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J Thorac Cardiovasc Surg 2009;138:1206-1212
© 2009 The American Association for Thoracic Surgery

General Thoracic Surgery

Routine surgical videothoracoscopy as the first step of the planned resection for lung cancer

Department of Surgical Sciences, University of Milan & Department of General Surgery, Ospedale Maggiore Policlinico, Mangiagalli e Regina Elena, IRCCS, Milan, Italy, and Ospedale San Giuseppe, Milan, Italy

Received for publication July 29, 2008; revisions received March 6, 2009; accepted for publication March 29, 2009.

^_* Address for reprints: Contardo Vergani, MD, FACS, Department of Surgical Sciences, University of Milan & Department of General Surgery. Ospedale Maggiore Policlinico, Mangiagalli e Regina Elena, IRCCS, Via Francesco Sforza, 35, 20122 Milano, Italy. (Email: contardo.vergani{at}unimi.it).

Objectives: Notwithstanding preoperative staging, a number of procedures still end in an exploratory thoracotomy as a result of unexpected findings. The aim of this work is to evaluate the validity of routine videothoracoscopy, performed as the first step of every planned resection for non–small cell lung cancer, to assess tumor resectability and feasibility of the resection through thoracoscopy.

Methods and Results: From November 1991 to December 2007, in our department, 1306 patients with non–small cell lung cancer, judged operable at conventional staging, underwent videothoracoscopy before the operation. Thoracoscopy revealed inoperability in 58 (4.4%) patients, mostly owing to pleural dissemination (2.5%) or mediastinal infiltration (1.7%). In the remaining 1248 (95.6%), thoracoscopy did not reveal inoperability. Of these, 449 (34.4%) underwent thoracoscopic resection. The other 799 (61.2%) underwent thoracotomy: 767 underwent resection, but 32 (2.5%) had an exploratory thoracotomy. Thoracoscopy had suggested unresectability in 7 (0.5%) patients, had been incompletely carried out in 4 (0.3%), and was unfeasible in 21 (1.6%) owing to insurmountable technical reasons. In our previous series from 1980 to 1991 the exploratory thoracotomy rate had been 11.6%. In the present series, after the introduction of routine thoracoscopy in the staging process, the exploratory thoracotomy rate was 2.5%. Thoracoscopy was reliable in excluding unresectability (negative predictive value 0.97). The global percentage of correct staging was significantly better (P < .0001) by thoracoscopy (73.3%) than by computed tomography (48.7%). Considering T descriptor, video-assisted thoracic surgery correctly matched with final pathologic staging in 96.2% of patients.

Conclusions: Routine preliminary videothoracoscopy ensured assessment of tumor resectability and feasibility of the resection through thoracoscopy and limited unnecessary thoracotomies.