Thoracoscopic Neodymium :Yttrium-Aluminum Garnet Laser-Assisted Pulmonary Resection Rodney J. Landreneau, MD, David B. Herlan, MD, Joel A. Johnson, MD, Theresa M. Boley, RN, MSN, Weerchai Nawarawong, MD, and Peter F. Ferson, MD Section of Thoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, and Division of Cardiothoracic Surgery, University of Missouri-Columbia, Columbia, Missouri
The recent explosion of interest in surgical endoscopic techniques has revived the application of an old thoracic surgical procedure-thoracoscopy. We report a case of a transthoracoscopic neodymium :yttrium-aluminum garnet laser resection of a limited-stage peripheral adenocarcinoma of the lung accomplished in an elderly man with serious chronic obstructive pulmonary disease. (Ann Thoruc Suvg 2992;52:1276-8)
I
ncreasing interest in minimally invasive surgical techniques has infiltrated most fields of surgery today. Laparoscopic cholecystectomy and appendectomy have dominated recent general surgical discussion and appear to be valuable adjuncts in the management of selected patients. A renewed interest in diagnostic and therapeutic thoracoscopy has also emerged [l,21. This report describes the successful transthoracoscopic neodymium :yttrium-aluminum garnet (Nd: YAG) laser-assisted resection of a 2.5-cm left lower lobe adenocarcinoma found in an elderly man with a synchronous stage I squamous cell carcinoma of the larynx and serious chronic obstructive pulmonary disease.
For editorial comment, see page 1036.
A 74-year-old man was referred for evaluation of a 2.3-cm noncalcified peripheral left lung nodule identified by chest roentgenography during the staging of a clinical stage I laryngeal carcinoma. Computed tomography of the chest and upper abdomen revealed a single lesion within the periphery of an emphysematous left lower lobe (Fig 1). Mediastinal lymph nodes of 1.0 to 1.5 cm in diameter were noted in the left lower paratracheal region and in the aortopulmonary window. The patient had a 60 pack-year history of smoking. Respiratory spirometric assessment was consistent with moderately severe chronic obstructive pulmonary disease (forced expiratory volume in 1 second, 1.4 L; forced vital capacity, 3.8 L). Room air arterial blood gas analysis further suggested moderate pulmonary functional impairment (pH, 7.43; Accepted for publication May 16, 1991. Address reprint requests to Dr Landreneau, Section of Thoracic Surgery, Montefiore University Hospital, University of Pittsburgh, 3459 Fifth Ave, Pittsburgh, PA 15213.
0 1991 by The Society of Thoracic Surgeons
oxygen tension, 61 mm Hg; carbon dioxide tension, 44 mm Hg). The patient was believed to be a marginal candidate for major pulmonary resection. Bronchoscopic examination and mediastinoscopic staging were considered appropriate before exploration of the thoracic cavity. After induction of general anesthesia, flexible bronchoscopy was performed through the endotracheal tube. No endobronchial lesions were identified. Cervical and left parasternal mediastinoscopic examinations with nodal sampling were then performed. The frozen section evaluation of nodal tissue obtained was negative for malignant infiltration. Thoracoscopic examination of the left chest followed. Our intention was to proceed with Nd:YAG laser excision of the left lung lesion endoscopically or through a small lateral musclesparing thoracotomy if malignant pleural involvement could be ruled out. Left lung collapse, achieved wilh a bronchus blocker, facilitated thoracoscopic inspection of the lung and thoracic cavity. Laparoscopic trocars were used to introduce the operating laparoscope (catalog No. 110730; Weck, lnc, Princeton, NJ) and endoscopic forceps into the left chest. The trocar incisions were located at the fifth intercostal space along the anterior axillary line (and the seventh intercostal space at the posterior axillary line. A slightly umbilicated visceral pleural surface was found over the