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• W1973900478 abstract "Video-assisted thoracic surgery (VATS) lobectomy provides a minimally invasive approach for the management of early-stage lung cancer. Questions about the safety of VATS lobectomy and its adequacy as a cancer operation compared with open thoracotomy have hindered its universal acceptance among thoracic surgeons. Evidence suggests that VATS lobectomy can be safely performed and is an adequate cancer operation for early-stage non-small cell lung cancer. However, adequately powered well-balanced studies comparing VATS with open thoracotomy for lobectomy are lacking in the literature. Video-assisted thoracic surgery (VATS) lobectomy provides a minimally invasive approach for the management of early-stage lung cancer. Questions about the safety of VATS lobectomy and its adequacy as a cancer operation compared with open thoracotomy have hindered its universal acceptance among thoracic surgeons. Evidence suggests that VATS lobectomy can be safely performed and is an adequate cancer operation for early-stage non-small cell lung cancer. However, adequately powered well-balanced studies comparing VATS with open thoracotomy for lobectomy are lacking in the literature. The earliest reports of minimally invasive lobectomy were published in the early 1990s. Since then, there has been significant reluctance on the part of thoracic surgeons to adopt video-assisted thoracic surgery (VATS) techniques to perform major anatomic lung resections. The two most common concerns with VATS lobectomy for lung cancer are its adequacy as an oncologically sound operation and operative safety. Few data have been published that directly compare VATS lobectomy with lobectomy by open thoracotomy and even less for robotic-assisted cases. However, the demand for VATS procedures is patient-driven. The arguments in favor of VATS lobectomy include cosmesis, less postoperative pain, shorter length of stay, and relative lower overall cost. An adequately powered, controlled clinical trial comparing VATS lobectomy with thoracotomy has not been performed, however.The definition of VATS lobectomy is ambiguous as well. The technique varies in the number of incisions from 2 to 5, length of utility incisions from 4 to 10 cm in size, degree of rib-spreading, if any, and individual hilar ligation vs tourniquet lobectomy. In addition, when VATS lobectomy is compared with open thoracotomy, one must take into account the type of open approach: standard posterolateral thoracotomy, complete muscle-sparing thoracotomy, thoracotomy sparing only the serratus muscle, anterolateral thoracotomy, and sternotomy. Therefore, both open and VATS techniques must be explicitly defined in order to draw any meaningful conclusions from published studies.MethodsA systematic review of the literature was performed by accessing the MEDLINE database for entries from 1966 through June 2006. We selected and reviewed relevant articles and abstracts, and the reference lists from those sources were searched for additional trials. Studies were divided into the following groups: randomized controlled trials (RCTs), case–control studies, and case series.In addition, all patients with clinical stage I lung cancer who had lobectomy by VATS at Memorial Sloan-Kettering Cancer Center were identified. Our standard VATS approach uses a 4-cm utility incision, an anterior 2-cm port for the camera, a posterior 2-cm port, no rib-spreading, individual ligation of hilar structures, and a mediastinal lymph node dissection or sampling. Our robotic technique uses the da Vinci Surgical System (Intuitive Surgical, Sunnyvale, CA) with the same three incisions and with the same camera and working ports.ResultsThe literature published to date on VATS or robotic lobectomy is scant and largely of a lesser weight on the evidence scale. A few centers worldwide are responsible for a large share of the studies, and most of the data are in the form of case series.Randomized Controlled TrialsFew RCTs exist in this area (Table 1). Of the three published trials comparing open with VATS lobectomies, two examine clinical outcomes and one investigates biochemical markers [1Rovario G.C. Rebuffat C. Varioli F. et al.Videoendoscopic pulmonary lobectomy for cancer.Surg Laparosc Endosc. 