- Anon.

Joe B. Putnam, Jr., MD, FACS

Houston, Texas

The hallmark of a "good" operation is that it:

(1) Can be consistently and reproducibly performed

(2) Is easy to teach to other surgeons

(3) Achieves the desired results, and

(4) Can be performed with minimal morbidity

Bright lights and high resolution video cameras for excellent visualization of the thorax, detailed and intricate instruments, and small, cosmetically appealing incisions, have combined to create in the mind of some surgeons that video-assisted thoracic surgery (VATS) provides a superior approach to pulmonary surgery. Despite its novelty and "modern image," video-assisted thoracic surgery (VATS) may be inconsistently applied in many situations where an open procedure would be preferred. VATS should not be forced onto an operation simply to find an application for a technique.

The role of VATS has evolved to one of diagnosis and staging; rarely as a primary treatment modality. Patients at increased physiological risk from thoracotomy may tolerate a simple wedge resection of the lung without difficulty. Overall, the number of VATS procedures as a proportion of overall operations is decreasing at M.D. Anderson.

The VATS technique for pulmonary resection is not appreciably less invasive than standard open approaches. The modern muscle sparing posterior or axillary thoracotomy with a six- to eight-inch incision and excellent epidural anesthesia provides good results and a median length of stay of five days. Multiple smaller incisions and a three to five inch "utility thoracotomy" (even with minimal rib spreading) and VATS does not minimize the length of stay or requirements for pain medication compared to an open technique (1).

Regardless of the approach chosen, the operation and resection performed must be consistent. Although a wedge resection of a peripheral lung cancer and a visual inspection of the mediastinal nodes (underneath the mediastinal pleura and fat) may be easily achieved using VATS techniques, anatomic resection and lymph node dissection remain challenging with standard anatomic variability. Ginsberg et al. demonstrated that lobectomy was the preferred procedure for T1N0 carcinoma of the lung compared to lesser operations (segment or wedge) (2).

Proper staging of patients with lung cancer is critical to perioperative management. Current staging procedures are inaccurate with over 36% of patients (30/84) in one prospective study having a greater pathological stage than clinical stage, even when mediastinoscopy was integrated into the clinical staging for protocol purposes (3). Mediastinal lymph node dissection with removal of all identifiable nodes provides optimal tissue for pathological staging. VATS does not enhance this tissue acquisition requirement. Thoracoscopy is my preferred route in lieu of the Chamberlain procedure (mediastinotomy). VATS provides excellent visualization of the left hilum, although dissection can be tedious.

Wedge resection of pulmonary metastases should not be performed using VATS techniques. McCormack and colleagues demonstrated that CT Chest and VATS had a 56% failure rate to detect all lesions. The frequency of bilateral and or occult metastases particularly in sarcoma precludes the use of the thoracoscopy. Thoracoscopy may play a role in highly selected patients with solitary metastasis of non-sarcomatous origin with a long disease-free interval. FNA should obviously exclude primary lung cancer.

Complications specific to thoracoscopy have been described. The obvious chest wall implant from tumor seeding has devastating effects on the patient (4). Postoperative pain from periosteal injury affects some patients.

Selection of patient remains a critical step in the appropriate use of VATS in thoracic surgical oncology (5). I would propose that VATS would be appropriate for

1) diagnosis or staging of thoracic neoplasms,

2) diagnosis (and treatment) of the solitary pulmonary nodule (if benign),

3) diagnosis, drainage of undiagnosed plural effusion, and

4) diagnosis of diffuse lung disease via wedge biopsy

The subjective risks of an incomplete, inadequate, or inconsistent operation must be compared to the benefits of the VATS approach. The surgeon must consider the technical skills required, the desired objectives for the patient, the instrumentation available for manipulation of the lung and other thoracic organs, and an assessment of the risk "closed" and "open." An inadequate lung cancer operation will cause much more morbidity than the benefits achieved by VATS. The surgeon must be morally certain that VATS will provide an optimal outcome for the patient. For diagnosis and staging, the VATS approach may indeed be preferred.

1. Kirby TJ, Mack MJ, Landreneau RJ, Rice TW. Lobectomy – video-assisted thoracic surgery versus muscle-sparing thoracotomy. A randomized trial. J Thorac Cardiovasc Surg 1995; 109(5):997-1001; discussion 100.
2. Ginsberg RJ, Rubinstein LV. Randomized trial of lobectomy versus limited resection for T1 N0 non-small cell lung cancer. Lung Cancer Study Group. Ann Thorac Surg 1995; 60(3):615-22; discussion 622-3.
3. Pisters KM, Ginsberg RJ, Bunn PAJ. Induction chemotherapy prior to surgery for early stage lung cancer – a novel approach. American Association of Thoracic Surgery 79^th Annual Meeting, New Orleans, LA April 18 – 21, 1999, 140.1999. (Abstract)
4. Walsh GL, Nesbitt JC. Tumor implants after thoracoscopic resection of a metastatic sarcoma [see comments]. Ann Thorac Surg 1995; 59(1):215 – 216.
5. Celik M, Halezeroglu S, Senol C, Keles M, Yalcin Z, Urek S et al. Video-assisted thoracoscopic surgery: experience with 341 cases. European Journal of Cardio-Thoracic Surgery 1998; 14(2):113-116.