lesion located within the lateral basilar segment of the lower lobe along the interlobar fissure. Thin adlhesions along the fissure were lysed sharply with endoscopic scissors and with the aid of the Nd:YAG laser, which was introduced through the suction channel of the laparoscope. The lung was then grasped over the lesion with the forceps and drawn toward the chest wall to demarcate the extent and the base of the lesion from the surrounding collapsed lung (Fig 2). Thoracoscopic resection was felt to be possible, however, preparations for possible open thoracotomy were made. The Nd:YAG laser system (Model 704, KTPI YA119995; Laserscope Inc, San Jose, CA) was calibrated and placed on a nonpulsed 50 W setting. Nd:YAG laser safety eye wear was used by all persons in the operaling room. A 28F chest tube was placed through the eighth intercostal space at the midaxillary line under thoracoscopic guidance and connected to a smoke evacuation system (LASE System 11, model SE-11111-BII; LASE Inc, Cincinnati, OH) to remove smoke generated during the anticipated laser resection. The endoscopic forceps was then applied to the perilesional lung tissue, and laser 0003-4975/91/$3.50
Ann Thorac Surg 1991;52:117-
CASE REPORT LANDRENEAU ET AL THORACOSCOPIC PULMONARY RESECTION
1177
Fig 1 . Computed tomography of the chest revealing pulmonary emphysema and a 2.5-cm noncalcified lesion within the periphery of the left lung.
resection was begun along the base of the lesion so as to obtain a 1.5-cm margin of normal lung tissue (Fig 3). Careful visualization along the resection margin was facilitated by frequently alternating the position of the laparoscope between the anterior and posterior intercostal trocar sites and applying countertraction with the endoscopic forceps. Hemostasis was assured during the resection by carefully identifying pulmonary parenchymal vessels as vaporization of the surrounding lung tissue occurred. The laser beam was then defocused and trained on the vessel until total coagulation was achieved. After 70 minutes of dissection the lesion was separated from the remaining normal lung tissue (Fig 4). The endoscopic
Fig 3 . Margin of N d : Y A G laser resection established beneath the lesion. A laser crater is formed as coagulation and vaporization of the surrounding lung tissue occurs.
forceps was then used to remove the lesion through the posterior axillary thoracoscopy site. Removal of the lesion was facilitated by extending the skin and fascia1 incision to a total length of 3 cm. No special measures were needed to close this incisional wound. Frozen section pathologic analysis of the lesion revealed a well-differentiated adenocarcinoma. The surgical margins were free of tumor.
\
Fig 2. Endoscopic forceps grasping the lung over the lesion to facilitate demarcation of the lesion from the collapsed normal lung.
Fig 4 . Parenchymal lung lesion and surrounding lung tissue being held to the underlying bed of resection by a pedicle of residual pulmonu y tissue.
1178
CASE REPORT LANDRESEAU ET A L THORACOSCOPIC PULMONARY RESECTION
Hemostasis at the bed of the resection was assured by applying the defocused Nd:YAG laser to oozing and noncoagulated surfaces. The bronchus blocker was temporarily deflated, the lung inflated, and the absence of a serious air leak assured. All trocar sites were closed with absorbable suture, and the procedure was terminated after establishment of underwater seal drainage and 20 cm suction to the previously placed chest tube system. The patient's postoperative course was uneventful except for the development of supraventricular tachycardia, which was successfully converted to sinus rhythm with digoxin therapy. Minimal postoperative air leak and chest tube drainage occurred in accordance with others' experience with laser lung resection [3, 41. The chest tubes were removed on the third postoperative day, and the patient was discharged from the hospital on the fifth postoperative day.
