A enthusiasm with minimally invasive operations

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1 Thoracoscopic Resection of 85 Pulmonary Lesions Rodney J. Landreneau, MD, Stephen R. Hazelrigg, MD, Peter F. Ferson, MD, Joel A. Johnson, MD, Weerchai Nawarawong, MD, Theresa M. Boley, RN, MSN, Jack J. Curtis, MD, Claudia M. Bowers, RN, David B. Herlan, MD, and Robert D. Dowling, MD Section of Thoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, and Division of Cardiothoracic Surgery, St. Luke's Medical Center, Milwaukee, Wisconsin Advances in endoscopic surgical equipment and laser technology have expanded the role of thoracoscopy to include thoracoscopic pulmonary resection. Eighty-five thoracoscopic pulmonary resections were performed on 6 consecutive patients with small lesions (<3 cm) in the outer third of the lung. Patients with preoperative. histologic evidence of bronchogenic carcinoma were excluded unless there was impairment of cardiopulmonary function, advanced age, or concomitant extrathoracic malignancy. These thoracoscopic pulmonary resections were accomplished with the neodymium:yttriumaluminum garnet laser (3), endoscopic stapler (29, or both (25). The mean diameter of the lesions was.3 cm (range, 0.4 to 2.7 cm). There has been one late death (38th postoperative day) unrelated to the operation. Morbidity consisted of postoperative atelectasis (2), pneumonia (2, bleeding requiring transfusion (l), and bronchopleural fistula of greater than 7 days duration (3). There were no wound problems. The mean period of chest tube drain- age was 3.3 & 3.0 days. Mean postoperative stay was days. The pathologic diagnosis was benign disease in 28 patients (interstitial fibrosis/pneumonitis, 5; radiation fibrosis, ; sclerosing hemangioma, ; rheumatoid nodules, ; granuloma, 2; nocardia, ; infarct, ; hamartoma, 4; scar, ; cytomegalovirus pneumonia, l), metastatic malignancy in 20 patients, and bronchogenic carcinoma in 3 patients. Five patients found at thoracoscopic pulmonary resection to have bronchogenic cancer had adequate pulmonary function and therefore underwent formal segmentectomy (3) or lobectomy (2). Thoracoscopic pulmonary resection was the only operation performed on patients with benign disease, patients with metastatic lesions, and selected patients with limited stage bronchogenic carcinoma at increased risk for thoracotomy. Continued success with thoracoscopic resection may have a significant impact on the operative management of carefully selected patients with peripheral pulmonary lesions. (Ann Thorac Surg 2992;54:425-20) dvances in endoscopic equipment and a growing A enthusiasm with minimally invasive operations have resulted in the emergence of a new therapeutic modality in general thoracic surgical practice, videoassisted thoracic surgery (VATS). Video-assisted thoracic surgery is an extension of the time-honored diagnostic approach to pleural disease, thoracoscopy [l]. The role of thoracoscopy has been expanded to now serve as a useful modality for the diagnosis and management of many intrathoracic problems. This report describes our recent experience with VATS to achieve closed, parenchyma-sparing lung resection. Video-assisted thoracic surgery was chosen as a potentially less morbid alternative to thoracotomy for carefully selected patients with newly found peripheral pulmonary lesions. Presented at the Twenty-eighth Annual Meeting of The Society of Thoracic Surgeons, Orlando, FL, Feb %5, 992. Address reprint requests to Dr Landreneau, Section of Thoracic Surgery, University of Pittsburgh, Montefiore University Hospital, 5th Floor East, 3459 Fifth Ave, Pittsburgh, PA 523 Material and Methods Pa tien t Selection Over an -month period (Dec 990 to Nov 99), 6 consecutive patients with peripheral pulmonary lesions were managed with thoracoscopic wedge resection by us. Thirty-one women and 30 men having a mean age of 57.9 f 6.2 years made up this study group. Most patients (n = 33) had undiagnosed pulmonary parenchymal lesions (Fig ). A subset of patients with a diagnosis of bronchogenic carcinoma with impairment in cardiopulmonary reserve, advanced age, confounding medical problems, or with a synchronous extrathoracic visceral malignancy (n = 8) were managed with primary thoracoscopic nonanatomic wedge resection of their pulmonary malignancy. Several other patients (n = 20) with suspected metastatic pulmonary spread from known visceral malignancies were also among this group undergoing primary thoracoscopic wedge resection. Operative Procedure All VATS was performed under general anesthesia. Double-lumen endotracheal intubation was used to allow contralateral ventilation and ipsilateral collapse of the lung. The usual preparation and draping of the patient in a lateral decubitus position for standard thoracotomy was by The Society of Thoracic Surgeons /92/$5.00

