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EDITORIAL |
Seoul, South Korea
Joo Hyun Kim, MD Email: jhkim10{at}snu.ac.kr
Various methods have been proposed and used for anatomical lung resection since the development of lung surgery. Among the many procedures performed by thoracic surgeons, the posterolateral thoracotomy has been considered the standard incision for anatomical lung resection. The posterolateral thoracotomy provides a superb surgical field for the lung and posterior mediastinum. However, the posterolateral thoracotomy has several major disadvantages. The procedure per se results in significant destruction of chest wall structures. It requires division of the latissimus dorsi or serratus anterior muscle, spreading of ribs, and intentional or unintentional rib fractures. All of the injuries incurred during a posterolateral thoracotomy result in destruction of the respiratory mechanics of the chest wall and are accompanied by severe postoperative pain. In the early period of thoracic surgery, these adverse effects were considered inevitable because no other options for anatomical lung resection existed at that time. On the other hand, current trends in medical practice focus on different aspects of treatment. Although the treatment of primary disease (surgical cure of lung cancer) is of utmost importance in our practice, avoidance of adverse effects caused by the treatment has also been emphasized. Fast recovery and improved quality of life after surgery have now became important parameters in the evaluation of treatment.
Initially introduced for diagnostic or minor surgical procedures, thoracoscopic surgery has a long history, as have other endoscopic operations. As with many minimally invasive procedures, only a few people thought that thoracoscopic surgery could replace open thoracotomy in major lung surgery. Nevertheless, recent studies have confirmed that thoracoscopic surgery can be applied in major thoracic operations.1,2 We can easily find similar situations in other disciplines. Laparoscopic cholecystectomy is now the standard procedure for cholecystectomy, and robotic prostatectomy is becoming one of the standard procedures for prostate cancer. What the role of thoracoscopic surgery in major lung resection will be in the future is not clear; however, the clinical indications for thoracoscopic surgery are gradually increasing.
The first obstacle that thoracoscopic surgery should overcome is the competency of the surgical result. Now most surgeons know that thoracoscopic surgery can result in early recovery and less postoperative pain, but can they also say that complete oncologic surgery can be attained by thoracoscopy, as in the open procedure? We think that many surgeons would disagree with this. What are the weak points of thoracoscopic surgery from an oncological perspective? The first weak point of the thoracoscopic procedure is in control of the primary mass. A small peripheral mass encountered during screening chest computed tomography is a very common indication for thoracoscopic lobectomy, and it is usually easy to manipulate and remove such a tumor. However, if a surgeon wants to extend the indication for thoracoscopic lobectomy to clinical T2 category, various types of advanced cancer that invade surrounding tissues might be encountered. Sometimes, chest wall resection, pulmonary artery angioplasty, and sleeve resection should be performed. These procedures are technically demanding, even if the surgeon is highly experienced in thoracoscopic procedures. We think that conversion to thoracotomy is another good choice in these situations, but the decision is sometimes not as easy as expected. Among the potential adverse outcomes are disruption of the primary tumor and catastrophic injury to adjacent organs. Both of these are usually avoidable in open thoracotomy if a surgeon is fully experienced. However, studies on failed thoracoscopic lobectomy are very scarce at present. The second weak point of thoracoscopic surgery is the possibility of incomplete dissection of lymph nodes. Several studies have reported the feasibility of lymph node dissection in thoracoscopic lobectomy;3,4 although the completeness of lymph node dissection depends not just on the number or extent of dissected lymph nodes but also on the preserved integrity of the lymph node capsule after dissection. En-bloc resection of the lymphatic chain, including perilymphatic tissue, is the preferred method that fulfills the principles of radical resection and prevention of tumor spillage from metastatic lymph nodes. If thoracoscopic lymphadenectomy removes lymphatic chains incompletely or disrupts metastatic lymph nodes, a higher incidence of locoregional nodal recurrence and malignant pleural effusion would be inevitable. Such events are rare in the early lung cancer patients who are currently the main candidates for thoracoscopic lobectomy. However, most thoracic surgeons know that the surgical stage of lung cancer does not always match that of the preoperative work-up. Upstaging is a frequent event, and thoracic surgeons must be prepared for an unexpected situation.
What will be the role of thoracoscopic lobectomy in the future? Can it be a standard surgery that can be applied to most lung cancer patients? Or will it be just a minor procedure for the subset with early lung cancer? Does the procedure have any real oncological or procedural advantages over an open thoracotomy? Do the advantages of thoracoscopic lobectomy come from the effect of patient selection? Many questions remain unresolved at present. We think that forthcoming studies will answer these questions in the near future, and if so, the indications for thoracoscopic lobectomy will expand the boundary in lung cancer surgery.
We think that we must consider the invasiveness of our procedures from another angle. Traditionally, surgical pulmonary resection was a very invasive procedure compared to other treatment modalities. Therefore, surgical resection was performed in cases where other treatment was either not possible or inferior to surgery. If an equal result was expected, surgical treatment was not considered as the primary treatment modality. However, if surgery can make the evolution to more and more minimally invasive procedures, and if equal invasiveness can be expected (as for example with concurrent chemoradiation), the time will come when surgery could be selected as the preferred treatment modality in spite of the same oncological cure rate. Some surgeons may think that minimally invasive surgery is just a temporary medical trend and cannot be an orthodox approach to oncologic surgery. However, we do not know which procedure will be the shortcut to the cure of lung cancer. We must wait for future well-designed clinical studies that will clarify which procedure will be "Deng Xiaoping’s good cat".
REFERENCES
Asian Cardiovasc Thorac Ann 2009;
17:131-132
© 2009 by SAGE Publications
DOI: 10.1177/0218492309102257
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