doi:10.1510/mmcts.2010.004762
Videoendoscopic resection of solitary peripheral lung nodule Stephanie Fraser, Tom Routledge, Marco Scarci* Department of Thoracic Surgery, Guy’s Hospital, London Minimally invasive surgery has transformed the management of peripheral lung nodules. In this interactive guide, we describe an evidence-based approach to video-assisted thoracic surgery (VATS) resection with a step-by-step operative guide. Keywords: Lung cancer; Solitary peripheral nodule; Videoendoscopic (VATS) Introduction Over 150,000 solitary lung nodules are diagnosed in the UK every year. If screening with helical-computed tomography (CT) scans is introduced, as suggested by recent research, this figure is likely to significantly increase w1x. The key to management of solitary nodules is appropriate preoperative planning (Graph 1). Percutaneous biopsy • Has a lower morbidity and mortality when compared to wedge resection, however, it produces a high number of indeterminate specimens w2x. VATS wedge resection
• Is associated with a lower rate of postoperative pain and reduced length of hospital stay when compared with open wedge resection w4x. For the reasons mentioned above, video-assisted wedge resection should be considered an evidencebased approach to the management of solitary pulmonary nodule as the one shown in Photo 1. Indications • Video-assisted thoracic surgery (VATS) resection is advised if a diagnosis of cancer is strongly suggested and progression to lobectomy is anticipated. • If nodules are not amenable to biopsy, or previous biopsies have been inconclusive, VATS resection should also be considered.
• Has been shown to yield a histological diagnosis with 100% specificity and sensitivity with little significant postoperative morbidity and no mortality w3x.
• Finally, patient preference should also be considered when weighing up options.
• Added benefit of allowing assessment of the thoracic cavity for evidence of pleural involvement or advanced disease.
Contraindications
• Allows the operating surgeon to proceed to lobectomy if indicated by macroscopic findings or frozen section analysis. * Corresponding author. Department of Thoracic Surgery, Guy’s Hospital, Great Maze Pond, London, UK. Tel.: q44-75-15542899; fax: q44-20-71881016. E-mail: [email protected] 2011 European Association for Cardio-thoracic Surgery
• Pleural symphysis resulting in inability to create a pleural space. • Although not an absolute contraindication, previous thoracotomy may complicate VATS biopsy due to pleural adhesions. • Co-morbid disease which has resulted in either inadequate lung function/physiological reserve to tolerate single lung ventilation. 1
S. Fraser et al. / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2010.004762 style used in minimally invasive anatomical lung resections, accordingly the surgeon stands anteriorly to the patient with the assistant posteriorly. Ports placement
Graph 1. Algorithm for the management of solitary peripheral lung nodule. Pet scanning is a useful tool and may add decision-making, but does not offer a definitive mean to differentiate between benign and malignant disease w3x.
Operative steps Anaesthetic considerations • Standard approach to intubation with a double lumen tube. Electric operating table allows flexing the patient at the hip level. The advantage is twofold: maximal separation of the ribs to aid port placement and unhindered movement of the thoracoscope, especially in women. Positioning • The patient should be placed in the lateral decubitus position and flexed at the hip. In our practice we standardized the VATS approach according to the
Photo 1. Preoperative CT-scan demonstrating a solitary left upper lobe nodule. CT, computed tomography.
2
• Port placement is tailored to the position of the lesion. The ports should be triangulated so that the camera and stapler are positioned in a parallel line facing the lesion and the manipulating port is placed beyond the lesion. It is often useful to note the position of the tip of the scapula and planned port sites prior to prepping the patient, as demonstrated in Photo 2, aligning the two superior ports along the ideal line of a thoracotomy avoids extra wounds, should a conversion become necessary. • The camera port is placed first in the 7th or 8th intercostal space in the anterior or mid-axillary line in most cases. In general, anterior port placement is favoured as this is associated with less postoperative pain w1x. A 30-degree scope is introduced and the macroscopic appearance assessed. Any associated effusion should be sampled at this point and sent for histopathology and microbiology. A subsequent stapler port is placed under direct visualisation. Lung retraction can be performed with endoscopic graspers and adhesiolysis can be performed with electrocautery if required for manipulation and safe port placement. A final manipulating port is placed under direct visualisation (Video 1). • The lesion is localised with lung retraction and atraumatic probing. If the lesion is not easily visualised thoracoscopically, the lung can be gently palpated
Photo 2. Ports positioning. VATS procedure on the right side with patient positioned in left lateral decubitus. VATS, video-assisted thoracic surgery.
