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 Table of Contents     
Year : 2018  |  Volume : 14  |  Issue : 4  |  Page : 291-297

Video-assisted thoracoscopic surgery lobectomy: The first Indian report

1 Centre for Chest Surgery, Sir Ganga Ram Hospital, New Delhi, India
2 Department of Cardiology, Sir Ganga Ram Hospital, New Delhi, India

Date of Submission04-Aug-2017
Date of Acceptance11-Sep-2017
Date of Web Publication3-Sep-2018

Correspondence Address:
Prof. Arvind Kumar
Room 2328, Super Speciality and Research Block, Sir Ganga Ram Hospital, Old Rajinder Nagar, New Delhi
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jmas.JMAS_148_17

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 ¤ Abstract 

Introduction: The fear of pleural adhesions and densely stuck lymph nodes in India, a country where tuberculosis is endemic, is one major factor keeping our surgeons away from video-assisted thoracoscopic surgery (VATS) lobectomy. In this paper, we aim to report our experience with performing VATS lobectomy in 102 cases using a standardised three-port anterior approach.
Materials and Methods: Between March 2012 and September 2016, we performed 102 VATS lobectomies. Sixty patients (58.8%) were males and 42 females (41.2%), with a mean age of 42.02 years. Diagnoses were as follows: benign disease (72), lung cancer (27) and pulmonary metastases (3). Among the cases with primary lung cancer, twenty out of 27 (74%) were adenocarcinoma and 7 cases of squamous carcinoma (25.92%). All patients underwent lobectomy by a standardised three-port anterior approach.
Results: The overall conversion rate was 8.82% (n = 9). We observed no postoperative complications in 82 (80.4%) patients. The average blood loss was 211.37 ml. Mean operative time was 173 min. Median length of hospital stay was 5 with median chest tube duration of 4.9 days. There was no in hospital or 30-day mortality. The most common complication was prolonged air leak.
Conclusion: From this first Indian series, it is clear that VATS lobectomy is feasible in both benign and malignant cases. It also shows that the fear of adhesions is unwarranted and properly selected benign cases can also undergo VATS lobectomy safely.

Keywords: Lobectomy for benign diseases, lung cancer, thoracoscopic lobectomy, video-assisted thoracoscopic surgery lobectomy

How to cite this article:
Kumar A, Asaf BB, Puri HV, Sharma MK, Lingaraju VC, Rajput VS. Video-assisted thoracoscopic surgery lobectomy: The first Indian report. J Min Access Surg 2018;14:291-7

How to cite this URL:
Kumar A, Asaf BB, Puri HV, Sharma MK, Lingaraju VC, Rajput VS. Video-assisted thoracoscopic surgery lobectomy: The first Indian report. J Min Access Surg [serial online] 2018 [cited 2021 Sep 20];14:291-7. Available from:

 ¤ Introduction Top

Since the introduction of thoracoscopy by Jacobeaus in 1910, Thoracoscopic surgery or video-assisted thoracoscopic surgery (VATS) has come a long way. The prospect of performing thoracic surgery in a minimally invasive way has always intrigued the thoracic surgeons; although, many of them have had little or no exposure to minimal invasive techniques. Despite its widely accepted advantages over open lung resection in terms of lesser pain, earlier return to work, less pulmonary complications and numerous reports for oncological adequacy, the percentage of lobectomies being performed by VATS is still low.

Even two decades after the first VATS lobectomy, there is a striking difference in the adoption of this new technology between developing and developed nations.[1] The developing nations in Africa and South America are clearly falling behind in adopting VATS lobectomy procedures. Although there is no reported data, India lags significantly in adoption of minimally invasive techniques in thoracic surgery. The fear of pleural adhesions and densely stuck lymph nodes in a country where tuberculosis is endemic is one major factor keeping surgeons away from VATS.[2] Lack of adequate technical or financial support, relatively late presentation of cases both benign and malignant together with lack of training programmes and dedicated general thoracic surgical units make adoption of VATS rather difficult. In this paper, we aim to report our experience with performing VATS lobectomy using a standardised three-port anterior approach popularised by Hansen HJ and Petersen RH from Copenhagen.[3] This is the first series on VATS lobectomy reported from India.

 ¤ Materials and Methods Top

This descriptive, retrospective analysis included all patients undergoing lobectomy by VATS at the Centre for Chest Surgery of Sir Ganga Ram Hospital, New Delhi India, since March 2012 to September 2016. The clinical records of all patients were analysed retrospectively.

Selection criteria

All patients who underwent VATS lobectomy for lung cancer and a multitude of benign conditions were included in the study.

