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ORIGINAL ARTICLE
Year : 2014  |  Volume : 51  |  Issue : 6  |  Page : 18-20
 

Two-incision approach for video-assisted thoracoscopic sleeve lobectomy treating the central lung cancer


Department of Thoracic Surgery, The Affiliated Hospital of Qingdao University, Qingdao 266003, China

Date of Web Publication24-Feb-2015

Correspondence Address:
W Jiao
Department of Thoracic Surgery, The Affiliated Hospital of Qingdao University, Qingdao 266003
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-509X.152001

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 » Abstract 

Background: We review our experiences with video-assisted thoracoscopic surgery (VATS) sleeve lobectomy with bronchoplasty for nonsmall-cell lung cancer, using only two incisions. The aim of this study was to evaluate the technical feasibility and safety of surgical approach. Materials and Methods: From January 2013 to January 2014, we completed 15 cases of VATS sleeve lobectomy with bronchoplasty in our hospital. The patients underwent sleeve lobectomy with bronchoplasty at the following locations: right upper lobe (n = 4), right lower and middle lobes (n = 1), left lower lobe (n = 5), and left upper lobe (n = 6). The operation consisted of VATS anatomic sleeve lobectomy with bronchoplasty combined with systematic lymph node dissection, using only two incisions. Results: The patients underwent sleeve lobectomy with bronchoplasty were no postoperative complications. Median operative time was 183 min; median bronchial anastomosis time was 39 min; median blood loss was 170 ml. Pathological examination showed 12 squamous cell carcinomas and 3 adenocarcinoma. Median postoperative chest tube drainage duration was 4.5 days, and median hospital stay was 6.9 days. Conclusions: Video-assisted thoracoscopic surgery sleeve lobectomy with bronchoplasty is a feasible and safe surgical approach, using only two incisions. This way of operation can promote the development of surgical technology.


Keywords: Incision, lung cancer, lobectomy, thoracoscopic


How to cite this article:
Wang X, Jiao W, Zhao Y, Xuan Y, Wang Z. Two-incision approach for video-assisted thoracoscopic sleeve lobectomy treating the central lung cancer. Indian J Cancer 2014;51, Suppl S2:18-20

How to cite this URL:
Wang X, Jiao W, Zhao Y, Xuan Y, Wang Z. Two-incision approach for video-assisted thoracoscopic sleeve lobectomy treating the central lung cancer. Indian J Cancer [serial online] 2014 [cited 2021 Nov 30];51, Suppl S2:18-20. Available from: https://www.indianjcancer.com/text.asp?2014/51/6/18/152001



 » Introduction Top


Lung cancer, mostly non-small cell type, is the most frequent type of cancer worldwide. [1],[2],[3] Undoubtedly, surgical resection remains the most effective therapeutic method for the NSCLC patients. The sleeve lobectomy was considered as an alternative procedure to pneumonectomy for patients with centrally located lesions and limited cardiopulmonary reserve [4] . Bronchial sleeve lobectomy is performed to anastomose and reconstruct the lobar bron-chus and main bronchus. First case reports describing video-assisted thoracoscopic sleeve lobectomy was published in 2002, [5] and 12 years later, a series of sleeve lobectomies using 3 incisions or 4 incisions was reported by Mahtabifard and colleagues. [6],[ 7] Although the video-assisted thoracoscopic Sleeve lobectomy approach was reported by colleagues, the bronchoplasty procedures is not standardized. The technical feasibility of these procedures should be investigated, so the purpose of this article is to summarize our experiences VATS sleeve lobectomy with bronchoplasty for the central lung cancer, using only two incisions.


 » Materials and Methods Top


Patients

From January 2013 to January 2014, we completed 16 cases of VATS sleeve lobectomy with bronchoplasty at the Department of Thoracic surgery in the Medical College Affiliated Hospital of Qingdao University.

The age of patients (14males and 2 females) ranged from 39 to 70 years, and the mean age was 55 years. The patients underwent sleeve lobectomy with bronchoplasty at the following locations: right upper lobe (n = 4), right lower and middle lobes (n = 1), left lower lobe (n = 5), and left upper lobe (n = 6). The operation consisted of VATS anatomic sleeve lobectomy with bronchoplasty combined with systematic lymph node dissection (including at least three groups of mediastinal regional lymph nodes). The article descript that follows is for left upper lobe sleeve lobectomy with bronchoplasty only, using only two incisions. Preoperative enhanced chest computed tomography (CT) was used to confirm a localized tumor [Figure 1].
Figure 1: Preoperative enhanced chest computed tomography (CT) scan. (a) Chest CT reconstruction shows bronchus of left upper lobe was blocked (white arrow). (b) The lung window shows the tumor located around the bronchus of the left upper lobe. (c) The mediastinal window shows tumor located around bronchus of the left upper lobe