S. Fraser et al. / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2010.004762 with a long straight instrument or manually with a finger through the anterior port site. • If at this time, it is not possible to identify the lesion safely, or a safe resection margin is unlikely to be obtained, conversion to thoracotomy to allow manual palpation is a recognised further operative step. • Once identified, a resection line can be planned below the lesion using forceps. The lung tissue surrounding the lesion is gently lifted with an instrument through the manipulating port, with care not to directly grasp the mass. An articulating stapler can then be advanced through the stapler port and staples applied with caution (Video 2). The graspers can be used to expose the staple line and guide further staple placement (Video 3). Particular care must be used not to tear the lung tissue. • Once the wedge is successfully resected, it is removed from the chest cavity with a protective bag, to prevent spillage of malignant cells and contamination of the chest cavity (Video 4).
Video 1. Ports placement.
Video 2. Staple’s introduction and positioning.
• Prior to closing the wound, insertion of an intercostal nerve block or paravertebral catheter will help with postoperative pain management. • Most surgeons still use one or two large bore chest drains in apical and basal positions through the inferior VATS ports. In our recent literature review, this is not always necessary if no air leak is detected at surgery, by submerging the lung with water and reinflating it.
Video 3. Progression of the staple line.
• The lung is re-inflated (Video 5) and the final superior wound is closed in routine layers. Particular care must be used to approximate the muscle layer to avoid aspiration of air or fluid leakage through the wound, especially in thin patients. In the case of nodules, which are difficult to localise with finger palpation, a number of alternative localisation techniques are available.
Video 4. Specimen removal.
• Intra-operative ultrasound: Prospective trials have demonstrated this to be a safe and accurate method of identifying pulmonary nodules. The technique involves the placement of an ultrasound probe thoracoscopically through a small trocar and is highly sensitive in the identification of deep nodules, while also allowing interrogation of the surrounding structures w5x. • Radio-guided localisation: This technique is also described in recent trials with high rates of successful localisation. However, this has been associated with higher complication rates than ultra-
Video 5. Final check to ensure full lung expansion.
sound and may be technically difficult due to diffusion of contrast into the lung parenchyma w6x. 3
S. Fraser et al. / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2010.004762
4
S. Fraser et al. / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2010.004762 • Preoperative techniques: CT-guided percutaneous dye staining, placement of microcoils, insertion of fiducial markers and hookwire insertion have been demonstrated to successfully guide resection of nodules which are deep within the lung parenchyma w7–10x. However, they have been associated with bleeding, pneumothorax and severe chest pain. While evidence suggests these techniques are safe and effective, they are dependent on the experience and skill of the surgeon. If the nodule is found to be deeper than anticipated intra-operatively, there are several alternative techniques for resection. These include: 1. Segmental resection: Appropriate for nodules in the anterior upper lobe or superior lower lobe/lingula. However, this resects an unnecessarily large volume of tissue in the instance of benign lesions. 2. Deep stapled nodulectomy: Involves bi-valving the lung tissue thereby preserving more parenchyma, however, this is often technically difficult to perform. 3. Nodulectomy with electrocautery: The nodule is excised with endoscopic cautery resulting in a ‘crater’. However, this requires the resection line to be over-sewn to prevent prolonged air leak and can be time consuming.
