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Mastering Thoracoscopic Upper Lobectomy - AATS Focus on Thoracic Surgery Lung Cancer

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					           Mastering
 Thoracoscopic Upper Lobectomy

AATS Focus on Thoracic Surgery: Lung Cancer
                        Boston
                    November 17, 2012

                    Thomas A. D’Amico MD
   Professor and Vice Chair of Surgery, Chief Thoracic Surgery
                 Duke University Medical Center
                         Chair, NCCN
                                Disclosure

   • No conflicts related to this presentation




Mastering Thoracoscopic Upper Lobectomy
    Thoracoscopic Lobectomy is Associated with
    Lower Morbidity Compared to Thoracotomy
       Villamizar N, et al. J Thorac Cardiovasc Surg 2009; 138: 419-425
                                          J Thorac Cardiovasc Surg 2009; 138: 419-425

             Western Thoracic Surgical Association 2008

   • Compared outcomes after lobectomy (n=1079)
   • Thoracoscopic (n=697) vs Thoracotomy (n=382)
   • Propensity analysis (n=284 each) matching preoperative
     variables and stage
   • Analysis of postoperative complications
Mastering Thoracoscopic Upper Lobectomy
    Propensity Matching: Greedy 5 to 1 Algorithm
Demographics       Fx Status     Comorbidity   PFTS         Other
    Age         Zubrod score         HTN       FEV1         Stage
   Gender            ASA             CAD       FVC        Smoking
                     BMI             CHF       DLCO      Steroid Use
                                      DM                Preop Chemo
                                     CVD                 Preop XRT
                                      CRI               Elective Status

Thoracotomy                                           Thoracoscopy
  N=284                                                  N=284
Mastering Thoracoscopic Upper Lobectomy
               Outcomes: Propensity Matched
Feature                Thoracotomy (n=284)   VATS (n=284)      P
At least 1 Cx                 49%               31%         0.0001
Atrial Fibrillation           21%               13%           0.01
Atelectasis                   12%                5%          0.006
Prolonged air leak              19%              13%         0.05
Pneumonia                       10%               5%         0.05
Transfusion                     13%               4%         0.02
Renal Failure                    5%               1%         0.02
Death                            5%               3%         0.20
CT duration (d)                   4                3        0.0001
Length of stay (d)                5                4        0.0001
Mastering Thoracoscopic Upper Lobectomy
               Outcomes: Propensity Matched
Feature                Thoracotomy (n=284)   VATS (n=284)      P
At least 1 Cx                 49%               31%         0.0001
Atrial Fibrillation           21%               13%           0.01
Atelectasis                   12%                5%          0.006
Prolonged air leak              19%              13%         0.05
Pneumonia                       10%               5%         0.05
Transfusion                     13%               4%         0.02
Renal Failure                    5%               1%         0.02
Death                            5%               3%         0.20
CT duration (d)                   4                3        0.0001
Length of stay (d)                5                4        0.0001
Mastering Thoracoscopic Upper Lobectomy
                                 STS Database: % Thoracoscopic Lobectomy
                                                                         * 5/2010


                                                                       45%
                                         Thoracoscopy
Number of Pulmonary Resections




                                         Thoracotomy




                                  <10%


     Ceppa DP, et al. Ann Surg Lobectomy
Mastering Thoracoscopic Upper2012 Aug 3. [Epub ahead of print] PMID: 22868367
              Thoracoscopic Upper Lobectomy

   •    Represents clear majority of VATS lobectomy
   •    Greatest degree of anatomic variation
   •    Higher likelihood of conversion to thoracotomy
   •    Higher likelihood of becoming pneumonectomy

   • Mastery of VATS Upper Lobectomy is essential
     to success
Mastering Thoracoscopic Upper Lobectomy
2 incisions: Camera port (1 cm) + Access incision (4.5 cm)

                            Duke Approach




  Thoracoscopic Lobectomy: Duke Approach
Mastering Thoracoscopic Upper Lobectomy
2 incisions: Camera port (1 cm) + Access incision (4.5 cm)

