T1 sympathectomy for facial hyperhidrosis is abandoned long time ago due to high risk of Horner´s syndrome. For some time level of choice is T2 ganglia. Although T2 is also seen as centre point of neurologic impulse transmission through the brachial plexus to the hand (Hsia et al. 1999), some investigators suggest preparing lower levels like T3 (Dewey et al. 2006; Kwong et al., 2008; X. Li et al., 2008), because T2 is close to stellate ganglion with a risk of Horner´s Syndrome non-negligible and the fact that higher levels can increase rate of CS (Schmidt et al., 2006). T4 still remains level of choice for axillary hyerphidrosis (Lee et al. 1999; Licht et al. 2005). Isolated plantar hyperhidrosis occurs rarely but rather in combination with palmar or axillary type. As combined manifestation it is often treated by sympathectomy for upper limb hyperhidrosis and leads in 85% of cases to an improvement of plantar symptoms, shown by Reisfeld and colleagues (Reisfeld et al., 2002). Causes of improvement are unknown. Treating plantar hyperhidrosis by preparing lower thoracic levels is no longer practised (Kwong et al., 2008). Today isolated plantar hyperhidrosis is treated at level L2 and L3 by endoscopic lumbar sympathectomy (Loureiro et al., 2008).

#### **<IP_ADDRESS> Complications and side effects**

Complications in hyperhidrosis surgery are rare and exceptional. Some can be avoided by experience or by technical improvement of the surgeon, others are unforeseeable. However any complications are less acceptable than for other sorts of thoracic operations because sympathectomy is a functional surgery for young patients in good health (Dumont, 2008).

In 2004 Ojimba and Cameron did a Medline search using the term thoracoscopic sympathectomy and analysed all publications for reported complications (Ojimba & Cameron, 2004) (Table 6): No death has ever been reported in any published series but there are anecdotal reports of nine deaths following thoracoscopic sympathectomy. Five patients died from excessive haemorrhage, three due to incidents of narcosis and one death remained unexplained. Nevertheless, mortality associated with thoracoscopic sympathectomy is a rare condition compared to the high number of surgical procedures. The most common complication is pneumothorax. Up to 75% of patients have some residual

Surgical Management of Primary Upper Limb Hyperhidrosis – A Review 173

greater amount of sweating elsewhere in the body compensates for the lack of sweating in the treated body area in order to maintain sweating balance of the whole body in a thermoregulatory way (Licht & Pilegaard, 2004). In 2008 Lyra and colleagues tried to study the exact pathogenesis and assumed that sympathetic block causes a dysfunction of control loop with lack of negative feedback to the hypothalamus resulting in CS (Lyra et al., 2008).

Fig. 7. Patient suffering from compensatory sweating of the thoracic and abdominal parts The published rates of CS vary widely from 1,2-90% (Dumont, 2008): On the one hand evaluating of CS is subjective and varies according to the patient (Leão et al. 2003). On the other hand most authors do not quantify a severity code. Some investigators only report on patients who have severe CS. They believe that almost all patients develop mild CS after sympathectomy (Ueyama et al., 2004). But also climate plays a decisive role (Lyra et al., 2008). High rates of CS are mostly found in studies of countries with warmer temperatures and humid weather (X. Li et al., 2008). Surgical technique also seems to influence the risk of CS: The lower the level of division and the smaller the extent of sympathectomy, the lower the incidence of CS (Dewey et al., 2006). Treatment options for severe CS are limited: Some investigators try local injection of botulinum toxine in areas where CS is the most severe (Bechara et al., 2006), others use the clamping method with moderate success. At the end of the nineties, Telaranta successfully performed reconstruction with nerve graft by open thoracotomy for a patient suffering from severe CS (Telaranta, 1998). But it is an individual case and a complex procedure. It should be able to avoid CS, because severity does not change over time in 70% of cases (Dumont, 2008). In Taiwan patients suffering from serious CS have already formed a support group based on an internet discussion forum to request the government to take this problem seriously (Hsu & Y.C. Li, 2005). Therefore surgeons are searching for preoperative measurements to determinate postsympathectomy CS. In 2008 Miller and colleagues developed a new technique of a temporary thoracoscopic sympathetic block of the nerve with a local anesthetic that can hopefully predict severity of postoperative

