A ment of video-assisted endoscopic instrumentation,

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1 Major Pulmonary Resections: Pneumonectomies and Lobectomies Giancarlo Roviaro, MD, Federico Varoli, MD, Carlo Rebuffat, MD, Contardo Vergani, MD, Andr6 DHoore, MD, Silvio Marco Scalambra, MD, Marco Maciocco, MD, and Fabrizio Grignani, MD Department of Surgery, S. Giuseppe Hospital, University of Milan, Milan, Italy We report on our experience in 0 patients who underwent major thoracoscopic pulmonary resections between October 99 and vember 99. These consist of left pneumonectomies, lobectomies, and segmentectomy. The indications were strictly limited to benign pulmonary diseases and stage I (TNM) primary lung cancer. A hilar lymphadenectomy was performed in all cases of malignancy. Our surgical technique is described. Our findings demonstrate the feasibility of performing major video-assisted thoracoscopic pulmonary resections, even though the definite role of this procedure in the management of lung cancer must still be defined. (Ann Thorac Surg 993;6:9-83) dvances in technology and the consequent improve- A ment of video-assisted endoscopic instrumentation, especially percutaneous stapling devices [l], has advanced the development of thoracoscopy, which was first described by the Swedish surgeon Jacobaeus in 90 [, 3. Armed with a vast experience in thoracic surgical procedures and an adequate training in endoscopic techniques, we have been able to perform standard pulmonary resections such as lobectomies and pneumonectomies using video-assisted thoracoscopy. These are essentially carried out using the same basic procedures as those used for traditional open resections. Material and Methods From October 99 to vember 99, thoracic interventions were performed in our department. Of these, 0 (9.%) were carried out using video-assisted thoracoscopy. The first thoracoscopic pulmonary was performed in October 99 []. We describe here a series of 0 major pulmonary resections, including pneumonectomies, segmentectomy, and lobectomies ( right lower lobectomies, 6 middle lobectomies, right upper, and 3 left lower lobectomies). There were male and 6 female patients. The average patient age was.9 years, with the youngest patient an ll-yearold girl and the eldest a -year-old man (Table ). A hilar lymphadenectomy was performed in all cases of malignancy. lndica tions All patients underwent an accurate preoperative assessment. The criteria used to identify general and cardiopul- Presented at The First International Symposium on Thoracoscopic Surgery, San Antonio, TX, Jan -3, 993. Address reprint requests to Dr Roviaro, Cattedra di Chirurgia Generale, UniversitA di Milano, Divisione Chirurgia, Ospedale S. Giuseppe, Via S. Vittore,, 0?-Milano, Italy. monary conditions that are contraindications to videoassisted procedures were the same as those used for open surgery. We selected for video-assisted resection patients with the following three main groups of pathologic conditions.. Benign lung disease requiring. There were patients (%) in this group; cases were due to localized purulent bronchiectasis. The fifth patient was a -year-old man with an arteriovenous fistula who underwent emergency middle for the treatment of hemoptysis after a few unsuccessful attempts at embolization.. Lung metastasis unremovable by wedge resection, but only when the extrapulmonary neoplastic site was under control. There were patients (0%) in this group. 3. Primary lung neoplasm in TNM stage I. There were 3 patients (6%) in this group, and the tumors consisted of 3 adenocarcinomas, 6 squamous cell carcinomas, bronchioloalveolar carcinomas, undifferentiated large cell carcinoma, and lung plasmacytoma, which occurred in the -year-old girl. Routine lymphadenectomy was always performed using the same criteria and technique as those used for open procedures, and pathologic analysis in cases revealed pt N Mx disease (TNM stage ). Technique A double-lumen Carlens tube is always employed for ventilation. The only exception in this series of patients was the -year-old girl who was intubated with a normal tube and ventilated with low-pressure flow, as we could not obtain a pediatric-sized Carlens tube. After the tube is positioned, the patient is placed in the lateral decubitus position as though for a classic postero by The Society of Thoracic Surgeons /93/$6.00