2 46 L.ANDRENEAU ET AL THORACOSCOPIC PULMONARY RESECTION Ann Thorac Surg 992;54:45-20 Fig. Outer third, undiagnosed pulmonary parenchymal lesion ideally suited for thoracoscopic uiedge resection. then performed [l-3. A trocar -mm in diameter (Autosuture Surgiport Trocars; United States Surgical Corp, Norwalk, CT) was introduced into the thoracic cavity, usually through the sixth intercostal space in the mid to posterior axillary line. A wide-angle, zero-degree thoracoscope with an operating port (Olympus Corporation, Lake Success, NY, or Karl Storz Endoscopic America Inc, Culver City, CA) was introduced through this trocar, and exploration of the thoracic cavity was performed. Intrapleural adhesions were divided by sharp dissection with endoscopic scissors. Two additional trocars were usually introduced to allow manipulation and examination of the entire lung (Fig 2). Collapse of the lung facilitated identification of most subpleural lesions, which became effaced against the surrounding atelectatic pulmonary tissue. Slight enlargement of one of the trocar sites to allow introduction of a palpating finger was used to identify deeper lesions. Preoperative computed tomographic scanning and hook wire localization has recently been used to identify small deep lesions [4]. Most lesions on the flat surface of the lung were resected using the neodymium:yttrium-aluminum garnet (Nd:YAC) laser (Model 704, KTPh'A9995; Laserscope Inc, San Jose, CA) in a noncontact mode. The laser was calibrated and activated at a 35 W, continuous setting. For smoke evacuation during laser resections, a 28F chest tube was placed through one of the trocar sites and connected to a smoke evacuation system (LASE System, Model SE--BII; LASE Inc, Cincinnati, OH). Lesions present on the edge of the lung were usually resected with an endoscopic stapler (Autosuture Multi-Fire Endo GIA , No ; United States Surgical Corp). Some lesions deeper within the lung or at a difficult angle for the endoscopic stapler required a combination of Nd:YAG laser and endoscopic stapler to accomplish an expedient and safe wedge resection (Figs 3, 4). Resection was accomplished using the Nd:YAG laser alone in 3 patients, endoscopic stapling alone in 29 patients, and a combination of Nd:YAG laser and stapling in 25 patients. All lesions were excised with a 0.5 cm or greater rim of normal lung parenchyma. During laser resections, hemostasis was obtained along the margin of resection with the defocused Nd:YAG laser Fig 2. Basic trocar positioning and camera orientation at proper distance and orientation to the pulmonary lesion for video-assisted thoracoscopic resection. for smaller vessels (<2 mm) or with the endoscopic clip applier (Autosuture Endoscopic Clip ML, No. 7665; United States Surgical Corp) for larger vessels. After completion of the wedge resection, specimens smaller than mm in diameter were withdrawn directly through a Fig 3. Primary method used of combining Nd:YAG laser and the endoscopic stapler for the video-assisted thoracoscopic resection of deeper seated pulmonary lesions.,

3 Ann Thorac Surg 992; LANDRENEAU ET AL 47 THORACOSCOPIC PULMONARY RESECTlON Fig 4. Alternate method used of combining Nd:YAG laser and the endoscopic stapler for the video-assisted thoracoscopic resection of deeper seated pulmona y lesions. Note application of endoscopic clips for larger pulmonary arterial branches illustrated in (b) and (c). one of the trocars. Larger specimens were placed within a sterile glove that was introduced into the chest and then removed by enlarging one of the trocar incisions to comfortably accommodate the lesion. These maneuvers allowed for the specimen to be removed intact and reduced the potential for spillage of tumor into the thoracic cavity or trocar tract. Hemostasis was assured at the margins of resection, and a single 28F chest tube was then guided under direct visualization to the apex of the chest through one of the trocar sites. The procedure was terminated after closure of the remaining trocar sites and establishing 20 cm H,O suction to the chest tube evacuation system. All patients received g of ceftriaxone (Rocephin; Roche Laboratories, Division of