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Surgery and Single-Port VATS

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After appropriate staging, if patients are found to have non-small cell lung cancer localized to the chest (stage II, II and some III), removal of the cancer using surgery is the preferred treatment, simply because removing the cancer offers the best chance for long-term cure. Operations for lung cancer removal involve two parts, both performed at the same time through the same incisions. First, the portion of lung containing the tumor needs to be removed (called lobectomy), and second, the lymph nodes near the tumor need to be removed (called lymph node dissection), because lung cancers can easily spread to the lymph nodes. There are no side effects of lymph node removal for lung cancer that are sometimes seen when lymph nodes are removed from other parts of the body for other diseases.

The figure above demonstrates the different types of procedures (resections) that can be used to remove lung cancers. Whenever possible, the lobe of the lung containing the tumor should be removed (lobectomy), as opposed to removing only part of the lobe (wedge resection or segmentectomy) because recurrence rates are lowest after lobectomy. Wedge resection or segmentectomy may be appropriate, however, for some patients with other lung diseases, such as severe emphysema, because these patients may not tolerate removal of the whole lobe. Some tumors may be very large, necessitating the removal of entire lung (pneumonectomy).

At many other institutions, lobectomy and lymph node dissection for lung cancer are performed through a six to eight inch incision of the side of the chest (called a thoracotomy), where the ribs are spread apart so that the surgeon can see and operate inside the chest. This is the way lung cancer surgery has been performed for many decades, but unfortunately, this approach can cause a lot of postoperative discomfort.

During a thoracotomy for lung cancer, a six to eight inch incision is made on the side of the chest and a retractor placed to spread the ribs apart so the surgeon can work. In addition to the incision, a small incision (half an inch) is made to place a drain (called a chest tube) which is removed in the early postoperative period in the hospital.

In recent years at some institutions, a less invasive technique similar to laparoscopy for abdominal surgery has been developed, called Video Assisted Thoracic Surgery (VATS). VATS involves the placement of several (usually three to four) small incisions (called ports) on the chest instead of a large incision. No rib spreading is needed and a telescopic camera is inserted so that the surgeon can perform the operation while looking at a video monitor using long, thin instruments specially designed to fit through the ports. Advantages of VATS include:

  • Less postoperative pain
  • Faster return to normal activities
  • Less postoperative complications
  • Easier to administer postoperative chemotherapy, if needed
  • Less time in the hospital
  • Reduced costs

At The Lung Cancer Center at Valley, we have extended the idea of VATS for lobectomy by reducing the number of operating ports to one (called Single-Port VATS). During Single-Port VATS, the telescope is inserted into the half inch chest tube site, and the entire procedure is performed through the single one and a half inch port through which the lobe is removed from the chest. Once again, no rib spreading is needed, but the number of incisions made by the surgeon is less than that needed for VATS. Single-Port VATS is clearly the most minimally invasive way to perform lung cancer surgery today. Even lung cancer operations involving robotics and surgical robots require more incisions (usually four to five), making them more invasive than Single-Port VATS.

In VATS, the surgeon makes three to four small incisions (ports), and uses a telescope to see inside the chest, without any retractors or rib spreading. One of the ports (arrow) needs to be large enough (about one and a half inches) to fit the lobe of the lung containing the tumor when it is removed from the chest.

In Single-Port VATS, surgeons at The Valley Hospital perform the entire lobectomy and lymph node dissection through a single incision (port), while the telescope is inserted through the chest tube site. This is the most minimally invasive way to perform lung cancer surgery described to date.

Throughout the United States, only about one quarter (25%) of lobectomies for early stage lung cancer are performed using VATS. The rest are done by surgeons performing thoracotomy, as described above. In 2009 at The Lung Cancer Center at Valley, 92% of all lobectomies for early stage lung cancer were performed using the Single-Port VATS technique.

Following lung cancer surgery, all patients are cared for in our dedicated thoracic surgery hospital unit at The Valley Hospital. This highly specialized unit, which opened in 2008, has dedicated thoracic surgery nurses and a high nurse-to-patient ratio to ensure that our patients receive the best care possible in the postoperative period. The minimally invasive nature of Single-Port VATS combined with our ability to deliver highly specialized postoperative care has resulted in our patients spending less time hospitalized following surgery for lung cancer.

The benefits of the minimally invasive nature of Single-Port VATS lobectomy and a dedicated inpatient lung surgery hospital unit are reflected in the short hospital stay for our lung cancer patients at The Valley Hospital. In 2009, the number of days patients spent in the hospital (called Length of Stay) after Single-Port VATS lobectomy is only three days at The Valley Hospital, two days less than the national average for lobectomy for lung cancer.

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