Uniportal Video-Assisted Thoracoscopic Lobectomy: Two Years of Experience

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1 Uniportal Video-Assisted Thoracoscopic Lobectomy: Two Years of Experience Diego Gonzalez-Rivas, MD, Marina Paradela, MD, Ricardo Fernandez, MD, Maria Delgado, MD, Eva Fieira, MD, Lucía Mendez, MD, Carlos Velasco, MD, and Mercedes de la Torre, MD Department of Thoracic Surgery, Minimally Invasive Thoracic Surgery Unit (UCTMI), and Department of Cardiac Surgery, Coruña University Hospital, Coruña, Spain Background. A video-assisted thoracoscopic approach to lobectomy varies among surgeons. Typically, 3 to 4 incisions are made. Our approach has evolved from a 3-port to a 2-port approach to a single 4- to 5-cm incision with no rib spreading. We report results with singleincision video-assisted thoracic major pulmonary resections during our first 2 years of experience. Methods. In June 2010, we began performing videoassisted thoracoscopic lobectomies through a uniportal approach (no rib spreading). By July 12, 2012, 102 patients had undergone this single-incision approach. Results. Of 102 attempted major resections, 97 were successfully completed with a single incision (operations in 3 patients were converted to open surgery and 2 patients needed 1 additional incision). Five uniportal pneumonectomies were not included in the study. We have analyzed early outcomes of successful uniportal lobectomies (92 patients studied). Right upper lobectomy was the most frequent resection (28 cases). Mean surgical time was minutes (range, minutes), mean number of lymph nodes was (range, 5 38 nodes), and mean number of explored nodal stations was (range, 3 8 stations). The mean tumor size was cm (0 6.5 cm). The median duration of time a chest tube was in place was 2 days and the median length of hospital stay was 3 days. There were complications in 14 patients; no postoperative 30-day mortality was reported. Conclusions. Single-incision video-assisted thoracoscopic anatomic resection is a feasible and safe procedure with good perioperative results, especially when performed by surgeons experienced with the double-port technique and anterior thoracotomy. (Ann Thorac Surg 2013;95:426 32) 2013 by The Society of Thoracic Surgeons Over the past 2 decades, video-assisted thoracic surgery (VATS) has revolutionized how thoracic surgeons diagnose and treat lung diseases. The major advance in VATS procedures is related to major pulmonary resections. With increased experience in VATS lobectomy, we have gradually improved less invasive techniques. The time has given us enough experience to be able to deal with complex cases. The use of multiple ports facilitates the completion of VATS lung resection by providing different angles for hilar dissection and lymphadenectomy. However the lobectomy can be accomplished with a single incision. We have hypothesized that the perioperative results of VATS lobectomies may be similar using single-port approaches whenever the technique is performed by surgeons with previous experience in the double-port approach and anterior thoracotomy. This article presents our experience with single-incision major pulmonary resections during a period of 2 years. Accepted for publication Oct 25, Address correspondence to Dr Gonzalez-Rivas, Department of Thoracic Surgery, Coruña University Hospital, Xubias 84, 15006, Coruña, Spain; diego.gonzalez.rivas@sergas.es. Material and Methods A retrospective descriptive prevalence study was performed in patients undergoing a single-port approach for major pulmonary resections in the Minimally Invasive Thoracic Surgery Unit and Coruña Hospital (Spain) between June 29, 2010 and July 12, This study was approved by the review board at Coruña University Hospital and Minimally Invasive Thoracic Surgery Unit, and all patients provided written informed consent before operation. The primary endpoint of this study was to demonstrate the feasibility of uniportal VATS lobectomy and report our initial experience during the first 2 years of use. Specifically, we analyzed morbidity, mortality, and the need for conversion in these procedures. One hundred two surgical interventions were attempted using this technique during the period of study. Most were conducted by a single surgeon and an assistant, both with previous experience in VATS 2-port technique and single-port technique for minor procedures. Indication Criteria Since 2009, our group has used VATS through the double-port technique for most pulmonary resections. In July 2010 we began performing single-incision VATS 2013 by The Society of Thoracic Surgeons /$36.00 Published by Elsevier Inc

