Indications for conversion of thoracoscopic to open thoracotomy in video-assisted thoracoscopic lobectomy.
ABSTRACT 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: Thoracoscopic lobectomy is performed with increasing frequency for early-stage lung cancer. Several published reports suggest thoracoscopic resection is safe, with the potential advantage of shorter hospital stay, quicker recovery, and comparable oncologic results. Data on 180 video-assisted thoracoscopic surgery (VATS) patients who underwent thoracoscopic lobectomy or sublobar anatomic resection at our institution between January 2002 and December 2006 were reviewed. The conversion rate to thoracotomy, complications, length of stay, and duration of chest tube drainage were determined. Similar variables were evaluated for patients aged older than 80 years, those with a forced expiratory volume in 1 second (FEV1) that was less than 50% predicted, those who had undergone preoperative neoadjuvant therapy, and those who had undergone lung-sparing anatomic resections. Thoracoscopic anatomic lung resection was performed successfully in 166 patients. One of 180 patients (0.6%) died, and 14 patients (9.2%) underwent conversions. Overall median length of stay was 4 days (range, 1 to 98; interquartile range [IQR], 3), and median duration of chest tube drainage was 3 days (range, 0 to 35 days; IQR, 2). The median length of hospital stay and median chest tube duration for the group aged 80 years and older was 5 and 3 days; for the segmental resection group, 4 and 3 days; for the chemotherapy or radiotherapy induction group, 3.5 and 3 days; and for the FEV1 less than 50% group, 5.5 and 4 days, respectively. No patients died in any of these groups. Thoracoscopic lung resection can be performed safely in selected patients aged 80 years and older, in those with marginal pulmonary function, and in those with pathologic response to neoadjuvant therapy.The Annals of thoracic surgery 03/2008; 85(2):S705-9. · 3.74 Impact Factor
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ABSTRACT: Although several studies have shown that video-assisted thoracic surgery (VATS) for major pulmonary resection is less invasive than open thoracotomy, VATS for lung cancer has been performed in only a limited number of institutions. We aimed to review our experience of VATS for major pulmonary resections, and to determine its safety and adequacy in stage I lung cancer. Between August 1999 and March 2003, we performed major pulmonary resection by VATS in 106 patients with lung cancer and preoperatively determined clinical stage I disease. We evaluated the number of procedures converted to open thoracotomy and the reasons for conversion, the intraoperative blood loss, interval between surgery and chest tube removal, length of postoperative hospital stay, postoperative complications, mortality rate, prognoses, and patterns of recurrence. We successfully performed VATS in 95 patients, whereas in another 11 patients (10%) conversion to open thoracotomy was required. The operative procedures were lobectomy in 86 patients, segmentectomy in 8 patients, and bilobectomy in 1 patient. In 95 patients who underwent VATS, postoperative complications developed in 9 patients (9%), and 1 patient (1%) died from pneumonia. In the 86 patients without complications, the mean postoperative hospital stay was 7.6 days (range, 4 to 15 days). In a mean follow-up period of 25 months (range, 6 to 48 months) in patients with non-small cell lung cancer (NSCLC), including the one perioperative death, the 3-year survival rate was 93% in 82 patients with clinical stage I disease, and 97% in 68 patients with pathologic stage I disease. The 3-year disease-free survival rate was 79% in patients with clinical stage I disease, and 89% in patients with pathologic stage I disease. Local recurrence was observed in six patients (6%): recurrence in mediastinal lymph nodes in five patients, and in the bronchial stump in one patient. Major pulmonary resection by VATS is acceptable in view of its low perioperative mortality and morbidity, and is an adequate procedure for the achievement of local control and good prognosis in patients with clinical stage I NSCLC.Chest 06/2004; 125(5):1742-6. · 5.85 Impact Factor
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ABSTRACT: While isolating the pulmonary arterial branches within the fissure is a crucial step in lobectomy, a largely fused fissure usually hinders its achievement, making lobectomy with video-assisted thoracoscopic surgery (VATS) difficult to achieve. For VATS lobectomy in lung cancer patients with a largely fused fissure, we have conducted an unusual approach for each lobe, and the surgical results were compared between patients with and without a fused fissure. Since1999, we have conducted VATS lobectomies in 77 patients. Of these, 10 had largely fused fissures that needed an unusual surgical approach for dividing the pulmonary arterial branches. The other 67 patients had separated fissures that allowed the isolation and division of the arterial branches within it. While the surgical approach used for the patients with largely fused fissures differed in each lobe, most often the lobar bronchus was divided before pulmonary arterial branches within the fissure were divided, with the fused fissure being divided last. There were no significant differences in age, lobectomy site, or tumor stage between the patients with fused fissures and those with separated fissures. The surgical data showed no significant differences between the two groups in operating time, blood loss, duration of chest tube drainage, and hospital stay after surgery. However, the patients with fused fissures required more staples to close the incision than did those with a separated fissure (mean number of staples, 7.7 vs 5.7; p < 0.001). There was no postoperative mortality or morbidity, including prolonged air leakage, in the patients with fused fissures. Although the performance of VATS lobectomy for patients with largely fused fissures is more costly, it is feasible and safe. A largely fused fissure is not a limiting factor for the performance of VATS lobectomy.Chest 02/2003; 123(2):619-22. · 5.85 Impact Factor