pulmonary nodules (see Table 1 with Literature Review summary). Recent research has recognised low postoperative complication rates w16x, shorter operative time and length of hospital stay w4x. As discussed earlier, patients with peripheral tumours, with a high index of suspicion for malignant disease, should particularly be considered for VATS wedge resection, due to the ability to assess the thoracic cavity and proceed to lobectomy as indicated intra-operatively. Complications we have observed include misfiring of stapling equipment, although meticulous care and washing in between stapler loads has reduced the incidence of this. Additionally, bleeding from staple line failure may occur and require further manoeuvres to obtain haemostasis. Finally, conversion to thoracotomy should not be considered a failure of VATS, but rather in certain cases, a necessary additional procedure to ensure safe resection of the nodule, which is the aim of the operation. Recent studies support this, given that while conversion to open increases operative time and hospital stay, it does not significantly impact postoperative survival w17x.
Conclusion For properly selected patients, VATS resection is a safe and reliable way of managing solitary pulmonary nodules.
Tips Plan port sites carefully. You should: • Position your initial port a rib space higher than usual in obese patients as the diaphragm is often raised. • Aim for at least 10 cm between port sites to avoid over-lapping instruments. • Avoid acute angles and try not to lever the ports against the ribs as this can crush the intercostals nerve leading to chronic neuropathic pain. Preference card • 30 degree scope • Endoscopic bag • Articulating stapler
Results and discussion Videoendoscopic resection has been demonstrated to be a reliable technique for the management of solitary
References w1x Aberle DR, Berg CD, Black WC, Church TR, Fagerstrom RM, Galen B, Gareen IF, Gatsonis C, Goldin J, Gohagan JK, Hillman B, Jaffe C, Kramer BS, Lynch D, Marcus PM, Schnall M, Sullivan DC, Sullivan D, Zylak CJ. The national lung screening trial: overview and study design. National Lung Screening Trial Research Team. Radiology 2011; 258:243–253. w2x Demmy TL. Pulmonary nodules and masses. In: Video-assisted thoracoscopic surgery. Landes Bioscience 2001:60–70. w3x Loscertales J, Jimenez-Merchan R, Congregado M, Ayarra FJ, Gallardo G, Trivio A. Video-assisted surgery for lung cancer. State of the art and personal experience. Asian Cardiovasc Thorac Ann 2009;17:313–326. w4x Sugi K, Kaneda Y, Nawata K, Fujita N, Ueda K, Nawata S, Esato K. Cost analysis for thoracoscopy: thoracoscopic wedge resection and lobectomy. Surg Today 1998;28:41–45. 5
S. Fraser et al. / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2010.004762 w5x Sortini A, Carrella G, Sortini D, Pozza E. Single pulmonary nodules: localization with intrathoracoscopic ultrasound – a prospective study. Eur J Cardiothorac Surg 2002;22:440–442. w6x Sortini D, Feo CV, Carcoforo P, Carrella G, Pozza E, Liboni A, Sortini A. Thoracoscopic localization techniques for patients with solitary pulmonary nodule and history of malignancy. Ann Thorac Surg 2005;79:258–262. w7x Lenglinger FX, Schwarz CD, Artmann W. Localization of pulmonary nodules before thoracoscopic surgery: value of percutaneous staining with methylene blue. AJR Am J Roentgenol 1994;163:297–300. w8x Mayo JR, Clifton JC, Powell TI, English JC, Evans KG, Yee J, McWilliams AM, Lam SC, Finley RJ. Lung nodules: CT-guided placement of microcoils to direct video-assisted thoracoscopic surgical resection. Radiology 2009;250:576–585. w9x Schroeder C, Hejal R, Linden PA. Coil spring fiducial markers placed safely using navigation bronchoscopy in inoperable patients allows accurate delivery of CyberKnife stereotactic radiosurgery. J Thorac Cardiovasc Surg 2010; 140:1137–1142. w10x Chen S, Zhou J, Zhang J, Hu H, Luo X, Zhang Y, Chen H. Video-assisted thoracoscopic solitary pulmonary nodule resection after CT-guided hookwire localization: 43 case reports and literature review. Surg Endosc 2011;25:1723– 1729. w11x Atkins BZ, Harpole DH Jr, Mangum JH, Toloza EM, D’Amico TA, Burfeind WR Jr. Pulmonary segmentectomy by thoracotomy or thoracoscopy: reduced hospital length of stay with a