In patients with lung cancer, VATS lobectomy was considered as the first choice except in:

  1. T3 or T4 tumours
  2. Tumours larger than 6 cm
  3. Tumours visible in the bronchus within 2 cm of the origin of the lobe to be resected
  4. Centrally placed tumours in the hilum and adherent to vessels
  5. Evidence of chest wall invasion.

In patients with benign pathology, the possibility of VATS resection was considered in all cases, all of whom underwent diagnostic thoracoscopy, to assess the feasibility of VATS resection except for cases where preoperative suspicion of dense adhesions was raised based on preoperative computed tomography scan. This subset of patients was taken up for an open approach per primum.

All patients planned for resection were evaluated by routine and haematological and biochemical parameters and pulmonary function testing to assess the fitness for undergoing lung resection. All patients above the age of 40 or with comorbidities such as diabetes or hypertension were evaluated by a cardiologist for assessing cardiac fitness.

Surgical technique

We follow a standardised three-port anterior approach for all VATS lobectomies as popularised by Hansen HJ and Petersen RH from Copenhagen.[3]

VATS lobectomy was defined as per the CALGB 39802 trial definition as the procedure for anatomical lung resection[4] with:

  1. Utility incision between 4 and 8 cm
  2. Individual dissection and division of hilar structures, i.e., artery, vein and bronchus [Figure 1]b,[Figure 1]c,[Figure 1]d
  3. No rib spreading
  4. Mandatory dissection under videoscopic guidance.
Figure 1: Port placement and hilar dissection during video-assisted thoracoscopic surgery lobectomy. (a) Three-port anterior approach. (b) Truncus anterior looped during right upper lobectomy. (c) Upper lobar division of right superior pulmonary vein being divided. (d) Right upper lobar bronchus being divided

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The patient was placed in a lateral decubitus position more towards the anterior edge of the table. The table was bent to allow for the widening of the ipsilateral intercostal spaces and to move the hip away. Three ports were used in all patients for all lobectomies [Figure 1]a. The utility incision is usually the first port as it allows for a safe entrance into the chest cavity and is useful even when one encounters adhesions which can be taken down safely under vision to create space. This incision was also used later for specimen retrieval.

We used a two-monitor setup with one monitor placed on each side of the table in front of the surgeons and the scrub nurse. The operating surgeon and the assistant stand on the anterior side of the patient. The scrub nurse stands on the opposite side and uses the other screen for viewing. A 10 mm 30° thoracoscope was used. Most dissection was done using curved suction cannula, standard long open surgery instruments and specialised VATS instruments. Before dividing the blood vessels, they are looped using vascular loop. Two sponge stick and vascular clamps were always kept ready on the table for any unexpected bleeding. The resected lobe was placed in a specimen bag and retrieved through the utility port. In all patients operated for lung cancer, a systematic mediastinal lymph node dissection was done.

All patients were mobilised on the day of surgery and the chest tube is removed when there is no air leakage and drainage <250 ml in 24 h. Patients were usually discharged 1 day after tube removal and seen 5 days later in the outpatient clinic. All the patients were operated by Consultant surgeons in the unit, but thoracic surgery residents and fellows were closely involved in outpatient department workup, preoperative workup, preoperative preparation, intraoperative assistance, postoperative care, discharge process and outpatient follow-up of all the patients.

The following patient variables were recorded: age, sex, clinical diagnosis, date of surgery, type of surgery, conversion to open surgery and reasons for conversion, duration of surgery, blood loss, need for transfusion, perioperative complications and morbidity. Data were also recorded for postoperative stay, final diagnosis, pathological staging of lung cancer, number of lymph nodes resected, resection status for cases operated for malignancy and mortality.

 ¤ Results Top

A total of 102 patients underwent VATS lobectomy between March 2012 and September 2016 for different indications at our tertiary care centre [Table 1]. The average age of patients operated is 42.02 years (range: 6–78 years) with a male:female ratio of 60:42 (58.8%:41.2%).
Table 1: Demography and summary of results

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Fifty-three patients were operated for right-sided pathology and 49 for left-sided lesions [Table 2]. We were able to complete 91.17% (93) cases by VATS with 9 (8.82%) conversions which include two emergency conversions done for injury to the pulmonary artery. Descriptive information about conversions is given in [Table 3]. Duration of surgery was 173 min for total series, it was 169.30 min for VATS cases and 187.28 min for VATS converted to open cases.
Table 2: Site of pulmonary resections

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Table 3: Conversions

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Amount of blood loss was 198.88 ml for VATS cases and 259.52 ml for VATS converted to open cases. The distribution of benign to malignant cases was 72:30 (70.6%:29.4%).

