Surg Endosc (2008) 22:298–310 DOI 10.1007/s00464-007-9586-0

REVIEW

Video-assisted thoracic surgery (VATS) of the lung Analysis of intraoperative and postoperative complications over 15 years and review of the literature

L. Solaini Æ F. Prusciano Æ P. Bagioni Æ F. di Francesco Æ L. Solaini Æ D. B. Poddie

Received: 25 February 2007 / Accepted: 13 June 2007 / Published online: 18 October 2007 Ó Springer Science+Business Media, LLC 2007

Abstract exeresis. The overall postoperative morbidity rate was Background Video-assisted thoracic surgery (VATS) in 8.3% with no deaths. the diagnosis and treatment of pulmonary diseases has been Conclusions The analysis of the literature and our expe- used since the early 1990s, yet its impact on intraoperative rience show that VATS is a reliable approach to the and postoperative morbidity has not yet been fully evalu- diagnosis and treatment of pulmonary diseases with low ated. This report aims to provide a retrospective analysis of complication rate. To further reduce intraoperative and the literature and the authors’ clinical experience with postoperative morbidity, however, it is necessary to select VATS in pulmonary surgery, with the goal of ascertaining the patients carefully, to adhere strictly to oncological rational criteria that explain operative complications and surgical principles, and to adopt a meticulous technique. thus improve outcomes. Although conversion to open surgery represents failure of Methods Over a period of 15 years 1,615 VATS proce- VATS, it is mandatory when the procedure is not com- dures were performed in our department, 743 of which pletely safe. involved only the lung. The accesses employed were based on the use of three ports through which a thoracoscope, Keywords Video-assisted thoracic surgery Á endoscopic instruments, and an endostapler were inserted; Pulmonary surgery Á Intraoperative complications Á for major pulmonary resections, a utility thoracotomy Postoperative complications Á Surgical biopsy Á without rib spreader was added. Resections less than seg- Wedge resection Á Lobectomy Á Pneumonectomy mentectomy were performed using the endostapler directly on the parenchyma, whereas in the anatomic resections all the hilar structures were isolated and separately sectioned. The first report of thoracic surgery performed using mini- Results The procedures performed were as follows: sur- accessses under telescopic guidance was for treatment of gical biopsy, 98; wedge resection, 412; segmentectomy, pneumothorax and was published in 1990 [40]. In 1991 15; lobectomy, 217; pneumonectomy, 1. Besides the cases other reports described this technique for the treatment of in which there were intraoperative complications that could pneumothorax [52] and for pleurectomy and thoracic be resolved thoracoscopically, it was necessary to convert sympatectomy [61], as well as for wedge resections for to open surgery in 80 patients (10.8%): in 24 (3.3%), for pulmonary nodules [36, 37]; shortly thereafter the first general reasons linked to the technique of VATS itself; in descriptions of pulmonary lobectomies and pneumonecto- 56 (7.5%), for specific causes correlated to the type of mies appeared [34, 43, 65, 84]. This technique then spread rapidly and in the early 1990s many thoracic lesions were approached using this method, so many that in 1995 [48] L. Solaini (&) Á F. Prusciano Á P. Bagioni Á F. di Francesco Á the term ‘‘video-assisted thoracic surgery’’ (VATS) had L. Solaini Á D. B. Poddie been coined. Now VATS is used in many pulmonary, Thoracic Surgery Unit–Department of Surgery, S. Maria delle Croci Hospital, V .le Randi, 5, 48100 Ravenna, Italy pleural, esophageal, and mediastinal operations, and it has e-mail: [email protected] become widely accepted as a standard approach in

123 Surg Endosc (2008) 22:298–310 299 diagnostic procedures and for the treatment of many benign exploration of the lung and the pleural cavity is inserted. diseases. In pulmonary cancer surgery, VATS is not yet As suggested by Sasaki et al. [69], the ideal positions of the considered a routine approach in performing segmentec- ports are the angles of an isosceles triangle, with the apex tomies, lobectomies, and pneumonectomies, removing at the bottom, where the first port has been introduced. metastases, or in lung volume reduction surgery for Under endoscopic guidance two more ports are usually emphysema; therefore these operations are carried out only introduced: an anterior one of 12-mm diameter in the forth in selected centers. or fifth intercostal space in the anterior axillary line and a As with every other surgical procedure, VATS is not posterior one of 5-mm diameter in the fifth or sixth inter- free from complications. Thus the aim of the present study costal space in the posterior axillary line. When the lesion was to evaluate this aspect of VATS in depth; after 15 or the biopsy area is identified, an endostapler is inserted years of performing VATS, a thorough evaluation of its through the anterior port and it is used to carry out the intraoperative and postoperative morbidity is necessary. On wedge resection. All specimens from the chest cavity are this topic some reports [18, 27, 29, 35, 92] have been retrieved in a plastic bag to avoid possible tumor cell published, but they are related to the first years of VATS implant. and they describe a limited number of cases from many For segmentectomies and lobectomies three ports and an different centers. Here we report our experience and we anterior utility thoracotomy no greater than 5 cm in length review the literature focusing on complications related to are used, without spreading the ribs. Through these the VATS technique itself, and the complications of the accesses, conventional and endoscopic instruments are pulmonary resections in general. The distinctive compli- inserted for the dissection of the bronchovascular struc- cations of VATS for the treatment of the diseases of pleura, tures. All arteries and veins are separately sectioned either mediastinum, and esophagus require a separate evaluation. with vascular endostaplers or, when they are thin, by applying clips and cutting with endoshears. If necessary, the fissures are completed by the use of the same endos- Patients and Methods tapler. Finally, the bronchus is isolated and sectioned by applying the endostapler with the provided cartridge. In all Between December 1991 and December 2006 at Thoracic cases of carcinoids and lung cancer, hilar and mediastinal Surgery Unit of S. Maria delle Croci Hospital of Ravenna lymphadenectomies or samplings are carried out. As with (Italy), 1,615 VATS procedures were performed, 743 of the wedge resections, the specimen is always extracted which involved only the lung. The indications for VATS inside a plastic bag. were as follows: large pulmonary biopsies for interstitial At the end of the procedure, after a pleural lavage, one diseases, indeterminate nodules, carcinoids, stage I non- or two chest tubes are inserted in the pleural cavity through small-cell lung cancers, and metastases. the port incisions; these are removed when air leakage stops and the fluid is less than 100 cc/day.