2 Ann Thorac Surg GONZALEZ-RIVAS ET AL 2013;95: UNIPORTAL THORACOSCOPIC LOBECTOMY EXPERIENCE lobectomies for the lower lobes because those presented less difficulty. Our previous experience with lower lobectomies using double-port VATS, in which all procedures are performed through the utility incision, helped us achieve the first wholly single-port lower lobectomy by only adding the optic to the incision [1]. Cases were not selected by stage or difficulty, and we used the same selection criteria as for the double-port technique. Thanks to our previous VATS experience, the only absolute contraindications we consider are surgeon discomfort, mediastinal invasion, and large tumors that are impossible to remove without rib spreading [2]. Variables studied in each patient were age, sex, smoking habits, chronic obstructive pulmonary disease, pulmonary function test results, presence of associated comorbidities, how the lesion presented, tumor type and position, type and duration of surgical intervention, operation-associated adhesions, stage, histologic type, tumor size, lymph node affectation (number of lymph nodes retrieved and number of nodal stations explored), duration of chest tube in place, length of hospital stay, postoperative complications, and 30-day mortality. Statistical Analysis A descriptive analysis of the variables studied was carried out. The quantitative variables are expressed as mean standard deviation, median, and range. Qualitative variables are expressed by means of frequencies and the corresponding percentages. SPSS, version 17 for Windows (IBM Corp, Armonk, NY) was used for statistical analysis. To compare the postoperative course according to perioperative characteristics, the Mann- Whitney test was used for quantitative variables and the 2 test or Fisher s exact test was used for qualitative variables. Surgical Technique The incision, about 4 to 5 cm long, is performed at the fifth intercostal space. We do not use rib retractors or soft tissue separators. This incision is the same as that used for the double- or triple-port VATS technique. The camera must be at 30 degrees to provide a panoramic view. We are accustomed to a 10-mm highdefinition scope. Instruments must preferably be long 427 and curved to allow simultaneous insertion of 2 or 3 instruments (proximal and distal articulation ease of instrumentation). In our first cases, we introduced the camera using a trocar. However we learned that it was not necessary, as it required valuable space in the utility incision and made instrumentation very difficult. Avoiding the trocar allowed more camera mobility, improved angles of vision, and diminished compression of the intercostal space. For most anatomic resections (upper and lower), we can achieve optimal angles for stapler insertion to vessels when we have adequate exposure. When there is no angle for stapler insertion or it is difficult to achieve from the incision, as with the lingular vein or the middle lobe vein, we use vascular clips (Click av, Grena Ltd, Rheinland, Germany). When possible, we recommend first dividing the upper lobe truncus anterior to facilitate the insertion of the staplers in the upper lobe vein during upper resections (Fig 1A). Camera placement for the lobectomy and lymph node dissection is usually at the posterior part of the incision, working with the instruments below (Fig 1B). However camera placement may vary depending on the anatomy of each thorax. When the fissure is complete, the lobectomy is easier and faster because the artery in the fissure is exposed and no lung parenchyma is opened. For upper lobectomies, we use the fissureless technique. In the case of lower lobectomies with no artery visible in the fissure, the procedure must be performed from bottom to top, with fissure stapling as the final step. When the lobectomy is completed, the lobe is removed in a protective bag and a systematic lymph node dissection is conducted. For paratracheal lymph node dissection, we open the pleura inferiorly to the azygos vein, lifting this vein and retracting the superior vena cava with a thoracoscopic instrument (Fig 2A). For subcarinal lymph node dissection, the esophagus, main bronchus, and aorta must be separated to facilitate the procedure, and bimanual instrumentation is recommended with the camera placed above (Fig 2B). Once the operation is completed, we insert a single chest tube in the posterior part of the incision (Fig 3A). We infiltrate the intercostal spaces with bupivacaine at the end of the operation under thoracoscopic vision. No epidural catheter is inserted. GENERAL THORACIC Fig 1. (A) Exposure for the procedure and stapling the artery. (B) Instrumentation.