Gustatory sweating (GS) is defined as facial sweating when eating certain foods particularly spicy or acidic food (Licht & Pilegaard, 2006) (Fig. 8). This phenomenon has no real

CS (Miller & Force, 2008).

gas or air in the thorax at the end of procedure, mostly resolving spontaneously. A temporary tube drainage is only required in 0,4-2,3% of cases, usually either after direct trauma to the lung at the time of trocar insertion, after dissolving adhesions or after rupture of a bulla as a consequence of anaesthesia, if high inflation pressures are used. Apart from the deaths mentioned above, reports of serious intraoperative bleeding are rare. Bleeding usually arises from disrupted intercostal veins or bleeding at the site of trocar insertion. The highest rate of significant bleeding with an incidence of 5,3% was reported by Gossot and colleagues. They also described one laceration of the subclavian artery demanding an immediate thoracotomy (Gossot et al., 2001). Horner´s Syndrome is the mostly feared complication. Occurred by irritation or damage to the stellate ganglion T1, it causes miosis, ptosis and enophthalmus on the same side of the face. Symptoms are often transient and decrease within weeks or months, but can also persist (Kaya et al., 2003). Since introduction of the videothoracoscope, which allows a better view, rate of postoperative Horner´s Syndrome could be significantly reduced (Zacherl et al., 1999). However it is mentioned in almost all series. Gossot and colleagues found three main causes: damage by a direct or indirect current diffusion using diathermy, by excessive traction on the nerve during dissection or misdetermination of the ribs by the surgeon (Gossot et al., 2001). Pain in the form of intercostal neuralgia with dysesthesia at the site of trocar insertion is rarely documented but more frequent than generally recognized. Many centres perform short-stay surgery that may lead to underestimation of pain results. In most series pain resolves within months, but Walles and colleagues could detect a persistence for years (Walles et al., 2008). Further unfrequent complications are wound infection, pneumonia, chylothorax arising from laceration of an accessory thoracic duct (Gossot, 1996), rhinitis caused by increased parasympathetic stimulation of nasal mucosa (Herbst et al., 1994) and cardiopulmonary modification. The latter is recently paid particular attention: In a case report in 2009 O´Connor and colleagues presented a patient with postoperative asystole. After successful resuscitation, permanent bradycardia required a pacemaker treatment (O´Connor et al., 2009). Surveys including pre-, peri- and postoperative measurements of cardiopulmonary function presented: the decreased activity of sympathetic nervous system after sympathectomy is comparable to the effect of a beta-blocker. It reduces heart rate and worsens pulmonary function. But the clinical importance of these findings was not significant (Vigil et al., 2005). However patients suffering from vasovagale syncope or high performance athletes should be advised of possible bradycardia and also asthmatics should be informed about potential deterioration of obstructive lung disease.

Table 6. Overview of possible complications caused by thoracoscopic sympathectomy

Side effects are almost constant and unavoidable. They occur in nearly all series of surgery and therefore they are main topic of numerous articles (Dumont, 2008).

