519

Lobectomy: Video-Assisted Thoracic SurgeryVersus Posterolateral Thoracotomy

Background: Video-assisted lobectomy has been adopted by many thoracic surgeons, because itis a less invasive approach to small peripheral lung cancers. However, some authors disagreethat video-assisted lobectomy is less invasive than traditional thoracotomy and lobectomy. Thepurpose of this study was to evaluate the advantages of video-assisted lobectomy over postero­lateral thoracotomy and lobectomy in terms of pain-related morbidity. Methods: A total of 70patients with clinical TINOMO non-small-cell lung carcinomas underwent lobectomy with com­plete mediastinal lymphadenectomy. Of these 35 underwent posterolateral thoracotomy (be­tween April 1994 and December 1995; open group), and 35 underwent video-assisted thoracicsurgery (VATS) (between January and December 1996; VATS group). Results: Although theoperative time was significantly longer in the VATS group (p=0.04), the intraoperative bloodloss was significantly less (p=0.03). No significant differences were found for the two groups withrespect to the total number of mediastinal lymph nodes dissected or duration of chest tubedrainage. Postoperative pain was less severe as determined by the number of doses of analgesicsrequired between postoperative days 0 and 7 (p<0.0001), and the length of postoperative hospi­talization was shorter in the VATS group (p<0.0001). Conclusion: Video-assisted lobectomy isassociated with decreased postoperative pain and shortened length of postoperative hospitaliza­tion, when compared with posterolateral thoracotomy and lobectomy. (JJTCVS 1998; 46:519-522)

Index words: VATS, lobectomy, posterolateral thoracotomy

Tashiro Ohbuchi, MD, Toshiaki Morikawa, MD*, Eriho Takeuchi, MD, PhD, and Hiroyuki Kato,MD, PhD*

V ideo-assisted thoracic surgery (VATS) is gen­erally accepted as a minimally invasive approachfor many benign and malignant diseases of thechest. Even major pulmonary resections for lungcarcinoma have been successfully performed usingVATS.I-IO However, the advantages of VATS over

From the Center of VATS, Minami-Ichijo Hospital, Sapporo,Japan and *Second Department of Surgery, HokkaidoUniversity School of Medicine, Sapporo, Japan.

Received for publication July 7,1997.Accepted for publication January 5, 1998.Address for reprint requests: Ohbuchi Toshiro, MD, Center of

VATS, Minami-Ichijo Hospital, South-I, West-13, Chuo-ku,Sapporo,060-0061,Japan.

traditional surgical approaches remain controver­sial. Some thoracic surgeons have claimed thatVATS is not less invasive, and that it is complicat­ed and expensive. II In contrast, there are those thathave reported that VATS decreases pain-relatedmorbidity and length of hospital stay.':'

Patients with resectable lung cancer are interest­ed in not only long-term control of the disease, butalso pain control and rapid recovery. The long-termcontrol of the malignant disease is associated withthe choice and execution of the surgical procedure(lobectomy or wedge excision), not with the ap­proach (VATS or posterolateral thoracotomy). Weperformed a retrospective study to define the ad­vantages and disadvantages of video-assisted

520 Ohbuchi et alThe Japanese Journal of

Thoracic and Cardiovascular Surgery

lobectomy, when compared with posterolateralthoracotomy and lobectomy.

Subjects and Methods

Between April 1994 and December 1995, 35 pa­tients with clinical TINOMO non-small-celllungcarcinoma underwent posterolateral thoracotomyand lobectomy with mediastinal lymphadenectomy(open group). Between January and December1996,35 patients with clinical TlNOMOnon-small­cell lung carcinoma underwent video-assistedlobectomy with mediastinal lymphadenectomy(VATS group) (Table I). All patients were goodoperative risks for pulmonary lobectomy.