Surgical technique Results The videothoracoscopic procedure applied has been described elsewhere [73, 75]; however, more technical Table 1 lists the 743 VATS procedures performed for details are necessary. The patient is placed in the lateral diagnosis or treatment of pulmonary diseases. There were decubitus position, allowing slight splaying of the ribs, and 702 patients, 41 of whom underwent two different proce- general anesthesia is induced via a double-lumen tube for dures. No intraoperative or postoperative deaths occurred. one lung ventilation. For the introduction of the first port, a Not all intraoperative problems led to conversion to open 1.5-cm skin incision is made, and through this a Kelly surgery; however, in 80 cases (10.8%) a thoracotomy was forceps is inserted to gently open wide the subcutaneous required. General and specific complications for every kind tissue layer and the muscular layers, along the superior of procedure were recorded, as shown in Table 1. border of the lower rib, until entering the parietal pleura. The overall postoperative morbidity rate was 8.3% (58/ This technique allows a small amount of air to enter the 702). Except for four cases of intercostal neuritis in the pleural cavity, and then the first port (10 mm) can be safely sites of port introduction and one case of pulmonary her- inserted. niation through the utility thoracotomy, no postoperative In cases where no anatomic resections are to be per- complications on the chest wall due to the VATS approach formed the procedure begins with the introduction of a 10- were observed. All complications were related to the pul- mm port in the mid-axillary line in the sixth or seventh monary resections. No study has been done to assess intercostal space, and through it the telescope (0°) for the postoperative pain. The general opinion, however, is that 123 300 Surg Endosc (2008) 22:298–310

VATS was much less painful than thoracotomy, requiring Table 1 Video-assisted thoracic surgery (VATS) pulmonary resec- only mild pain killers during the first 2–3 days after sur- tions in 743 cases. Type of procedure and complications observed gery. This pattern was the same for those patients who No. Conversion to open surgery Percent required a utility thoracotomy. cases General Specific reasons reasons