Comment Thoracoscopy is certainly not a new procedure; however, interest in this diagnostic and therapeutic modality has been limited until recently [5]. Reports of thoracoscopic laser-assisted management of spontaneous pneumothorax by Torre and associates [l] and Wakabayashi and co-workers [2] have rekindled interest in therapeutic thoracoscopy. Our group has applied the Nd:YAG laser to perform diagnostic thoracoscopic lung biopsy previously; however, this case represents our first case of transthoracoscopic therapeutic pulmonary resection. Growing experience and success with open Nd:YAG laser pulmonary resection [3, 41 encouraged this attempt at endoscopic removal of this peripheral lung mass. Collapse of the lung by a bronchus blocker or by the use of a double-lumen endotracheal tube is essential for adequate visualization of the lung and effective maneuvering of the lasing thoracoscope, endoscopic forceps, and suction catheters used during the resection. Other investigators have demonstrated segmental pulmonary resection to have therapeutic benefit similar to lobectomy in the management of small, limited-stage non-small cell carcinoma of the lung [6]. Miller and Hatcher [7] have further shown limited pulmonary resection to be a successful surgical approach for the physiologically impaired patient with lung cancer. We strongly recommend careful prethoracoscopic staging of the patient (including mediastinoscopy when appropriate) to reduce the possibility of missing a more advanced malignancy that may be better treated with a more radical operation. At present, we would reserve thoracoscopic resection for those peripheral, limited-stage primary pulmonary malignancies found in patients with severely impaired pulmonary function or those patients with other
Ann Thorac Surg 1991;521 "7623
confounding physiologic problems that seriously increase the risk of standard thoracic resection. This technique may also be used as a means of diagnosing presumed metastatic or other peripheral lung nodules of uncertain cause. Although we are encouraged by this successful thoracoscopic resection of a small peripheral adenocarcino ma, we caution that this technique is not applicable for more deeply seated lesions in closer proximity to the pulmonary hilar structures. In fact, we suggest limiting the use of thoracoscopic resection to small (less than 3 crnl in diameter) pulmonary lesions located in the outer third of the pulmonary parenchyma. Additionally, the thoracic surgeon should always be prepared to convert to open thoracotomy if there is uncertainty regarding the completeness or safety of the endoscopic resection. Familiarity with thoracoscopy and Nd :YAG laser pulmonary resective techniques are undeniably important prerequisites to attempting this procedure [3, 41. Appreciation of the effects of the Nd:YAG laser on pulmonary tissue is also essential to ensure hemostasis and to avoid excessive postoperative pulmonary parenchymal air leak [3, 4, 81. Despite these stipulations, this limited experience suggests that thoracoscopic Nd :YAG laser-assisted pulmonary resection may become a valuable modality in the armamentarium of the thoracic surgeon approaching selected patients with peripheral pulmonary lesions.
References 1. Torre M, Belloni P. Nd:YAG laser pleurodesis through thoracoscopy: new curative therapy in spontaneous pneumothorax. Ann Thorac Surg 1989;47887-9. 2. Wakabayashi A, Brenner M, Wilson AF, Tadir Y, Berns M. Thoracoscopic treatment of spontaneous pneumothorax using carbon dioxide laser. Ann Thorac Surg 1990;50:786-90. 3. LoCicero J 111, Frederiksen JW, Hartz RS, Michaelis LL. Laser-assisted parenchyma-sparing pulmonary resection. J Thorac Cardiovasc Surg 1989;97732-6. 4. Landreneau RJ, Hazelrigg SR, Johnson JA, Boley TM, Nawarawong W, Curtis JJ. Neodymium: yttrium-aluminum garnet laser-assisted pulmonary resections. Ann Thorac Surg 1991;51:97M. 5. Thomas P. Thoracoscopy:an old procedure revisited. In: Kittle CF, ed. Current controversies in thoracic surgery. Philatlelphia: W.B. Saunders, 1986:lOl-12. 6. Errett LE, Wilson J, Chiu RC, Munro DD. Wedge resection as an alternative procedure for peripheral bronchogenic carcinoma in poor-risk patients. J Thorac Cardiovasc Surg 1985;90:
65661.