HoffmadLaRoche Inc, Nutley, NJ) intravenously in the operating room before the start of the procedure and two doses at 2-hour intervals after the procedure. Results All peripheral pulmonary lesions diagnosed roentgenographically (roentgenogram or computed tomographic scan) in this VATS series were able to be thoracoscopically located and resected. During this same period, 4 patients undergoing thoracoscopic exploration for peripheral lesions were converted to open thoracotomy after the lesions were identified to be in a hilar location inappropriate or unsafe for thoracoscopic wedge resection. The discrepancy between the number of resections and patients in this series results from multiple wedge resections performed in patients with interstitial lung disease and other patients with multiple discrete nodules ultimately found to be metastases. The histologic evaluation of the 85 lesions resected in these 6 patients is as follows: 46 benign lesions in 28 patients Interstitial fibrosis/pneumonia Nocardia Rheumatoid Hamartoma Anthroscilicosis Pulmonary infarctlscar Granulomata Sclerosing hemangioma Sarcoid nodules Cytomegalovirus pneumonitis malignant lesions in 33 patients 3 primary lung cancers in 3 patients Adenollarge cell 6*;t Bronchioalveolar 3t Squamous 2t Carcinoid Small Cell 26 metastatic cancers in 20 patients Sarcoma 2 Lymphoma 4 Colon 3 Breast 3 Renal 3 Hepa tocellular 0 Melanoma * Subsequent lobectomy was performed in 2 patients. ' Subsequent formal segmentectomy was performed in 3 patients ( each with bronchioalveolar, squamous, and adenocarcinoma).

4 48 LANDRENEAU ET AL THORACOSCOPIC PULMONARY RESECTION Ann Thorac Surg 992; We emphasize that VATS was primarily used as a diagnostic modality for most of these lesions. In all 6 patients, adequate tissue for pathologic diagnosis was obtained using VATS. The management of primary malignant lesions was individualized, with the decision for more extensive concomitant surgical treatment being dictated by the cardiopulmonary reserve, age, and associated medical problems of the patient. A forced expiratory volume in second of less than.2 L, age greater than 70 years, or concomitant extrathoracic malignancy were important characteristics among patients with malignant lesions managed exclusively with thoracoscopic wedge resection of their primary pulmonary malignancy. Preliminary mediastinoscopic examination was performed on all patients with computed tomographic scan evidence of enlarged paratracheal lymph nodes (>.0 cm in diameter). Intraoperative thoracoscopic mediastinal lymph node sampling was performed to ensure that we were approaching early stage disease when malignancy was diagnosed. Five patients with adequate pulmonary reserve undergoing a diagnostic thoracoscopic resection were found to have a primary bronchogenic malignancy by frozen section analysis. These patients then were converted to an open muscle-slparing thoracotomy for formal pulmonary resection [5]. Notably, the tissue margins of the previous wedge resection were clear of tumor in all of these formal segmentectomy and lobectomy specimens removed. Most VATS metastasectomies were performed to diagnose, prciject prognosis, and provide direction for further systemic therapy among patients with a history of malignancy having multiple pulmonary nodules identified by chest roentgenography and computed tomography. Three patients having favorable primary tumor histology (renal cell, colon, melanoma) with single pulmonary nodules identified by computed tomographic scanning (and confirmed by digital palpation of the lung) underwent thoracoscopic resection alone in an attempt to provide a potential survival benefit [6]. The mean diameter of the resected lesions was.3 cm with a range of 0.4 to 2.7 cm. In all cases, intraoperative blood loss was minimal. One patient with a myelophthisic anemia and associated coagulopathy had a serious decrease in hematocrit during the postoperative period which required component transfusion therapy. The mean duration of chest tube drainage and postoperative hospital stay were and 5.7 & 4.9 days, respectively. The average operative time (incision to dressing) was minutes. There were few perioperative complications and only one late postoperative death occurring 38 days after VATS from late respiratory failure unrelated to the operative procedure. Complications included atelectasis (2), pneumonia (2), bleeding (l), and prolonged air leak (3). No patient required reoperation. The 3 patients having postoperative lobar atelectasis