Thoracoscopic Resection of 85 Pulmonary Lesions Rodney J. Landreneau, MD, Stephen R. Hazelrigg, MD, Peter F. Ferson, MD, Joel A. Johnson, MD, Weerchai Nawarawong, MD, Theresa M. Boley, RN, MSN, Jack J. Curtis, MD, Claudia M. Bowers, RN, David B. Herlan, MD, and Robert D. Dowling, MD Section of Thoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, and Division of Cardiothoracic Surgery, St. Luke's Medical Center, Milwaukee, Wisconsin
Advances in endoscopic surgical equipment and laser technology have expanded the role of thoracoscopy to include thoracoscopic pulmonary resection. Eighty-five thoracoscopic pulmonary resections were performed on 61 consecutive patients with small lesions (1.0 cm in diameter). Intraoperative thoracoscopic mediastinal lymph node sampling was performed to ensure that we were approaching early stage disease when malignancy was diagnosed. Five patients with adequate pulmonary reserve undergoing a “diagnostic” thoracoscopic resection were found to have a primary bronchogenic malignancy by frozen section analysis. These patients then were converted to an open muscle-slparing thoracotomy for formal pulmonary resection [5]. Notably, the tissue margins of the previous wedge resection were clear of tumor in all of these formal segmentectomy and lobectomy specimens removed. Most VATS metastasectomies were performed to diagnose, prciject prognosis, and provide direction for further systemic therapy among patients with a history of malignancy having multiple pulmonary nodules identified by chest roentgenography and computed tomography. Three patients having favorable primary tumor histology (renal cell, colon, melanoma) with single pulmonary nodules identified by computed tomographic scanning (and confirmed by digital palpation of the lung) underwent thoracoscopic resection alone in an attempt to provide a potential survival benefit [6]. The mean diameter of the resected lesions was 1.3 cm with a range of 0.4 to 2.7 cm. In all cases, intraoperative blood loss was minimal. One patient with a myelophthisic anemia and associated coagulopathy had a serious decrease in hematocrit during the postoperative period which required component transfusion therapy. The mean duration of chest tube drainage and postoperative hospital stay were 3.3 2 3.0 and 5.7 & 4.9 days, respectively. The average operative time (incision to dressing) was 138 2 76 minutes. There were few perioperative complications and only one late postoperative death occurring 38 days after VATS from late respiratory failure unrelated to the operative procedure. Complications included atelectasis (2), pneumonia (2), bleeding (l), and prolonged air leak (3). No patient required reoperation. The 3 patients having postoperative lobar atelectasis responded to appropriate attention to pulmonary hygiene. Three patients in whom “down lung” pneumonia developed were successfully treated with broad-spectrum antibiotics. All peripheral bronchopleural fistulas resolved with conservative mea-
Ann Thorac Surg 1992;54415-20
sures at 8, 12, and 34 days postoperatively. The one prolonged bronchopleural fistula occurred in a patient with rheumatoid arthritis on high-dose preoperative and perioperative prednisone therapy who underwent Nd: YAG laser resection of a rheumatoid pulmonary nodule. We now rely primarily on endoscopic stapling techniques to perform thoracoscopic wedge resection lung biopsy for patients on high-dose steroidal therapy.
Comment Thoracoscopy is an established diagnostic modality enjoying increased attention as minimally invasive surgical concepts pervade general thoracic surgery. For many surgeons, thoracoscopy’s primary role was for the diagnosis and occasional treatment of pleural disorders [7, 81. Others have used it to perform limited lung biopsies in patients with diffuse infiltrates [l, 21. Success with open, laser-assisted pulmonary resections and improvements in endoscopic surgical equipment have now allowed for video-assisted thoracoscopic management of many intrathoracic conditions [3, 9, lo]. Recent reports have described video-assisted thoracoscopic management of a variety of mediastinal conditions and for the ablation of apical bullous disease [ll-141. We were thus encouraged to employ VATS for the diagnosis and management of carefully selected patients with peripheral pulmonary lesions [3]. In this series, all target peripheral pulmonary lesions identified by preoperative high-resolution computed tomography were able to be located at exploratory thoracoscopy. An additional benefit obtained at thoracoscopic exploration was a panoramic view of the pleural and mediastinal surfaces superior to that seen through most standard thoracotomy approaches. Endoscopic visual identification of most lesions was achieved because of their subpleural location or as a result of effacement of the pulmonary lesion against the surrounding atelectatic lung. Palpation with endoscopic forceps or a ”probing” finger through a trocar site were also effective localization techniques; however, we have come to rely on computed tomography-directed hook wire localization for most small, deeper seated parenchymal lesions [4]. Our impression is that thoracoscopic resection may result in reduced perioperative morbidity and a shortened hospital stay for many patients requiring resection of peripheral pulmonary lesions. The postoperative hospital stay after video-assisted thoracoscopic resection in this series compares favorably with recent series of open resection of peripheral lung lesions reporting mean hospital stays of 7 to 10 days [9, 10, 151. Additionally, postthoracotomy pain may be lessened using the minimally invasive VATS approach. Studies comparing perioperative pain, shoulder girdle function, and postoperative morbidity presently underway at our institution (and others) may help to clarify the objective clinical differences between VATS and open thoracic surgical procedures [5, 161. Our approach to the undiagnosed peripheral pulmonary nodule remains a conscientious preoperative work-up
Ann Thorac Surg 1992;54:415-20