7. Miller JI, Hatcher CR. Limited resection of bronchogenic carcinoma in the patient with marked impairment of pulmonary function. Ann Thorac Surg 1987;44:34@-3. 8. Fisher JC. The power density of a surgical laser beam: its meaning and measurement. Lasers Surg Med 1983;2:301-4.
The recent explosion of interest in surgical endoscopic techniques has revived the application of an old thoracic surgical procedure-thoracoscopy. We report a case of a transthoracoscopic neodymium :yttrium-aluminum garnet laser resection of a limited-stage peripheral adenocarcinoma of the lung accomplished in an elderly man with serious chronic obstructive pulmonary disease. (Ann Thoruc Suvg 2992;52:1276-8)
I
ncreasing interest in minimally invasive surgical techniques has infiltrated most fields of surgery today. Laparoscopic cholecystectomy and appendectomy have dominated recent general surgical discussion and appear to be valuable adjuncts in the management of selected patients. A renewed interest in diagnostic and therapeutic thoracoscopy has also emerged [l,21. This report describes the successful transthoracoscopic neodymium :yttrium-aluminum garnet (Nd: YAG) laser-assisted resection of a 2.5-cm left lower lobe adenocarcinoma found in an elderly man with a synchronous stage I squamous cell carcinoma of the larynx and serious chronic obstructive pulmonary disease.
For editorial comment, see page 1036.
A 74-year-old man was referred for evaluation of a 2.3-cm noncalcified peripheral left lung nodule identified by chest roentgenography during the staging of a clinical stage I laryngeal carcinoma. Computed tomography of the chest and upper abdomen revealed a single lesion within the periphery of an emphysematous left lower lobe (Fig 1). Mediastinal lymph nodes of 1.0 to 1.5 cm in diameter were noted in the left lower paratracheal region and in the aortopulmonary window. The patient had a 60 pack-year history of smoking. Respiratory spirometric assessment was consistent with moderately severe chronic obstructive pulmonary disease (forced expiratory volume in 1 second, 1.4 L; forced vital capacity, 3.8 L). Room air arterial blood gas analysis further suggested moderate pulmonary functional impairment (pH, 7.43; Accepted for publication May 16, 1991. Address reprint requests to Dr Landreneau, Section of Thoracic Surgery, Montefiore University Hospital, University of Pittsburgh, 3459 Fifth Ave, Pittsburgh, PA 15213.
0 1991 by The Society of Thoracic Surgeons
oxygen tension, 61 mm Hg; carbon dioxide tension, 44 mm Hg). The patient was believed to be a marginal candidate for major pulmonary resection. Bronchoscopic examination and mediastinoscopic staging were considered appropriate before exploration of the thoracic cavity. After induction of general anesthesia, flexible bronchoscopy was performed through the endotracheal tube. No endobronchial lesions were identified. Cervical and left parasternal mediastinoscopic examinations with nodal sampling were then performed. The frozen section evaluation of nodal tissue obtained was negative for malignant infiltration. Thoracoscopic examination of the left chest followed. Our intention was to proceed with Nd:YAG laser excision of the left lung lesion endoscopically or through a small lateral musclesparing thoracotomy if malignant pleural involvement could be ruled out. Left lung collapse, achieved wilh a bronchus blocker, facilitated thoracoscopic inspection of the lung and thoracic cavity. Laparoscopic trocars were used to introduce the operating laparoscope (catalog No. 110730; Weck, lnc, Princeton, NJ) and endoscopic forceps into the left chest. The trocar incisions were located at the fifth intercostal space along the anterior axillary line (and the seventh intercostal space at the posterior axillary line. A slightly umbilicated visceral pleural surface was found over the lesion located within the lateral basilar segment of the lower lobe along the interlobar fissure. Thin adlhesions along the fissure were lysed sharply with endoscopic scissors and with the aid of the Nd:YAG laser, which was introduced through the suction channel of the laparoscope. The lung was then grasped over the lesion with the forceps and drawn toward the chest wall to demarcate the extent and the base of the lesion from the surrounding collapsed lung (Fig 2). Thoracoscopic resection was felt to be possible, however, preparations for possible open thoracotomy were made. The Nd:YAG laser system (Model 704, KTPI YA119995; Laserscope Inc, San Jose, CA) was calibrated and placed on a nonpulsed 50 W setting. Nd:YAG laser safety eye wear was used by all persons in the operaling room. A 28F chest tube was placed through the eighth intercostal space at the midaxillary line under thoracoscopic guidance and connected to a smoke evacuation system (LASE System 11, model SE-11111-BII; LASE Inc, Cincinnati, OH) to remove smoke generated during the anticipated laser resection. The endoscopic forceps was then applied to the perilesional lung tissue, and laser 0003-4975/91/$3.50
Ann Thorac Surg 1991;52:117-
CASE REPORT LANDRENEAU ET AL THORACOSCOPIC PULMONARY RESECTION
1177
Fig 1 . Computed tomography of the chest revealing pulmonary emphysema and a 2.5-cm noncalcified lesion within the periphery of the left lung.
