Video-assisted thoracic surgery of major pulmonary resections for lung cancer: the Southampton experience

Objective: Despite proven safety and long-term results of video-assisted thoracic surgery (VATS) lobectomy, the technique is not widely adopted in the UK. We set out to start a VATS lobectomy programme against financial and time constraints to meet cancer waiting times. We present clinical outcomes of patients undergoing VATS major pulmonary resections (VMPRs) with emphasis on postoperative events.

Methods: Patients were deemed suitable for VMPR if on computed tomography (CT)/positron emission tomography (PET); the lesion was suspected to represent lung cancer T1-2, N0-1 and M0. VMPR involved individual hilar structures dissection without rib spreading. Systematic mediastinal nodal dissection was added in the last 64 cases.

Results: Between April 2005 and December 2009, 165 patients were considered suitable for first-time VMPR. Seventy were males and 95 were females. Mean age was 67.5 ± 10.1 (range 34.9-85.5 years) years. Nine patients were not suitable after initial videoscopic assessment and 156 proceeded to VMPR: 150 lobectomies, four bilobectomies, one pneumonectomy and one patient with poor lung function who underwent segmentectomy. There were 23 (14.7%) conversions to thoracotomy. The median operative time for VATS lobectomy was 03:20 ± 00:56 (hh:mm). The median length of hospital stay was 4.0 ± 4.0 days (range 1-25 days, mode 3 days). There were no in-hospital deaths and three (1.9%) out-of-hospital <30 days' mortality. Complications included protracted air leak >3 days in 18 (11.5%) cases, intensive care unit (ICU) admission in 18 (11.5%), pneumothorax in 24 (15.4%) respiratory complications in 14 (9%), bronchial complications in six (3.8%) and bleeding requiring exploration in one (0.6%). The median follow-up was 13.6 months (range 0.1-54.4 months). The actuarial survival at 1, 2 and 3 years for all stages was 85.0 ± 3.8%, 82.2 ± 4.2% and 73.5 ± 7.0%, respectively.

Conclusion: High postoperative events are to be expected when starting a VATS lobectomy programme. Nevertheless, VATS major pulmonary resections are safe and long-term results are not compromised. They should be considered the first choice for T1-2, N0-1 and M0 lung lesions. An aggressive approach to postoperative complications reduced the length of hospital stay to a median of 4 days. Air leak remains the most important cause for prolonged hospital stay.