Visual analogue score (VAS) was 5.38 for total series, 5.09 for VATS and 6.47 for cases converted to open on postoperative day 1 (POD 1), VAS was 2.13 for total series, 2.01 for VATS and 2.61 for cases converted to open on day of discharge and it was 0.16 for total series, 0.02 for VATS and 0.71 for cases converted to open on POD 30. The average duration of chest tube was 4.90 days for total series, it was 4.70 days for VATS cases and 5.80 days for cases converted to open. Average hospital stay was 5.01 days for total series, it was 5 days for VATS cases and was 5.09 days for cases converted to open.

The complication rate in our series is 19.60% with it being 12.74% in benign cases and 6.86% in malignant cases with the descriptive analysis given in [Table 4]. There were 26 adenocarcinomas and 4 squamous cell carcinomas in present series and stage-wise distribution of nonsmall cell lung cancer patients are shown in [Table 5]. There was no 30-day mortality in our series.
Table 4: Complications (n=102)

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Table 5: Stage wise distribution of nonsmall cell lung cancer patients

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 ¤ Discussion Top

VATS lobectomy is being performed all over the world. However, its penetrance into active thoracic surgical practice is far from complete. According to Society of Thoracic Surgeons (STSs) (STS-General Thoracic Database) data, the percentage of VATS lobectomy procedures has increased progressively as compared to traditional open approach surgeries, from 10% in 2002 to 29% in 2007.[5]

The highest rate of VATS lobectomy over thoracotomy procedures was reported from Denmark (55%). However, for lung cancer, this figure was almost 80%.[3] In our centre, the current percentage of VATS lobectomy versus open lobectomy is 30.69% (93 of 303). More often than not, VATS is generally recognised as a modality dedicated to the management of early-stage cancer (Stages I and II). However, in our series, benign pathology was the indication in the majority (72 of 102), the most common of which was bronchiectasis. Although not an established indication, VATS lobectomy is being performed more and more commonly for benign diseases as well. English literature is full of reports about VATS lobectomy for malignancy;[4],[6],[7],[8],[9] however, similar reports for benign indications are very few.[10],[11] The fear of pleural symphysis or adhesions is the greatest deterrent for VATS in benign cases. In our series, 70.5% of patients underwent VATS lobectomy for benign pathology. Of these, seven patients needed conversion, i.e., 9.7%. These conversions were due to dense pleural symphysis or dense adhesions around the hilum with only one emergency conversion because of injury to the pulmonary artery. In a series of 163 patients who underwent lobectomy for benign disease, Kim et al. reported six conversions into thoracotomy and hence completed VATS anatomic lung resection in 96% of their series demonstrating feasibility in the vast majority of cases.[12]

Our series has an overall conversion rate of 8.82% (9/102), in which there were seven elective conversions as described above and two emergency conversions [Table 3]. Various published series report a conversion rate in the range of 0% to 23% and shows diminution with increasing experience.[13],[14] The elective conversions were done mostly in view of dense pleural adhesions making progression with VATS a difficult and tedious job or unclear hilar anatomy in which continuation with VATS was not deemed safe.

Our conversion rate is slightly on the higher side which reflects the initial learning curve. Kim et al. have accepted in their article that it is possible that the results could be poorer in other institutions as compared to theirs since their results were from a high-volume hospital.[12] It must be emphasised that VATS lobectomy for benign disease is feasible and effective in selected cases. Our experience with VATS adhesiolysis during surgery for other indications such as empyema, recurrent pneumothorax, metastatic lung nodule resection and other nonanatomic wedge resections for aspergillomas made our progress to VATS lobectomy slightly easier. Careful case selection and meticulous approach to surgery is mandatory for optimal results. Adhesions were encountered in 58 patients with benign pathology. Six out of these patients had to be electively converted due to dense pleural adhesions. We were able to complete the procedure by VATS in 90.27% (65/72) of the benign cases selected for VATS lobectomy. This clearly demonstrates that a good majority of patients with adhesion can still undergo VATS lobectomy even in tuberculosis-endemic country like ours. Most series report augmented blood loss, increased operative time and increased complications in converted patients which were also the case with our series.[15],[16]

The mean duration of surgery was 173.0 min overall. The mean operative time for benign cases was 184.95 min. The cases done for lung cancer on the other hand had a mean operative time of 144 minutes. These results match with the other series reporting operative time.[17],[18] The increased operative time in benign cases was due to the time-consuming and tedious job of taking down the adhesions.