responded to appropriate attention to pulmonary hygiene. Three patients in whom down lung pneumonia developed were successfully treated with broad-spectrum antibiotics. All peripheral bronchopleural fistulas resolved with conservative mea- sures at 8, 2, and 34 days postoperatively. The one prolonged bronchopleural fistula occurred in a patient with rheumatoid arthritis on high-dose preoperative and perioperative prednisone therapy who underwent Nd: YAG laser resection of a rheumatoid pulmonary nodule. We now rely primarily on endoscopic stapling techniques to perform thoracoscopic wedge resection lung biopsy for patients on high-dose steroidal therapy. Comment Thoracoscopy is an established diagnostic modality enjoying increased attention as minimally invasive surgical concepts pervade general thoracic surgery. For many surgeons, thoracoscopy s primary role was for the diagnosis and occasional treatment of pleural disorders [7, 8. Others have used it to perform limited lung biopsies in patients with diffuse infiltrates [l, 2. Success with open, laser-assisted pulmonary resections and improvements in endoscopic surgical equipment have now allowed for video-assisted thoracoscopic management of many intrathoracic conditions [3, 9, lo]. Recent reports have described video-assisted thoracoscopic management of a variety of mediastinal conditions and for the ablation of apical bullous disease [ll-4. We were thus encouraged to employ VATS for the diagnosis and management of carefully selected patients with peripheral pulmonary lesions [3]. In this series, all target peripheral pulmonary lesions identified by preoperative high-resolution computed tomography were able to be located at exploratory thoracoscopy. An additional benefit obtained at thoracoscopic exploration was a panoramic view of the pleural and mediastinal surfaces superior to that seen through most standard thoracotomy approaches. Endoscopic visual identification of most lesions was achieved because of their subpleural location or as a result of effacement of the pulmonary lesion against the surrounding atelectatic lung. Palpation with endoscopic forceps or a probing finger through a trocar site were also effective localization techniques; however, we have come to rely on computed tomography-directed hook wire localization for most small, deeper seated parenchymal lesions [4]. Our impression is that thoracoscopic resection may result in reduced perioperative morbidity and a shortened hospital stay for many patients requiring resection of peripheral pulmonary lesions. The postoperative hospital stay after video-assisted thoracoscopic resection in this series compares favorably with recent series of open resection of peripheral lung lesions reporting mean hospital stays of 7 to 0 days [9, 0, 5. Additionally, postthoracotomy pain may be lessened using the minimally invasive VATS approach. Studies comparing perioperative pain, shoulder girdle function, and postoperative morbidity presently underway at our institution (and others) may help to clarify the objective clinical differences between VATS and open thoracic surgical procedures [5, 6. Our approach to the undiagnosed peripheral pulmonary nodule remains a conscientious preoperative work-up

5 Ann Thorac Surg 992;54:45-20 LANDRENEAU ET AL 49 THORACOSCOPIC PULMONARY RESECTION including computed tomography of the chest (and percutaneous, transbronchial, or cervical mediastinoscopic biopsy when indicated) [3, 7. Thoracoscopic resection is now our preferred approach, in lieu of thoracotomy, for most small (<3 cm in diameter), peripheral undiagnosed pulmonary lesions. The need for an open resection can usually be determined by the preoperative morphology and location of the pulmonary lesion [7]. Thoracotomy, with its attendant morbidity, can be avoided for many patients with benign or metastatic malignant pulmonary lesions. The results of frozen section pathologic analysis of the VATS resected specimen will assist in directing the need for a further operation among those patients with primary bronchogenic malignancies. Although this remains the subject of continued debate, a select group of patients with pathologically confirmed limited stage bronchogenic carcinoma with impairment of cardiopulmonary reserve, advanced age, or confounding other medical problems may also be best managed by thoracoscopic wedge resection as definitive operative therapy [3, 5, 8-20]. We thank Pamela Ritter, RN, for her assistance with the assimilation of data for the