6
w12x
w13x
w14x
w15x
w16x
w17x
minimally-invasive approach. Ann Thorac Surg 2007;84:1107–1112. Schuchert MJ, Pettiford BL, Pennathur A, Abbas G, Awais O, Close J, Kilic A, Jack R, Landreneau JR, Landreneau JP, Wilson DO, Luketich JD, Landreneau RJ. Anatomic segmentectomy for stage I non-small-cell lung cancer: comparison of video-assisted thoracic surgery versus open approach. J Thorac Cardiovasc Surg 2009;138: 1318–1325. Mack MJ, Hazelrigg SR, Landreneau RJ, Acuff TE. Thoracoscopy for the diagnosis of the indeterminate solitary pulmonary nodule. Ann Thorac Surg 1993;56:825–830. Mitruka S, Landreneau RJ, Mack MJ, Fetterman LS, Gammie J, Bartley S, Sutherland SR, Bowers CM, Keenan RJ, Ferson PF. Diagnosing the indeterminate pulmonary nodule: percutaneous biopsy versus thoracoscopy. Surgery 1995;118: 676–684. Santambrogio L, Nosotti M, Bellaviti N, Mezzetti M. Videothoracoscopy versus thoracotomy for the diagnosis of the indeterminate solitary pulmonary nodule. Ann Thorac Surg 1995;59:868–870. Solaini L, Prusciano F, Bagioni P, di Francesco F, Solaini L, Poddie DB. Video-assisted thoracic surgery (VATS) of the lung: analysis of intraoperative and postoperative complications over 15 years and review of the literature. Surg Endosc 2008;22:298–310. Park JS, Kim HK, Choi YS, Kim J, Shim YM, Kim K. Unplanned conversion to thoracotomy during video-assisted thoracic surgery lobectomy does not compromise the surgical outcome. World J Surg 2011;35:590–595.
Videoendoscopic resection of solitary peripheral lung nodule Stephanie Fraser, Tom Routledge, Marco Scarci* Department of Thoracic Surgery, Guy’s Hospital, London Minimally invasive surgery has transformed the management of peripheral lung nodules. In this interactive guide, we describe an evidence-based approach to video-assisted thoracic surgery (VATS) resection with a step-by-step operative guide. Keywords: Lung cancer; Solitary peripheral nodule; Videoendoscopic (VATS) Introduction Over 150,000 solitary lung nodules are diagnosed in the UK every year. If screening with helical-computed tomography (CT) scans is introduced, as suggested by recent research, this figure is likely to significantly increase w1x. The key to management of solitary nodules is appropriate preoperative planning (Graph 1). Percutaneous biopsy • Has a lower morbidity and mortality when compared to wedge resection, however, it produces a high number of indeterminate specimens w2x. VATS wedge resection
• Is associated with a lower rate of postoperative pain and reduced length of hospital stay when compared with open wedge resection w4x. For the reasons mentioned above, video-assisted wedge resection should be considered an evidencebased approach to the management of solitary pulmonary nodule as the one shown in Photo 1. Indications • Video-assisted thoracic surgery (VATS) resection is advised if a diagnosis of cancer is strongly suggested and progression to lobectomy is anticipated. • If nodules are not amenable to biopsy, or previous biopsies have been inconclusive, VATS resection should also be considered.
• Has been shown to yield a histological diagnosis with 100% specificity and sensitivity with little significant postoperative morbidity and no mortality w3x.
• Finally, patient preference should also be considered when weighing up options.
• Added benefit of allowing assessment of the thoracic cavity for evidence of pleural involvement or advanced disease.