2 80 THORACOSCOPY ROVIARO ET AL Ann Thorac Surg 993;6:9-83 Table. Series Overview Patient Age. Sex (Y) Intervention Pathology TNM M Adenocarcinoma T NO MO M 3 Left pneumonectomy Squamous cell ca. T NO MO 3 M Middle Arteriovenous fistula M Middle Metastasis from renal ca. M 0 Squamous cell ca. T NO MO 6 F 0 Middle Purulent bronchiectasis M 3 Left lower Purulent bronchiectasis 8 M 68 Left lower Adenocarcinoma 9 M Segmentectomy of superior Squamous cell ca. segment right lower lobe 0 M 6 Squamous cell ca. F 3 Middle Purulent bronchiectasis M 69 Squamous cell ca. 3 M Right upper Adenocarcinoma M 6 Left lower Large cell undifferentiated ca. F Middle Plasma cell granuloma 6 M 8 Metastasis from adenocarcinoma of colon T NO MO T NO MO T NO MO T NO MO T N MO T NO MO F 6 Bronchioloalveolar ca. T NO MO 8 F 38 Middle Purulent bronchiectasis 9 M 9 Left pneumonectomy Squamous cell ca. T N MO 0 F 60 Bronchioloalveolar ca. T NO MO M = male; F = female; ca. = carcinoma lateral thoracotomy. Two video monitors are placed on either side of the patient s head, thus guaranteeing optimal viewing for all members of the team. After exclusion of the lung, the first 0-mm trocar is introduced in the seventh or eighth intercostal space on the midaxillary line. The optic instrument is introduced and the cavity is carefully explored. As most endoscopic instruments are rigid, rectilinear, and rather limited in length, the most favorable position and angle for carrying out dissection of the fissure is first attempted with fine needles. The operating trocars are then inserted under direct endoscopic control, usually in the fifth intercostal space (we used two additional trocars in 6 cases, and three additional trocars in cases). Once the feasibility of a video-assisted thoracoscopic procedure has been confirmed, a 3- to -cm incision [] is made, usually in the fourth intercostal space on the anterior axillary line. We call this a utility thoracotorny, as it is necessary for extracting the specimen, but also permits the introduction of traditional instruments not yet available in an endoscopic version. In female patients, the site is marked preoperatively along the inframammary fold to obtain an optimal cosmetic result. We usually start the resection by dissecting the artery within the fissure because this is the most difficult and critical step, and the ability to continue the operation thoracoscopically mostly depends on it. Dissection is carried out using electrocoagulating endoscissors and graspers, or endoswabs, for blunt dissection. Once the larger vessels are freed up, they are surrounded with a thread using a traditional dissecting clamp or the newer endoroticulator graspers. This facilitates positioning of the stapler. Before stapling the vessel, a traditional vascular clamp (such as a Satinsky) can be positioned to prevent severe hemorrhagic complications in the event of stapler dysfunction. Once the major arteries and veins are dissected, they are sectioned with a vascular Endo GIA (Autosuture; United States Surgical Corporation, rwalk, CT). Minor segmental vessels are secured with Endoclips (United States Surgical Corporation). The bronchial vessels are also clipped. The lobar bronchus is dissected and sectioned by means of an Endo GIA parenchymal stapler. For a lower, the apical lower bronchus should be stapled separately to avoid possible stenosis of the middle bronchus. When performing pneumonectomies, the main bronchus is usually too thick to allow the safe use of a parenchymal Endo GIA. In these cases, we use a traditional TA. Roticulator (Autosuture; United States Surgical Corporation) introduced through the utility thoracotomy after removal of the lung. The bronchial stump is held with two endograspers to permit its stapling. fissures represent a main problem. Completion can usually be obtained by means of either a parenchymal Endo-GIA or traditional stapler (Table ). Once freed up, the specimen can be extracted through the utility thoracotomy. In the event of malignancy, the specimen is first inserted in a plastic bag to prevent tumoral implantation. In the event of primary lung cancer, a lymphadenectomy can be carried out as accurately as that accomplished with open procedures. After copious irrigation of the

3 Ann Thorac Surg 993; THORACOSCOPY ROVIARO ET AL 8 Table. Use of Stapling Devices in Major Pulrnonay Resections Procedure Lower Middle Right upper Pneumonectomy Endoclips Artery to the apical lower segment, bronchial artery Middle lobe veins and arteries, bronchial artery Posterior ascending artery, bronchial arteries Endostapler Lower pulmonary vein, intermediate pulmonary artery, lower lobar bronchus (or apical lower bronchus separately), fissures Middle lobe veins and arteries, middle lobar bronchus, fissure Anterior arterial trunk, upper pulmonary vein, right upper lobar bronchus, fissure Lower and upper pulmonary veins, pulmonary artery, fissure nendoscopic Stapler Main bronchus cavity with saline solution and careful control of