3 428 GONZALEZ-RIVAS ET AL Ann Thorac Surg UNIPORTAL THORACOSCOPIC LOBECTOMY EXPERIENCE 2013;95: Fig 2. (A) Right paratracheal lymph node dissection. (B) Left subcarinal lymph node dissection. Results From June 29, 2010 to July 12, 2012, we attempted 102 major pulmonary resections using the uniportal approach. Most were performed by a single surgeon and an assistant, both with experience in VATS, specifically in the double-port technique for major pulmonary resections and the single-port technique for minor procedures. The demographic and preoperative patient characteristics are described in Table 1. The anatomic pulmonary resections included right upper lobectomy in 28 patients (combined with anatomic lower segmentectomy in 1 patient), middle lobectomy in 7 patients, bilobectomy in 2 patients, right lower lobectomy in 16 patients, left upper lobectomy in 26 patients, anatomic lingulectomy in 1 patient, left lower lobectomy in 17 patients, right pneumonectomy in 2 patients, and left pneumonectomy in 3 patients. Figure 4 shows the monthly distribution of cases performed. Of the 102 cases attempted, there were 5 patients in whom we were unable to finish the operation using the single-incision approach. Three conversions to open thoracotomy were necessary (lengthening the utility incision, 2.9% conversion rate) because of bleeding and oncologic reasons (complex cases), which included a large tumor involving fissure, malignant lymph node vascular involvement, and a postchemotherapy tumor with bronchus fused to artery that was impossible to dissect by thoracoscopy. In 2 other patients, an additional incision was required to complete the lobectomy (double-port technique). One patient was a 70-year-old emphysematous man with a fused fissure who had a lower lobectomy, and the second patient was a 60-year-old man with silicotic lymph nodes surrounding vessels and bronchus (bleeding during truncus anterior dissection required a second incision for inserting staplers into the vein and performing the operation with artery division as the final step of the procedure). We have analyzed the results of lobectomies completed by the single-incision approach (n 92). The most common diagnosis was non-small cell lung cancer (NSCLC) of adenocarcinoma histologic type, which is the most prevalent (38%). Our series includes complex benign cases and advanced tumor stages such as post chemoradiotherapy tumors. The histologic types and NSCLC stages are described in Table 2. The mean surgical time was minutes (range, minutes). After anatomic resection, a complete mediastinal lymphadenectomy was performed in patients with a diagnosis of malignancy, according to oncologic criteria (Fig 2). The mean number of nodal stations explored in patients diagnosed with NSCLC (n 76) was (1 8), with a mean of (5 38) lymph node resections. The mean tumor size was cm (0 6.5 cm). If we divide the period into 2 years, we Fig 3. (A) Postoperative result of a single chest tube placed in the posterior part of the incision. (B) Incision after 6 months.

4 Ann Thorac Surg GONZALEZ-RIVAS ET AL 2013;95: UNIPORTAL THORACOSCOPIC LOBECTOMY EXPERIENCE Table 1. Patient Characteristics (N 102) Variable Mean SD (range) or No. (%) Age (30 82) Sex Male 69 (67.6) Female 33 (32.4) Smoking history Yes 84 (82.4) No 18 (17.6) Comorbidity Chronic obstructive pulmonary 44 (43.1) disease Cardiovascular risk factor 89 (87.3) Cardiac disease 25 (24.5) Previous cancer 27 (27.3) Previous operation (no 54 (52.9) thoracic) Other diseases 89 (87.3) Symptoms Casual finding 62 (60.8) Hemoptysis 14 (13.7) General syndrome 13 (12.7) Cough 4 (3.9) Pneumonia 6 (5.9) Endobronchial tumor 13 (12.7) Preoperative histologic type 32 (31.7) Neoadjuvant treatment 20 (19.6) Chemotherapy alone 16 (80) Chemoradiotherapy 4 (20) Pulmonary function Forced expiratory volume in (35 132) second Vital capacity (58 139) SD standard deviation. observe more lymph node dissections performed during the second period: versus 16 8(p 0.055). 