including c o m p u t e d tomography of t h e chest (and percutaneous, transbronchial, or cervical mediastinoscopic biopsy when indicated) [3, 171. Thoracoscopic resection is now our preferred approach, i n lieu of thoracotomy, for m o s t small (
Advances in endoscopic surgical equipment and laser technology have expanded the role of thoracoscopy to include thoracoscopic pulmonary resection. Eighty-five thoracoscopic pulmonary resections were performed on 61 consecutive patients with small lesions (1.0 cm in diameter). Intraoperative thoracoscopic mediastinal lymph node sampling was performed to ensure that we were approaching early stage disease when malignancy was diagnosed. Five patients with adequate pulmonary reserve undergoing a “diagnostic” thoracoscopic resection were found to have a primary bronchogenic malignancy by frozen section analysis. These patients then were converted to an open muscle-slparing thoracotomy for formal pulmonary resection [5]. Notably, the tissue margins of the previous wedge resection were clear of tumor in all of these formal segmentectomy and lobectomy specimens removed. Most VATS metastasectomies were performed to diagnose, prciject prognosis, and provide direction for further systemic therapy among patients with a history of malignancy having multiple pulmonary nodules identified by chest roentgenography and computed tomography. Three patients having favorable primary tumor histology (renal cell, colon, melanoma) with single pulmonary nodules identified by computed tomographic scanning (and confirmed by digital palpation of the lung) underwent thoracoscopic resection alone in an attempt to provide a potential survival benefit [6]. The mean diameter of the resected lesions was 1.3 cm with a range of 0.4 to 2.7 cm. In all cases, intraoperative blood loss was minimal. One patient with a myelophthisic anemia and associated coagulopathy had a serious decrease in hematocrit during the postoperative period which required component transfusion therapy. The mean duration of chest tube drainage and postoperative hospital stay were 3.3 2 3.0 and 5.7 & 4.9 days, respectively. The average operative time (incision to dressing) was 138 2 76 minutes. There were few perioperative complications and only one late postoperative death occurring 38 days after VATS from late respiratory failure unrelated to the operative procedure. Complications included atelectasis (2), pneumonia (2), bleeding (l), and prolonged air leak (3). No patient required reoperation. The 3 patients having postoperative lobar atelectasis responded to appropriate attention to pulmonary hygiene. Three patients in whom “down lung” pneumonia developed were successfully treated with broad-spectrum antibiotics. All peripheral bronchopleural fistulas resolved with conservative mea-
Ann Thorac Surg 1992;54415-20
sures at 8, 12, and 34 days postoperatively. The one prolonged bronchopleural fistula occurred in a patient with rheumatoid arthritis on high-dose preoperative and perioperative prednisone therapy who underwent Nd: YAG laser resection of a rheumatoid pulmonary nodule. We now rely primarily on endoscopic stapling techniques to perform thoracoscopic wedge resection lung biopsy for patients on high-dose steroidal therapy.
Comment Thoracoscopy is an established diagnostic modality enjoying increased attention as minimally invasive surgical concepts pervade general thoracic surgery. For many surgeons, thoracoscopy’s primary role was for the diagnosis and occasional treatment of pleural disorders [7, 81. Others have used it to perform limited lung biopsies in patients with diffuse infiltrates [l, 21. Success with open, laser-assisted pulmonary resections and improvements in endoscopic surgical equipment have now allowed for video-assisted thoracoscopic management of many intrathoracic conditions [3, 9, lo]. Recent reports have described video-assisted thoracoscopic management of a variety of mediastinal conditions and for the ablation of apical bullous disease [ll-141. We were thus encouraged to employ VATS for the diagnosis and management of carefully selected patients with peripheral pulmonary lesions [3]. In this series, all target peripheral pulmonary lesions identified by preoperative high-resolution computed tomography were able to be located at exploratory thoracoscopy. An additional benefit obtained at thoracoscopic exploration was a panoramic view of the pleural and mediastinal surfaces superior to that seen through most standard thoracotomy approaches. Endoscopic visual identification of most lesions was achieved because of their subpleural location or as a result of effacement of the pulmonary lesion against the surrounding atelectatic lung. Palpation with endoscopic forceps or a ”probing” finger through a trocar site were also effective localization techniques; however, we have come to rely on computed tomography-directed hook wire localization for most small, deeper seated parenchymal lesions [4]. Our impression is that thoracoscopic resection may result in reduced perioperative morbidity and a shortened hospital stay for many patients requiring resection of peripheral pulmonary lesions. The postoperative hospital stay after video-assisted thoracoscopic resection in this series compares favorably with recent series of open resection of peripheral lung lesions reporting mean hospital stays of 7 to 10 days [9, 10, 151. Additionally, postthoracotomy pain may be lessened using the minimally invasive VATS approach. Studies comparing perioperative pain, shoulder girdle function, and postoperative morbidity presently underway at our institution (and others) may help to clarify the objective clinical differences between VATS and open thoracic surgical procedures [5, 161. Our approach to the undiagnosed peripheral pulmonary nodule remains a conscientious preoperative work-up
Ann Thorac Surg 1992;54:415-20
including c o m p u t e d tomography of t h e chest (and percutaneous, transbronchial, or cervical mediastinoscopic biopsy when indicated) [3, 171. Thoracoscopic resection is now our preferred approach, i n lieu of thoracotomy, for m o s t small (