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Operative technique

Incision and suture selection


The patient was placed in the lateral decubitus position. All procedures were carried out under general anesthesia with double-lumen endotracheal intubation. We carry out 2 incisions, one of 3-4 cm in the 4th intercostal space on the anterior axillary line without rib spreading, and another of 1 cm in the 7th intercostal space, median axillary line [Figure 2]. Although many authors report they used absorbable suture in the process of anastomosis, we prefer to use the 3-0 prolene suture. [8]
Figure 2: Schematic diagram for locate the two incisions. The 1 cm thoracoscopic observation incision was made in the 7th intercostal space on the median axillary line. The 3-4 cm operating point was made in the 4th intercostal space on the anterior axillary line

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Bronchoplasty procedures

After the inferior pulmonary ligament had been incised, the mediastinal pleura around the perihilar area were divided, after which the bronchial artery was transected. Firstly, the left superior pulmonary vein and the pulmonary artery were dissected, and then be transected by the endoscopic linear stapler. Secondly, artery for apical segment/lingular segment was dissected. Then we use surgical scissors to cut off the left main bronchus and lower lobe bronchus. This dissection must promote adequate mobility of the bronchus and make extensive dissection of the main bronchus. The bronchus must be cut circumferentially proximally and distally to the tumor. The fissures are completely transected by the endoscopic linear stapler. Finally, the left upper lobe specimen was removed by 8 gloves. Stations 4, 5, 6, 7, 9, 10 and 11 lymph nodes were dissected. Left bronchial anastomosis was then performed.

We use the 3-0 prolene suture in the process of bronchial anastomosis. We chose the deepest posterior wall of bronchus as the starting point in a simple continuous fashion. Once the starting point is located, a U-shape suturing technique is recommended to enhance the tensile strength [Figure 3]a. From this suture to the direction of the bronchial membrane, the bronchial membrane and part of the anterior wall were brought together in a simple continuous pattern by the continuous suturing clockwise. The suture line was continued to the bronchial anterior wall of the midpoint and then pulled out via the posterior port without forming a knot. The remaining part of the bronchus was sutured from the starting point to the mid-point of the anterior wall of the bronchus in a simple continuous pattern by the continuous suturing counter clockwise [Figure 3]b. A knot was formed when the continuous suturing is finished. [Figure 3]c This anastomosis method can secure the tensile strength as well as saving the operation time. In addition, this method makes it is not easy to bronchial stenosis. We divided the anterior mediastinum fat flap, which be used to covered the anastomotic stoma [Figure 3]d. In the whole process of anastomosis, we insist on no clamping of bronchus. We think that this method can also improve the anastomotic stoma blood supply. Leak testing was conducted following the anastomosis, in which no leakage was detected up to an airway pressure of 30 cm H2O.
Figure 3: Schematic diagram for sleeve bronchoplasty: (a) A U-shape suturing technique is recommended to enhance the tensile strength. (b) Simple continuous suturing with 3-0 prolene suture material was used for anastomosis of the bronchus. In the whole process of anastomosis, we insist on no clamping of bronchus. (c) A knot was formed when the continuous suturing is finished. (d) The anterior mediastinum fat flap was used to covered the anastomotic stoma

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 » Results Top


Totally, 16 patients underwent sleeve lobectomy with bronchoplasty were no postoperative complications. Median operative time was 183 min; median bronchial anastomosis time was 39 min; median blood loss was 170 ml. Median postoperative chest tube drainage duration was 4.5 days, and median postoperative hospital stay was 6.9 days. Postoperative pathological examination indicated 11 cases of squamous cell carcinoma and 4 case of adenocarcinoma. Totally, 12 patients were at stage IIA-B, 4 patients were at stage IIIA-B [Table 1].
Table 1: The characteristics and treatment-related data of patients who underwent sleeve lobectomy with bronchoplasty, using only two incisions

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 » Discussion Top


Non-small-cell lung cancer (NSCLC) confined to the lung is generally treated by surgical resection. The extent of resection is dictated by the location of the central NSCLC and the patient's physiological ability to withstand resection. The sleeve lobectomy was considered as an alternative procedure to pneumonectomy for patients with centrally located lesions and limited cardiopulmonary reserve, the bronchoplasty procedures is not standardized. First case reports describing video-assisted thoracoscopic sleeve lobectomy were published in 2002, and 12 years later, a series of sleeve lobectomies using 3 incisions or 4 incisions was reported by Mahtabifard and colleagues. [9],[10] Our article described a successful application of this technique, using only two incisions.

Sleeve lobectomy is a complicated procedure with a greater level of complexity than a pneumonectomy. The key to successful sleeve lobectomy is skill proficiency in anastomotic suture. The suturing technique of VATS bronchoplasties is even more complex, because it generally more technically challenging for the transmission from direct-view to locally 2D screen and be affected by the number of incisions and their location. [11] Most articles report using simple interrupted sutures or Interrupted suture combined with continuous suture, [6],[12] but we use a simple continuous sutures. Although the continuous suturing was reported that it may lead to anastomotic leak or anastomotic dehiscence, [6],[13],[14] our experiences have shown that the continuous suturing can avoid intertwined sutures and shorten the anastomosis time. This suture method conforms to our mode of operation, using only two incisions.

