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Minimally Invasive Thoracic Surgery: Video-Assisted Lobectomy

• How can I be evaluated for VATS, and what tests do I need?
• How much recovery time will I need following VATS?

Lung cancer is the leading cause of cancer death in the United States, with approximately 180,000 new cases diagnosed each year.

While surgical resection offers the best chance of a cure for those with early-stage lung cancer, the traditional open-chest approach (called a thoracotomy) typically requires 5 to 7 days of recovery in the hospital, with an extended recovery at home.

Cleveland Clinic thoracic surgeons offer a less invasive surgical approach called a video-assisted lobectomy for select patients as treatment of early-stage lung cancer. This video-assisted thoracic surgery (VATS) technique reduces a patient’s hospital stay to about 3 to 4 days and the patient experiences a more rapid recovery with less pain after surgery as compared with the traditional thoracotomy approach.

Cleveland Clinic is one of the few centers in the nation with significant experience in video-assisted lobectomy. In addition, the surgical outcomes of video-assisted lobectomy are comparable to traditional lobectomy outcomes.

What is a lobectomy?
A lobectomy is the surgical removal of a large section of lung. Lobectomy is the most common surgery performed to treat lung cancer.

Lobectomy has been traditionally performed during thoracotomy surgery. During thoracotomy surgery, an incision is made on the side of the chest between the ribs. The ribs are then spread apart so the surgeon can see into the chest cavity and remove the tumor or affected tissue.

What happens during lobectomy?
Video-assisted lobectomy is less invasive than traditional thoracotomy. During VATS lobectomy, three 1-inch incisions and one 3- to 4-inch incision are made in the chest to provide access to the chest cavity without spreading of the ribs.

During a VATS lobectomy, a thorascope (small video camera) and surgical instruments are inserted into the incisions. The thoracic surgeon is guided by the images of the operative area transmitted from the thorascope. The images are projected onto a computer monitor that is positioned next to the patient.

Cutline: Position of small incisions
front view		side view

Your surgeon will remove the tumor or affected tissue from the lung through the small incisions. If an early-stage cancer tumor is being removed, the lymph nodes (small, bean-shaped structures) in the mid-chest area may also be removed or biopsied to ensure that the cancer has not spread.

Before completing the VATS procedure, the surgeon will check that there are no areas of bleeding, rinse out the chest cavity and close the small incisions. One or two drains remain in place after the surgery to remove excess fluid and air from around the lung. The drains are removed at a later time during the patient’s recovery.

Which patients are candidates for VATS lobectomy?
Patients who need a variety of diagnostic and/or therapeutic procedures of the outer area of the lung may be candidates for video-assisted surgery. The best candidates for VATS lobectomy include patients with stage I non-small cell lung cancer (a small, primary tumor, under 3 cm, in the first stage of cancer that has not spread beyond the lungs) or patients who have a single enlarging pulmonary nodule.  

Although minimally invasive approaches are considered for every patient, some patients may not be candidates for video-assisted lobectomy. Traditional thoracotomy may be more appropriate for some patients with large tumors, involved lymph nodes or prior chest surgery.

How can I be evaluated for VATS lobectomy?
Please call McAllen Heart Surgeons appointment line 956.630.9430 to schedule a pre-surgical evaluation with a thoracic surgeon.

When you meet with the thoracic surgeon for the pre-surgical evaluation, a physical exam will be performed. The surgeon will ask you questions about your condition and health history. The thoracic surgeon will discuss your treatment options and the benefits and potential risks of the procedure that is recommended for you. Additional tests will be ordered to make sure video-assisted lobectomy is the right treatment for you.

What tests are needed before video-assisted lobectomy?
If lung cancer has been found, more tests will be done to find out if cancer cells have spread from one or both lungs to other parts of the body (staging). Your doctor needs to know the stage of the disease to plan your treatment.
Pre-surgical tests usually last about one day and are scheduled a few weeks before your surgery date. The thoracic surgery scheduler will schedule the tests and consultations that have been requested by your surgeon. In general, after your first meeting with your surgeon, all tests are scheduled on a single returning visit for your convenience.

Pre-surgical tests include:

• A complete physical exam
• Chest x-ray
• Computed tomography (CT) scan
• Positron emission tomography (PET) scan
• Blood tests
• Electrocardiogram or cardiac stress test
• Breathing tests, such as a spirometry or a pulmonary function test

Your surgeon will determine if any other preoperative tests are needed.

As part of your preoperative evaluation, you will meet with an anesthesiologist who will discuss anesthesia and post-operative pain control.

What are the benefits of video-assisted lobectomy?
Patients who have video-assisted lobectomy generally experience less pain and have a quicker recovery than those who have traditional thoracotomy surgery. Other possible benefits include reduced risk of infection and less bleeding.

Recent research indicated that video-assisted lobectomy can be performed with low rates of complications and reduced in-hospital recovery to approximately 3 to 4 days. Additional studies also demonstrate video-assisted lobectomy is as effective in removing stage I lung cancers as the traditional, open-chest thoracotomy.

What are the risks of video-assisted lobectomy?
There are risks of every surgical procedure. Your doctor will discuss the potential risks of the procedure with you. Possible risks of the procedure may include:

• Risk of bleeding, requiring opening of the chest (thoracotomy)
• A persistent air leak (greater than 7 days) from the lung
• Subcutaneous emphysema (the presence of air or gas in subcutaneous tissues)
• Fever

How long will it take to recover from video-assisted lobectomy?
Your hospital stay following video-assisted lobectomy is usually 3 to 4 days after surgery.  Your thoracic surgery team, including your surgeon, surgical residents and fellows, surgical nurse clinicians, social workers and anesthesiologist, will help you recovery as quickly as possible.

During your hospital recovery, you and your family will receive updates about your progress so you’ll know when you can go home.

Your health care team will provide specific instructions for your recovery and return to work, including guidelines for activity, driving, incision care and diet. In general, you may be able to return to work (if you have a sedentary job), resume driving and participate in most non-strenuous activities within 4 to 6 weeks after minimally invasive thoracic surgery. You can resume heavy lifting and other more strenuous activities within 6 to 12 weeks after surgery.

A follow-up appointment will be scheduled 7 to 10 days after your surgery. You will have a chest x-ray and your surgeon will assess the wound site and your recovery. The surgeon will provide additional guidelines about your activities, return to work and diet at this time.

References:

McKenna RJ, Houck W, Beeman Fuller C. Video-assisted thoracic surgery lobectomy: experience with 1,100 cases. The Annals of Thoracic Surgery, February 2006. 81(2):421-426.

Roviaro G, et al. Long-term survival after videothoracoscopic lobectomy for stage I lung cancer. Chest. September 2004. 126(3):725-732.

Lung/Thoracic Surgery, The Society of Thoracic Surgeons http://www.sts.org/sections/patientinformation/lungthoracicsurgery/ (web site accessed 8/11/06)

VATS Lobectomy For Early Stage Lung Cancer, Flores RM, The Cardiothoracic Surgery Network. http://www.ctsnet.org/sections/clinicalresources/thoracic/expert_tech-.html (web site accessed 8/12/06)