1992; 2: 244-247PubMed Google Scholar, 2Kirby T.J. Mack M.J. Landreneau R.J. et al.Initial experience with video-assisted thoracoscopic lobectomy.Ann Thorac Surg. 1993; 56: 1248-1253Abstract Full Text PDF PubMed Scopus (146) Google Scholar, 3Kirby T.J. Mack M.J. Landreneau R.J. et al.Lobectomy–video-assisted thoracic surgery versus muscle-sparing thoracotomy: a randomized trial.J Thorac Cardiovasc Surg. 1995; 109: 997-1002Abstract Full Text Full Text PDF PubMed Scopus (388) Google Scholar, 4Sugi K. Kaneda Y. Esato K. Video-assisted thoracoscopic lobectomy achieves a satisfactory long-term prognosis in patients with clinical stage IA lung cancer.World J Surg. 2000; 24: 27-31Crossref PubMed Scopus (301) Google Scholar, 5Craig S.R. Leaver H.A. Yap P.L. Pugh G.C. Walker W.S. Acute phase responses following minimal access and conventional thoracic surgery.Eur J Cardiothorac Surg. 2001; 20: 455-463Crossref PubMed Scopus (227) Google Scholar]. The first well-known RCT was published by Kirby and colleagues [3Kirby T.J. Mack M.J. Landreneau R.J. et al.Lobectomy–video-assisted thoracic surgery versus muscle-sparing thoracotomy: a randomized trial.J Thorac Cardiovasc Surg. 1995; 109: 997-1002Abstract Full Text Full Text PDF PubMed Scopus (388) Google Scholar]. They randomized 61 patients with clinical stage I non-small cell lung cancer (NSCLC) to undergo lobectomy by VATS (31 patients) or muscle-sparing thoracotomy (30 patients). The VATS were performed without rib-spreading. One patient in the open group and 2 patients in the VATS group had benign disease and were excluded from analysis. In addition, 3 patients in the VATS group required conversion to thoracotomy and were also excluded from the analysis, leaving 30 in the open group and 25 in the VATS group. There were few differences between the groups. The incidence of postoperative complications was less in the VATS group (6% vs 16%). No significant differences were noted in operating time, blood loss, duration of chest tube placement, length of hospital stay, or incidence of disabling postthoracotomy pain (2 in the open vs 1 in the VATS group).Table 1Randomized Control Trials of Video-Assisted Thoracic Surgery Major Lung ResectionsStudy (first author)PatientsOutcomesResultsCommentKirby [3Kirby T.J. Mack M.J. Landreneau R.J. et al.Lobectomy–video-assisted thoracic surgery versus muscle-sparing thoracotomy: a randomized trial.J Thorac Cardiovasc Surg. 1995; 109: 997-1002Abstract Full Text Full Text PDF PubMed Scopus (388) Google Scholar], 199525 VATS; 30 OpenLOS, OR time, complicationsFewer complications in VATS, no other differencesStage I tumors, 3 VATS excluded due to conversionSugi [4Sugi K. Kaneda Y. Esato K. Video-assisted thoracoscopic lobectomy achieves a satisfactory long-term prognosis in patients with clinical stage IA lung cancer.World J Surg. 2000; 24: 27-31Crossref PubMed Scopus (301) Google Scholar], 200048 VATS; 52 OpenSurvival, recurrencesNo differencesAll patients had MLNDCraig [5Craig S.R. Leaver H.A. Yap P.L. Pugh G.C. Walker W.S. Acute phase responses following minimal access and conventional thoracic surgery.Eur J Cardiothorac Surg. 2001; 20: 455-463Crossref PubMed Scopus (227) Google Scholar], 200122 VATS; 19 OpenAcute phase reactantsLower CRP and IL-6 in VATSShigemura [6Shigemura N. Akashi A. Nakagiri T. Ohta M. Matsuda H. Complete vs. assisted thoracoscopic approach: a prospective randomized trial comparing a variety of video-assisted thoracoscopic lobectomy techniques.Surg Endosc. 