It is worthwhile to note that our operation method has three features: 1. using only two incisions; 2. the anterior mediastinum fat flap was used to cover the anastomotic stoma; 3. no clamping of bronchus. Postoperative recovery was satisfactory. All patients underwent sleeve lobectomy with bronchoplasty were no postoperative complications. Median postoperative chest tube drainage duration was 4.5 days, and median postoperative hospital stay was 6.9 days. In the whole process of anastomosis, we insist on no clamping of bronchus, which can avoid bronchial injury. In addition, we divided the anterior mediastinum fat flap, which be used to covered the anastomotic stoma. We think our operation method can improve the anastomotic stoma blood supply and reduce the occurrence of postoperative complications.


 » Conclusion Top


Sleeve lobectomy is a valid alternative to pneumonectomy for the treatment of centrally located operable non-small cell lung cancer. Our results demonstrate that our operation method is a feasible and safe surgical approach, using only two incisions. The anastomotic stoma be covered by the anterior mediastinum fat flap and no clamping of bronchus can improve the anastomotic stoma blood supply. With these refinements, our operation method can be successfully performed. This way of operation can promote the development of surgical technology.

 
 » References Top

1.
Jemal, A., T. Murray, A. Samuels, et al., Cancer statistics, 2003. CA Cancer J Clin, 2003. 53: p. 5-26.  Back to cited text no. 1
    
2.
Ikeda, N., J. Usuda, H. Kato, et al., New aspects of photodynamic therapy for central type early stage lung cancer. Lasers Surg Med, 2011. 43: p. 749-54.  Back to cited text no. 2
    
3.
Grinberg-Rashi, H., E. Ofek, M. Perelman, et al., The expression of three genes in primary non-small cell lung cancer is associated with metastatic spread to the brain. Clin Cancer Res, 2009. 15: p. 1755-61.  Back to cited text no. 3
    
4.
Ma, Z., A. Dong, J. Fan, et al., Does sleeve lobectomy concomitant with or without pulmonary artery reconstruction (double sleeve) have favorable results for non-small cell lung cancer compared with pneumonectomy? A meta-analysis. Eur J Cardiothorac Surg, 2007. 32: p. 20-8.  Back to cited text no. 4
    
5.
Mahtabifard, A., C.B. Fuller, and R.J. McKenna, Jr., Video-assisted thoracic surgery sleeve lobectomy: A case series. Ann Thorac Surg, 2008. 85: p. S729-32.  Back to cited text no. 5
    
6.
Li, Y. and J. Wang, Video-assisted thoracoscopic surgery sleeve lobectomy with bronchoplasty. World J Surg, 2013. 37: p. 1661-5.  Back to cited text no. 6
    
7.
Han, Y., D.P. Yu, S.J. Zhou, et al., [Video-assisted thoracoscopic surgery bronchial sleeve lobectomy for lung cancer]. Zhonghua Yi Xue Za Zhi, 2013. 93: p. 1836-7.  Back to cited text no. 7
    
8.
Pena, E., M. Blanco, and J.P. Ovalle, Two-incision approach for video-assisted thoracoscopic sleeve lobectomy. Asian Cardiovasc Thorac Ann, 2014. 22: p. 371-3.  Back to cited text no. 8
    
9.
Schmid, T., F. Augustin, G. Kainz, et al., Hybrid video-assisted thoracic surgery-robotic minimally invasive right upper lobe sleeve lobectomy. Ann Thorac Surg, 2011. 91: p. 1961-5.  Back to cited text no. 9
    
10.
Tse, D.G., N. Vadehra, and L. Iancu, Left tracheal sleeve pneumonectomy: A combined approach. J Thorac Cardiovasc Surg, 2005. 129: p. 454-5.  Back to cited text no. 10
    
11.
Pena, E., M. Blanco, and J.P. Ovalle, Two-incision approach for video-assisted thoracoscopic sleeve lobectomy. Asian Cardiovascular and Thoracic Annals, 2013. 22: p. 371-373.  Back to cited text no. 11
    
12.
Xu, G., W. Zheng, Z. Guo, et al., Complete video-assisted thoracoscopic surgery upper left bronchial sleeve lobectomy. J Thorac Dis, 2013. 5(Suppl 3): p. S298-300.  Back to cited text no. 12
    
13.
He, J., W. Shao, C. Cao, et al., Long-term outcome of hybrid surgical approach of video-assisted minithoracotomy sleeve lobectomy for non-small-cell lung cancer. Surg Endosc, 2011. 25: p. 2509-15.  Back to cited text no. 13
    
14.
Eichhorn, F., K. Storz, H. Hoffmann, et al., Sleeve Pneumonectomy for Central Non-Small Cell Lung Cancer: Indications, Complications, and Survival. The Annals of Thoracic Surgery, 2013. 96: p. 253-258.  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1]

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