Stafford S. Balderson

Thoracoscopic Lobectomy Is a Safe and Versatile Procedure: Experience With 500 Consecutive Patients

Objective:Advantages of thoracoscopic lobectomy for early stage non-small cell lung cancer (NSCLC), as compared with lobectomy by conventional thoracotomy, include less postoperative pain and shorter length of hospitalization. The outcomes after thoracoscopic lobectomy in patients with more complex pulmonary conditions are analyzed to determine safety, efficacy, and versatility. Methods:A prospective database of 500 consecutive patients who underwent thoracoscopic lobectomy between June 1999 and January 2006 was queried. Demographic, histopathologic, perioperative, and outcome variables were assessed using standard descriptive statistics and Kaplan-Meier survival analyses. Results:Thoracoscopic lobectomy was successfully performed in 492 patients (conversion rate, 1.6%). Pathologic analysis included primary NSCLC in 416 patients (83.2%), centrally located secondary pulmonary malignancy in 37 patients (7.4%), and a variety of benign conditions in 45 patients (9%). Among the 416 patients with NSCLC, pathologic analysis demonstrated stage I in 330 patients (55.3%), stage II in 40 patients (9.6%), and stage III or greater NSCLC in 44 patients (10.6%). The operative and perioperative (30-day) mortality was 0% and 1%, respectively. The overall 2-year survival rate for the entire cohort was 80%, and the 2-year overall survival rates for stage I NSCLC, stage II or greater NSCLC, secondary pulmonary malignancy, and granulomatous disease patients were 85%, 77%, 73%, and 89%, respectively. Conclusions:Thoracoscopic lobectomy is applicable to a spectrum of malignant and benign pulmonary disease and is associated with a low perioperative morbidity and mortality rate. Survival rates are comparable to those for lobectomy with thoracotomy.

Thoracoscopic lobectomy: a safe and effective strategy for patients with stage i lung cancer

BACKGROUND Thoracoscopic lobectomy is emerging as a potential alternative to thoracotomy for early stage lung cancer. The issues of safety and oncologic efficacy should be analyzed before recommending this procedure for widespread use. METHODS Thoracoscopic lobectomy was attempted in 110 consecutive patients (age, 35 to 81 years) with tumors that were judged to be amenable to lobectomy over a 26-month period. Exclusion criteria included tumors greater than 5 cm in diameter, T3 tumors, endobronchial tumors visible at bronchoscopy, the use of induction therapy, extensive N1 disease on computed tomographic scan, and N2 disease at mediastinoscopy. The procedures were performed without rib spreading using two ports and included anatomic hilar dissection and individual vessel stapling. RESULTS Thoracoscopic lobectomy and mediastinal lymph dissection was successfully performed in 108 patients (98.2%); 2 patients required conversion to thoracotomy to control bleeding in the setting of dense hilar adenopathy. There were no intraoperative deaths and 4 perioperative deaths (3.6%) caused by pneumonia and associated adult respiratory distress syndrome (3 patients) and stroke (1 patient). Major complications included pneumonia (5 patients), stroke (1 patient), and return to the operating room to revise the bronchial closure (1 patient). Minor complications included prolonged air leak (6 patients), atrial fibrillation (4 patients), blood transfusion (2 patients) and ileus (1 patient). Median time to chest tube removal was 3 days, and median length of stay was 3 days. CONCLUSIONS Thoracoscopic lobectomy is a safe and effective strategy for patients with early stage lung cancer. Long-term follow-up is required to determine if recurrence rate and 5-year survival are comparable with thoracotomy for lobectomy.

