Single Incision Thoracoscopic Left Lower Lobe Superior Segmentectomy for Non-Small Cell Lung Cancer

Korean J Thorac Cardiovasc Surg 2014;47:185-188 □ Case Report □ http://dx.doi.org/10.5090/kjtcs.2014.47.2.185 ISSN: 2233-601X (Print) ISSN: 2093-6516 (Online)

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Department of Thoracic and Cardiovascular Surgery,

Bucheon St. Mary’s Hospital,

Seoul St. Mary’s Hospital,

St. Vincent’s Hospital, The Catholic University of Korea College of Medicine

Received: July 22, 2013, Revised: September 25, 2013, Accepted: October 1, 2013

Corresponding author: Young Pil Wang, Department of Thoracic and Cardiovascular Surgery, Seoul St. Mary’s Hospital, The Catholic University of Korea College of Medicine, 222 Banpo-daero, Seocho-gu, Seoul 137-701, Korea

(Tel) 82-2-2258-2858 (Fax) 82-2-594-8644 (E-mail) [email protected]

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The Korean Society for Thoracic and Cardiovascular Surgery. 2014. All right reserved.

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Single Incision Thoracoscopic Left Lower Lobe Superior Segmentectomy for Non-Small Cell Lung Cancer

Hyun Woo Jeon, M.D.

, Soo Hwan Choi, M.D.

, Young Pil Wang, M.D., Ph.D.

, Kwan Yong Hyun, M.D.

Lobectomy with mediastinal node dissection has been standard treatment for non-small cell lung cancer (NSCLC).

Nowadays, video-assisted thoracoscopic surgery (VATS) is gaining acceptance as an alternative treatment option, given the quality-of-life benefits that it confers. For the VATS procedure, most surgeons create two or three ports with a utility incision of 3 to 5 cm. However, with acquired skill and instrumentation advances, single-incision thor- acoscopic surgery has emerged over time. Here, we report the case of an 86-year-old female with NSCLC treated by single-incision segmentectomy.

Key words: 1. Video-assisted thoracic surgery (VATS) 2. Minimally invasive surgical procedures 3. Lung neoplasms

4. Adenocarcinoma of lung 5. Segmentectomy

CASE REPORT

An 86-year-old female was referred to Seoul St. Mary's Hospital because of abnormal chest X-ray findings. The chief complaints were intermittent cough and mild fever ongoing for one month. Computed tomography (CT) revealed a mass (3.3×2.2 cm) in the lingula of the left upper lobe (LUL) and a second lesion (2.2×1.6 cm) in the superior segment of the left lower lobe (LLL), which were most likely malignant (Fig. 1A, B). Preoperative assessments included magnetic res- onance imaging of the brain, bone scan, whole-body positron emission tomography-CT, echocardiography, and broncho- scopy. Clinically, an abscess of LUL and a cancer of LLL (stage cT1bN0M0) were suspected. Preoperative forced ex- piratory volume in one second (FEV

) was 1.37 L. Echocar-

diography revealed normal ejection fraction (60%), but aki- nesia on the basal posterior wall and a ventricular premature complex were observed in the electrocardiography. For the complete resection, lingular segmentectomy and LLL lobec- tomy should be carried out. Postoperative FEV

was esti- mated to be 0.9 L. Due to advanced age and poor respiratory function, the surgical plan was wedge resection for the LUL lesion first. If the lesion was not malignant on the frozen re- port, the next step was the superior segmentectomy of LLL.

Under general anesthesia, a double-lumen endotracheal tube

was placed, and the patient was transitioned to the right later-

al decubitus position. Once selective lung ventilation was

achieved, a 4-cm incision was made in the fifth intercostal

space at the anterior axillary line with a wound protector

(Applied Medical, Rancho Santa Margarita, CA, USA). The

Hyun Woo Jeon, et al

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Fig. 1. (A) Computed tomography revealed a mass measuring approx- imately 3.3×2.2 cm in the lingula and a nodule measuring 2.2×1.6 cm with speculation in the superior seg- ment of left lower lobe. (B) After contrast injection, the left upper lobe lesion showed peripheral enhance- ment with central low attenuation.

Fig. 2. (A) The first step is inter- lobar dissection using an ultrasonic device. (B) The superior segmental artery was identified and divided us- ing an endostapler.

Fig. 3. (A) The superior segmental bronchus was dissected and ob- structed using a right-angle clamp.

(B) After lung inflation, the segmen- tal plane was divided.

two distinct masses were digitally palpable, with a visible re- traction of the lower lobe visceral pleura. The cavitary lesion in LUL was sizable. Simple wedge resection was difficult for complete resection. First, the anterior portion of the fissure was dissected and divided, exposing the interlobar artery (Fig.

2A). The lingular segmental artery was then identified and divided, followed by the elevation and resection of the upper lobe mass. Then, complete resection was achieved, and the distance between the mass and the resection margin was 0.6 cm. After there was no evidence of malignancy on the frozen

section report, the superior segmental artery (encircled by a drain catheter) was identified and divided using an endo- stapler (TriStapler; Covidien, Norwalk, CT, USA) (Fig. 2B).