General intraoperative complications Surgical biopsy 98 0 0 0 Wedge resection 412 18 33 12.4 General intraoperative complications led to conversion to Segmentectomy 15 0 2 13.3 thoracotomy in 24 cases. Problems with anesthesia and Lobectomy and 217 6 21 12.6 various technical problems led to difficulty with the VATS bilobectomy procedure and conversion to thoracotomy in 9 cases. In two Pneumonectomy 1 0 0 0 patients, it was not possible to obtain satisfactory collapse of the lung; in another four, it was not possible to maintain sufficient O2 saturation with one lung ventilation; and in pleural effusion (1 patient), pneumonia (2 patients), inex- one other patient irreparable displacement of the double- plicable fever (2 patients), atrial fibrillation (1 patient), and lumen tube during the procedure required conversion. A prolonged worsening of respiratory function necessitating block of the video system led to conversion in one case, re-intubation (2 patients). All these complications were and in another technical problems caused conversion to an successfully treated, and the patients were discharged from open procedure. the hospital within 16 days of the date of surgery. In 2 In five cases, problems occurred during the introduction patients, postoperative intercostal neuritis resulting from of the first port, but none of these problems led to thora- insertion of the ports required treatment for a period of 2–4 cotomy conversion. In another three cases the pulmonary months. parenchyma was injured and in two more perforation of the diaphragm occurred, with a mild laceration of the liver on the right side. In the latter two cases, the examination at the Wedge resection: 412 cases end of the procedure did not reveal any sub-diaphragmatic problems, and the holes in the diaphragm were easily The indications for atypical resections were as follows: repaired with two stitches. indeterminate nodules, solitary metastases, and peripheral Pleural adhesions led to conversion to open surgery in non-small-cell cancer not suitable for lobectomy. Actually 15 cases. Usually, mild or limited adhesions were easily 422 wedge resections were performed because 8 patients sectioned by VATS, but in these 16 cases the adhesions had two excisions and 1 patient had three. The two criteria were so thick and adherent to the lung that lysis was for using the VATS approach were based on careful impossible. In these 16 cases a decortication had to be assessment of the computed tomography (CT) scan images: performed at the end of the open procedure. the nodule had to be located in the outer third of the lung and its maximum diameter had to be less than 3 cm. In our early experience with VATS, when it was nec- Complications by type of procedure essary to localize the nodule, we used in the method of positioning a hook wire preoperatively under x-ray guid- Surgical pulmonary biopsy: 98 cases ance in 48 cases. This technique was abandoned for two reasons: first, because during VATS the wire was often Because the aim of the VATS procedure in pulmonary found to be displaced and second, if the nodule was deeply biopsy is diagnosis, at least two small wedge resections of located, it was impossible to resect it by endoscopic the parenchyma were performed with the endostapler at the approach. Subsequently, when the nodule had not been point or points where the disease was most evident. In no previously identified and it could not be identified by case was conversion from VATS to open surgery required. means of the endoscopic instruments, the surgeon inserted Because of the stiffness if the tissue, complete suturing was a finger into the chest through the anterior hole and pal- not obtained in three cases in which we employed a stapler pated the pulmonary surface. The most significant cartridge of 30 mm. This was remedied by a second firing difficulty in performing this procedure was detection of the with a 48-mm cartridge. nodule and its excision when it was located deep in the The postoperative course was uneventful in 85 cases parenchyma and far from the fissure. In 25 cases this sit- (86.6%) with a mean hospital stay of 4.2 ± 4.9 days. The uation led to abortion of the VATS procedure: 13 nodules complications involved prolonged air leak (3 patients), had a maximum diameter less than 0.5 cm and were not 123 Surg Endosc (2008) 22:298–310 301 found, even when the surgeon’s hand was used to palpate the hilar bronchovascular structures in the course of the lung; the other 12 nodules were located close to the resecting the superior segment of the lower lobe. There- hilum of the lobe and all maneuvers to achieve a safe fore, in two of these cases conversion to thoracotomy was resection were ineffective. necessary. Moreover, in the same segmentectomy it was Three other cases of conversion to thoracotomy were much more difficult to recognize the intersegmental planes registered: two were required because resection by the for the parenchymal sectioning. This maneuver was very VATS procedure was insufficient in cases of malignancy; time consuming. in both cases frozen section showed that the tumor was With the exception of one patient (6.6%) who experi- close to the resection margin. The third failure was due to a enced a prolonged air leak (14 days after surgery), the failed deep suture of the parenchyma with the endostapler; postoperative course was uneventful in all cases, and dis- despite the attempts to achieve a satisfying repair by charge from the hospital occurred within 5–7 days of the endoscopic means, thoracotomy was unavoidable. More- operation over, in 12 cases, to obtain satisfactory resection without removing too much parenchyma, a fourth port was used to obtain a good angle of the endostapler. Lobectomy and bilobectomy: 217 cases Further difficulties involved retrieval of the specimen. In one case, extraction of the specimen from the chest cavity Indications for VATS lobectomy [74, 75] were as follows: was difficult because it was larger than the anterior chest stage I non-small-cell lung cancers, carcinoids, metastases, wall hole; in such situations it is possible to enlarge the and benign lesions not removable by lesser resections. On hole to allow retrieval of the specimen. In two other cases the left side 31 upper lobectomies and 58 lower lobecto- rupture of the plastic bag occurred during the retrieval mies were performed, and on the right side, 43 upper, 15 maneuver. This did not create any danger to the patient middle, 66 lower lobectomies, and 4 bilobectomies were because the specimen did not contain any neoplastic tissue. performed. In 56 patients frozen section of an indeterminate nodule Especially in the first cases, some problems were showed non-small-cell lung cancer and therefore 41 pro- encountered during the VATS procedure. The most dan- ceeded to VATS lobectomy and 5 to open lobectomy; the gerous of them was bleeding, which led to immediate other 10 could no bear a major resection. thoracotomy in 3 cases. Eight injuries of the arterial The postoperative course was uneventful in 350 of the branches during dissection of the hilum were recorded. In 371 patients who underwent only wedge resection (94.3%). these cases, to achieve immediate hemostasis, pressure was The mean hospital stay was 3.8 ± 4.4 days. In 21 of these applied with a sponge mounted on a conventional curved patients the following complications were observed: pro- clamp inserted through the utility thoracotomy. In five of longed air leak (9 cases), pneumonia (2 cases), pleural these cases the hemorrhage was staunched by applying effusion (3 cases), wound infection (1 case), acute pan- several clips or by firing with an endostapler below the creatitis (1 case), acute cholecystitis (1 case), arrhythmia (1 laceration, but in three cases thoracotomy was necessary, case), and deep venous thrombosis (1 case). Two patients and blood transfusion was required in two. This intraop- with prolonged air leak and one with pleural effusion were erative complication occurred in four patients during left in the group in which a conversion to open surgery was upper lobectomy, which proved to be the most difficult required. VATS lobectomy. In a case described elsewhere [75], the Two cases of delayed postoperative complications endostapler did not open after firing through the inferior involved intercostal neuritis, which required daily analge- pulmonary vein, and the chest had to be opened so that the sic use, for three months in one patient and for 5 months in lower lobectomy was performed intrapericardically, with the other. removal of the lobe and the attached stapler. Pleuropulmonary adhesions were another important cause of conversion in the early years: apart from the 6 Segmentectomy: 15 cases cases in which adhesions prohibited sufficient access to the pleural cavity (Table 1), open thoracotomy was required in For anatomical reasons segmentectomy was restricted to two more cases because the adhesions completely fused the the lingula (11 cases) and to the superior segment of the fissures. Moreover, in performing middle or upper right lower lobe (4 cases). The indications were as follows: lobectomy, where the minor fissure is often incomplete, carcinoids, solitary metastasis, and lung cancer not suitable difficulties were met in cases in which it was not possible for lobectomy. to isolate the arterial plane in the major fissure; in these The difficulties associated with the performance of this cases it was necessary to spend a lot of time to find the procedure via VATS were mostly related to dissection of right layer. 123 302 Surg Endosc (2008) 22:298–310