Patients in the open group had a posterolateralthoracotomy performed through the fourth or fifthintercostal space with rib spreading. Patients in theVATS group had three small ports plus a 4 to 7 em

minithoracotomy

Fig. 1. Skin incisions in VATS lobectomy.

long mini thoracotomy in the fourth intercostalspace (ICS) anteriorly without rib spreading. Thethree small ports were placed in the fourth ICS inthe posterior axillary line, in the sixth ICS in theanterior axillary line, and in the sixth ICS in theposterior axillary line (Fig. 1). No patient in theVATS group required conversion to a traditionalapproach, even those having incomplete lobulationor severe adhesions. Every patient underwent ananatomic lobectomy with a hilar and mediastinallymphadenectomy.

All postoperative patients received epiduralanalgesia using morphine for 7 postoperative days,unless adverse effects were observed. Additionally,suppositories of indomethacin (25 or 50 mg) wereused as needed. Postoperative pain was evaluatedbased on the total number of analgesic require­ments administered over the first 7 postoperativedays.

The variables were analyzed using Student's ttest. A p value less than 0.05 was considered sig­nificant.

Results (Table I)

The two groups were similar with respect to gen­der and mean age. Although the operative time wassignificantly longer in the VATS group than in theopen group (open, 195.1 minutes versus VATS,216.6 minutes; p=0.04), the intraoperative blood

Table I. Comparison of the two groups

Number of patientsAge (years)Male/femaleOperative time (min)Blood loss (g)Total number of mediastinal

lymph nodes dissectedDuration of chest tube

drainage (days)Analgesic requirements

(times)Length of postoperative

hospitalization (days)

Open Group

3539 to 72 (58.7±8.0)

20115195.1±38.4125.2±94.4

12.9±6.3

7.6±6.3

26.3±6.5

24.0±8.0

VATS Group

3537 to 77 (61.1±9.9)

19/16216.6±48.2

81.5±67.815.8±6.8

5.3±3.7

19.1±6.9

15.4±4.5

p value

n.s.n.s.

0.0440.031n.s.

n.s.

<0.0001

<0.0001

Volume 46 Number 6June 1998 Lobectomy: VATS vs posterolateral thoracotomy 521

loss was significantly less in the VATS group(open, 125.2 g versus VATS, 81.5 g; p=0.03). Nosignificant differences were detected between thetwo groups with respect to duration of chest tubedrainage (open, 7.6 days versus VATS, 5.3 days)or total number of mediastinal lymph nodes dis­sected (open, 12.9 versus 15.8). Analgesic require­ments for the first seven days postoperatively weresignificantly less (open, 26.3 times versus VATS,19.1 times; p<O.OOOl), and length of postoperativehospitalization was significantly shorter (open,24.0 days versus VATS, 15.4 days;p<O.OOOI) inthe VATS group than in the open group. All pa­tients were discharged in good condition.

Discussion

Although some authors have reported thatVATS is associated with advantages such as de­creased pain and shortened hospitalization, 1-6

others disagree. II In our institution, the patientswho underwent video-assisted lobectomy had afaster, less painful recovery than those who under­went traditional thoracotomy and lobectomy.Moreover, there should be no difference in the effi­cacy of cancer treatment, because the only differ­ence between the operations was the skin incision.

The feasibility of video-assisted lobectomy hasbeen widely reported, but the necessity of VATShas received little attention.>" In fact, even the pro­ponents of VATS have not clearly shown that themorbidity is reduced." Kirby and his co-authorsclaim that video-assisted lobectomy is not associat­ed with a significant decrease in length of hospital­ization, postoperative pain, or a faster recoverytime."

In contrast, we found significant advantages as­sociated with the VATS approach with respect topostoperative pain and length of hospitalization.Although this study is a retrospective one, whichhad a small number of patients, we are consideringthat the VATS approach may be superior to so­called conventional thoracotomy in terms of pain­control and the duration of hospitalization. Wethink that our average length of stay in which theVATS group was 15.4 days and the open groupwas 24.0 days is a little long, but not extremelylong in Japan. Unlike in other countries, especially

the United States, Japanese patients are not dis­charged from the hospital until they have com­pletely recovered and can return to work. Becauseof the way the Japanese national medical insurancesystem operates, the charges for an operation andhospitalization are usually about US $600. In addi­tion, most Japanese patients receive between US$50 and 100 for each day of hospitalization fromprivate insurance companies. They thus tend tostay longer, particularly elderly patients.Therefore, the shorter postoperative hospitalizationstrongly supports the advantages of VATS inJapan.