                            Duke Approach




  Thoracoscopic Lobectomy: Duke Approach
Mastering Thoracoscopic Upper Lobectomy
                          Right Upper Lobectomy

                                    Ports
                                            Bronchus
                                            Pulmonary artery
                                            Pulmonary vein




  Thoracoscopic Lobectomy: Duke Approach
Mastering Thoracoscopic Upper Lobectomy
                         Duke Thoracic
             Thoracoscopic Upper Lobectomy:
                    General Principles
   •   Hilar dissection, avoidance of fissures
   •   Posterior pleural incision and dissection
   •   Dissection from anterior to posterior
   •   Mediastinal lymph node dissection

   • Have a defined plan but flexibility may be
     necessary
Mastering Thoracoscopic Upper Lobectomy
             Right Upper Lobectomy: Standard

   1.   Upper Lobe Pulmonary Vein
   2.   Truncus Anterior
   3.   Posterior Ascending Artery
   4.   Upper Lobe Bronchus
   5.   Horizontal Fissure
   6.   Oblique Fissure

Mastering Thoracoscopic Upper Lobectomy
        Right Upper Lobectomy: Bronchus First

   1.   Upper Lobe Bronchus
   2.   Truncus Anterior
   3.   Upper Lobe Pulmonary Vein
   4.   Posterior Ascending Artery
   5.   Horizontal Fissure
   6.   Oblique Fissure

Mastering Thoracoscopic Upper Lobectomy
              Left Upper Lobectomy: Standard

   1.   Upper Lobe Pulmonary Vein
   2.   Apical and Anterior Arterial Branches
   3.   Upper Lobe Bronchus
   4.   Posterior and Lingular Arterial Branches
   5.   Fissure



Mastering Thoracoscopic Upper Lobectomy
          Left Upper Lobectomy: Hilar Tumors

   1.   Upper Lobe Pulmonary Vein
   2.   Lingular and Posterior Arterial Branches
   3.   Transect Upper Lobe Bronchus
   4.   Apical and Anterior Arterial Branches
   5.   Fissure
   6.   Staple Upper Lobe Bronchus

Mastering Thoracoscopic Upper Lobectomy
                                     Lobectomy
               Troubleshooting VATSThorac Surg 2005; 79: 1744 - 1752
                                 Ann
                 Demmy TL, Ann Thorac Surg 2005; 79: 1744 - 1752


   •   Technical Considerations
   •   Instrumentation
   •   Retraction
   •   Exposure
   •   Fissures
   •   Management of Bleeding
   •   Specimen Removal
Mastering Thoracoscopic Upper Lobectomy
                 Mastering Upper Lobectomy

   1.   Central or large tumors
   2.   Adhesions
   3.   Retraction and hilar dissection
   4.   Bleeding from PA
   5.   Difficult Fissure
   6.   Bag won’t fit out

Mastering Thoracoscopic Upper Lobectomy
                     Large or Central Tumors

   • Contributing factors: how big, how central, any
     calcified lymph nodes?
   • Pneumonectomy vs sleeve lobectomy?
   • It never hurts to put the scope in first
   • Experience with retraction will improve angles
     and simplify dissection and stapling
   • Sometimes opening the fissure will help (video)
Mastering Thoracoscopic Upper Lobectomy
                                Adhesions

   • If expected, use access incision first and start
     with single port exposure and ahesiolysis
   • Only 1 cm of space is needed; withdraw port on
     scope to improve access
   • When possible, add 2nd port and switch camera
   • Extended electrocautery wand is essential
   • Most difficult areas: apex and diaphragm
Mastering Thoracoscopic Upper Lobectomy
                                Retraction

   • Rarely is more than 1 retracting instrument
     required
   • Larger tumors: successful retraction is more
     difficult and more important
   • Rotate table anteriorly and posteriorly as needed
   • The lung has an axis and the lobe can rotate
     around it to improve angles of dissection