Despite these difficulties, the most frequent reason for used was decided during the endoscopic exploration. The aborting the VATS procedure was oncologic when patients resection planned was left lower lobectomy, but a cancer were found to have lung cancer: in three cases the tumor infiltration of the upper lobe, which also had large bullous was larger than the expected and in twelve others, the disease, was found. Therefore it was decided to attempt a presence of enlarged hilar lymph nodes not only led to the pneumonectomy. No complications were noted intraoper- suspicion that the disease was not at stage I but also pre- atively or postoperatively, and the patient was discharged vented satisfactory dissection of the vessels. Another from the hospital 8 days after operation in very good problem that needs to be mentioned was encountered in 8 condition. of our patients: during extraction of the specimen from the chest cavity, the tumor and the surrounding parenchyma inside the plastic bag were lacerated; as a result it was Discussion difficult to measure the exact size of the tumor for a precise TNM classification. Finally it must be said that in 27 The introduction of a high-resolution videoendoscopic patients, to achieve a correct mediastinal lymph node dis- system in 1990s has changed thoracic surgery so much that section one more 5-mm port was used. No particular nowadays many thoracic diseases are electively approa- difficulty was encountered in performing the four ched by VATS. For many others, however, the treatment of bilobectomies. choice is a matter of debate. Although there are undeniable The amount of time required for the procedure dimin- benefits from the use of VATS, problems that have never ished with the increase in experience; whereas the first before been considered have arisen. Such problems can be operation took 5 h, the later operations took no more than solved during operation by implementing videoendoscopic 2.5 h, even in complicated cases. maneuvers or converting to open surgery. If course, the The postoperative course was uneventful in 194 patients latter solution also means failure of the mini-invasive (89.9%) including those that underwent thoracotomy, and approach. The literature contains many reports of the the mean length of postoperative stay was 5.8 ± 6.8 days. numbers and reasons for conversion to thoracotomy; As already mentioned, bleeding was the most serious however, very few authors [1, 35, 83] have reported how to complication; it occurred in 4 patients: 1 patient who had resolve intraoperative complications without opening the undergone a lower lobectomy had a hemothorax that chest. required reoperation, again performed by VATS; 2 patients The overall conversion rate to thoracotomy ranges from only needed blood transfusions, and the fourth patient was 1.04% [27] to 33.1% [1], and the incidence of postopera- transfused after a converted upper left lobectomy. Eleven tive morbidity ranges from 3.6% [27] to 10.9% [29]. patients experienced prolonged air leak for more than 7 However, for a better understanding the complications of days, and three of them also suffered a large subcutaneous VATS, it is necessary to analyze in detail the complications and a mediastinal emphysema that resolved within less that underlie these percentages. Most can be related to the than 21 days. Other postoperative complications, appro- videoendoscopic technique itself (general complications), priately and successfully treated, were pneumonia (3 or linked to the type of procedure being performed (specific cases), atrial fibrillation (2 cases), secretion retention complications). The latter complications can be grouped as necessitating bronchoscopic toilet (1 case), and urinary intraoperative, postoperative, and delayed. retention (1 case). Regarding long-term complications of lobectomy, no case of cancer implantation has been observed at the sites General Complications of chest wall accesses. As reported elsewhere [76] the incidence of local cancer recurrence seems to be similar to Video-assisted thoracic surgery requires the collapse of that reported after open surgery and is not correlated to the one lung, and therefore all conditions that prevent this VATS approach. One complication linked to the anterior maneuver lead to conversion to thoracotomy. In addition, utility thoracotomy was registered: 6 months after surgery, the inability to achieve or maintain one-lung ventilation a herniation of the lung through the thoracotomy site is a reported complication in the literature [1, 6, 16, 29, occurred, but it did not require surgical repair. 35, 92], as well as in the present study. Likewise, tech- nical problems with the thoracoscope or with the video- system can lead to a change in approach, as reported by Pneumonectomy: 1 case some authors [1, 26] and in this study. To avoid con- version owing to problems with the video-system, it is As reported elsewhere [75] no VATS pneumonectomy was advisable to always have a second working video-system scheduled, and the one case in which this approach was available. 123 Surg Endosc (2008) 22:298–310 303