2004; 18: 1492-1497Crossref PubMed Scopus (69) Google Scholar], 200418 cVATS; 16 aVATSOR time, LOS, pain, complications, markersLonger OR, shorter LOS, lower CRP with cVATSComplete VATS–no rib-spreadingaVATS = assisted VATS; CRP = C-reactive protein; cVATS = complete VATS; IL-6 = interleukin 6; LOS = length of stay; MLND = mediastinal lymph node dissection; OR = operating room; VATS = video-assisted thoracic surgery. Open table in a new tab The other RCT that compared clinical outcomes between open and VATS lobectomy was published by Sugi and colleagues in Japan [4Sugi K. Kaneda Y. Esato K. Video-assisted thoracoscopic lobectomy achieves a satisfactory long-term prognosis in patients with clinical stage IA lung cancer.World J Surg. 2000; 24: 27-31Crossref PubMed Scopus (301) Google Scholar]. They randomized 100 patients with clinical stage IA lung cancer to open (52 patients) or VATS (48 patients) lobectomy and mediastinal lymph node dissection. The additional two patients in the open group were conversions from VATS and were analyzed in the open group. There were no significant differences in the recurrence rates or survival. The reported 3- and 5-year survival rates were 93% and 85% in the open group and 90% and 90% in the VATS group, respectively. This was the only RCT we found that examined survival differences between VATS and open lobectomies.A study comparing acute phase responses randomized 22 patients to VATS and 19 patients to open lobectomy [5Craig S.R. Leaver H.A. Yap P.L. Pugh G.C. Walker W.S. Acute phase responses following minimal access and conventional thoracic surgery.Eur J Cardiothorac Surg. 2001; 20: 455-463Crossref PubMed Scopus (227) Google Scholar]. They used a nonrib-spreading technique, and all patients had mediastinoscopy preoperatively. Blood samples were taken before and at various times in the first week after the operation. Both procedures increased acute-phase response markers, but VATS was associated with lower rises in C-reactive protein (CRP) and interleukin 6.The final RCT was performed comparing complete VATS (c-VATS) with assisted VATS (a-VATS) [6Shigemura N. Akashi A. Nakagiri T. Ohta M. Matsuda H. Complete vs. assisted thoracoscopic approach: a prospective randomized trial comparing a variety of video-assisted thoracoscopic lobectomy techniques.Surg Endosc. 2004; 18: 1492-1497Crossref PubMed Scopus (69) Google Scholar]. The authors randomized 18 patients with clinical stage I lung cancer to a nonrib-spreading approach (c-VATS) and 16 patients to a minithoracotomy approach with rib-spreading (a-VATS). The authors found significantly shorter length of stay (11 vs 15 days), longer operating room times, less blood loss, and lower serum markers (CRP, white blood cells) in the c-VATS group.Case–Control StudiesA number of case–control studies with different primary end points have been performed on VATS major lung resections (Table 2). Two studies have investigated the effects of VATS lobectomies in high-risk patients [7Koizumi K. Haraguchi S. Hirata T. et al.Lobectomy by video-assisted thoracic surgery for lung cancer patients aged 80 years or more.Ann Thorac Cardiovasc Surg. 2003; 9: 14-21PubMed Google Scholar, 8Demmy T.L. Curtis J.J. Minimally invasive lobectomy directed toward frail and high-risk patients: a case-control study.Ann Thorac Surg. 1999; 68: 194-200Abstract Full Text Full Text PDF PubMed Scopus (237) Google Scholar]. A Japanese case–control study done with patients aged 80 years or older with 17 VATS cases and 15 open