Video-Assisted Thoracoscopic Surgery (VATS)
The standard open surgical approaches to the thoracic spine usually involve creating a large opening in the chest wall. Video assisted thoracic surgery (VATS), is a minimally invasive (keyhole) surgical procedure. It allows the surgeon to directly examine the chest cavity without a big incision. Three or four small incisions will be made to allow the surgeon to use the special instruments (video camera and endoscope) needed for this operation. A very small video camera is used to project pictures of the chest cavity onto a screen during the procedure.
VATS avoids the extensive damage to the chest wall. Specific tools and implant systems permit the spine surgeon to remove thoracic discs. This procedure is also used to biopsy vertebral masses/tumors, release scoliosis curves, and graft bone disc spaces.
When surgeons at Cedars-Sinai Medical Center developed the VATS lobectomy procedure in 1992, the hope was that minimally invasive surgery, when compared to invasive traditional surgery, offered patients a shorter hospital stay, less risk, and quicker recovery, without compromising the completeness of the cancer operation.
In 2006, Dr. Robert McKenna, pioneer of the VATS procedure, published a retrospective review of 1100 consecutive patients who underwent a standard VATS lobectomy (removal of a lobe of the lung) with lymph node dissection for lung cancer. The research showed that VATS lobectomy for bronchogenic carcinoma appears to be safe and provides the same survival rates as expected for lobectomy done by the traditional invasive thoracotomy incision (opening up the chest) that most other surgeons use for surgery. The population studied included 595 (54.1%) women and 505 men (45.9%), with mean age of 71.2 years (range 39-85 years).
The VATS operations were the standard cancer operations that are usually performed by thoracotomy (a large, invasive incision). This was not a compromise operation for patients with poor performance status. The procedure was performed through a <2 inch incision without spreading the ribs and 2 or 3 other small incisions.
There were 9 deaths (0.8%)- none were intra-operative or due to bleeding. 932 patients had no postoperative complications (84.7%). Blood transfusion was required in 45 of the 1100 patients (4.1%). Length of hospital stay was median of 3 days, mean of 4.78 days. One hundred and eighty (180) patients were discharged on post-operative day (POD) 1 or 2 (20%). Conversion to a thoracotomy occurred in 28 patients (2.5%). In 2005, 94% of 224 lobectomies were performed with VATS.
Cedars-Sinai Medical Center is the leader in minimally invasive surgery of the lung. The series of 1100 VATS lobectomies is the largest series in the world. In the United States, few centers even perform the procedure. About five percent of the lobectomies in the United States are performed by VATS. In contrast, 94 percent of lobectomies at Cedars-Sinai were performed by VATS in 1995. Frequently, thoracic surgeons from around the country and around the world visit Cedars-Sinai Medical Center to learn how to perform VATS lobectomy.
Why don't more centers perform VATS lobectomy?
The operative skills are not taught in training programs because few surgeons performs the procedure. Not all surgeons have the video skills to perform the procedure. There is a significant learning curve to become comfortable with advanced minimally invasive operations, such as VATS lobectomy.
What about robotic surgery?
Robotic surgery is performed at Cedars-Sinai Medical Center, and it has been shown to be beneficial for certain procedures, such as heart surgery and prostate surgery. The current technology for robotic surgery is cumbersome and not beneficial for lung surgery.
Lobectomy via VATS is controversial because: (1) the adequacy of the cancer operation via VATS has been questioned; (2) no study to date has conclusively demonstrated a benefit from the procedure compared to lobectomy via thoracotomy; and (3) tumor seeding of VATS incisions (spreading of cancer cells on the skin) has been reported. Our series shows that these concerns are not warranted.
Multiple papers in the medical literature now show that minimally invasive surgery has advantages over traditional invasive approaches. Giudicelli analyzed the postoperative courses in 67 patients following a lobectomy by VATS (44 patients) or by muscle-sparing thoracotomies (23 patients). The postoperative pain was significantly less (<0.02) after a VATS procedure. The pain-related morbidity, the mean duration of air leaks, the chest tube duration and the hospital stay were all less after the VATS procedure, compared to the open procedure (thoracotomy). The overall patient deaths and the pulmonary impairment were the same for both procedures.
Thomas J. Kirby reported on 55 lobectomies, 30 of which were done by thoracotomy and 25 of which were by VATS. The length of hospital stay (8.3 versus 7.1 days) and the time the chest tubes stayed in the patients (6.5 versus 4.5 days) favored the VATS approach, but also did not reach statistical significance. Most operative complications occurred in the thoracotomy group compared to the VATS group (p<0.05). Kirby cautioned, "In the final analysis, the potential short-term benefits or the surgeon's ability to perform a VATS procedure is of little value to the patients if the goal of long-term cure is compromised."
In a randomized trial from Germany, there were fewer complications after the VATS approach (14.2% versus 50%). Cost, as measured by anesthesia charges, lab charges and hospital charges, were less with the VATS approach. In a non-randomized comparison of VATS and thoracotomy for lobectomy, Sugiura found no difference in the morbisity and mortality.
In 2004-5, the average hospital stay for VATS lobectomy was less than 3 days. No series of lobectomy by thoracotomy to date has demonstrated a length of stay.
The demographics in this series reflect the current trends in lung cancer. Adenocarcinoma is the most common type of lung cancer. This series included more women than men, which is consistent with the sex ratio of patients undergoing lobectomy by thoracotomy in our practice. This reflects the increasing incidence of lung cancer in women.
A cautious approach to lobectomy by VATS is recommended. VATS lobectomy is not appropriate for all lobectomies or all surgeons. It requires excellent video skills and knowledge of thoracic anatomy. The procedure should be performed only in appropriately selected patients by surgeons with the VATS skills that allow them to perform a complete cancer operation, not a compromise operation, with minimal morbidity and mortality. Care should be taken to reduce the risk of local recurrence by placing the specimen in a bag. Because there is a risk of bleeding, the surgeon must be prepared for the possibility that a thoracotomy might have to be performed.
In conclusion, this multi-institutional series demonstrates that VATS lobectomy for lung cancer can be performed safely with minimal morbidity, survival comparable to that of lobectomy by thoracotomy and, perhaps, a shorter length of stay in the hospital than when a patient undergoes a thoracotomy. VATS lobectomy is a reasonable treatment option for selected patients with Stage I lung cancer when surgeons with the skills to perform a complete cancer operation using VATS perform it.
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