Video-assisted thoracic surgery (VATS) can be used for all of the procedures listed below, but may not be indicated or may be a secondary option in some. In which of the following conditions is VATS most reasonable?
A. bleb resection for an initial spontaneous pneumothorax
B. diagnostic lung biopsy for a critically ill patient on a ventilator
C. drainage of a malignant pericardial effusion secondary to unresectable lung cancer
D. resection of a 5.2 cm indeterminate pulmonary nodule in a low-risk patient
E. wedge resection to treat a Stage I lung cancer in a patient with limited pulmonary reserve
Answer E
Although video-assisted thoracic surgery (VATS) has many applications in thoracic surgery, it needs to be applied appropriately. VATS is an excellent method of surgically managing spontaneous pneumothorax, but operation is not usually recommended for a first occurrence. The recurrence rate is only 20-30% with a chest tube alone and hence surgery would subject 70-80% of patients to an operation that they do not need.
VATS is an excellent technique for lung biopsy in the ambulatory setting. It is not recommended for a critically ill patient already on a ventilator. Exchanging a standard endotracheal tube for a double-lumen tube can be risky, and a marginal patient would not tolerate single lung ventilation well. In addition, hospital stay would not be shortened. Expeditious thoracotomy without single lung ventilation is the safest approach.
VATS is a valuable way to drain pericardial fluid. Its greatest benefit over subxiphoid drainage or needle pericardiocentesis is the possibility of a lower long-term recurrence rate. Because the patient with a documented malignant pericardial effusion from lung cancer has a short expected life span (< 6 months), the simplest method of drainage should be used. Catheter drainage with instillation of sclerosing agents has worked well in this group of patients, so VATS offers no advantages for most patients.
VATS resection is satisfactory for resection of most indeterminate nodules, and thoracotomy can be avoided for many patients. VATS is best used for peripheral lesions (in the outer one-third of the lung) that are less than 3 cm in diameter. A 5.2 cm lesion may be difficult to resect and extract by VATS, and at this size it is likely to be malignant. Thoracotomy for biopsy and probable lobectomy is a better option for most patients.
If an equivalent resection can be performed using minimally invasive techniques then VATS is an acceptable option. Wedge resection is an inferior operation for a low-risk patient with lung cancer whether an open or minimally invasive technique is used. For a patient with poor preoperative pulmonary function, however, a limited resection offers the best chance of cure for limited stage lung cancer. If single lung ventilation is tolerated, VATS is a reasonable approach with possible recovery advantages.
Landreneau RJ, Mack MJ, Hazelrigg SR, et al. Video-assisted thoracic surgery: basic technical concepts and intercostal approach strategies. Ann Thorac Surg 1992;54:800-807.
Video-assisted thoracic surgery is emerging as a viable approach to a number of intrathoracic disorders. Technical difficulties related to improper instrument selection and suboptimal intercostal operative access can reduce the utility of, and the enthusiasm for, the video-assisted thoracic surgical approach. This report describes the intercostal access strategy and the instrument positioning that we now prescribe for many video-assisted thoracic surgical procedures. These approaches have become refined during the course of our experience with 467 patients undergoing video-assisted thoracic operations over the last 18 months.
Hazelrigg SR, Landreneau R, Mack M, et al. Thoracoscopic stapled resection for spontaneous pneumothorax. J Thorac Cardiovasc Surg 1993;105:389-393.
Video-assisted thoracoscopy has recently evolved as an alternative to thoracotomy for several thoracic disorders. Spontaneous pneumothorax may be ideally suited for thoracoscopic management. Stapling of apical blebs and pleurodesis or pleurectomy can now be performed thoracoscopically in a fashion identical to the standard operation done through a lateral or axillary thoracotomy. We compared our results with thoracoscopic management of spontaneous pneumothorax in 26 patients (group I) with a group of 20 patients previously subjected to axillary thoracotomy (group II). Indications for operation, sex distribution, and average age (group I, 32.3 years; group II, 33.7 years) were comparable. Hospital stay was less in group I (2.88 +/- 0.99 days versus 4.47 +/- 1.07 days; p = 0.07), as was the use of parenteral narcotics after 48 hours (2/26 = 7.7% versus 14/20 = 70%; p = 0.01). There have been no recurrences to date (mean follow-up, 8 months) in the thoracoscopic group. Video-assisted thoracoscopic management of spontaneous pneumothorax allows performance of the standard surgical procedure while avoiding the thoracotomy incision. Video-assisted thoracoscopic management is safe and offers the potential benefits of shorter hospital stays and less pain.
Mack MJ, Landreneau RJ, Hazelrigg SR, Acuff TE. Video thoracoscopic management of benign and malignant pericardial effusions. Chest 1993;103:390S-393S.