429 A total of 28 patients (30.8%) had strong adhesions, whereas 56.5% (n 52) had an incomplete or fused fissure (fissureless technique was performed in these cases). We have analyzed several preoperative variables (upper lobectomies, strong adhesions, chemotherapy, fissureless technique, and extensive lymphadenectomy) according to surgical time, days of drainage, hospital stay, and rate of complications (Table 3). Patients with upper lobectomies, strong adhesions, incomplete fissure, or induction chemotherapy had longer surgical times. Patients with incomplete fissure or strong adhesions also had more days with a chest tube in place and a longer hospital stay. In turn, the upper lobectomies (most performed with the fissureless technique) and the performance of an extensive lymphadenectomy (most performed in complex or advanced cases) were associated with a higher rate of prolonged air leak and complications (p 0.004). The median intensive care unit stay was 1 day (0 3 days) and the median morphine use was 1 day (0 6 days). The median duration of chest tube placement was 2 days (1 to 16 days) and the median length of stay was 3 days (1 14 days). Postoperative complications are shown in Table 4. There was no operative or 30-day mortality (to date 95.6% of patients are alive). Two patients required reoperation postoperatively because of bleeding. Both had advanced disease and had undergone extensive lymph node dissection. The first was a 60-year-old patient who had undergone a left upper lobe procedure after chemotherapy. The second patient was 40 years old with a left upper lobe adenocarcinoma attached to the aorta and supraaortic trunks (very complex detachment). They underwent a second operation by VATS and were discharged with no complications on the second and seventh postoperative days, respectively, after reoperation. Induction chemotherapy was administered in 18.4% (17/92) of patients who received lobectomies. Pathologic N2 lymph node involvement was observed in 8.8% of all patients with NSCLC, with unexpected N2 status found in 3.6% of patients with stage I disease. In our series, we GENERAL THORACIC Fig 4. Monthly distribution of cases performed.

5 430 GONZALEZ-RIVAS ET AL Ann Thorac Surg UNIPORTAL THORACOSCOPIC LOBECTOMY EXPERIENCE 2013;95: Table 2. Histologic Types and Concordance Among Stages in NSCLC (n 76) Histologic n (%) Adenocarcinoma 35 (38) Squamous cell 26 (28.3) Adenosquamous 1 (1.1) Large cell 4 (4.3) Carcinoid 7 (7.6) Metastasis 5 (5.4) Sarcoma 3 (3.3) Lymphoma 2 (2.2) Oat cell 1 (1.1) Benign 8 (8.7) Bronchiectasis 1 Aspergilloma 1 Situs inversus organizing pneumonia 1 Adenomatoid cystic malformation (bronchial atresia) 1 Central chondroid hamartoma 1 Tuberculosis 3 Postoperative Stage n/% IA IB IIA IIB IIIA pt0 Total Preoperative Stage n/% IA 32 (84.2) 1 (2.6) 1 (2.6) 0 4 (10.5) 0 38 (100) IB 0 16 (100) (100) IIA (88.9) 0 1 (11.1) 0 9 (100) IIIA 2 (15,4) 1 (7.7) 1 (7.7) 2 (15.4) 3 (23.1) 4 (30.8) 13 (100) Total 34 (44.7) 18 (23.7) 10 (13.2) 2 (2.6) 8 (10.5) 4 (5.3) 76 (100) NSCLC non-small cell lung cancer. found 4 patients with advanced disease who were treated preoperatively (chemoradiotherapy or chemotherapy alone) in whom a complete response was found after analyzing the pathologic specimen (T0N0M0). The mean size of tumors in preoperative computed tomographic scans of these patients was 5.2 cm (1 12 cm). Comment VATS lobectomy for lung cancer was initially described in 1992 [3, 4]. Most authors describe the VATS approach to lobectomy using 3 to 4 incisions [5], but the operation can be performed using only 1 incision with similar outcomes [6]. Since June 2010, and after performing 95 cases using the 2-port approach, we began performing VATS lobectomies with a single incision [7]. The first reports of single-port procedures were described in abdominal operations [8]. Currently, those abdominal procedures are performed with a SILS port (Covidien, Mansfield, MA) (single-incision laparoscopic surgery), which is placed at an entry port. Since 2004, Rocco and associates [9, 10] have published different articles on the single-port VATS technique for diagnostic and therapeutic procedures. Some authors have reported pneumothorax operations with the SILS device [11]. Our unit published results of the first major pulmonary resections performed through a uniportal approach [1, 12] and our initial results [6]. With the single-port approach, the view is directed to the target tissue [9] and we only need coordination between the surgeon and the assistant handling the camera. We have not noticed reduced safety or any instrumentation problems. The perspective of the view is the same as with open procedures when performed through an anterior thoracotomy, and instrumentation is similar when working in the sagittal plane (no horizontal plane and no triangulation as in conventional VATS). We strongly recommend 2 conditions before starting