74: Vats Lobectomy

Introduction

Video-assisted thoracic surgery (VATS) lobectomy has been used in the treatment of lung cancer since the early 1990s. While there is evidence that lobectomy is better than wedge resection in most patients, there are no large prospective, randomized studies favoring video-assisted lobectomy over conventional lobectomy by thoracotomy.¹ However, there are several series that support the use of VATS lobectomy technique. These include some small (n ≤ 100) prospective, randomized studies that compare VATS with lobectomy by thoracotomy (Table 74-1). From these data, as well as data from several exclusive VATS series, it is clear that VATS lobectomy is technically feasible and safe and even may provide better quality-of-life outcomes in patients with resectable lung cancer. Despite these efforts, VATS lobectomies represent about 25% to 30% of all lobectomies performed in the United States.⁶

The VATS cancer operation is specifically defined as an anatomic lobectomy (or segmentectomy, when indicated) and consists of individual hilar ligation by means of three or four small incisions and no rib spreading. This anatomic lobectomy should leave the patient with results identical to a cancer resection by thoracotomy. That is, the surgeon resects the tumor with negative margins, performing individual vascular and bronchial ligation and division and a complete hilar lymph node dissection. Furthermore, mediastinal lymph node dissection or sampling is performed as appropriate. Certain aspects of the technique, most notably avoidance of rib spreading or the use of a rib retractor, are emphasized, with the goal of improving the patient's postoperative experience. Cosmetic aspects, such as smaller scars (largest incision is usually 5 cm), are also important. One variant, the video-assisted simultaneously stapled lobectomy, does not involve individual hilar ligation. In essence, it is a different operation and is not ...