Contraindications
• Allows the operating surgeon to proceed to lobectomy if indicated by macroscopic findings or frozen section analysis. * Corresponding author. Department of Thoracic Surgery, Guy’s Hospital, Great Maze Pond, London, UK. Tel.: q44-75-15542899; fax: q44-20-71881016. E-mail: [email protected] 2011 European Association for Cardio-thoracic Surgery
• Pleural symphysis resulting in inability to create a pleural space. • Although not an absolute contraindication, previous thoracotomy may complicate VATS biopsy due to pleural adhesions. • Co-morbid disease which has resulted in either inadequate lung function/physiological reserve to tolerate single lung ventilation. 1
S. Fraser et al. / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2010.004762 style used in minimally invasive anatomical lung resections, accordingly the surgeon stands anteriorly to the patient with the assistant posteriorly. Ports placement
Graph 1. Algorithm for the management of solitary peripheral lung nodule. Pet scanning is a useful tool and may add decision-making, but does not offer a definitive mean to differentiate between benign and malignant disease w3x.
Operative steps Anaesthetic considerations • Standard approach to intubation with a double lumen tube. Electric operating table allows flexing the patient at the hip level. The advantage is twofold: maximal separation of the ribs to aid port placement and unhindered movement of the thoracoscope, especially in women. Positioning • The patient should be placed in the lateral decubitus position and flexed at the hip. In our practice we standardized the VATS approach according to the
Photo 1. Preoperative CT-scan demonstrating a solitary left upper lobe nodule. CT, computed tomography.
2
• Port placement is tailored to the position of the lesion. The ports should be triangulated so that the camera and stapler are positioned in a parallel line facing the lesion and the manipulating port is placed beyond the lesion. It is often useful to note the position of the tip of the scapula and planned port sites prior to prepping the patient, as demonstrated in Photo 2, aligning the two superior ports along the ideal line of a thoracotomy avoids extra wounds, should a conversion become necessary. • The camera port is placed first in the 7th or 8th intercostal space in the anterior or mid-axillary line in most cases. In general, anterior port placement is favoured as this is associated with less postoperative pain w1x. A 30-degree scope is introduced and the macroscopic appearance assessed. Any associated effusion should be sampled at this point and sent for histopathology and microbiology. A subsequent stapler port is placed under direct visualisation. Lung retraction can be performed with endoscopic graspers and adhesiolysis can be performed with electrocautery if required for manipulation and safe port placement. A final manipulating port is placed under direct visualisation (Video 1). • The lesion is localised with lung retraction and atraumatic probing. If the lesion is not easily visualised thoracoscopically, the lung can be gently palpated
Photo 2. Ports positioning. VATS procedure on the right side with patient positioned in left lateral decubitus. VATS, video-assisted thoracic surgery.
S. Fraser et al. / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2010.004762 with a long straight instrument or manually with a finger through the anterior port site. • If at this time, it is not possible to identify the lesion safely, or a safe resection margin is unlikely to be obtained, conversion to thoracotomy to allow manual palpation is a recognised further operative step. • Once identified, a resection line can be planned below the lesion using forceps. The lung tissue surrounding the lesion is gently lifted with an instrument through the manipulating port, with care not to directly grasp the mass. An articulating stapler can then be advanced through the stapler port and staples applied with caution (Video 2). The graspers can be used to expose the staple line and guide further staple placement (Video 3). Particular care must be used not to tear the lung tissue. • Once the wedge is successfully resected, it is removed from the chest cavity with a protective bag, to prevent spillage of malignant cells and contamination of the chest cavity (Video 4).
Video 1. Ports placement.
Video 2. Staple’s introduction and positioning.
• Prior to closing the wound, insertion of an intercostal nerve block or paravertebral catheter will help with postoperative pain management. • Most surgeons still use one or two large bore chest drains in apical and basal positions through the inferior VATS ports. In our recent literature review, this is not always necessary if no air leak is detected at surgery, by submerging the lung with water and reinflating it.
Video 3. Progression of the staple line.
• The lung is re-inflated (Video 5) and the final superior wound is closed in routine layers. Particular care must be used to approximate the muscle layer to avoid aspiration of air or fluid leakage through the wound, especially in thin patients. In the case of nodules, which are difficult to localise with finger palpation, a number of alternative localisation techniques are available.