the technique: previous double-port VATS experience and familiarity with using the anterior small thoracotomy for open procedures. We recommend starting the uniportal technique in lower lobectomies with complete fissure, which is preferable for nonsmoking female patients and early tumor stages. Our study has several limitations. Indeed, this is a retrospective and descriptive study, so our results should be interpreted with caution. We cannot obtain conclusions about benefits over a 2-port or three-port technique because the study was not designed for that comparison. Actually, the single-incision approach is our first option for all major pulmonary resections using VATS in our unit. Even though the perspective is always from the anterior, the movement of the 30-degree camera alongside the incision will create different angles of vision, and a rotating movement will contribute to an increased field of vision. One potential advantage of this approach may be a reduction in postoperative pain. There could be several

6 Ann Thorac Surg GONZALEZ-RIVAS ET AL 2013;95: UNIPORTAL THORACOSCOPIC LOBECTOMY EXPERIENCE Table 3. Comparative Table of Several Variables With Outcomes Variable Operative Time Median (Range) Chest Tubes Median (Range) Hospital Stay Median (Range) Prolonged Air Leak n (%) Complications n (%) Upper lobes No (3) Yes (13.6) 14 (23.7) p p p p p Fissureless technique No (5) Yes (15.4) 13 (25) p p p p p Strong adhesions No (7.9%) 9 (14.3) Yes (10.7%) 6 (21.4) p p p p p Induction chemotherapy No (9.1) 12 (15.6) Yes (6.7) 3 (20) p p p p p Tumor size 3 cm (7) 6 (14) 3 cm (10.9) 8 (17.4) p p p p p Extensive lymphadenectomy a No (5) 8 (13.3) Yes (26.7) 6 (40) p p p p p GENERAL THORACIC a More than 20 lymph nodes removed in patients with non-small cell lung cancer. explanations for this: 1 explanation is that only 1 intercostal space is involved, and avoiding the use of a trocar could minimize the risk of intercostal nerve injury (during instrumentation, we try to apply the force over the superior aspect of the inferior rib through the utility incision). We have observed that in patients operated on by conventional VATS, pain is sometimes referred toward the posterior and inferior incisions and only a few times is pain referred to the utility incision. Some authors have reported less postoperative pain and fewer paresthesias in patients operated on for pneumothorax through a single incision compared with the classic triple-port approach [13, 14]. Further studies will be required to demonstrate that there is less pain with single-incision techniques compared with conventional VATS for lobectomy. One possible disadvantage is that we lose other entry points for introducing staplers, which affects access to the Table 4. Postoperative Complications (n 14 patients) Complication No. % Prolonged air leak ( 5 d) Atelectasis Wound infection Atrial fibrillation Postoperative bleeding requiring reoperation Reinsertion of chest tube upper lobe vein and artery. However the view from the utility incision facilitates artery dissection as the first step for the upper lobes. First sectioning the arterial trunk helps access to the upper lobe vein with the aid of staplers. This is the most uncomfortable structure to access with staplers from the utility incision. When the use of staplers is not feasible, we may use vascular clips (Click av, Grena Ltd). Thoracoscopic lobectomy for advanced stages or complex cases may be performed safely, with results equivalent to open techniques [15, 16]. Consequently, the more experience we accumulate, the more complex the cases we performed, hence expanding indications for single-incision thoracoscopic lobectomy. In our study, there were complex benign cases and advanced-stage tumors (almost 20% of total) with good early outcomes. There were 4 stage IIIA NSCLC tumors, which were pathologically down-staged to T0N0M0, total tumor regression (2 patients treated preoperatively with chemotherapy and 2 patients treated with concurrent chemoradiotherapy). There are reports that pulmonary resection may be performed safely after induction chemotherapy and high doses of radiotherapy. We expect to see good survival rates in these patients, according to total pathologic response obtained, which indicates good prognostic factors as addressed by some authors [17]. We are involved in a study to compare outcomes of patients with advanced early-stage tumors operated on using single-port VATS.