resection was begun along the base of the lesion so as to obtain a 1.5-cm margin of normal lung tissue (Fig 3). Careful visualization along the resection margin was facilitated by frequently alternating the position of the laparoscope between the anterior and posterior intercostal trocar sites and applying countertraction with the endoscopic forceps. Hemostasis was assured during the resection by carefully identifying pulmonary parenchymal vessels as vaporization of the surrounding lung tissue occurred. The laser beam was then defocused and trained on the vessel until total coagulation was achieved. After 70 minutes of dissection the lesion was separated from the remaining normal lung tissue (Fig 4). The endoscopic
Fig 3 . Margin of N d : Y A G laser resection established beneath the lesion. A laser crater is formed as coagulation and vaporization of the surrounding lung tissue occurs.
forceps was then used to remove the lesion through the posterior axillary thoracoscopy site. Removal of the lesion was facilitated by extending the skin and fascia1 incision to a total length of 3 cm. No special measures were needed to close this incisional wound. Frozen section pathologic analysis of the lesion revealed a well-differentiated adenocarcinoma. The surgical margins were free of tumor.
\
Fig 2. Endoscopic forceps grasping the lung over the lesion to facilitate demarcation of the lesion from the collapsed normal lung.
Fig 4 . Parenchymal lung lesion and surrounding lung tissue being held to the underlying bed of resection by a pedicle of residual pulmonu y tissue.
1178
CASE REPORT LANDRESEAU ET A L THORACOSCOPIC PULMONARY RESECTION
Hemostasis at the bed of the resection was assured by applying the defocused Nd:YAG laser to oozing and noncoagulated surfaces. The bronchus blocker was temporarily deflated, the lung inflated, and the absence of a serious air leak assured. All trocar sites were closed with absorbable suture, and the procedure was terminated after establishment of underwater seal drainage and 20 cm suction to the previously placed chest tube system. The patient's postoperative course was uneventful except for the development of supraventricular tachycardia, which was successfully converted to sinus rhythm with digoxin therapy. Minimal postoperative air leak and chest tube drainage occurred in accordance with others' experience with laser lung resection [3, 41. The chest tubes were removed on the third postoperative day, and the patient was discharged from the hospital on the fifth postoperative day.