controls showed no significant difference in survival or complications with trends favoring the VATS group [7Koizumi K. Haraguchi S. Hirata T. et al.Lobectomy by video-assisted thoracic surgery for lung cancer patients aged 80 years or more.Ann Thorac Cardiovasc Surg. 2003; 9: 14-21PubMed Google Scholar].Table 2Case–Control Series of Major Lung Resections With Video-Assisted Thoracic SurgeryStudy (first author)PatientsOutcomesResultsCommentShiraishi [27Shiraishi T. Shirakusa T. Miyoshi T. Hiratsuka M. Yamamoto S. Iwasaki A. A completely thoracoscopic lobectomy/ segmentectomy for primary lung cancer–technique, feasibility, and advantages.Thorac Cardiovasc Surg. 2006; 54: 202-207Crossref PubMed Scopus (22) Google Scholar], 200610 VATS; 9 mini; 19 openMediastinal LNs, LOS, pain by VASEqual mediastinal LN resected; less pain in VATSClinical Stage IA, pain less in VATS vs open on POD 2Watanabe [29Watanabe A. Koyanagi T. Ohsawa H. et al.Systematic node dissection by VATS is not inferior to that through an open thoracotomy: a comparative clinicopathologic retrospective study.Surgery. 2005; 138: 510-517Abstract Full Text Full Text PDF PubMed Scopus (126) Google Scholar], 2005191 VATS; 159 openNumber of mediastinal LNs, mortality, recurrenceMediastinal LNs equal; 5-year recurrence-free survival similarGroups not equivalent, more T2 in openMuraoka [28Muraoka M. Oka T. Akamine S. et al.Video-assisted thoracic surgery lobectomy reduces the morbidity after surgery for stage I non-small cell lung cancer.Jpn J Thorac Cardiovasc Surg. 2006; 54: 49-55Crossref PubMed Scopus (47) Google Scholar], 200643 VATS; 42 openSurgical invasiveness variables, complicationsLess blood loss, shorter chest tube duration, less pain, lower WBC and CRP all in VATSAn overall decreased morbidity rate in VATS (25.6% vs 47.6%); clinical stage IDemmy [8Demmy T.L. Curtis J.J. Minimally invasive lobectomy directed toward frail and high-risk patients: a case-control study.Ann Thorac Surg. 1999; 68: 194-200Abstract Full Text Full Text PDF PubMed Scopus (237) Google Scholar], 199919 VATS; 19 openLOS, return to activity, painAll favor VATSHigh-risk patients; 3 deaths in VATS, 1 in controlKoizumi [7Koizumi K. Haraguchi S. Hirata T. et al.Lobectomy by video-assisted thoracic surgery for lung cancer patients aged 80 years or more.Ann Thorac Cardiovasc Surg. 2003; 9: 14-21PubMed Google Scholar], 200317 VATS; 15 openComplications, survivalTrend favors VATSPatient age >80Demmy [9Demmy T.L. Plante A.J. Nwogu C.E. Takita H. Anderson T.M. Discharge independence with minimally invasive lobectomy.Am J Surg. 2004; 188: 698-702Abstract Full Text Full Text PDF PubMed Scopus (54) Google Scholar], 200420 VATS; 38 openDischarge independence, LOSShorter LOS, less pain, fewer transfers to care facilitiesGroups well matchedKawai [10Kawai H. Tayasu Y Saitoh A. et al.Nocturnal hypoxemia after lobectomy for lung cancer.Ann Thorac Surg. 2005; 79: 1162-1166Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar], 200510 VATS; 11 openNocturnal hypoxemia on POD 3 and 14Less hypoxemia at POD 14 with VATSOpen were >2 cm, VATS were <2 cmNagahiro [11Nagahiro I. Andou A. Aoe M. Sano Y. Date H. Shimizu N. Pulmonary function postoperative pain, and serum cytokine level after lobectomy: a comparison of VATS and conventional procedure.Ann Thorac Surg. 2001; 72: 362-365Abstract Full Text Full Text PDF PubMed Scopus (424) Google Scholar], 200113 VATS; 9 openPFTs, pain, cytokinesLess pain, lower IL-6 in VATSOpen were T2, VATS were T1Nakata [12Nakata M. Saeki H. Yokoyama N. Kurita A. Takiyama W. Takashima S. Pulmonary function after lobectomy: vidoe-assisted thoracic surgery versus thoracotomy.Ann Thorac Surg. 2000; 70: 938-941Abstract Full Text Full Text PDF PubMed Scopus (158) Google Scholar], 200010 