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Lobectomy
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Compare Surgical Approaches
There are two approaches that have been developed for lobectomy. One involves sequential anatomic ligation of the hilar structures, similar to a standard lobectomy. The other involves mass ligation of the pulmonary vessels and the bronchus. Both approaches require at least two port incisions in addition to the utility thoracotomy incision.36
The sequential anatomic ligation approach has been well described and follows established surgical oncologic principles. Accordingly, it is a preferred method of performing video assisted thoracic surgery (VATS) lobectomy.
Standard techniques for video assisted lobectomy have been developed and can be recommended in acute settings.36 Here are some of the procedure approaches for VATS:
- Right Upper Lobectomy
- Right Middle Lobectomy
- Right Lower Lobectomy
- Left Upper Lobectomy
- Left Lower Lobectomy
- Left Pneumonectomy
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In lobectomy procedures, the primary difference between video-assisted thoracic surgery (VATS) and open surgery is how the diseased area is accessed. In many types of open surgery, a large incision is made in the chest to access the surgical site, cutting major muscles in the chest wall and spreading the ribs apart, potentially damaging the surrounding nerves. The incision extends from the patient's side – under the arm – and up the back for approximately six or more inches.35 For these reasons, open chest surgery may result in considerable postoperative pain.38
In contrast, only small incisions (about one inch) are necessary during VATS and the procedure does not require rib spreading.35 The incisions serve as ports, which allow insertion of a small camera (thoracoscope), along with specially designed surgical tools that are used to remove diseased tissue, drain fluids, and repair damaged areas. VATS, or video-assisted thoracic surgery, is a common type of minimally invasive thoracic surgery that allows the surgeon to view the procedure on a video monitor.
VATS can be used to take biopsies to determine the presence of disease. It is also effective for removing diseased tissue and for treating certain traumas or painful conditions. Patients with early stage cancers and small tumors are the best candidates for VATS.
The Benefits of VATS vs. Open Surgery
When performed by a qualified surgeon and in patients with clinical stage 1 non small cell cancer, VATS results in less trauma to the patient's body, while allowing the surgeon to perform a thorough, highly effective procedure.38 Many VATS patients are able to leave the hospital sooner, experience less pain after surgery, and return to work and daily activities quicker compared to patients who have open surgery.35 Additionally, when considering the overall impact to the healthcare system, the use of VATS versus open lobectomy has been associated with a 40% reduction in cost.38
Additional Clinical Support of Video Assisted Thoracic Surgery (VATS)
In a study examining the safety and effectiveness of VATS when compared with conventional open thoracotomy in adults undergoing lobectomy for the treatment of lung cancer, VATS was found to reduce preoperative morbidity and mortality:
- VATS lobectomy is associated with a significantly lower (70%) risk of overall postoperative complications compared with open lobectomy.35
- VATS lobectomy is associated with a significantly lower (61%) incidence of pulmonary complications compared with open lobectomy.35
VATS has also been found to reduce pain and improve functionality, satisfaction and quality-of-life:
- VATS lobectomy may significantly reduce total dosage, duration, and administration of analgesia when compared with open lobectomy.35
- VATS lobectomy may significantly reduce early postoperative pain, measured by VAS at 1 day, 1 week, and 2 to 4 weeks, but not at 3 months, when compared with open lobectomy.35
When compared with open lobectomy, VATS does not compromise the oncologic outcomes:
- The study found no difference in five-year survival rates for VATS lobectomy when compared with open lobectomy.35
- Delivery of planned adjuvant chemotherapy may be more feasible after VATS lobectomy when compared with open lobectomy.35
- Delays in planned adjuvant chemotherapy were reduced by 85 percent when compared with open lobectomy.35
When compared with open lobectomy, VATS may affect overall resource utilization:
- Length of hospital stay for VATS compared with open lobectomy was reduced by 20% in non-RCTs (randomized controlled trials).35
- There is no difference in operative times between VATS and open lobectomy in RCTs, but operative time is prolonged by approximately 16 minutes in non-RCTs.35
Additional long-term studies are ongoing in order to expand the data associated with the far reaching impact and benefits of VATS.