manuscript. References. Brandt H, Loddenkemper R, Mai J. Atlas of diagnostic thoracoscopy. Indications-techniques. New York: Thieme Medical Publishers, 985: Thomas P. Thoracoscopy: an old procedure revisited. In: Kittle CF, ed. Current controversies in thoracic surgery. Philadelphia: W.B. Saunders, 986:lOl Landreneau RJ, Herlan DB, Johnson JA, Nawarowong W, Boley TM, Ferson PF. Thoracoscopic Nd:YAG laser-assisted pulmonary resection. Ann Thorac Surg 99;52: Mack M, Gordon M, Postma T, et al. Percutaneous localization of pulmonary nodules for thoracoscopic lung resection. Ann Thorac Surg 992;53: Hazelrigg SR, Landreneau RJ, Boley TM, et al. The effect of muscle-sparing versus standard posterolateral thoracotomy on pulmonary function, muscle strength and postoperative pain. J Thorac Cardiovasc Surg 99;0: Kern KA, Pass HI, Roth JA. Treatment of metastatic cancer to lung. In: Rosenberg SA, ed. Surgical treatment of pulmonary metastases. Philadelphia: J.B. Lippincott, Page RD, Jeffrey RR, Donnelly RJ. Thoracoscopy: a review of 2 consecutive surgical procedures. Ann Thorac Surg 989; 48: Menzies R, Charbonneau M. Thoracoscopy for the diagnosis of pleural disease. Ann Intern Med 99;4: Landreneau RJ, Hazelrigg SR, Johnson JA, Boley TM, Nawarawong W, Curtis JJ. Neodymium:yttrium-aluminum garnet laser-assisted pulmonary resections. Ann Thorac Surg 99;5: LoCicero J, Frederiksen JW, Hartz RS, Michaelis LL. Laserassisted parenchyma-sparing pulmonary resection. J Thorac Cardiovasc Surg 989; Landreneau RJ, Dowling RD, Castillo WM, Ferson PF. Thoracoscopic resection of an anterior mediastinal tumor. Ann Thorac Surg 992;54: Ryckeran FC, Rodger B. Thoracoscopy for intrathoracic neoplasms in children. J Pediatr Surg 982;7: Landreneau RJ, Dowling RD, Ferson PF. Thoracoscopic resection of a posterior mediastinal mass. Chest (in press). 4. Torre M, Belloni P. Nd:YAG laser pleurodesis through thoracoscopy: new curative therapy in spontaneous pneumothorax. Ann Thorac Surg 989; Miller JI, Hatcher CR. Limited resection of bronchogenic carcinoma in the patient with marked impairment of pulmonary function. Ann Thorac Surg 987;44: Dajczman E, Gordon A, Kreisman H, Wolkove N. Long term postthoracotomy pain. Chest 99;99:27M. 7. Lillington GA. Management of solitary pulmonary nodules. Dis Mon 99; Ginsberg RJ, for the Lung Cancer Study Group. Limited resection for peripheral TlNO tumors. Lung Cancer 988;4 A Erret LE, Wilson J, Chiu RC, et al. Wedge resection as an alternative procedure for peripheral bronchogenic carcinoma in poor-risk patients. J Thorac Cardiovasc Surg 985;90: Keagy BA, Pharr WF, Bowes DE, Wilcox BR. A review of morbidity and mortality in elderly patients undergoing pulmonary resection. Am Surg 984;50:23-6. DISCUSSION DR MICHAEL J. MACK (Dallas, TX): I would like to acknowledge the contribution of Dr Landreneau and Dr Hazelrigg in two areas of thoracic surgery: one is the use of lasers for lung resections and the second is their pioneering efforts in innovative techniques in thoracoscopy. Our own practice has been significantly advanced by the contributions that they have made. What we have seen here is a marriage of the two techniques of both laser lung resection and thoracoscopy for the treatment of parenchymal lung disease. I have three questions for Dr Landreneau. The first is that we have all run across frustrations thoracoscopically in locating nodules that are not pleural based or immediately subpleural or that are small in size because the ability to perform bimanual palpation has been lost. Can you describe the techniques that you go through to locate lesions? Second, would you further define where you feel the role of the laser is in thoracoscopic lung resection? Specifically, do surgeons who are going to be performing thoracoscopic lung resection need to go out and get trained in laser techniques, or if their hospital does not have a laser, do they need to go out and have their hospital buy a laser, or are other techniques that have been described, such as precision electrocautery or argon beam coagulation, sufficient in place of the laser? And, third, would you describe how you approach primary lung cancer now that you have another approach to address this? DR LANDRENEAU: The localization of small pulmonary nodules can be difficult. Our first approach is to put a finger in through one of the trocar sites and try to palpate the lesion. Second, we also do this on all metastatic cases to examine the pulmonary parenchyma. Through one of the other trocar sites (or incisional sites) we introduce a Pennington clamp (or small Duval clamp) and bimanually palpate and identify the location of the lesion based on preoperative computed tomographic scan guidance. Having the Duval clamp in place next to the lesion, we then introduce the endoscopic stapler alongside it, fire the stapler,

