Now that minimally invasive surgery is well accepted as a treatment for stage I lung cancer, surgeons have pushed the limit to use minimally invasive surgery for more advanced and complex procedures. In this chapter, we discuss the benefits of minimally invasive video-assisted thoracic surgery (VATS) sleeve resection and bronchoplasty.
Philosophically, the goal of lung cancer surgery is to perform an operation that achieves good margins around the tumor so as to minimize the chances of local recurrence, while trying to preserve as much lung tissue and hence as much lung function as possible. Initially, pneumonectomy was the treatment of choice for centrally located lung lesions, but several studies have shown that sleeve lobectomy (SL) has similar survival to pneumonectomy.1–8 Sleeve lobectomies are more technically complicated than lobectomy and pneumonectomy for several reasons: the evaluation of the tumor to determine if the procedure should be a lobectomy, a sleeve resection, or a pneumonectomy; the dissection around the blood vessels; and intracorporeal suturing of the bronchial anastomosis. Strict adherence to surgical technique and avoidance of tension on the anastomosis by performing hilar release and incising the inferior pulmonary ligament decreases the mortality risk of SL when compared to pneumonectomy.7 In addition, SL has been found to be as safe as standard pulmonary lobectomy and is beneficial to patients with limited pulmonary reserve.6,9–14 Several studies have shown that SL is as effective as pneumonectomy in clearance of tumor while preserving functional lung parenchyma.5–7 For patients with central tumor, SL achieves local tumor control and is associated with low mortality and low rates of bronchial anastomotic complication.5,9,10,12–14
Thoracotomy has conventionally been the surgical technique of choice for sleeve lobectomy. The use of VATS for SL was contraindicated until the 2008 case series by McKenna and colleagues, which demonstrated that VAT SL can be safely done without increasing morbidity or mortality.9,12 Davoli and colleagues demonstrated the utility of VATS for operative management of centrally located tumors, if the following principles are followed: (1) disease-free margins of the bronchial stump confirmed by intraoperative frozen sections, (2) en bloc resection, and (3) tension-free end-to-end bronchial anastomosis.2
If the tumor extends into the origin of the right upper lobe orifice, then a bronchoplasty may provide adequate margins. A lesion within a lobar or main bronchus that impinges on or involves the main bronchus is an indication for sleeve resection. The most common sleeve lobectomy is a right upper lobe sleeve resection; this is typically needed when the tumor extends from the right upper lobe bronchus into the right mainstem bronchus and or bronchus intermedius but does not extend to the distal bronchus intermedius or to the carina (Fig. 77-1A).