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J Thorac Cardiovasc Surg 2006;132:701-702
© 2006 The American Association for Thoracic Surgery

Brief Communication

Segmental rib resection for difficult cases of video-assisted thoracic surgery

Norihisa Shigemura, MD, PhD, Michael K. Hsin, mBBChir, FRCS, Anthony P.C. Yim, MD*

Division of Cardiothoracic Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, NT, Hong Kong SAR.

Received for publication March 30, 2006; accepted for publication April 20, 2006.

* Address for reprints: Anthony P. C. Yim, MD, Professor of Surgery and Chief of Cardiothoracic Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, NT, Hong Kong SAR (Email: yimap{at}cuhk.edu.hk).


Figure 1
Dr Hsin, Professor Yim, and Dr Shigemura (left to right)


Although video-assisted thoracic surgery (VATS) has been in existence for more than a decade, the application of VATS to major pulmonary resections is still not widely practiced. This may simply reflect the fact that many surgeons may still perceive this operation to be technically demanding. By resecting a segment of rib underneath the utility minithoracotomy (without rib spreading), the surgeon can perform difficult VATS cases safely and easily with conventional thoracic instruments. We have found this a very useful approach in difficult VATS cases. We present our technique here, which we have found to be simple and safe.

Technique and Indications

We place the patient in the full lateral decubitus position with the operating table flexed to open up the upper intercostal spaces.1Go We use this technique of rib resection for difficult VATS resections—redo cases, tumor size larger than 3 cm, and cases in which bidigital palpation is required or considered desirable. For upper and middle lobectomies, the minithoracotomy is usually placed over the fourth rib (fifth rib for the lower lobes) in the anterolateral chest. The skin incision is generally 6 cm in length. The incision is carried down to the rib, which is then resected subperiosteally for the length of the incision (Figure 1). With the use of a soft tissue retractor only (ie, no rib spreading), a gap of up to 5 cm between ribs can be obtained underneath the wound to allow accurate bidigital palpation and retrieval of large specimens (Figure 2). We advocate the use of conventional instruments, which are light, easy to use, familiar to all surgeons, universally available, and inexpensive. Further, these instruments allow tactile feedback through instrument palpation.1Go Details of our VATS hilar dissection techniques have been previously reported.2Go No attempt is made at closure of the wound to reapproximate the ribs.


Figure 1
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  		Figure 1. Minithoracotomy with a segment of the underlying rib exposed (A) and after rib resection to reveal the underlying lung (B). Only a soft tissue retractor was used throughout.

 

Figure 2
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  		Figure 2. Bidigital palpation of the specimen can be easily performed through the minithoracotomy in this case to identify a deeply seated lung nodule.

 
Discussion

VATS major resection is not a unified technique but includes a broad spectrum of operative techniques that range from complete endoscopic surgery to minithoracotomy with a thoracoscope serving only as a light source.3Go We describe here a strategy that adds a new dimension to this spectrum of techniques.

We have used this approach in our institution for more than 100 consecutive cases of difficult VATS major lung resections without complications. These include redo VATS, stage IIIA lung cancer after neoadjuvant chemotherapy, as well as for parenchymal lung tumors larger than 3 cm. Postoperative pain among patients who underwent VATS with rib resection does not seem to differ from that of patients who did not have rib resection in terms of analgesic requirements. In the few very thin patients, there is only slight paradoxical motion in the chest wall over the area where the rib had been resected. However, this has no functional consequence and all the patients accepted this well, including cosmetically. As the objective of VATS is to minimize chest wall access trauma, we firmly believe that rib resection is superior to rib spreading when increased utility access is considered necessary or desirable. This strategy is useful to experienced VATS surgeons dealing with difficult cases, as well as to beginner VATS surgeons learning complex VATS procedures. We believe this approach may lead to wider acceptance of VATS major pulmonary resection among the thoracic surgical community.

References

  1. Yim APC. Minimizing chest wall trauma in video assisted thoracic surgery. J Thorac Cardiovasc Surg 1995;109:1255-1256.[Free Full Text]
  2. Yim APC. VATS major pulmonary resection revisited—controversies, techniques, and results. Ann Thorac Surg 2002;74:615-623.[Abstract/Free Full Text]
  3. Shigemura N, Akashi A, Nakagiri T, Ohta M, Matsuda H. Complete vs. assisted thoracoscopic approach. A prospective randomized trial comparing a variety of video-assisted thoracoscopic lobectomy techniques. Surg Endosc 2004;18:1492-1497.[Medline]



This article has been cited by other articles:


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Impact of Video-Assisted Thoracoscopic Major Lung Resection on Immune Function
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[Abstract] [Full Text] [PDF]

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