VATS; 11 openPFTs, early and latePFTs better for VATS on POD 7, no change at 1 yearSelection of controls ill-defined, rib-spreading usedYim [13Yim A.P. Wan S. Lee T.W. Arifi A.A. VATS lobectomy reduces cytokine responses compared with conventional surgery.Ann Thorac Surg. 2000; 70: 243-247Abstract Full Text Full Text PDF PubMed Scopus (292) Google Scholar], 200018 VATS; 18 openCytokines, analgesic requirementIL-6, IL-8, IL-10 lower and less IV narcotic in VATSControls were initially attempted VATSKaseda [14Kaseda S. Aoki T. Hangai N. Shimizu K. Better pulmonary function and prognosis with video-assisted thoracic surgery than with thoracotomy.Ann Thorac Surg. 2000; 70: 1644-1646Abstract Full Text Full Text PDF PubMed Scopus (280) Google Scholar], 200044 VATS; 77 openPFTs 3 months post-op, survivalPFT changes and stage I survival better for VATSHistorical controls not well definedCRP = C-reactive protein; IL = interleukin; IV = intravenous; LN = lymph node; LOS = length of stay; PFT = pulmonary function test; POD = postoperative day; WBC = white blood cells; VATS = video-assisted thoracic surgery. Open table in a new tab Demmy and Curtis [8Demmy T.L. Curtis J.J. Minimally invasive lobectomy directed toward frail and high-risk patients: a case-control study.Ann Thorac Surg. 1999; 68: 194-200Abstract Full Text Full Text PDF PubMed Scopus (237) Google Scholar] performed a case–control study comparing VATS lobectomy patients with matched controls who had open operations. VATS was only offered to patients who were deemed high risk because of either poor pulmonary function tests or poor function. Each group had 19 patients. Despite having higher-risk patients, the VATS group had a shorter length of stay, a quicker return to activity, and less pain at 3 weeks postoperatively than the open group.A number of other case–control series examining pain, changes in pulmonary function tests, nocturnal hypoxemia, and various markers of inflammation have been performed and are summarized in Table 2 [10Kawai H. Tayasu Y Saitoh A. et al.Nocturnal hypoxemia after lobectomy for lung cancer.Ann Thorac Surg. 2005; 79: 1162-1166Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar, 11Nagahiro I. Andou A. Aoe M. Sano Y. Date H. Shimizu N. Pulmonary function postoperative pain, and serum cytokine level after lobectomy: a comparison of VATS and conventional procedure.Ann Thorac Surg. 2001; 72: 362-365Abstract Full Text Full Text PDF PubMed Scopus (424) Google Scholar, 12Nakata M. Saeki H. Yokoyama N. Kurita A. Takiyama W. Takashima S. Pulmonary function after lobectomy: vidoe-assisted thoracic surgery versus thoracotomy.Ann Thorac Surg. 2000; 70: 938-941Abstract Full Text Full Text PDF PubMed Scopus (158) Google Scholar, 13Yim A.P. Wan S. Lee T.W. Arifi A.A. VATS lobectomy reduces cytokine responses compared with conventional surgery.Ann Thorac Surg. 2000; 70: 243-247Abstract Full Text Full Text PDF PubMed Scopus (292) Google Scholar, 14Kaseda S. Aoki T. Hangai N. Shimizu K. Better pulmonary function and prognosis with video-assisted thoracic surgery than with thoracotomy.Ann Thorac Surg. 2000; 70: 1644-1646Abstract Full Text Full Text PDF PubMed Scopus (280) Google Scholar]. They generally favored VATS approaches, but the selection of controls was problematic. For example, in one study of cytokines before and after operation, the control group comprised patients with T2 tumors and the VATS patients had T1 tumors [10Kawai H. Tayasu Y Saitoh A. et al.Nocturnal hypoxemia after lobectomy for lung cancer.Ann Thorac Surg. 2005; 79: 1162-1166Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar].Case SeriesNumerous case series have been published, many of which have been updated to reflect the ongoing experience of the authors, follow-up of patients, and modifications in technique. A review of the English-language series with more than 100 patients is in Table 3.Table 3Case Series of Major Lung Resections With Video-Assisted Thoracic SurgeryStudyPatients (ITT)TechniqueSurvivalLOS, daysCommentRoviaro [15Roviaro G. Varoli F. Vergani C. Nucca O. Maciocco M. Grignani F. Long-term survival after videothoracoscopic lobectomy for stage I lung cancer.Chest. 