Minimally Invasive Thoracic Surgery 3.0

摘要

Over the past 2 decades, general thoracic surgery has been revolutionized by rapid development and assimilation of minimally invasive techniques for lung cancer surgery. Whereas these gains have been impressive with great benefit to thousands of patients, focus upon mere minimization of number and size of incisions may distract surgeons from other vital considerations. In fact, surgical trauma includes not only incisional injury, but also functional loss due to organ removal, and also systemic and psychological trauma induced by surgical stress. Therefore, minimally invasive surgery (MIS) by its definition should be an idea to “minimize surgical trauma, but still achieve comparable or better therapeutic results.”1 In fact, the history of general thoracic surgery can be viewed as a gradual and inexorable development of MIS by the broad definition above. The first radical resection of lung cancer was completed via a left pneumonectomy by Dr Evarts Graham in 1933.2 Although lobectomy was described earlier and used for benign conditions, it was initially thought to be inadequate for patients with lung cancer. However, pneumonectomy was quickly replaced by lobectomy for patients with peripheral lung cancer in the next decade because the latter was shown to remarkably reduce operational mortality and morbidity without making impact on long-term survival. This landmark evolution directly led to the development of bronchoplasty and arterioplasty for the treatment of selected patients with central lung cancer, whose lung cancer and quality of life were greatly improved.3 Both examples highlight the importance of lung parenchyma preservation in reducing surgical trauma and thus should undoubtedly be considered MIS. However, the more modern concept of MIS was only realized and became popular in the early 1980s after the application of the “keyhole” video-assisted procedures which were quickly adopted by thoracic surgeons in the 1990s.4 Over the next years, advances in minimally invasive lung cancer surgery can be expected to occur in size/number of incisions, extent of resection, and systemic response to surgery. MIS 1.0: IMPROVING SURGICAL OUTCOMES BY REDUCING INCISIONAL INJURY The impact of video assisted thoracic surgery (VATS) on reducing incisional trauma is overt; both postoperative pain and recovery greatly improved as compared with conventional open surgery. Although randomized comparative evidence is still lacking, most retrospective studies demonstrate comparable oncological results of VATS to open surgery in selected patients with lung cancer (mainly clinical stage I).4 Many now promote VATS as the new standard of treatment for early-stage lung cancer. However, real challenges encountered by many VATS surgeons are efficacy of lymphadenectomy and use of endoscopic techniques in complicated cases. Fixed ports in VATS limit intrathoracic maneuverability of instrumentation, making complete lymph node dissection relatively difficult, especially to surgeons at the beginning phase of the learning curve. Meanwhile, for patients with difficult conditions such as a large nodule, central mass, or calcified lymph node, endoscopic operation is extremely difficult and VATS is often abandoned either preoperatively or intraoperatively. Each surgeon must continually evaluate his or her ability to perform an oncologically sound operation as incisional/technical changes are made. Currently, there are 2 directions of development in thoracoscopic surgery. The first direction is to continuously reduce the size and number of incisions, or alter the location of the incision (subxiphoid or subcostal).5 The theoretical advantages of uniportal over multiportal approaches include improved postoperative pain control and shortened recovery time, but objective evidence is currently lacking. Before the advent of the uniportal approach, there was no consensus on the use of 2 ports, 3 ports, or 4 ports, suggesting that some surgeons believed that the use of mo