Indications for conversion of thoracoscopic to open thoracotomy in video-assisted thoracoscopic lobectomy

Department of Thoracic Surgery, People's Hospital of Peking University, Beijing, China.
ANZ Journal of Surgery (Impact Factor: 1.12). 04/2012; 82(4):245-50. DOI: 10.1111/j.1445-2197.2011.05997.x
Source: PubMed


BACKGROUD: The study aims to discuss indications for conversion to thoracotomy in completely thoracoscopic lobectomy.
From September 2006 to April 2010, 306 patients (164 men, 142 women, median age 58.1 years, range 15 to 86 years) underwent completely thoracoscopic lobectomy. There were 223 cases of primary lung cancer, 11 other malignant diseases and 72 cases of benign disease. The steps of the thoracoscopic procedures are almost identical to those of traditional open lobectomy, which requires standard mediastinal lymph node dissection for primary lung cancer patients. When conversion to an open procedure is necessary, such as in the presence of lymph node adhesions or metastases and bleeding, operative incisions are extended 12-15 cm towards lower angle of the scapula, retractors are used to separate the ribs, and the procedure is completely under direct visualization.
All procedures were performed without significant complications or intraoperative deaths. The average surgical duration was 195 min, and average blood loss was 256 mL with no blood transfusions required. The average chest tube drainage duration was 7.45 days. The average post-operative hospital stay was 10.34 days. There were 27 cases (8.8%) of conversion to open thoracotomy, for the reasons of interference by lymph nodes (n = 18), bleeding (n = 4), inflammatory adhesions of arteries (n = 3) and large size tumours (n = 2).
Adhesions or lymph node metastases and bleeding were the most important causes of conversion to thoracotomy in completely thoracoscopic lobectomy. Large tumours, fused fissures and dense pleural adhesions can always be managed thoracoscopically.

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    ABSTRACT: To study causes and implications of intraoperative conversion to thoracotomy during video-assisted thoracoscopic surgery (VATS) lobectomy. We performed an institutional review of patients undergoing lobectomy for known or suspected lung cancer with root cause analysis of every conversion from VATS to open thoracotomy. Between 2004 and 2012, 1227 patients underwent lobectomy. Of these, 517 procedures (42%) were completed via VATS, 87 procedures (7%) were converted to open procedures, and 623 procedures (51%) were performed via planned thoracotomy. Patients undergoing thoracotomy were younger and had a higher incidence of prior lung cancers. Planned thoracotomy and conversion group patients had higher clinical T stage than patients in the VATS group, whereas the planned thoracotomy group had higher pathologic stage than patients in the other groups. Postoperative complications were more frequent in patients in the conversion group (46%) than in the VATS group (23%; P < .001), but similar to the open group (42%; P = .56). Validating a previous classification of causes for conversion, 22 out of 87 conversions (25%) were due to vascular causes, 56 conversions (64%) were for anatomy (eg, adhesions or tumor size), and 8 conversions (9%) were the result of lymph nodes. No specific imaging variables predicted conversion. Within the conversion groups, emergent (20 out of 87; 23%) and planned (67 out of 87; 77%) conversion groups were similar in patient and tumor characteristics and incidence of perioperative morbidity. The conversion rate for VATS lobectomy dropped from 21 out of 74 (28%), to 29 out of 194 (15%), to 37 out of 336 (11%) (P < .001) over 3-year intervals. Over the same periods, the proportion of operations started via VATS increased significantly. With increasing experience, a higher proportion of lobectomy operations can be completed thoracoscopically. VATS should be strongly considered as the initial approach for the majority of patients undergoing lobectomy. Copyright © 2014 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.
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