The insertion of the first port can cause damage to the as hamartoma (13) and schwannoma (3) have been underlying organs if not done carefully. If the lung is described. The most common site of implantation is at the adherent to the chest wall or the diaphragm is too elevated, port site after wedge resection of a metastatic nodule or a the port can cause pulmonary tears or injuries to the liver or primary lung cancer, but Yim et al. [89] have reported a the spleen. To avoid these problems, when air does not local recurrence in the utility thoracotomy after VATS flow in after the pleura is entered with the Kelly forceps, lobectomy. Other sites of tumor implantation are the digital exploration of the intercostal access site is manda- pleura, the pulmonary parenchyma, and the resection tory. Sometimes it is advisable to change the position at margins. which the port is to be inserted. As described above, at the It is difficult to determine with precision the incidence beginning of our experience we occasionally observed such of this late and serious complication. In the literature it is complications, but they were always resolved by VATS usually reported in single case reports. In addition, it is maneuvers without consequences. Pulmonary tears [27] unlikely that all the cases worldwide are reported. Downey and a case of conversion for repair of a diaphragmatic tear et al. [19] collected 21 cases recorded up until February [1] have also been reported. Small hemorrhages caused by 1994 from 48 surgeons, and they warned the thoracic introduction of the ports through the chest wall are quite surgery community about this problem. As suggested by common and easily treated, but there is also a report of many authors [2, 18, 60], tumor deposition and dissemi- more significant bleeding from injury to the intercostal nation results from failure to observe established vessels [27]. oncological surgical principles. Therefore it is strongly Pleural adhesions are the most frequent reason of con- recommended that resection is performed only when the version to open surgery, and they have been reported from lesion is clearly removable by VATS, using meticulous almost all authors. We are of the opinion that mild adhe- technique without laceration of the tumor and contamina- sions can be cut without a problem allowing the entire lung tion by the instruments of the distant pleura or lung. The to be mobilized but, when they are very thick and strongly use of an impermeable bag for specimen retrieval is man- adherent to the lung, conversion is unavoidable. datory, and all care should be taken to avoid rupture of the The most peculiar postoperative complications related to bag during extraction from the chest cavity. If necessary, the VATS technique itself are pain and neuritis in the site the parietal hole can be enlarged to facilitate removal. At of port insertion. This problem, which is reported by some the end of the procedure a sterile lavage of all port sites and authors [27, 39, 92] and our group as well, has been the pleural cavity needs to be done. thoroughly studied by Landreneau et al. [38, 39]. They believe that it is caused by an excessive torquing of the instrumentation in the port site, which injures the inter- Specific complications costal nerve. It can be sidestepped by creating the chest wall hole at an angle perpendicular to the intercostal space, Surgical Pulmonary Biopsy thereby avoiding an oblique tunnel. To reduce postopera- tive pain they [39] also recommend sharp incisional entry With the exclusion of patients in whom one-lung ventila- through the soft tissues and the use of dilators to cross the tion is not feasible, VATS is the standard approach for intercostal space. Moreover they advise, when possible, the surgical pulmonary biopsy of diffuse interstitial disease use of 3- or 5-mm ports, to avoid posterior accesses and the [64]. The surgical technique is based on one or more small insertion of instruments without trocar protection. wedge resections of pathologic parenchyma by means of an Another reported delayed complication of VATS is endostapler. herniation of the lung through the chest wall accesses [80]; Conversion rate to open surgery, mean postoperative as in the case reported in the present series of lobectomies, stay, and complication rates reported in the major series [4, it did not require surgical correction. 5, 9, 59, 63, 88, 93] are shown in Table 2. No intraoper- ative deaths have been recorded. During the procedure complications that led to open surgery were these: exten- Tumor seeding and implantation after VATS resection sive pleural adhesions [63, 92], bleeding [5], pulmonary of pulmonary malignant lesions laceration [93], and stiff lung parenchyma unsuited to en- dostapler excision [92]. The last complication also The first case of chest wall implantation after thoracoscopic occurred in the present series of patients, but it was solved resection of a malignant pulmonary nodule was reported by endoscopically with the use of another endostapler fitted Thurer just after the introduction of VATS in 1993 [82]. with a cartridge having larger stitches. Later, some other reports on the subject were published [2, There are occasional reports of deaths related to the 8, 18, 21, 29, 35, 60]; even seeding of benign diseases such underlying pulmonary disease occurring in the 123 304 Surg Endosc (2008) 22:298–310 postoperative course [59, 93]. Also, postoperative mor- The postoperative course is rather difficult in these bidity is most commonly associated with prolonged air patients, and morbidity can affect more than 50% of the leaks, but it should be considered as normal if the patient cases [32, 49]. The 30-day mortality [32, 49, 53, 56]is underwent mechanical ventilation. Other important com- reported as high as 8.1% [67]. Respiratory failure [32, 49, plications reported are pneumonia [93], respiratory failure 67], contralateral tension pneumothorax in unilateral LVRS [88], bleeding [59], and pneumothorax after tube removal [49], bleeding [56, 67], and cardiac events [49, 53] are the [93]. main causes of death. Video-assisted thoracic surgery for pulmonary biopsy of Air leak persisting longer than 7 days is almost interstitial disease should be considered a simple and safe unavoidable after lung volume reduction and it is reported procedure. Some intraoperative difficulties may be in over the 90% of cases in the literature [15]. Air leak is encountered if there are adhesions or if the parenchyma is generally also a reason for reoperation [7, 49, 53, 56]. very thick and stiff. In such cases the choice of the proper Attempts to overcome this problem by buttressing the cartridge of the endostapler avoids incomplete suture of the suture line have not yet been demonstrated as a safe pulmonary tissue during resection. Postoperative compli- solution; air leak is associated with the pathologic features cations are usually due to the underlying lung disease or to of the pulmonary tissue and the corticosteroid drugs with the poor general conditions of the patient and are not linked which these patients are treated [15]. Bleeding is reported to the VATS approach. in 4.8%–6% [49, 53, 78] of the patients requiring reoper- ation at a rate of 1.9% [56]. Pneumonia is also a quite common complication [7, 22, 25, 32, 49, 53, 78] that Lung volume reduction surgery sometimes leads to re-intubation and ventilation. Other chest complications include pneumothorax [7, 25, 78], Video-assisted thoracic surgery has slowly gained a role in empyema [32], respiratory failure requiring mechanical lung volume reduction surgery (LVRS): it has the advan- ventilation [7, 77], and rupture of the hemidiaphragm [79]. tages of minimally invasive surgery, which is very Other causes of morbidity reported are myocardial infarc- important in these seriously ill frail patients. The procedure tion, arrhythmias, stroke, deep venous thrombosis, involves unilateral [22, 32, 53, 56, 67] or bilateral [7, 25, perforated ulcer, and acute abdomen. 49, 77, 78] stapled pulmonary resection of the target areas Although there is not uniform agreement on the use of or the upper lobes in the case of homogeneous disease. To VATS in LVRS, it seems that the intraoperative and reinforce the suture line, it can be buttressed with bovine postoperative complications do not differ from those pericardium [25, 49, 56]. Laser ablation has also been used occurring with open surgery; the morbidity of this opera- in resection of emphysematous pulmonary tissue, but it tion is linked to the poor condition of the patients and not seems to be less reliable than the endostapler [32, 50]. to the surgical approach employed. The intraoperative and postoperative complication rates of VATS in LVRS are indicated in Table 3. There has been no intraoperative mortality, and the rate of conversion to Wedge resection open surgery is very low. During the procedure the main problems are associated with adhesions that usually can be The indications for wedge resection are these: diagnosis of sectioned without damage to the lung; in some cases, indeterminate pulmonary nodules, excision of benign dis- however, adhesions lead to conversion from VATS to open ease, solitary metastases, and stage I lung cancer not thoracotomy [32, 56]. amenable to treatment by lobectomy. The lesion should be