Comment Thoracoscopy is certainly not a new procedure; however, interest in this diagnostic and therapeutic modality has been limited until recently [5]. Reports of thoracoscopic laser-assisted management of spontaneous pneumothorax by Torre and associates [l] and Wakabayashi and co-workers [2] have rekindled interest in therapeutic thoracoscopy. Our group has applied the Nd:YAG laser to perform diagnostic thoracoscopic lung biopsy previously; however, this case represents our first case of transthoracoscopic therapeutic pulmonary resection. Growing experience and success with open Nd:YAG laser pulmonary resection [3, 41 encouraged this attempt at endoscopic removal of this peripheral lung mass. Collapse of the lung by a bronchus blocker or by the use of a double-lumen endotracheal tube is essential for adequate visualization of the lung and effective maneuvering of the lasing thoracoscope, endoscopic forceps, and suction catheters used during the resection. Other investigators have demonstrated segmental pulmonary resection to have therapeutic benefit similar to lobectomy in the management of small, limited-stage non-small cell carcinoma of the lung [6]. Miller and Hatcher [7] have further shown limited pulmonary resection to be a successful surgical approach for the physiologically impaired patient with lung cancer. We strongly recommend careful prethoracoscopic staging of the patient (including mediastinoscopy when appropriate) to reduce the possibility of missing a more advanced malignancy that may be better treated with a more radical operation. At present, we would reserve thoracoscopic resection for those peripheral, limited-stage primary pulmonary malignancies found in patients with severely impaired pulmonary function or those patients with other
Ann Thorac Surg 1991;521 "7623
confounding physiologic problems that seriously increase the risk of standard thoracic resection. This technique may also be used as a means of diagnosing presumed metastatic or other peripheral lung nodules of uncertain cause. Although we are encouraged by this successful thoracoscopic resection of a small peripheral adenocarcino ma, we caution that this technique is not applicable for more deeply seated lesions in closer proximity to the pulmonary hilar structures. In fact, we suggest limiting the use of thoracoscopic resection to small (less than 3 crnl in diameter) pulmonary lesions located in the outer third of the pulmonary parenchyma. Additionally, the thoracic surgeon should always be prepared to convert to open thoracotomy if there is uncertainty regarding the completeness or safety of the endoscopic resection. Familiarity with thoracoscopy and Nd :YAG laser pulmonary resective techniques are undeniably important prerequisites to attempting this procedure [3, 41. Appreciation of the effects of the Nd:YAG laser on pulmonary tissue is also essential to ensure hemostasis and to avoid excessive postoperative pulmonary parenchymal air leak [3, 4, 81. Despite these stipulations, this limited experience suggests that thoracoscopic Nd :YAG laser-assisted pulmonary resection may become a valuable modality in the armamentarium of the thoracic surgeon approaching selected patients with peripheral pulmonary lesions.
References 1. Torre M, Belloni P. Nd:YAG laser pleurodesis through thoracoscopy: new curative therapy in spontaneous pneumothorax. Ann Thorac Surg 1989;47887-9. 2. Wakabayashi A, Brenner M, Wilson AF, Tadir Y, Berns M. Thoracoscopic treatment of spontaneous pneumothorax using carbon dioxide laser. Ann Thorac Surg 1990;50:786-90. 3. LoCicero J 111, Frederiksen JW, Hartz RS, Michaelis LL. Laser-assisted parenchyma-sparing pulmonary resection. J Thorac Cardiovasc Surg 1989;97732-6. 4. Landreneau RJ, Hazelrigg SR, Johnson JA, Boley TM, Nawarawong W, Curtis JJ. Neodymium: yttrium-aluminum garnet laser-assisted pulmonary resections. Ann Thorac Surg 1991;51:97M. 5. Thomas P. Thoracoscopy:an old procedure revisited. In: Kittle CF, ed. Current controversies in thoracic surgery. Philatlelphia: W.B. Saunders, 1986:lOl-12. 6. Errett LE, Wilson J, Chiu RC, Munro DD. Wedge resection as an alternative procedure for peripheral bronchogenic carcinoma in poor-risk patients. J Thorac Cardiovasc Surg 1985;90:
65661.
7. Miller JI, Hatcher CR. Limited resection of bronchogenic carcinoma in the patient with marked impairment of pulmonary function. Ann Thorac Surg 1987;44:34@-3. 8. Fisher JC. The power density of a surgical laser beam: its meaning and measurement. Lasers Surg Med 1983;2:301-4.