The inferior pulmonary ligament was divided to reveal the in-

ferior pulmonary vein. Eventually, the superior segmental

vein was divided using a Hem-o-lok (Teleflex Medical Inc.,

Research Triangle Park, NC, USA). After identifying the su-

perior segmental bronchus, the peribronchial tissue and lymph

nodes were dissected. Then, the bronchus was clamped, and

both lungs were ventilated (Fig. 3A), enabling the visual-

Single Incision Thoracosopic Segmentectomy

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Fig. 4. (A) Subcarinal and (B) para- aortic lymph nodes were dissected for complete resection.

Fig. 5. (A) The chest tube was placed via the posterior portion of the utility incision, and (B) the skin incision was closed with the sub- cuticular running suture method.

ization of the segmental plane and stapler division (Fig. 3B).

Mediastinal lymph node dissection (para-aortic, subcarinal, in- ferior pulmonary ligament, and paraesophageal lymph nodes) was performed (Fig. 4A, B). A chest tube (24 Fr.) was placed in the pleural cavity through the utility incision, and the wound was closed (Fig. 5A, B). The total operative time was 135 minutes. Histopathology confirmed an abscess of LUL and an adenocarcinoma (1.6×1.4 cm) of LLL with the invasion of the visceral pleura (stage T2aN0M0), and a dis- tance of 3 cm was obtained between the tumor and the div- ided segmental plane. The patient was discharged on post- operative day 7 without complications.

DISCUSSION

Since its introduction in the 1990s, video-assisted thoraco- scopic surgery (VATS) has been an attractive treatment mo- dality for thoracic surgery, resulting in shorter recovery peri- ods and less postoperative pain than open procedures [1].

Although, generally, three or four incisions are used for VATS lobectomy or the segmentectomy of lung cancers, a report by Rocco et al. [2] on uniportal VATS wedge re- section, citing the potential to reduce postoperative pain and paresthesia, has caught the interest of thoracic surgeons. Since 2010, Gonzalez-Rivas et al. [3] have adopted this technique for lung cancer surgery, confirming its feasibility in a recent publication.

Recently, many centers have adopted the abovementioned

technique [4]. Furthermore, segmentectomy has also been per-

formed by single incision [5]. Although lobectomy is the

standard surgical management for early lung cancer, lobec-

tomy is not suitable for all patients. Most of these patients

are elderly and have poor cardiopulmonary reserve. Segmen-

tectomy is a reasonable alternative procedure. In a compar-

ison of segmentectomy with lobectomy for non-small cell

lung cancer ＜2 cm, Okada et al. [6] found that the 5-year

survival rates did not differ by procedure. In particular, in the

older patients, segmentectomy leads to less complications and

Hyun Woo Jeon, et al

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We extended our experience with VATS for lung cancer to include a single-incision approach using a 4-cm utility in- cision of the 5th intercostal space (at the anterior axillary line). A wound protector is employed to protect the camera lens from oozing by the intercostal muscle. The required in- strumentation does not otherwise differ from that of conven- tional VATS (endograsper, 10-mm camera with 30

angle, right-angle clamp, and ultrasonic device). The operative pro- cedure differs according to the affected lobe. During dis- section, we use a harmonic scalpel (Ethicon Endo-Surgery Inc., Cincinnati, OH, USA).

A harmonic scalpel is very useful and suitable for the dis- section and coagulation of microvessels because of its blunt tip and scissors-like action. We preferred a long right-angle clamp with a blunt tip during the tunneling and encircling of the vessels and the bronchus.

Single-incision VATS does have some limitations. Clearly, when the multiple views of conventional VATS are forfeited, obstruction of view and impingement of instruments com- monly occur. However, the surgical technique is not different, including the identification and division of the vessels and the bronchus, and lymph node dissection. We generally center the camera on the incision, inserting instruments on either side of it; further, for better visualization, the stapler is placed in the thoracic cavity beneath the camera. Conducting extensive surgery through a single, small incision is often er- gonomically problematic for surgeons and assistants. During an operation, the operator and the assistant are sometimes su- perimposed; therefore, it is important to prevent contami- nation.

We made a utility incision in the 5th intercostal space. The procedure through the 6th intercostal space allows the divi- sion of the inferior pulmonary ligament and the inferior pul- monary vein more easily. However, our first step is the dis- section of the interlobar space; this approach is easier through the 5th intercostal space. If a conversion to conventional VATS is required, a utility incision in the 5th intercostal space is more convenient because a utility incision in the 5th intercostal space is always used during conventional VATS.

In our experience, this approach is safe, feasible, and reproducible. Although segmentectomy is generally expected

to be more difficult than lobectomy, superior, basal, and lin- gula segmentectomies are more easily executed, owing to the readily defined segmental planes. However, without multiple views through a single incision, the division of segmental planes has to be performed in one direction. Division of seg- mental planes is slightly difficult during the division of seg- mental planes in single-incision segmentectomy.

In conclusion, single-incision VATS superior segmentec- tomy of LLL for early-stage lung cancer was both feasible and safe in this instance. However, its merits in cancer treat- ment require further study.

CONFLICT OF INTEREST

No potential conflict of interest relevant to this article was reported.

ACKNOWLEDGMENTS

This manuscript has been edited by the native English- speaking experts of BioMed Proofreading.

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