Evolution of video-assisted thoracic surgery (VATS) techniques for Lung cancer; Minimizing surgical injury and Expanding applications

Keywords

non-small cell lung cancer;surgery;VATS

Minimizing surgical wound is major contribution of VATS. Reduced surgical injury could induce lesser surgical pain thereby preventing catastrophic postoperative cytokine cascade, consequentially enhance functional recovery.¹ The less invasiveness is likely to be the reason that VATS approaches have been expanding their territories continuously, and various novel techniques such as single port VATS or subxiphoid approaches have been developed.²

The three-port two instrument (TPTI) technique introduced in the attractive article by Cheng et al³ is part of efforts to improve the standard VATS approaches. The author had reported successful 60 cases of complete VATS lobectomy using three 1.2 cm ports. It was interesting that this technique could be applied for all stages of lung cancers accompanied by sufficient lymph node dissection, and the learning curve was shorter than standard VATS lobectomy techniques. The article reported that there had been no need to expand the port wound to extract resected specimen. The author insisted that he could remove 5 cm sized tumor with at least 1 cm of safety margin without destruction. This was surely feasible and may have advantages for cosmetic concern and reduction of pain.

However, the TPTI technique did not seemed to be attempted to complex VATS surgery like bronchoscopy or pneumonectomy, and the resected lung inevitably cut into several strip using surgical endo-staplers. Although the cutting of resected lung in thoracic cavity might be possible technically, it could increase medical expenses and the oncologic safety has not been demonstrated.

We had applied standard VATS approaches of two thoracoscopic port incision and one accessory 4 cm sized incision into advanced lung cancer which needed bronchoplasty or pneumonectomy. Between March 2012 and November 2014, we had experienced 12 cases of complex VATS surgery by a single experienced surgeon (K. Kim), consisting of 2 cases of simple and 3 cases of wedge bronchoplasty, 7 cases of pneumonectomy including 4 cases of completion pneumonectomy. One patient was suffered from postoperative bronchopleural fistula which could be repaired using VATS technique. No conversion and no postoperative mortality was observed. Unlikely the TPTI technique, we used 4 cm sized working port, instead, the resected lung could be preserved in all cases. Perioperative outcomes were described in Table 1.

Table 1. Perioperative outcomes of 12 patients. The longest operative time took more than 10 hours and the most extensive blood loss was 1200 ml. There records were the patient who had underwent intrapericardial completion pneumonectomy by VATS. The patient needed only one day of ICU care, no transfusion, and could be discharged postoperative 8 day.

Variables	Mean ± SD	Min	Max
Tumor size (mm)	40.8 ± 17.06	20	75
Operation time (min)	212.5 ± 102.86	80	475
Anesthesia time (min)	265.8 ± 102.80	125	250
Blood loss during operation (ml)	341.7 ± 347.61	0	1200
Duration of ICU care (day)	0.67 ± 12.68	0	1
Hospital stay (day)	10.5 ± 12.68	2	49
Duration of chest tube (day)	1.1 ± 1.24	0	3

Which technique is better than others, standard VATS, TPTI, single port or robot? This seemed stupid question. Surgeon can choose the appropriate technique suitable for their patients considering their diverse medical environment. Although there still has no demonstrated evidence for oncologic comparability, VATS could be beneficial because they provide lesser surgical trauma, less impairment of immune response, thereby improved response to the chemotherapy and postoperative recovery.⁴ The endeavor to reduce surgical wound may lead to expanding the treatment role of minimally invasive surgical techniques.

The authors responses to the comments

Thank you for Dr. Kims comments and also for Editors' kindness to have me the responses. I sincerely make a commentary one by one in the following paragraphs, and also make some comments.

• Dr. Kim described I had successful 60 cases of complete VATS lobectomy using three 1.2cm ports with sufficient lymph node dissection in all stages lung cancers, and he had some doubts about the learning curve was shorter than standard VATS lobectomy techniques. As I mentioned in the methods section in the article,¹ the cases of bulky N2 disease were not included for surgery. And in the discussion section, I supposed that the VATS lobectomy is the precursor to the TPTI technique. All surgical procedures in this study were performed by the author (Y.-J.C.), who has experienced VATS lobectomy more than 300 cases since 2009. That is the reason why the TPTI learning curve was shorter than the other physicians' performances.
• Dr. Kim described the TPTI technique did not seemed to be attempted to complex VATS surgery like bronchoscopy or pneumonectomy, and the resected lung inevitably cut into several strip using surgical endo-staplers, with doubts of the oncologic safety and increase of the medical expenses. As I mentioned in the conclusion section in the article¹, the results of this study only demonstrate that TPTI thoracoscopic lobectomy without extending the port wound to remove the specimens is feasible. I did not emphasize this is a more complex procedure. The resected lobe is cut into several strips using endo-staplers, with a cutting margin of at least 1 cm. I agree that this increase medical expenses with more endo-staplers used. The safety of cutting margin of at least 1 cm has been demonstrated in Dr. Roviaro article,² and there is no port site recurrence in all our cases.
• Dr. Kim have the conclusion that Surgeon can choose the appropriate technique suitable for their patients considering their diverse medical environment. There is no one operation better than others - standard VATS, TPTI, single port or robot.
• Recently I have developed a more advanced technique (mini-TPTI) from TPTI, which is a complete thoracoscopic approach accomplished via mini-ports using three-ports (0.5mm, 0.5mm, 1.2 mm) two-instrument technique for fast recovery of lung cancer lobectomy. I submit to Asian Journal of Surgery. Hopefully it can be accepted and presented to Dr. Kim for more discussion.

Abbreviation explanation:

• Standard VATS lobectomy: Video-assisted thoracoscopic (VATS) lobectomy with several port-wounds and one accessory incision
• TPTI technique: The TPTI technique is defined as a lobectomy performed during a complete thoracoscopic procedure. There are only three ports in three separate wounds of 1.2 cm without accessory thoracotomy wound
• Single port: Video-assisted thoracoscopic (VATS) lobectomy with only one operation wound
• Robot: da Vinci^® Surgery: Minimally Invasive Surgery

Disclosure of conflicts of interest

There are no potential financial and non-financial conflicts of interest.

References

1. 1 Y.J. Cheng; The learning curve of the three-port two-instrument complete thoracoscopic lobectomy for lung cancer-A feasible technique worthy of popularization; Asian J Surg, 38 (2015), pp. 150–154
2. 2 G. Roviaro, F. Varoli, C. Rebuffat, et al.; Videothoracoscopic staging and treatment of lung cancer; Ann Thorac Surg, 59 (1995), pp. 971–974

Acknowledgment

The authors declare no competing financial interest or funding of sources.

References

1. 1 S. Jheon, H.C. Yang, S. Cho; Video-assisted thoracic surgery for lung cancer; Gen Thorac Cardiovasc Surg, 60 (2012), pp. 255–260
2. 2 M.A. Gaudet, T.A. D'Amico; Thoracoscopic lobectomy for non-small cell lung cancer; Surg Oncol Clin N Am, 25 (2016), pp. 503–513
3. 3 Y.J. Cheng; The learning curve of the three-port two-instrument complete thoracoscopic lobectomy for lung cancer-A feasible technique worthy of popularization; Asian J Surg, 38 (2015), pp. 150–154
4. 4 B.A. Whitson, J. D'Cunha, R.S. Andrade, et al.; Thoracoscopic versus thoracotomy approaches to lobectomy: differential impairment of cellular immunity; Ann Thorac Surg, 86 (2008), pp. 1735–1744