2004; 126: 725-732Crossref PubMed Scopus (133) Google Scholar], 2004259 (344)No spreading5 y, 68.9%578 (23%) conversions, 2 deathsIwasaki [16Iwasaki A. Shirakusa T. Shiraishi T. Yamamoto S. Results of video-assisted thoracic surgery for stage I/II non-small cell lung cancer.Eur J Cardiothorac Surg. 2004; 26: 158-164Crossref PubMed Scopus (76) Google Scholar], 2004140No spreading5 y, 77.3%; I, 80.9%; II, 70.3%NR100 lobes, 40 segmentsOhtsuka [17Ohtsuka T. Nomori H. Horio H. Naruke T. Suemasu K. Is major pulmonary resection by video-assisted thoracic surgery an adequate procedure in clinical stage I lung cancer?.Chest. 2004; 125: 1742-1746Crossref PubMed Scopus (74) Google Scholar] 200495 (106)Spreading3 y, 93%7.6Survival in only 82 patients, 1 death, 10% conversionWalker [18Walker W.S. Codispoti M. Soon S.Y. Stamenkovic S. Carnochan F. Pugh G. Long-term outcomes following VATS lobectomy for non-small cell bronchogenic carcinoma.Eur J Cardiothorac Surg. 2003; 23: 397-402Crossref PubMed Scopus (244) Google Scholar], 2003158 (178)No spreading5 y I, 77.9%; II, 51.4%61.8% 30-d mortality, 11% conversionGharagozloo [23Gharagozloo F. Tempesta B. Margolis M. Alexander E.P. Video-assisted thoracic surgery lobectomy for stage I lung cancer.Ann Thorac Surg. 2003; 76: 1009-1015Abstract Full Text Full Text PDF PubMed Scopus (110) Google Scholar], 2003179Simultaneous stapling, no spreading5 y, 83%4.11 deathSolaini [19Solaini L. Prusciano F. Bagioni P. Di Francesco F. Basilio Poddie D. Video-assisted thoracic surgery major pulmonary resections Present experience.Eur J Cardiothorac Surg. 2001; 20: 437-442Crossref PubMed Scopus (71) Google Scholar] 2001112 (125)No spreading3 y, 85%; I, 90%6.2Survival in 86 patients with NSCLC, 10% conversionLewis [22Lewis R.J. Caccavale R.J. Bocage J.P. Widmann M.D. Video-assisted thoracic surgical non-rib spreading simultaneously stapled lobectomy.Chest. 1999; 116: 1119-1124Crossref PubMed Scopus (101) Google Scholar], 1999250Simultaneous stapling, no spreading3 y, 83%2.8About half of patients were stage IIYim [20Yim A.P. Izzat M.B. Liu H.P. Ma C.C. Thoracoscopic major lung resection: an Asian perspective.Semin Thorac Cardiovasc Surg. 1998; 10: 326-331Abstract Full Text PDF PubMed Scopus (69) Google Scholar], 1998214 (266)Spreading2 y, 93%NR1.8% 30-d mortality, 19% conversionMcKenna [21McKenna R. J, Houck W, Fuller CB Video-assisted thoracic surgery lobectomy: experience with 1,100 cases.Ann Thorac Surg. 2006; 81: 421-426Abstract Full Text Full Text PDF PubMed Scopus (840) Google Scholar], 20061100No spreading5 y, I, ∼80%; II, ∼60%3 med 4.78 mean0.8% mortality, 2.5% conversion; port site recurrence, 0.6%Onaitis [26Onaitis M.W. Petersen R.P. Balderson S.S. et al.Thoracoscopic lobectomy is a safe and versatile procedure: experience with 500 consecutive patients.Ann Surg. 2006; 244: 420-425PubMed Google Scholar], 2006500No spreading2 y, 80%31% mortality, 1.6% conversionI = stage I; II = stage II; ITT = intention to treat; LOS = length of stay; NSCLC = non-small cell lung cancer. Open table in a new tab Roviaro and colleagues [1Rovario G.C. Rebuffat C. Varioli F. et al.Videoendoscopic pulmonary lobectomy for cancer.Surg Laparosc Endosc. 