Table 2 Complications in the largest reported series of VATS surgical pulmonary biopsies No. cases Conversion, % Postoperative complications, % Mean hospital stay, days

Bensard et al. [5], 1993 22 4.5 4.5 2.6 Zegdi et al. [93], 1998 64 15.6 13 4.6 Rena et al. [63], 1999 58 1.7 3.4 4 Caccavale and Lewis [9], 2000 61 0 3.3 1.5 Ayed [4], 2003 79 0 9 Ooi et al. [59], 2005 55 0 9 2.8 Yamaguchi et al. [88], 2004 30 0 10 Present series 98 0 13.4 4.2

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Table 3 Complications in the largest reported series of lung volume reduction surgery (LVRS) by VATS No. cases Conversion, % Postoperative complications, % Mean hospital stay, days

McKenna et al. [50], 1996 166 0 62.5 11.2 Naunheim et al. [53], 1996 50 0 46.0 8 Keenan et al. [32], 1996 67 8.9 79.0 17 Stammberger et al. [78], 1997 42 0 30.9 12 Hazelrigg et al. [25], 1998 50 2 70 21.1 Geiser et al. [22], 2001 28 0 42.8 29.9 Soon et al. [77], 2003 71 0 2.8 18 Oey et al. [56], 2003 52 1.9 17.3 14 located in the outer third of the lung or near the fissure, detected by exploratory thoracoscopy, the use of a finger without evidence of intrabronchial extension, with a max- introduced through the chest hole can help enormously. In imum diameter of less than 3 cm. The most popular our opinion, if the nodule is not easily detectable, its surgical technique employed is the stapled resection, but excision is also difficult. Therefore, it may be better to some authors advocate supplemental use of a laser [26, 37, consider the use of mini-thoracotomy in such cases. Other 45, 70] or argon beam coagulator [26, 42]. intraoperative complications that have led to conversion to The VATS complication rates of wedge resections are thoracotomy are pleural adhesions [6], bleeding [1, 6, 24], show in Table 4. The most important reasons for conver- stapler malfunction [1], and air leak [6, 47]. sion to thoracotomy are the discovery of malignancy and Postoperative morbidity in the largest series ranges from an inability to localize the nodule. Malignancies are 3.6 % [45]to11%[47]. Some deaths not related to sur- reported in about 8%–11% of the cases [1, 6, 30]. The gical technique are reported [1, 6, 16, 30]. According to the malignant lesions in which a wedge excision is a correct literature and in our experience the most frequent com- oncological resection need a margin of at least of 1 cm, and plication is prolonged air leak; it is also reported as a cause frozen section must demonstrated that; otherwise a further of redo VATS [10]. Other common complications are resection, by thoracoscopy or open surgery, is mandatory. pulmonary atelectasis [6, 45], pneumonia [6, 45], bleeding The inability to find the nodule is noted in almost all [6, 10, 30], and atrial fibrillation [1]. published reports, and its impact ranges from 0.8% [45]to The average postoperative hospital stay ranges from 2.4 7.5% [6]. Without the possibility of lung palpation and [45] to 6.2 [30] days. Wedge resection with VATS can be a using only the video system, the main difficulty of this very simple procedure, and some authors have proposed procedure is the detection of very small nodules [47] and avoiding use of a chest tube after the procedure [86] or its their resection when they are located deep in the paren- early removal with same-day discharge [11]. In our opin- chyma. To solve this problem, many technical solutions ion, this management of the patients should be widespread, have been proposed: preoperative injection of methylene but with careful patient selection. In patients with co- blue [6, 33, 87] or colored collagen [54] into the lesion, morbidities and generalized poor health, complications different methods of preoperative positioning of a wire such as pneumothorax and atelectasis are likely to develop hook under CT guidance [6, 17, 20, 24, 46, 62], and in- and readmission thus becomes unavoidable. traoperative ultrasonography [46]. All of these methods offer advantages and disadvan- tages, but when the nodule is really deep in the Lobectomy, bilobectomy, and segmentectomy parenchyma, even if it is identified clearly, it is difficult to perform a satisfactory resection with the disposable en- Anatomic resection less than pneumonectomy are per- dostaplers. Moreover, as it has been thoroughly described formed for stage I non-small-cell lung cancer, carcinoid, by Roviaro et al. [67], considering the thickness of the metastasis not removable by wedge resection, and for some parenchyma, nodules that are located in the convex areas of benign diseases such as granuloma, organized pneumonia, the lung are particularly difficult to resect. As mentioned bronchiectasis, abscess, and some malformations. Among earlier in this article, early in our experience we adopted these resections, segmentectomy is carried out less often preoperative positioning of hook wire for localizing the and is therefore reported together with lobectomy [16, 28, nodule, but during the procedure it was often found to be 51, 57, 67, 81, 90]; there is only one article [72] describing displaced, and so we abandoned the technique. As also segmentectomy for the treatment of small peripheral lung suggested by Mack et al. [46], when a nodule is not cancer. We have to underline that segmentectomy is very