Mastering Thoracoscopic Upper Lobectomy
                           Hilar Dissection

   • Goal of dissection is to LENGTHEN the hilum
   • Begin with adequate posterior dissection for upper
     and lower lobes
   • When vessels appear difficult. clear all nodal
     tissue (N1 and N2) prior to dissection of vessels
   • May need intrapericardial access


Mastering Thoracoscopic Upper Lobectomy
               Bleeding from Nodal Dissection

   • Common during subcarinal dissection & level 11
   • Try to ignore it; work somewhere else
   • Apply pressure or surgical cellulose if necessary
   • Occasionally a small bronchial vessel is
     visualized and cauterized (Stations 7 and 11)
   • No clips!


Mastering Thoracoscopic Upper Lobectomy
                         Bleeding from PA
   • Have a preop plan for conversion with every case
   • Avoid PANIC; use sponge stick on bleeding site
   • Most bleeding (minor vascular injuries) will stop
   • Do not try to clamp the PA at the site as it well
     extend the injury; gain proximal control
   • If proximal or more major injury, convert
   • Other options: open fissure and approach PA
     from another angle, or open pericardium and
     place tape or clamp proximal to injury
Mastering Thoracoscopic Upper Lobectomy
                         Fissure Completion

   • Staple last whenever possible
   • Use the bronchial stump to stretch and flatten
     poorly developed horizontal fissure during right
     upper lobectomy




Mastering Thoracoscopic Upper Lobectomy
                           Difficult Fissure

   • When there is a need to open the fissure prior to
     completing the lobectomy, open from the bottom
   • Divide vein, dissect free the posterior hilum and
     identify where pulmonary artery enters fissure
   • Dissect directly along the PA, stapling the fissure
     if possible, or with energy source
   • Routine for middle lobectomy and lingulectomy

Mastering Thoracoscopic Upper Lobectomy
              Bag Won’t Fit Out Of The Chest
   • Adequate division of the intercostal muscle within
     the access incision (longer than skin incision)
   • Orient specimen in bag so that the lung is
     streamlined and the tumor is dependent and
     comes out last; use bag as wound protector
   • Gentle constant circular traction
   • If necessary, enlarge skin incision by 1-2 cm
   • Last resort: dividing rib anteriorly to prevent fx
Mastering Thoracoscopic Upper Lobectomy
           Anatomic Errors (Normal Anatomy)

   • Ligating the R PA instead of the truncus anterior
     during R upper lobectomy
   • Ligating the L main bronchus instead of the L
     lower lobe bronchus during L lower lobectomy




Mastering Thoracoscopic Upper Lobectomy
                        Anatomic Variations

   • Posterior ascending artery multiple (30%)
   • May arise from superior segment artery (14%)
   • Anterior ascending branch (25%)
   • Posterior or Superior segment artery may arise
     from posterior basilar segmental artery (7-10%)
   • Lingular a. may arise from anterior basilar a.
   • Common Pulmonary Vein
Mastering Thoracoscopic Upper Lobectomy
                                          d



             LUL Vein



                                                        LLL Vein


Mastering Thoracoscopic Upper Lobectomy
                                          Common Vein
    Middle Lobe Vein
Lower Lobe Vein (stapled)
Inferior Pulmonary Vein
 Mastering Thoracoscopic Upper Lobectomy
                        Technical Variations

   •   RUL: staple bronchus first
   •   LUL: transect bronchus and staple later
   •   Encircle main pulmonary artery during difficult
       cases
   •   Open the fissure and staple the truncus last for
       central tumors
   •   Intrapericardial access
Mastering Thoracoscopic Upper Lobectomy
             Avoiding and Managing Disasters

   •   Disasters are easier to avoid than to manage
   •   Be aware of anatomic variations
   •   Have a plan for each lobe but be flexible
   •   As experience grows, the factors that lead to
       bleeding become predictable to the observant
       surgeon


Mastering Thoracoscopic Upper Lobectomy
Mastering Thoracoscopic Upper Lobectomy

				
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