bleeding, a chest drain is positioned and the remaining lung is reexpanded under direct endoscopic control. In our series, the mean operating time was 0 minutes (range, 0 to minutes). Results There were no perioperative or postoperative deaths, and no reoperations were necessary. The postoperative morbidity in our patients was significantly lower than that observed after traditional posterolateral thoracotomies, and the need for pain relief medication was dramatically less. Functional recovery was consequently much more rapid, which is of major importance in elderly patients who are in poor general condition. Of the 0 patients, (0%) had an uneventful postoperative course and the chest drain was removed a mean of.9 days postoperatively (range, to 0 days). One patient operated on for purulent bronchiectasis and diffuse inflammatory changes needed a postoperative blood transfusion, but his further course was normal. Six patients (0%) had a prolonged postoperative course. In, this was due to a protracted air leak that lasted for a mean period of days (range, to days); of these was complicated by a pleural infection. In other patients, a hematic pleural effusion developed after removal of the chest drain (on the third and fourth postoperative day, respectively). In one of these, a new chest drain was placed under computed tomographic control; in the other, the hospital stay was not prolonged and the patient was discharged on the seventh postoperative day (Table 3). Comment Until now, major pulmonary resections required large incisions, and, without any doubt, posterolateral thoracotomy provides a wide access to the thoracic cavity and offers good control of the pulmonary hilar structures. Advances in video-assisted thoracoscopic technology and the development of endostapling devices have allowed the application of minimally invasive approaches in thoracic surgical procedures. It is generally accepted that thoracoscopic approaches minimize surgical trauma and promote an accelerated functional recovery (, 6. The cosmetic result is also far better and, in most cases, the postthoracotomy pain syndrome is avoided. Nevertheless, only the approach itself has changed. In all other respects, the surgical procedures-the steps and problems implied in the pulmonary procedure, and so onremain the same. The present instrumentation, mainly conceived for laparoscopic purposes, is too rigid and rectilinear, and often too short and therefore inadequate for thoracic surgery. This is an important limiting factor in performing major pulmonary resections, and, particularly in the case of incomplete fissures, resection can prove extremely difficult. The utility thoracotomy, which is necessary for extracting the specimen, offers several additional advantages:. Traditional instruments such as dissecting clamps and staplers can be used if required.. In the event of hemorrhagic accidents, vessels can be clamped and controlled with greater ease. 3. It can be extended rapidly if an emergency posterolatera thoracotomy is needed. All candidates for pulmonary resections in our department now regularly undergo thoracoscopy. This avoids the need to subject a patient to an explorative thoracotomy, in case of, for example, local inoperability or pleural metastasis, which often implies great morbidity and sometimes even mortality. As mediastinal structures are easily accessible and controllable using thoracoscopic procedures, utmost attention must be paid to the dissection of the fissural planes, as this remains the most difficult step and is usually crucial to completion of the procedure thoracoscopically. In cases, we had to convert to an open procedure. The causes for conversion closely reflect the main problems inherent in thoracoscopic procedures. In case, displace-

4 8 THORACOSCOPY ROVIARO ET AL Ann Thorac Surg 993;6:93 Table 3. Postoperative Results Drain Patient Postoperative Discharge. Intervention Adhesions Fissure. Days Course Transfusion Reoperation (day) Left pneumonectomy Middle Middle Middle Left lower Left lower Segmentectomy of superior segment of right lower lobe Middle Right upper Left lower Middle Middle Left pneumonectomy = present; - = not present; ++ = diffuse; CT = computed tomography. Hematic pleural effusion (drain placed under CT control) leakgge and pleural infection Pleural effusion 3 U packed cells intraop. U packed cells postop. th th th 6th 9th 30th th th 3rd 0th th th 0th 6th 0th th ment of the Carlens tube occurred just after the sectioning and suturing of the superior pulmonary vein and the anterior arterial trunk, and the consequent irreversible reexpansion of the lung prevented fissural dissection. In other cases, an inflammatory