Surgical management of symptomatic benign and malignant effusive pericarditis is often required. Twenty-two patients with medically recalcitrant effusive, nonconstrictive pericarditis underwent pericardial resection by a video-assisted thoracoscopic surgical (VATS) technique (9 malignant, 13 benign). Pericardiectomy, resulting in complete drainage of the pericardial space and control of patient symptoms was accomplished routinely. Ipsilateral pleural effusions, originally present in 11 patients, were also managed. The VATS pericardiectomy was well tolerated even by gravely ill patients. This approach should be considered as an alternative to lateral thoracotomy or subxiphoid pericardial window for the surgical management of patients with symptomatic benign and malignant pericardial effusions.
Ferson PF, Landreneau RJ, Dowling RD, et al. Comparison of open versus thoracoscopic lung biopsy for diffuse infiltrative pulmonary disease. J Thorac Cardiovasc Surg 1993;106:194-199.
BACKGROUND: Patients with diffuse pulmonary infiltrates often require biopsy for a diagnosis. Standard operative therapy, open wedge resection via thoracotomy, is associated with known morbidity. We hypothesized that closed thoracoscopic wedge resection may result in reduced morbidity and decreased duration of hospital stay. This retrospective study compares open resection with thoracoscopic wedge resection in patients with diffuse pulmonary infiltrates. METHODS: Seventy-five patients with diffuse pulmonary infiltrates underwent diagnostic lung biopsy. Patients requiring mechanical ventilation and high levels of pressure support before biopsy were excluded from the study. Between March 1987 and September 1991, a total of 28 patients underwent open wedge resection via lateral thoracotomy. Since April 1991, a total of 47 patients underwent thoracoscopic resection. RESULTS: There was no difference between the groups in age, sex, presence of immunosuppression, or final pathologic diagnosis. Adequate tissue was obtained for pathologic diagnosis in all patients of both groups. All surgeons believed that thoracoscopic biopsy provided better visualization of the entire lung than did a limited thoracotomy. Mean operative time was 69 minutes for open biopsies and 93 minutes for thoracoscopic biopsies [p = 0.038]. Mean duration of chest tube drainage was not significantly different between the two groups. Duration of hospital stay was significantly less for thoracoscopic biopsy (4.9 days) than for open biopsy (12.2 days) (p = 0.018). Fourteen of 28 open biopsies resulted in complications compared with 9 of 47 closed biopsies (p = 0.009). There were 6 deaths among patients having open biopsies and 3 deaths among those having closed biopsies (p = not significant). CONCLUSION: A significant decrease in hospital stay was noted with thoracoscopic biopsy when compared with lung biopsy via the standard open approaches. Thoracoscopy provided excellent visualization and allowed for wedge resection that provided adequate tissue for diagnosis in patients with diffuse pulmonary interstitial disease.
Mack MJ, Hazelrigg SR, Landreneau RJ, Acuff TE. Thoracoscopy for the diagnosis of the indeterminate solitary pulmonary nodule. Ann Thorac Surg 1993;56:825-832.
Traditional nonoperative diagnostic approaches to the indeterminate solitary pulmonary nodule include bronchoscopy and percutaneous needle biopsy. Although both methods are minimally invasive, the diagnosis of the small, peripheral nodule may remain elusive. Open thoracotomy is often required when these methods fail to obtain a diagnosis. Between January 1991 and June 1992, 242 patients with indeterminate solitary lung nodules underwent thoracoscopic excisional biopsy as the primary diagnostic method. Wedge excisions of the nodules were all performed by thoracoscopic techniques using an endoscopic stapler alone (72%), neodymium:yttrium-aluminum garnet laser (18%), or both (10%). A definite diagnosis was obtained in all patients. Two patients required conversion to thoracotomy to locate the nodule (both malignant). A benign diagnosis was obtained in 127 patients (52%) and a malignant diagnosis in 115 (48%). Of the malignant nodules, 51 (44%) were primary lung cancer and 64 (56%) were metastases. All patients diagnosed with primary lung cancer having adequate pulmonary reserve (n = 29) underwent formal open lung resection during the same procedure. There was no mortality, and significant morbidity was limited to atelectasis in 3 patients (1.2%), pneumonia in 2 patients (0.8%), and prolonged air leak more than 7 days in 4 patients (1.6%). Average hospital stay for patients having thoracoscopy only (n = 213) was 2.4 days (range, 1 to 12 days). Thoracoscopy offers a minimally invasive approach for the diagnosis of the indeterminate solitary nodule. It has advantages over traditional diagnostic methods of being virtually 100% sensitive and 100% specific with no mortality and minimal morbidity.