The percentage of complications following VATS lobectomy varies from 6% to 34.2%.[8],[17],[19] These rates are much lower than those reported for thoracotomy where complication rates are as high as 58%.[20] Prolonged air leak of >7 days (56%), atrial fibrillation (32%), massive pleural drainage (14%), pneumonia (13%), and myocardial infarction (10%) were some of the common complications reported by Whitson et al. after thoracotomy.[8]

The complication rate in our series was 19.60% with 80.39% of patients having no complications at all. The most common complication noted was prolonged air leak which was seen in 13 (12.7%) patients. This appears to be slightly higher than other reported series (5.09%)[17] which can be explained by the learning curve. In our initial cases, we tried to find the artery in the interlobar fissure which led to air leak. As our experience increased, we adopted the no-touch technique for the fissure which was handled with endoscopic staplers only with intact visceral pleura. We are collecting data prospectively to see if this change in approach leads to lesser incidence of prolonged air leak. The next most common complication was atrial fibrillation which was seen in two patients (1.96%) of cases. Both these patients were over 60 years of age. There was a case of postoperative chylothorax in our series which was of low output and was managed conservatively. The complication rate of our series is in accordance with reviewed literature.[3],[17] There was no 30-day mortality in our series.

Duration of intercostal drainage was guided by the policy of no air leak and drainage of <250 ml in 24 h and it was 4.90 days in VATS series and 5.80 days in those converted to thoracotomy which is similar to reported series on VATS lobectomy.[3],[17] We routinely use digital chest drainage system (THOPAZ-Medela™) in all our lung surgeries. It effectively guides us in the quantification of postoperative air leak and in our experience has helped us in the early cessation of air leak allowing faster removal of chest tubes. Similar results have been reported by Brunelli et al. and Pompili et al.[21],[22]

In our series, average blood loss in procedure completed by VATS was 198.88 ml and in cases converted to open it was 259.52 ml and there were only two emergency conversions due to bleeding because of injury to the pulmonary artery. More blood loss in converted cases is attributed to the fact that most of the conversions were done electively in cases of dense adhesions and most of these adhesions were vascular adhesions which led to increased blood loss. This compares well with blood loss reported in other VATS series.[3],[17]

The mean hospital stay in our series for cases completed by VATS was 5 days. The rate is comparable to most published series.[17],[23] However, one has to keep in mind that in our country the difference might not be much when we compare to thoracotomy. This may largely be attributed to the sociocultural factors. Vast majority of our patients and their relative express their desire for continued hospital care even when fit for discharge.

One major observation made during the study was reduced postoperative pain as noted by VAS score in VATS cases on POD 1, at the time of discharge and at 30th POD. This finding is also substantiated by published scientific literature.[17],[24],[25],[26]

Another major concern among thoracic surgery community is adequacy of VATS as a procedure for lung cancer which had time and again been proved to be equivalent if not superior to open surgery.[27],[28] The third edition of American College of Chest Physicians Evidence-based Clinical Practice guidelines stated that VATS lobectomy is preferred over open surgery for clinical Stage 1 lung cancer.[29] In all the cases of carcinoma lung in our series, we were able to achieve R0 histopathological resection margins. We routinely do complete nodal dissection as guided by European Society of Thoracic Surgeons guidelines which recommend systematic nodal dissection wherever possible.[30] Our average lymph node yield in cancer cases was 18.06 (range: 16–44) which is similar to other series concentrating on this specific issue,[31] thus depicting adequacy of our lymph node dissection.

Our study has several limitations. The number of cases is relatively small. In addition, as it is a retrospective and noncomparative study, our results should be interpreted with caution. Prospective randomised trials are required for more conclusive results. Our cases were assessed very carefully, and only those with favourable factors were selected for VATS lobectomy producing selection bias, wherein patients with favourable factors will have better outcomes compared with those undergoing open surgery. It should also be borne in mind that we progressed to VATS lobectomy after years of experience with VATS procedures such as wedge resection, blebectomy, bullectomy and decortication. This might have helped us in our progression to VATS lobectomy and in our personal opinion; progression to VATS lobectomy should only be done by surgeons experienced in open lobectomies and after enough experience with nonresectional thoracic surgical procedures by VATS. Needless to say, that proper training in the procedure at a high volume centre is essential for program initiation. We adopted the standardised anterior approach for all lobectomies. After reviewing various techniques, we found this approach easier to understand and adopt. Whichever technique is adopted, it is important to stick to one technique to achieve proficiency and to maintain it by doing adequate volumes.

 ¤ Conclusion Top

From this first Indian series, it is clear that VATS lobectomy can be performed safely in both benign and malignant cases. It also shows that the fear of adhesions is unwarranted and properly selected benign cases can also undergo VATS lobectomy safely. There appears to be a definite advantage of VATS lobectomy in the form of reduced blood loss, operative time, postoperative chest tube drainage and pain along with oncological adequacy.

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Conflicts of interest

There are no conflicts of interest.

 ¤ References Top

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  [Figure 1]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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