An Inexpensive, Reproducible Tissue Simulator for Teaching Thoracoscopic Lobectomy

PURPOSE Simulation is rapidly becoming an integral part of surgical education at all levels including the education of practicing surgeons in new techniques such as thoracoscopic lobectomy. Current thoracoscopic lobectomy simulator models have significant limitations including expense and requirement for specialized facilities. This study describes a novel low-cost, easily reproducible, bench top simulator. DESCRIPTION Tissue blocks consisting of a porcine heart and bilateral lungs with intact pericardium were secured from a commercially available source. The pulmonary artery and veins were statically distended with ketchup to more realistically mimic the technique of dissection and allow for simultaneous identification of technical errors. EVALUATION This simulator has been used at seven different industry and society sponsored thoracoscopic lobectomy training programs by more than 100 participants. Qualitative data on the performance of the model was collected from faculty and course participants. CONCLUSIONS A low-cost porcine heart-lung block statically perfused with ketchup provides an inexpensive, easily reproducible model for teaching thoracoscopic lobectomy, which reasonably and accurately simulates a clinical experience.

Feasibility of hybrid thoracoscopic lobectomy and en-bloc chest wall resection

OBJECTIVES Lobectomy with an en-bloc chest wall resection is an effective but potentially morbid treatment of lung cancer invading the chest wall. Minimally invasive approaches to lobectomy have reduced morbidity compared with thoracotomy for early stage lung cancer, but there is insufficient evidence regarding the feasibility of hybrid thoracoscopic lobectomy chest wall resection. We reviewed our experience with an en-bloc chest wall resection and lobectomy to evaluate the outcomes of a hybrid approach using thoracoscopic lobectomy combined with the chest wall resection where rib spreading is avoided. METHODS All patients who underwent lobectomy and en-bloc chest wall resection with ribs for primary non-small cell lung cancer from January 2000 to July 2010 were reviewed. Starting in April 2003, a hybrid approach was introduced where thoracoscopic techniques were utilized to accomplish the pulmonary resection and a limited counter incision was used to perform the en-bloc resection of the chest wall, avoiding scapular mobilization and rib spreading. Preoperative, perioperative and outcome variables were assessed using the standard descriptive statistics. RESULTS During the study period, 105 patients underwent en-bloc lobectomy and chest wall resection, including 93 patients with resection via thoracotomy and 12 patients with resection via the hybrid thoracoscopic approach. Complete resection was achieved in all patients in both groups. Tumour size and the extent of resection were similar in the two groups. There were no conversions and no perioperative mortality in the hybrid group. Post-operative outcomes were similar, although patients who underwent the hybrid approach had a shorter length of stay (P = 0.03). CONCLUSIONS A hybrid approach that combines thoracoscopic lobectomy and chest wall resection is feasible and effective in selected patients. The use of a limited counter incision without rib spreading does not compromise oncologic efficacy. Further experience is needed to determine if this approach provides any advantage in outcomes, including post-operative morbidity.

Validation of a thoracoscopic lobectomy simulator

OBJECTIVES Although simulation is considered integral to general surgery training, its role has only recently been recognized in thoracic surgical education, perhaps due to a lack of widely available, validated simulators for advanced thoracic procedures. This study evaluates the construct, content and face validity of an inexpensive, easily reproducible simulator for teaching thoracoscopic lobectomy. METHODS Construct validity (ability of the simulator to discriminate between users of different skill levels) was assessed by having surgical trainees perform a lobectomy on the simulator. Participants were divided into three groups (experienced, intermediate and novice) based on self-reported experience with minimally invasive surgery. After instruction and practice time to limit the effect of any simulator-specific learning curve, each performed a left upper lobectomy that was scored using a standardized assessment tool incorporating total time plus weighted penalty minutes assigned for errors. Content validity (simulator requires same steps and decision-making as a clinical lobectomy) was assessed using a Likert scale by those participants who had previously seen a thoracoscopic lobectomy in a patient. RESULTS Thirty-one residents participated in the study (12 experienced, 6 intermediate and 13 novice). All 12 experienced participants completed the lobectomy. The other groups were less successful with 4 of 6 in the intermediate group and 5 of 13 in the novice group completing the lobectomy (P = 0.004). The mean times for lobectomy + penalty minutes were 35 + 6.8 (experienced), 50 + 13 (intermediate) and 54 + 20 (novice). Differences between groups were statistically significant for experienced vs. novice (P < 0.001) and experienced vs. intermediate (P < 0.04). Content validity was assessed by the 18 participants who had previously seen a thoracoscopic lobectomy with a mean of 9.2 of 10 possible points. CONCLUSIONS The thoracoscopic lobectomy simulator used in this study demonstrates acceptable validity and can be a useful tool for teaching thoracoscopic lobectomy to trainees or experienced surgeons.