1992; 2: 244-247PubMed Google Scholar] from Milan have been publishing their experience with VATS for major lung resections since 1993. Their most recent update looked at their 11-year experience with 344 patients (278 with NSCLC, 6 metastases, 68 benign) that underwent VATS for major resection. Their indications in patients with lung cancer were clinical stage I with peripheral tumors less than 3 cm in diameter [15Roviaro G. Varoli F. Vergani C. Nucca O. Maciocco M. Grignani F. Long-term survival after videothoracoscopic lobectomy for stage I lung cancer.Chest. 2004; 126: 725-732Crossref PubMed Scopus (133) Google Scholar]. Their technique does not use rib-spreading and involves 3 to 4 incisions, with largest being 5 cm for withdrawal of the specimen.Two recent case series have been published from different centers in Japan [16Iwasaki A. Shirakusa T. Shiraishi T. Yamamoto S. Results of video-assisted thoracic surgery for stage I/II non-small cell lung cancer.Eur J Cardiothorac Surg. 2004; 26: 158-164Crossref PubMed Scopus (76) Google Scholar, 17Ohtsuka T. Nomori H. Horio H. Naruke T. Suemasu K. Is major pulmonary resection by video-assisted thoracic surgery an adequate procedure in clinical stage I lung cancer?.Chest. 2004; 125: 1742-1746Crossref PubMed Scopus (74) Google Scholar]. Iwasaki and colleagues [16Iwasaki A. Shirakusa T. Shiraishi T. Yamamoto S. Results of video-assisted thoracic surgery for stage I/II non-small cell lung cancer.Eur J Cardiothorac Surg. 2004; 26: 158-164Crossref PubMed Scopus (76) Google Scholar] published their experience with 140 procedures (100 lobes, 40 segments). Their technique did not involve rib-spreading, and their indications were clinical stage I disease with peripheral tumors sized less than 3 cm. They reported a 5-year survival of 77.3% for the VATS patients, with 80.9% for stage I and 70.3% for stage II tumors.The other Japanese case series involved 106 patients; of whom 95 had a VATS procedure and the other 11 were converted to thoracotomy (10% conversion rate) [17Ohtsuka T. Nomori H. Horio H. Naruke T. Suemasu K. Is major pulmonary resection by video-assisted thoracic surgery an adequate procedure in clinical stage I lung cancer?.Chest. 2004; 125: 1742-1746Crossref PubMed Scopus (74) Google Scholar]. Their main indication was clinical stage I. Tumor size was not a criterion. Their technique involved the use of a minithoracotomy and rib-spreading. They reported a 3-year survival of 93%, but only included the 82 patients for whom they had follow-up data for more than 6 months.Yim and colleagues [20Yim A.P. Izzat M.B. Liu H.P. Ma C.C. Thoracoscopic major lung resection: an Asian perspective.Semin Thorac Cardiovasc Surg. 1998; 10: 326-331Abstract Full Text PDF PubMed Scopus (69) Google Scholar] from Hong Kong published their series of 266 patients with tumors sized less than 5 cm for whom they attempted VATS resections. They converted to thoracotomy 19% of the time and completed 214 VATS major lung resections. A rib-spreader was used. They reported a 22% incidence of nonfatal complications, one postoperative death, and 93% of patients alive at 2 years.In the largest series of VATS major lung resections, McKenna and colleagues [21McKenna R. J, Houck W, Fuller CB Video-assisted thoracic surgery lobectomy: experience with 1,100 cases.Ann Thorac Surg. 2006; 81: 421-426Abstract Full Text Full Text PDF PubMed Scopus (840) Google Scholar] reported their experience of 1100 patients for whom they performed 1072 procedures with a conversion rate of 2.5%. There were no intraoperative deaths, and their mortality rate was only 0.8%. The complication rate was 15.3%, with the most common complications being prolonged air leak and atrial fibrillation. Extrapolation of the Kaplan-Meier survival curves for their study shows 5-year survivals of about 80% for stage I cancer and 60% for stage II cancer. The incidence of port site recurrence was 0.6%.Finally, two independent series using forms of simultaneous stapling have been published [22Lewis R.J. Caccavale R.J. Bocage J.P. Widmann M.D. Video-assisted thoracic surgical non-rib spreading simultaneously stapled lobectomy.Chest. 