lung is the SonoSurg in an effort to prevent postoperative chyle leakage, inflated, and the wounds are closed in the standard fashion. though we have not yet encountered this complication. If there are no contraindications to lobectomy, individual isola- Right middle lobe The main access incision is created in the tion of the hilar structures proceeds with dissection around the midaxillary line one interspace below the level of the superior pul- hilar vessels and bronchi performed with a combination of cauter- monary vein, and MLND of the right paratracheal and subcarinal ization and sharp and blunt dissection, much as would be done spaces is performed. With the middle lobe retracted laterally, the through a thoracotomy. The tissues overlying each structure, par- mediastinal pleura overlying the middle lobe pulmonary vein is ticularly the regional lymph nodes, are precisely dissected away. incised with the Cadiere forceps in the left instrument arm and the When either a vessel or the bronchus is sufficiently mobilized, two permanent spatula attached to the cautery in the right arm. The blunt-tipped Cadiere forceps are used to reach around the struc- mediastinal pleura is further incised down to the level of the infe- ture, place a tie, and create sufficient space for placement of an rior pulmonary vein. The spatula is replaced with a second endovascular stapler. Cadiere forceps; the vein is encircled with a tie and divided with the 2.5 mm endoscopic GIA vascular stapler inserted via the pos- Step 3: Lobectomy terior access incision. Right upper lobe The main utility incision is created in the Next, the anterior portion of the major fissure is completed with midaxillary line at the level of the superior pulmonary vein. The the spatula and the cautery, and all regional lymph nodes encoun- right upper lobe is retracted inferiorly and posteriorly for MLND tered are excised. The middle lobe bronchus is identified and from the right paratracheal space, then anteriorly for the subcari- mobilized, with the peribronchial tissue swept distally. Division of nal space. Next, the right upper lobe is retracted laterally, and the the bronchus with a 3.5 mm endoscopic GIA stapler placed via mediastinal pleura overlying the superior pulmonary vein is in- the posterior incision facilitates subsequent dissection and ligation cised with the Cadiere forceps in the left instrument arm and the of the middle lobe branches of the pulmonary artery. This is best permanent spatula attached to the cautery in the right instrument accomplished by resecting the tissue overlying the ongoing pul- arm. The full extent of the vein is defined by identifying the take- monary artery proximally up to the takeoff of the middle lobe arte- off of the middle lobe vein inferiorly and the junction between the rial supply. The middle lobe pulmonary artery is encircled and superior vein and the truncus arteriosus superiorly. Any regional divided with the 2.5 mm endoscopic GIA vascular stapler through nodes present are resected. The spatula is replaced with a second the posterior incision. The minor fissure is completed with multi- Cadiere forceps, and the vein is encircled with a tie to allow gen- ple firings of the 4.8 mm endoscopic GIA stapler through the tle retraction.The left instrument arm is removed from the poste- anterior superior utility incision. The lobe is placed in a large tis- rior inferior access incision just far enough to permit introduction sue pouch and brought out through the anterior utility incision. of a 2.5 mm endoscopic GIA vascular stapler that is passed behind The robot is removed, and the procedure is completed in the same the vessel. The tie is removed, the stapler is closed, and the vessel manner as a right upper lobectomy. is stapled and divided. The left instrument arm is replaced, and dissection continues by dividing the mediastinal pleura superiorly Right lower lobe As in a right middle lobectomy, the anteri- and posteriorly over the truncus arteriosus toward the bronchus or utility incision is placed in the midaxillary line one interspace with a combination of cauterization and blunt dissection. Any inferior to the level of the superior pulmonary vein, and MLND additional regional nodes encountered are resected. of the subcarinal space is performed. The lower lobe is retracted The truncus branches are isolated with the Cadiere forceps and toward the apex of the chest, the inferior pulmonary ligament is divided in the same manner as the vein. Attention is turned to the divided with the electrocautery, and additional mediastinal lymph right upper lobe bronchus, and the peribronchial tissue is bluntly nodes from levels 8 and 9 are resected. The pleura overlying the swept distally.The bronchus is mobilized with the Cadiere forceps, inferior pulmonary vein is incised superiorly both anterior and and an endoscopic GIA stapler with 4.8 mm staples is introduced posterior to the vessel.The Cadiere forceps are used to isolate this again via the posterior access incision and closed around the vein, and a 2.5 mm endoscopic GIA vascular stapler placed bronchus.The remaining lung is minimally ventilated to ensure that through the utility incision is used to divide the vessel. Retraction the middle and the lower lobe are uncompromised; if this is the case, of the lung is maintained superiorly and posteriorly while the