2006 Volume 46 Issue 4 Pages 337-343
Objective. VATS lobectomy is not a standard operative procedure for lung cancer at present because there are various technical approaches and evaluation methods of VATS lobectomy. Therefore, we retrospectively compared clinical outcomes of thoracoscopy-assisted and completely thoracoscopic VATS lobectomy for primary lung cancer. Methods. We treated 80 cases with clinical Stage IA lung cancer with VATS lobectomy with lymphadenectomy. Of these, 42 were performed using a thoracoscopic light guide of through a 10-cm thoracotomy with a rib retractor, from June, 1999 to October, 2005 (group A: thoracoscopy-assisted). In 38 cases, we only watched the monitor without a rib retractor to reduce operative stress on the chest wall from April, 2003 to December, 2005 (group P: completely thoracoscopic procedure). Surgery in both groups was carried out basically in the same way except the difference related to the level of VATS lobectomy. In both groups, dissection of upper mediastinal nodes was performed in cases with upper lobectomy and that of subcarinal nodes was performed in cases with lower lobectomy. In cases of right middle lobectomy, both nodes were dissected. In group P, various devices and ideas were employed with access to improve technical maneuvers and safety. A 4-cm thoracotomy was made and three ports were inserted to complete the surgery via a flexible thoracoscope. Results. Operation time was 248 minutes in group P, which was significantly longer than the 202 minutes in group A (P=0.0001). Blood loss was 146 gram versus 263 gram, which was not significantly different between the two groups. Numbers of dissected upper mediastinal nodes were 11.0 in group P versus 7.2 in group A, respectively. Numbers of dissected subcarinal nodes were 4.7 in group P versus 4.8 in group A, respectively. There was no significant difference between the two groups. Length of hospital stay, total amount of chest tube drainage, and dose of suppository pain killer (diclofenac sodium) were 8.0 days in group P versus 15.0 days in groups A (P<0.0001), 746 ml in group P versus 1015 ml in groups A (P=0.031), and 15 mg in group P versus 45 mg, in groups A (P<0.001), respectively. They were significantly less in group P compared with those in group A. Three cases (7.9%) were converted to open thoracotomy in group P because of technical reasons in two cases and injury to the pulmonary artery in one case. Postoperative morbidity was observed in 5 cases (13.2%) in group P versus 11 cases (26.2%) cases in group A, respectively. Prolonged air leakage was similarly observed in 3 cases (7.9%) in group P versus 5 cases (11.9%) in group A, respectively. Three patients with chest pain required consultation with anesthesiologists in group A. No operative or hospital death was seen in either group. The 2-year survival rate was 87.7% in group P and 90.5% in group A. Conclusion. Minimum operative stress on the chest wall achieves reduction of chest pain after completely thoracoscopic VATS lobectomy. Establishment of a standard procedure is anticipated for future randomized control trials to provide objective evidence and revise the Japanese Guidelines of lung cancer treatment, in which VATS lobectomy still only has a grade C recommendation.