Complete staging of hilar and mediastinal lymphnodes for bronchogenic carcinoma is necessary.Some investigators fear the underestimation of N2disease using the VATS approach." However,using our approach with a port at the post-axillaryline of the sixth intercostal space, it is easy to ob­serve and dissect mediastinal lymph nodes such as#7 and (r)#4.

Although we did not compare VATS with mus­cle-sparing thoracotomy, Landreneau and associ­ates have previously shown no significant differ­ence between muscle-sparing thoracotomy andposterolateral thoracotomy in terms of length ofhospital stay, postoperative narcotic requirement,or postoperative mortality."Video-assisted lobectomy is a less-invasive tech­nique than posterolateral thoracotomy and lobecto­my. We conclude that a decrease in the length ofstay and improved pain control by VATS are bene­ficial.

REFERENCES

1. Landreneau RJ, Hazelrigg SR, Mack MJ, DowlingRD, Burke D, GavlickJ, et al. Postoperative pain­related morbidity: video-assisted thoracic surgeryversus thoracotomy. Ann Thorac Surg 1993; 56:1285-9.

2. Giudicelli R, Thomas P, Lonjon T, Ragni J, MoratiN, Ottomani R, et al. Video-assisted minithoracoto­myversus muscle-sparing thoracotomy forperfqrm­ing lobectomy. AnnThorac Surg 1994; 58: 721~8.

3. Tschemko EM, Hofer S, Bieglmayer C, WisserW,Haider W. Video-assisted wedge resectionllobecto­my vs conventional axillary thoracotomy. Chest1996; 109: 1636--42.

522 Ohbuchi et atThe Japanese Journal of

Thoracic and Cardiovascular Surgery

4. Liu HP, Chang CH, Lin PJ, Chang JP, Hsieh MJ.Thoracoscopic-assisted lobectomy, preliminary ex­perience and results. Chest 1995; 107: 853-5.

5. Walker WS, Carnochan FM, Pugh oc.Thoracoscopic pulmonary lobectomy, early opera­tive experience and preliminary clinical results. JThorac Cardiovasc Surg 1993; 106: 1111-7.

6. McKenna RJ. Lobectomy by video-assisted thoracicsurgery with mediastinal node sampling for lungcancer. J Thorac Cardiovasc Surg 1994; 107:879-82.

7. Kirby TJ, Mack MJ, Landreneau RJ, Rice TW.Initial experience with video-assisted thoracoscopiclobectomy. Ann Thorac Surg 1993; 56: 1248-52.

8. Kirby TJ, Rice TW. Thoracoscopic lobectomy. AnnThorac Surg 1993; 56: 784-6.

9. Walker WS, Camochan FM, Tin M. Thoracoscopyassisted pulmonary lobectomy. Thorax 1993; 48:921-4.

10. Roviaro G, Varoli F, Rebuffat C, Vergani C,D'Hoore A, Scalambra SM, et al. Major pulmonaryresections: pneumonectomies and lobectomies. AnnThorac Surg 1993; 56: 779-83.

11. Kirby TJ, Mack MJ, Landreneau RJ, Rice TW.Lobectomy - video-assisted thoracic surgery versusmuscle-sparing thoracotomy. J Thorac CardiovascSurg 1995; 109: 997-1002.

12. Asamura H, Nakayama H, Kondo H, Tsuchiya R,Shimosato Y, Naruke T. Lymph node involvement,recurrence, and prognosis in resected small, periph­eral, non-small-cell lung carcinomas: are these car­cinoma candidates for video-assisted lobectomy? JThorac Cardiovasc Surg 1996; 111: 1125-34.

13. Landreneau RJ, Pigula F, Luketich JD, Keenan RJ,Bartley S, Fetterman LS, et al. Acute and chronicmorbidity differences between muscle-sparing andstandard lateral thoracotomies. J Thorac CardiovascSurg 1996; 112: 1346-51.