1999; 116: 1119-1124Crossref PubMed Scopus (101) Google Scholar, 23Gharagozloo F. Tempesta B. Margolis M. Alexander E.P. Video-assisted thoracic surgery lobectomy for stage I lung cancer.Ann Thorac Surg. 2003; 76: 1009-1015Abstract Full Text Full Text PDF PubMed Scopus (110) Google Scholar]. This technique involves no rib-spreading and uses variations on stapling the bronchus and vascular structures together without formal dissection. Lewis and colleagues [22Lewis R.J. Caccavale R.J. Bocage J.P. Widmann M.D. Video-assisted thoracic surgical non-rib spreading simultaneously stapled lobectomy.Chest. 1999; 116: 1119-1124Crossref PubMed Scopus (101) Google Scholar] reported a complication rate of 11.2% and 3-year survival of 83%. Of note, almost half of the patients were stage II. Gharagozloo and colleagues [23Gharagozloo F. Tempesta B. Margolis M. Alexander E.P. Video-assisted thoracic surgery lobectomy for stage I lung cancer.Ann Thorac Surg. 2003; 76: 1009-1015Abstract Full Text Full Text PDF PubMed Scopus (110) Google Scholar] reported 179 patients with a 5-year survival of 83%. They performed 29 right upper and middle bilobectomies (16%) in the series. This high number was performed as a conscious decision after some early recurrences in the N1 nodes between upper and middle lobes.From 2002 to 2007, we have performed approximately 400 VATS lobectomies at our institution without any perioperative deaths, and analyses of the data are ongoing.Robotic LobectomyRobotic surgical technique varies not only by technical details but also by type of robotic equipment used. The most commonly used robotic system is the da Vinci Surgical System, which requires that the surgeon operate on a console separate from the operative field. The surgeon controls 3 arms (2 dissecting arms and a camera port). Other techniques involve voice-controlled robots, such as the Automated Endoscopic System for Optimal Positioning (AESOP) robotic system and Zeus (both from Computer Motion Inc, Goleta, CA), which respond to surgical voice commands to maneuver the camera; the remainder of the procedure is performed using VATS techniques. In contrast to the da Vinci system, AESOP and Zeus require the surgeon be physically present at the operative field.Our experience with robotic lobectomy was published in 2006 [24Park B.J. Flores R.M. Rusch V.W. Robotic assistance for video-assisted thoracic surgical lobectomy: technique and initial results.J Thorac Cardiovasc Surg. 2006; 131: 54-59Abstract Full Text Full Text PDF PubMed Scopus (223) Google Scholar]. The technique, which uses 3 ports, is described in detail using the da Vinci Surgical System. There were a total of 30 robotic-assisted lobectomy cases. All 5 lobes were resected by this technique. There were no perioperative deaths, but median operative time was 218 minutes.We have also used the AESOP system on several occasions. This method differs from our standard VATS technique only by having the robot run the camera instead of an assistant. We consider this technique a VATS lobectomy rather than a robotic lobectomy.Another relatively large series from Italy describes a 4-port technique us" @default.
• W1973900478 created "2016-06-24" @default.
• W1973900478 creator A5012645733 @default.
• W1973900478 creator A5060347349 @default.
• W1973900478 date "2008-02-01" @default.
• W1973900478 modified "2023-10-12" @default.
• W1973900478 title "Video-Assisted Thoracic Surgery Lobectomy (VATS), Open Thoracotomy, and the Robot for Lung Cancer" @default.
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