reaction had caused the fissures to seal, and the consequent absence of a cleavage plane prevented dissection. In another case, modest bleeding from a small artery was controlled by the application of a vascular clamp, but again a fibrotic fissure prevented further dissection and arterial transection. In the fifth case, after incision of the lower pulmonary ligament and section of the inferior pulmonary vein, video-assisted thoracoscopic exploration revealed infiltration of the chest wall, which required conversion to an open procedure. Many difficulties are also due to the lack of adequate thoracoscopic instrumentation. Also for this reason, we believe that a left upper is very difficult to perform, as the dissection and control of these particularly short, fragile arterial branches is hazardous. The currently available endostapling devices guarantee the safe man- agement of the large arterial and venous vessels. In our series, 39 large vessels were stapled without any complications. The lobar bronchi can also be accurately secured with endostaplers. bronchial fistulas developed in any of our patients postoperatively. When performing a pneumonectomy, dissection of the main vessels and stapler positioning are more difficult, as these vessels are larger and closer to the main bronchus. The main bronchus itself is too large and cannot be safely sutured with an endostapler, and the larger traditional stapler must be used. In our experience, a TA. Roticulator introduced through the utility thoracotomy achieved good results in both of the patients who underwent a pneumonectomy. All cases of prolonged air in our series occurred in patients with incomplete fissures that required several stapler applications. Air is particularly likely to occur where the suture lines cross over. This inconvenience will probably be eliminated once longer endostapler cartridges come available. As far as the indications for major video-assisted thora-

5 Ann Thorac Surg 993;6:9-83 THORACOSCOPY ROVIARO ET AL 83 coscopic pulmonary resections are concerned, all benign pulmonary diseases can be explored thoracoscopically, but the feasibility of resection depends on the local anatomic characteristics. In the setting of inflammatory pathologic conditions such as purulent bronchiectasis, dissection of the vascular elements within the fissure can be very difficult if there is diffuse fibrosis or enlarged calcified lymph nodes, which can seal the fissures. The use of video-assisted thoracoscopic approaches for the treatment of primary lung cancer remains controversial. We are convinced that a thoracoscopic approach can be considered for small peripheral lesions in stage I, and an accurate lymphadenectomy is also possible. Large tumors hinder adequate mobilization of the lobe, which is necessary for endoscopic dissection. Intrabronchial tumors are contraindications to a thoracoscopic approach, as stapling of the bronchus is necessarily performed blindly and endoscopic palpation is not very effective for localizing the limits of the lesion. In the event of pleural invasion, dissection can still be performed, but, when the chest wall is involved, the procedure must be converted to an open approach to prevent tumor dissemination and to carry out an adequately extensive en bloc local chest wall resection. In conclusion, we believe that in selected cases and with an accurate surgical technique, video-assisted thoracoscopic and pneumonectomy can be safely performed. The extension of indications depend mainly on the development of new endoscopic instruments specifically designed for thoracoscopic surgery. As the surgical trauma is considerably less than that incurred in traditional interventions, patients in poor general health or elderly patients benefit most from this technique. Video-assisted thoracoscopic interventions have rapidly become valid techniques, but their definite role in the performance of major pulmonary resections must still be defined. References. Lewis RJ, Caccavale RJ, Sisler GE, MacKenzie JW. One hundred consecutive patients undergoing video-assisted thoracic operations. Ann Thorac Surg 99;:.. Jacobaeus HC. Practical importance of thoracoscopy of the chest. Surg Gynecol Obstet 9;3:9> Davis CJ. A history of endoscopic surgery. Surg Laparosc Endosc 99;():&3.. Roviaro GC, Rebuffat C, Varoli F, et al. Videoendoscopic pulmonary for cancer. Surg Laparosc Endosc 99; (3):-.. Landreneau RJ, Hazelrigg SR, Ferson PF, et al. Thoracoscopic resections of 8 pulmonary lesions. Ann Thorac Surg 99;: Mack MJ, Aronoff RJ, Acuff TE, Douthit MB, Bowman RT, Ryan WH. Present role of thoracoscopy in the diagnosis and treatment of diseases of the chest. Ann Thorac Surg 99;: 0S9.