Simultaneously stapled lobectomy: a safe technique for video-assisted thoracic surgery.

Abstract

Currently, techniques for video-assisted thoracic surgery are being borrowed from the open conventional thoracotomy. However, these same techniques have made video-assisted lobectomy difficult, burdensome, and even dangerous. Simultaneously stapled lobectomy (simultaneous stapling of all hilar structures in their natural anatomic configuration) has been performed successfully in 16 patients. Every attempted simultaneously stapled lobectomy is included. The lesions included 14 malignant tumors, one giant benign pulmonary cyst, and one large necrotizing granuloma. Three right upper lobes, one right middle lobe, six right lower lobes, four left upper lobes, and two left lower lobes were resected uneventfully. Nine adenocarcinomas, two large cell carcinomas, and three squamous cell carcinomas ranging in size from 2.5 to 5 cm were removed. Lung fissures, the hilum, and the mediastinum were explored for lymph nodes in each patient. Median operative time was 110 minutes. Average blood loss was less than 100 ml. Median hospitalization was 6 days, although eight patients were discharged between 3 and 5 days. Three patients had air leaks for an average of 14 days and one patient had mild subcutaneous emphysema for 5 days. There was no surgical mortality. Median follow-up is 15 months (range 8 to 20 months). Simultaneously stapled lobectomy is not meant to replace conventional lobectomy by open thoracotomy. Indications are cardiac or renal problems, contralateral chest wall paralysis, neurogenic deficiencies, adamant refusal to undergo open lobectomy, psychologic aberrations, and pain from a previous thoracotomy. Contraindications include absent fissures, enlarged matted invasive nodes, fibrotic hilum, central or bulky lesions, calcific bronchi, chest wall invasion, and lesions crossing a fissure. Precedent for this technique will be discussed. When used with discretion in carefully selected patients, in whom an open lobectomy would be contraindicated, simultaneously stapled lobectomy might eventually prove to be another available option. Time and further experience will be necessary to determine its true merits.