7 432 GONZALEZ-RIVAS ET AL Ann Thorac Surg UNIPORTAL THORACOSCOPIC LOBECTOMY EXPERIENCE 2013;95: A very important consideration is the performance of mediastinal lymphadenectomy the latter defined as systematic node dissection. We currently perform lymph node dissection in patients undergoing lobectomy for NSCLC through the VATS approach [18]. We have shown that as more patients are treated with the singleport approach, the number of lymph nodes removed increases; this reflects improvement in executing the surgical technique. In our uniportal series, the mean number of lymph nodes resected was greater than the mean number we reported using 2- or 3-port VATS ( versus ) [7]. In any case, we have performed the adequate mediastinal staging proposed by some authors [19]. Uniportal lobectomies are a consequence of greater skills acquired with experience. Our global conversion rate was low (2.9%). This is explained by previous practice and experience in vascular dissection and management of the fissure, specifically in complex cases, operation after chemotherapy, or patients with strong adhesions. It is interesting to note that patients who underwent conversion were difficult cases with advanced-stage disease. Conversion was necessary because of problems related to oncologic reasons, not to the uniportal approach. Different groups have reported conversion rates ranging from 2% to 14% [20]. With increased experience, the technique is refined and taught to other surgeons in our unit. We have had success in teaching uniportal VATS lobectomies to trainees given adequate supervision and selecting the cases carefully. We have a wet lab available in our institution to train residents. The use of simulators and practicing on live animal models has contributed to their success in learning the technique. This procedure should neither prolong estimated operative time nor hinder cleaning of the lymph nodes nor increase the likelihood of surgical or postoperative complications compared with our double- or triple-vats technique [7]. In our study, we observed that upper lobectomies and a fissureless technique require more surgical time and are associated with more days with a chest tube in place, longer lengths of stay, and complications (the most frequent being prolonged air leak). Stapling the fissure at the end of the procedure [21] (usually performed in upper lobes) can be a difficult step, especially in patients with advanced disease or emphysema. This could explain a greater incidence of air leak in our subset. One curious piece of data shows that patients on whom we performed a radical lymph node dissection (considered as more than 20 lymph nodes removed) had higher rates of air leak and complications. This could be explained by the fact that 60% of these patients (9/15) had advanced-stage disease and 80% of these lobectomies were performed with the fissureless technique. In conclusion, single-incision VATS lobectomy is a feasible and safe procedure, with good postoperative outcomes, especially when performed in centers with previous experience in the double-port VATS approach and surgeons familiar with anterior thoracotomy for open operations. References 1. Gonzalez D, Paradela M, Garcia J, de la Torre M. Single-port video-assisted thoracoscopic lobectomy. Interact Cardiovasc Thorac Surg 2011;12: Gonzalez-Rivas D, Fernandez R, De la Torre M, Martin-Ucar A. Thoracoscopic lobectomy through a single incision. MMCTS 2012;mms007 doi: /mmcts/mms Landreneau RJ, Mack MJ, Hazelrigg SR, et al. Video-assisted thoracic surgery: basic technical concepts and intercostal approach strategies. Ann Thorac Surg 1992;54: Roviaro G, Rebuffat C, Varoli F, Vergani C, Mariani C, Maciocco M. 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Uniportal video-assisted thoracic surgery for primary spontaneous pneumothorax using a single-incision laparoscopic surgery port: a feasible and safe procedure. Surg Endosc 2011;25: Gonzalez-Rivas D, de la Torre M, Fernandez R, Mosquera VX. Single-port video-assisted thoracoscopic left upper lobectomy. Interact Cardiovasc Thorac Surg 2011;13: Salati M, Brunelli A, Rocco G. Uniportal video-assisted thoracic surgery for diagnosis and treatment of intrathoracic conditions. Thorac Surg Clin 2008;18: Jutley R, Khalil M, Rocco G. Uniportal vs standard three-port VATS technique for spontaneous pneumothorax: comparison of post-operative pain and residual paraesthesia. Eur J Cardiothorac Surg 2005;28: Hennon M, Sahai RK, Yendamuri S, Tan W, Demmy TL, Nwogu C. Safety of thoracoscopic lobectomy in locally advanced lung cancer. Ann Surg Oncol 2011;18: Petersen R, Pham D, Toloza E, et al. 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