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Table 4 Complications in the largest reported series of VATS wedge resections No. cases Conversion, % Postoperative complications, % Mean hospital stay, days

Mack et al. [45], 1993 242 0.8 3.6 2.4 Allen et al. [1], 1996 352 22.2 7.7 4 Bernard et al. [6],1996 388 17 8 6 Jimenez et al. [30], 2001 209 16.3 9.6 6.2 Marasugi et al. [47], 2001 81 11 1.2 9.2 Cardillo et al. [10], 2003 429 0 3.0 4.6 Present series 412 12.4 5.7 3.8 time consuming procedure because often it is difficult to surgical margins. The impact of such findings on the con- recognize the intersegmental planes for the parenchymal version rate is, respectively, 0.2% [58], 0.6% [51], 1.9 [57], section; furthermore the surface of this section may be the and 5.9% [68]. Other reasons for aborting the VATS cause of an air leak in the postoperative period. Bilobec- approach are adhesions and fusion of the fissures [51, 57, 68, tomy, which is performed only rarely, is always counted 71, 75, 83], injuries of the bronchus [51, 58, 68], dense hilar among the major pulmonary resections and does not need adenopathies [58, 68, 71, 75], malfunctions of the stapler [68, particular mention because it is similar to lobectomy. 71, 75, 83], and contralateral pneumothorax [83]. As has been thoroughly discussed by many authors [68, In the postoperative course some authors report sporadic 71, 75, 83, 91] VATS lobectomy is a procedure performed deaths that do not seem to relate to the VATS approach: with different technical modalities according to the pref- pulmonary embolus [51, 83], myocardial infarction [44, 51, erences of the surgeon, and therefore it is very difficult to 68], pneumonia [23, 31, 57, 68], respiratory failure [31, compare the reported results. However, most surgeons use 51], adrenal failure [83], sepsis [44], mesenteric infarction a mini-thoracotomy without rib spreader and two or three [51], and unknown origin [89]. The mean postoperative ports for access; they then isolate and fire with the en- hospital stay after VATS is 3–10 days, and postoperative dostaplers the vessels and the bronchus separately. A morbidity ranges from 2.3% [31] to 36.6% [83]. mediastinal lymphadenectomy or sampling is always per- Bleeding has been observed by many authors [51, 58, formed in case of tumor. 68, 75, 90], but only few of them [58, 68] including our The intraoperative and postoperative results of the main group [75] reported reoperations. Yim et al. [89] had to published series of VATS lobectomy are shown in Table 5. carry out a second resection by thoracotomy because of Conversion rates range between 0% [23, 41] and 23.1% positive resection margin after right upper lobectomy. [86] and are affected by different factors. The most dan- Persistent air leak is the most frequent cause of morbidity gerous intraoperative complication is bleeding from which is observed in almost all the reports with a maximum vascular injury; it is reported from some authors and from of incidence of 13.4% [72]. Sporadic cases of broncho- us with an impact on the conversion rate of 0.2% [58], pleural fistula have been reported by Walker [83], 0.5% [51], 0.7% [28], 1.8% [57, 68], and 4.6% [83], but in McKenna et al. [51], Roviaro et al. [68], and Loscertales no case was it the cause of death. Bleeding usually occurs et al. [44]. Other serious complications are pneumonia, during the vascular dissection of the hilum, but cases of respiratory failure, dysrhythmias, myocardial infarction, bleeding for malfunction of the stapler on the inferior pancreatitis, stroke, and pyothorax. Minor complications pulmonary vein [90] and artery [31] are also reported. As such as late pleural effusion, subcutaneous emphysema, observed in our experience, some cases of bleeding from wound infections, acute retention of urine, and chest pain, the veins or the arteries can be controlled without opening are also reported. the chest by compressing the site of the laceration and There are no significant reports of delayed complica- closing the vessel below that point. Careful and prudent tions after VATS lobctomy; we only report a lung hernia dissection of the hilar vascular structures can avoid large through the utility thoracotomy. Yim et al. [90] reported a lacerations and, when an injury occurs, it is quite easy to sporadic case of tumor implant in the utility thoracotomy. control the hemorrhage, although Walker [83] reports a The rate of local recurrence of lung cancer after VATS case of potentially life-threatening bleeding. lobectomy, as an expression of ineffective curative surgery, The most frequent reason for conversion to open surgery seems do not differ from that observed after open surgery: is the finding of an oncologic situation not amenable by the results reported by Walker et al. [85] and by our group VATS: a primary tumor larger than expected, invasion of the [76] are similar to those achieved by the conventional chest wall or hilum, metastatic N2 disease, and cancer in the thoracotomy approach.