6 420 LANDRENEAU ET AL THORACOSCOI IC PULMONARY RESECTION Ann Thorac Surg 992;54:4520 reaffirm the location of the staple line beneath the lesion, and then fire a counter staple line which completes the wedge resection. For deep or very small lesions, we have used an approach that will be described in The Annals of Thoracic Surgery soon that uses a percutaneous needle localization technique. The patient goes to the computed tomographic scanner the morning of operation and the same hook wire that is used for breast biopsies is introduced percutaneously and confirmed by computed tomographic scan to be in a position next to the lesion. We will also introduce 0. ml of methylene blue into the area through the needle tract to facilitate the localization. The endoscopic stapler or the Nd:YAG laser is then used to resect around the area of the needle and methylene blue imprint. We have been able to localize all lesions sought in this way, and I think it is a very important adjunct to this thoracoscopic approach. Now, as far as the issue of lasers versus precision electrocautery excision, I think that there are sufficient data in the literature to allow me to say that I think that the YAG laser is a better tool for nonanatomic wedge resection of the lung. I think that a stapled resection should be performed whenever feasible, but deep lesions or thick lesions on the flat surface of the lung may not be safely approached with the stapler alone. This opinion is based on work primarily performed by Dr Walt Wolfe from Duke University and Joe LoCicero at New England Deaconess Hospital, who showed that in animal and clinical studies, better control of air leak, hemostasis, and improved deep margins of resections are achieved with the Nd:YAG laser. Finally, I bring up a controversial issue. The Lung Cancer Study Group data were recently analyzed with regard to the effectiveness of wedge resection versus lobectomy in the management of pathologic stage I non-small cell carcinoma of the lung. Patient survival was equivalent between groups, although local recurrence was greater in the wedge resection group. Interestingly, these results parallel the earlier experiences of Dr Erret of Montreal and Dr Joseph Miller of Emory regarding limited resection for early stage non-small cell lung cancer. I think that the thoracoscopic approach to wedge resection of small peripheral lung cancers found in the patient with impaired pulmonary function may be a good alternative resective approach after adequate staging of their disease. DR LOYDE H. ROMERO (Medford, MA): I too rise to congratulate Dr Landreneau on his fine work in thoracoscopic pulmonary resections. We found that experimentally to remove a larger segment of lung, ie, a lobe, you needed a 2-inch incision, and to do this we have used a bivalved thoracoscope with direct lighting. You get three-dimensional viewing and normal tissue coloration. I have developed the following surgical technique for a videoassisted lobectomy. A 2-inch incision is made in the fifth intercostal space and the surgical thoracoscope is inserted into the chest cavity. A 2-mm trocar is inserted in the sixth intercostal space anterior to the surgical thoracoscope. This port is used for telescopic viewing and later for insertion of the Endo GIA stapling device. The left lower lobe pulmonary artery, the bronchus, and the vein are ligated sequentially with staplers, and all that is left is the fissure to take down. The fissure is opened using the electrocautery and the lobe is eased out by rocking it back and forth. Once the lobe is out, two chest tubes are placed and the incision is closed. We are using a bivalved thoracoscope. It has two fiberoptic light bundles powered by a high-intensity xenon light source. The blades are expandable both at the base and at the apex so that you can actually put the scope into the fissure and use the scope as a retractor to retract your lobes. The working area of the vessels and the bronchus are then in direct view through the thoracoscope. I think the real advantage to this type of operation is in preventing the spreading of the ribs and therefore the attendant intercostal neuritis and the subsequent postthoracotomy pain.