Video 4. Specimen removal.
• Intra-operative ultrasound: Prospective trials have demonstrated this to be a safe and accurate method of identifying pulmonary nodules. The technique involves the placement of an ultrasound probe thoracoscopically through a small trocar and is highly sensitive in the identification of deep nodules, while also allowing interrogation of the surrounding structures w5x. • Radio-guided localisation: This technique is also described in recent trials with high rates of successful localisation. However, this has been associated with higher complication rates than ultra-
Video 5. Final check to ensure full lung expansion.
sound and may be technically difficult due to diffusion of contrast into the lung parenchyma w6x. 3
S. Fraser et al. / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2010.004762
4
S. Fraser et al. / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2010.004762 • Preoperative techniques: CT-guided percutaneous dye staining, placement of microcoils, insertion of fiducial markers and hookwire insertion have been demonstrated to successfully guide resection of nodules which are deep within the lung parenchyma w7–10x. However, they have been associated with bleeding, pneumothorax and severe chest pain. While evidence suggests these techniques are safe and effective, they are dependent on the experience and skill of the surgeon. If the nodule is found to be deeper than anticipated intra-operatively, there are several alternative techniques for resection. These include: 1. Segmental resection: Appropriate for nodules in the anterior upper lobe or superior lower lobe/lingula. However, this resects an unnecessarily large volume of tissue in the instance of benign lesions. 2. Deep stapled nodulectomy: Involves bi-valving the lung tissue thereby preserving more parenchyma, however, this is often technically difficult to perform. 3. Nodulectomy with electrocautery: The nodule is excised with endoscopic cautery resulting in a ‘crater’. However, this requires the resection line to be over-sewn to prevent prolonged air leak and can be time consuming.
pulmonary nodules (see Table 1 with Literature Review summary). Recent research has recognised low postoperative complication rates w16x, shorter operative time and length of hospital stay w4x. As discussed earlier, patients with peripheral tumours, with a high index of suspicion for malignant disease, should particularly be considered for VATS wedge resection, due to the ability to assess the thoracic cavity and proceed to lobectomy as indicated intra-operatively. Complications we have observed include misfiring of stapling equipment, although meticulous care and washing in between stapler loads has reduced the incidence of this. Additionally, bleeding from staple line failure may occur and require further manoeuvres to obtain haemostasis. Finally, conversion to thoracotomy should not be considered a failure of VATS, but rather in certain cases, a necessary additional procedure to ensure safe resection of the nodule, which is the aim of the operation. Recent studies support this, given that while conversion to open increases operative time and hospital stay, it does not significantly impact postoperative survival w17x.
Conclusion For properly selected patients, VATS resection is a safe and reliable way of managing solitary pulmonary nodules.
Tips Plan port sites carefully. You should: • Position your initial port a rib space higher than usual in obese patients as the diaphragm is often raised. • Aim for at least 10 cm between port sites to avoid over-lapping instruments. • Avoid acute angles and try not to lever the ports against the ribs as this can crush the intercostals nerve leading to chronic neuropathic pain. Preference card • 30 degree scope • Endoscopic bag • Articulating stapler
Results and discussion Videoendoscopic resection has been demonstrated to be a reliable technique for the management of solitary