Modified Uniportal Video-Assisted Thoracoscopic Lobectomy: Duke Approach

Traditional thoracoscopic strategies using two to four ports has been demonstrated to be oncologically successful for patients with resectable lung cancer, with numerous advantageous over thoracotomy. A single-incision approach has been described, but it is associated with potential disadvantages. The modified uniportal approach described may address those disadvantageous, with retention of the potential advantages of using a single incision.

Needs Assessment for an Errors-Based Curriculum on Thoracoscopic Lobectomy

BACKGROUND Research suggests a benefit from a skills curriculum emphasizing error prevention, identification, and management. Our purpose was to identify common errors committed by trainees during simulated thoracoscopic lobectomy for use in developing an error-based curriculum. METHODS Twenty-one residents (postgraduate years 1 to 8) performed a thoracoscopic left upper lobectomy on a previously validated simulator. Videos of the procedure were reviewed in a blinded fashion using a checklist listing 66 possible cognitive and technical errors. RESULTS Of the 21 residents, 15 (71%) self-reported completing the anatomic lobectomy; however, only 7 (33%) had actually divided all of the necessary structures correctly. While dissecting the superior pulmonary vein, 16 residents (76%) made at least one error. The most common (n=13, 62%) was dissecting individual branches rather than the entire vein. On the bronchus, 14 (67%) made at least one error. Again, the most common (n=9, 43%) was dissecting branches. During these tasks, cognitive errors were more common than technical errors. While dissecting arterial branches, 18 residents (86%) made at least one error. Technical and cognitive errors occurred with equal frequency during arterial dissection. The most common arterial error was excess tension on the vessel (n=10, 48%). CONCLUSIONS Curriculum developers should identify skill-specific technical and judgment errors to verify the scope of errors typically committed. For a thoracoscopic lobectomy curriculum, emphasis should be placed on correct identification of anatomic landmarks during dissection of the vein and airway and on proper tissue handling technique during arterial dissection.

Challenging cases: thoracoscopic lobectomy with chest wall resection and sleeve lobectomy—Duke experience

Video-assisted thoracoscopic surgery (VATS) had recent advances in both equipment and technique so has been applied to more complex conditions in some thoracic surgery centers. We have adopted our VATS lobectomy experience for patients with chest wall invasion and endobronchial localized tumor requiring bronchial sleeve resection. We are describing our decision-making and surgical methods for these patients which we believe will be decreasing the number of contraindications for VATS and offering this surgical method for more patients.

Modified uniportal video-assisted thoracoscopic surgery (VATS).

Video-assisted thoracoscopic surgery (VATS) for resectable lung cancer patients has been frequently used in the past decades. The potential beneficial advantages and safety of VATS has been shown in large patient series and meta-analyses. The strategy of limiting access to one incision in one intercostal space (uniportal VATS) has been adopted by some thoracic surgeons in recent years. We have described a modified uniportal VATS technique with its potential advantages. Modified uniportal VATS potentially offers better exposure, beneficial opportunities for education and improved comfort for the thoracic surgery team in clinical usage.

Video assisted transaxillary first rib resection in treatment of thoracic outlet syndrome (TOS)

A 24-year-old woman presented with a history of swelling and heaviness in her right upper extremity following swimming or any prolonged physical activity involving overhead arm abduction. She noted occasional numbness and paresthesia. Electromyography (EMG) and nerve conduction velocity (NCV) results were normal. Venogram demonstrated high-grade narrowing of the subclavian vein at the thoracic outlet with provocative maneuvers (hyperabduction and rotation) of right upper extremity. She was referred for surgical treatment of thoracic outlet syndrome (TOS).