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Table 5 Complications in the largest reported series of VATS lobectomy No. cases Conversion, % Postoperative complications, % Mean hospital stay, Days

Lewis et al. [41], 1997 100 0 11 3.5 Kaseda et al. [31], 1998 145 11.7 2.3 10 Walker [83], 1998 150 11.8 36.6 6 Yim et al [89], 1998 266 19.5 21.9 6.8 Gharagozloo et al. [23], 2003 179 0 20.6 4.1 Roviaro et al. [68], 2004 337 23.1 7.7 5 Onaitis et al. [58], 2006 500 1.6 20.2 3 McKenna et al. [51], 2006 1,100 2.5 15.3 4.8 Present series 217 12.6 10.1 5.8

The VATS anatomic resection of the lung is a safe exploration of the hilum for a possible sleeve resection and procedure; the intraoperative complications have a very the risks of bleeding from the main pulmonary artery low impact, and the postoperative mortality and morbidity during hilar dissection. Moreover, the high rate of post- do not differ significantly from those of conventional sur- operative complications of pneumonectomy probably will gery. Obviously it is necessary to select the patients very not decrease even if it is approached by VATS. carefully and to convert to open thoracotomy whenever it is hazardous to continue the procedure by videothoracoscopy. May be in the future new technical supports and devices Conclusions will make these procedures simpler and the conversion rate will decrease. After 15 years since its introduction, VATS is now con- sidered a routine approach for many pulmonary procedures: it offers good results without significant com- Pneumonectomy plications. In benign diseases, achieving a very ambitious goal, it allows performance of the operative procedures Pneumonectomy is performed rarely and only in very required with minimum damage to the chest wall. In cases selected centers; small numbers of cases are recorded, no of malignancy, there are still some doubts about its safety more than 14 for a single surgeon [51]. The results of regarding the oncologic reliability and the discussion is still VATS pneumonectomy are often included with lobectomy in progress. The feasibility of VATS in the performance of results [51, 75, 81, 89] or less frequently in a separate very demanding procedures, such as pneumonectomy, is setting [12, 14, 55, 66]. The indications are limited to the well documented, and associated complications are very cases in which the disease does not invade the broncho- limited in experienced hands. The analysis of the literature vascular structures of the hilum but it is necessary to and our experience shows that VATS is a reliable approach remove the entire lung; the majority of the cases are per- and that complications are generally related to the under- formed for bronchial tumor not amenable to sleeve lying disease and not to videothoracoscopic technique. To resection. The technique is similar to that proposed for further reduce intraoperative and postoperative morbidity it lobectomy, and the difficulties are related to the dissection is necessary to carefully select the patients, to strictly of the vessels and the bronchus at the hilum [12, 14, 66]. observe established oncological surgical principles, and to There are no reports of intraoperative complications of adopt a very meticulous technique. Although the conver- VATS pneumonectomy, and only one case of conversion to sion to open surgery represents the failure of VATS, it is open surgery to facilitate a bronchoplastic procedure is mandatory when the procedure is not completely safe. described [55]. Postoperative hospital stay and morbidity seem to be similar to those obtained by standard thoracotomy. Atrial References fibrillation [14, 55], pulmonary edema [55], and gastroin- testinal ileus [55] are the postoperative complications 1. Allen MS, Deschamps C, Jones DM, Trastek VF, Pairolero PC reported. (1996) Video-assisted thoracic surgical procedures: the Mayo At present VATS pneumonectomy has to be considered experience. Mayo Clin Proc 71:351–359 2. Ang KL, Tan C, Hsin M, Goldstraw P (2003) Intrapleural tumor an exceptional procedure: the advantages of the minimally dissemination after video-assisted thoracoscopic surgery metas- invasive surgery do not counterbalance the need for careful tasectomy. Ann Thorac Surg 75:1643–1645

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