References w1x Aberle DR, Berg CD, Black WC, Church TR, Fagerstrom RM, Galen B, Gareen IF, Gatsonis C, Goldin J, Gohagan JK, Hillman B, Jaffe C, Kramer BS, Lynch D, Marcus PM, Schnall M, Sullivan DC, Sullivan D, Zylak CJ. The national lung screening trial: overview and study design. National Lung Screening Trial Research Team. Radiology 2011; 258:243–253. w2x Demmy TL. Pulmonary nodules and masses. In: Video-assisted thoracoscopic surgery. Landes Bioscience 2001:60–70. w3x Loscertales J, Jimenez-Merchan R, Congregado M, Ayarra FJ, Gallardo G, Trivio A. Video-assisted surgery for lung cancer. State of the art and personal experience. Asian Cardiovasc Thorac Ann 2009;17:313–326. w4x Sugi K, Kaneda Y, Nawata K, Fujita N, Ueda K, Nawata S, Esato K. Cost analysis for thoracoscopy: thoracoscopic wedge resection and lobectomy. Surg Today 1998;28:41–45. 5
S. Fraser et al. / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2010.004762 w5x Sortini A, Carrella G, Sortini D, Pozza E. Single pulmonary nodules: localization with intrathoracoscopic ultrasound – a prospective study. Eur J Cardiothorac Surg 2002;22:440–442. w6x Sortini D, Feo CV, Carcoforo P, Carrella G, Pozza E, Liboni A, Sortini A. Thoracoscopic localization techniques for patients with solitary pulmonary nodule and history of malignancy. Ann Thorac Surg 2005;79:258–262. w7x Lenglinger FX, Schwarz CD, Artmann W. Localization of pulmonary nodules before thoracoscopic surgery: value of percutaneous staining with methylene blue. AJR Am J Roentgenol 1994;163:297–300. w8x Mayo JR, Clifton JC, Powell TI, English JC, Evans KG, Yee J, McWilliams AM, Lam SC, Finley RJ. Lung nodules: CT-guided placement of microcoils to direct video-assisted thoracoscopic surgical resection. Radiology 2009;250:576–585. w9x Schroeder C, Hejal R, Linden PA. Coil spring fiducial markers placed safely using navigation bronchoscopy in inoperable patients allows accurate delivery of CyberKnife stereotactic radiosurgery. J Thorac Cardiovasc Surg 2010; 140:1137–1142. w10x Chen S, Zhou J, Zhang J, Hu H, Luo X, Zhang Y, Chen H. Video-assisted thoracoscopic solitary pulmonary nodule resection after CT-guided hookwire localization: 43 case reports and literature review. Surg Endosc 2011;25:1723– 1729. w11x Atkins BZ, Harpole DH Jr, Mangum JH, Toloza EM, D’Amico TA, Burfeind WR Jr. Pulmonary segmentectomy by thoracotomy or thoracoscopy: reduced hospital length of stay with a
6
w12x
w13x
w14x
w15x
w16x
w17x
minimally-invasive approach. Ann Thorac Surg 2007;84:1107–1112. Schuchert MJ, Pettiford BL, Pennathur A, Abbas G, Awais O, Close J, Kilic A, Jack R, Landreneau JR, Landreneau JP, Wilson DO, Luketich JD, Landreneau RJ. Anatomic segmentectomy for stage I non-small-cell lung cancer: comparison of video-assisted thoracic surgery versus open approach. J Thorac Cardiovasc Surg 2009;138: 1318–1325. Mack MJ, Hazelrigg SR, Landreneau RJ, Acuff TE. Thoracoscopy for the diagnosis of the indeterminate solitary pulmonary nodule. Ann Thorac Surg 1993;56:825–830. Mitruka S, Landreneau RJ, Mack MJ, Fetterman LS, Gammie J, Bartley S, Sutherland SR, Bowers CM, Keenan RJ, Ferson PF. Diagnosing the indeterminate pulmonary nodule: percutaneous biopsy versus thoracoscopy. Surgery 1995;118: 676–684. Santambrogio L, Nosotti M, Bellaviti N, Mezzetti M. Videothoracoscopy versus thoracotomy for the diagnosis of the indeterminate solitary pulmonary nodule. Ann Thorac Surg 1995;59:868–870. Solaini L, Prusciano F, Bagioni P, di Francesco F, Solaini L, Poddie DB. Video-assisted thoracic surgery (VATS) of the lung: analysis of intraoperative and postoperative complications over 15 years and review of the literature. Surg Endosc 2008;22:298–310. Park JS, Kim HK, Choi YS, Kim J, Shim YM, Kim K. Unplanned conversion to thoracotomy during video-assisted thoracic surgery lobectomy does not compromise the surgical outcome. World J Surg 2011;35:590–595.