Compensatory sweating (CS) represents the most common side effect. It is defined as a postoperative increased sweating in body regions unaffected by sympathectomy (Lyra et al., 2008) (Fig. 7). The exact mechanism remains poorly understood. It is speculated that a

gas or air in the thorax at the end of procedure, mostly resolving spontaneously. A temporary tube drainage is only required in 0,4-2,3% of cases, usually either after direct trauma to the lung at the time of trocar insertion, after dissolving adhesions or after rupture of a bulla as a consequence of anaesthesia, if high inflation pressures are used. Apart from the deaths mentioned above, reports of serious intraoperative bleeding are rare. Bleeding usually arises from disrupted intercostal veins or bleeding at the site of trocar insertion. The highest rate of significant bleeding with an incidence of 5,3% was reported by Gossot and colleagues. They also described one laceration of the subclavian artery demanding an immediate thoracotomy (Gossot et al., 2001). Horner´s Syndrome is the mostly feared complication. Occurred by irritation or damage to the stellate ganglion T1, it causes miosis, ptosis and enophthalmus on the same side of the face. Symptoms are often transient and decrease within weeks or months, but can also persist (Kaya et al., 2003). Since introduction of the videothoracoscope, which allows a better view, rate of postoperative Horner´s Syndrome could be significantly reduced (Zacherl et al., 1999). However it is mentioned in almost all series. Gossot and colleagues found three main causes: damage by a direct or indirect current diffusion using diathermy, by excessive traction on the nerve during dissection or misdetermination of the ribs by the surgeon (Gossot et al., 2001). Pain in the form of intercostal neuralgia with dysesthesia at the site of trocar insertion is rarely documented but more frequent than generally recognized. Many centres perform short-stay surgery that may lead to underestimation of pain results. In most series pain resolves within months, but Walles and colleagues could detect a persistence for years (Walles et al., 2008). Further unfrequent complications are wound infection, pneumonia, chylothorax arising from laceration of an accessory thoracic duct (Gossot, 1996), rhinitis caused by increased parasympathetic stimulation of nasal mucosa (Herbst et al., 1994) and cardiopulmonary modification. The latter is recently paid particular attention: In a case report in 2009 O´Connor and colleagues presented a patient with postoperative asystole. After successful resuscitation, permanent bradycardia required a pacemaker treatment (O´Connor et al., 2009). Surveys including pre-, peri- and postoperative measurements of cardiopulmonary function presented: the decreased activity of sympathetic nervous system after sympathectomy is comparable to the effect of a beta-blocker. It reduces heart rate and worsens pulmonary function. But the clinical importance of these findings was not significant (Vigil et al., 2005). However patients suffering from vasovagale syncope or high performance athletes should be advised of possible bradycardia and also asthmatics should

be informed about potential deterioration of obstructive lung disease.

and therefore they are main topic of numerous articles (Dumont, 2008).

Pneumothorax Bleeding

Horner´s Syndrome Pain and Dysesthesia

More frequently reported complications Less frequently reported complications

Table 6. Overview of possible complications caused by thoracoscopic sympathectomy

Side effects are almost constant and unavoidable. They occur in nearly all series of surgery

Compensatory sweating (CS) represents the most common side effect. It is defined as a postoperative increased sweating in body regions unaffected by sympathectomy (Lyra et al., 2008) (Fig. 7). The exact mechanism remains poorly understood. It is speculated that a

Wound infection Pneumonia Chylothorax Rhinitis

Cardiopulmonary modification

greater amount of sweating elsewhere in the body compensates for the lack of sweating in the treated body area in order to maintain sweating balance of the whole body in a thermoregulatory way (Licht & Pilegaard, 2004). In 2008 Lyra and colleagues tried to study the exact pathogenesis and assumed that sympathetic block causes a dysfunction of control loop with lack of negative feedback to the hypothalamus resulting in CS (Lyra et al., 2008).

Fig. 7. Patient suffering from compensatory sweating of the thoracic and abdominal parts

The published rates of CS vary widely from 1,2-90% (Dumont, 2008): On the one hand evaluating of CS is subjective and varies according to the patient (Leão et al. 2003). On the other hand most authors do not quantify a severity code. Some investigators only report on patients who have severe CS. They believe that almost all patients develop mild CS after sympathectomy (Ueyama et al., 2004). But also climate plays a decisive role (Lyra et al., 2008). High rates of CS are mostly found in studies of countries with warmer temperatures and humid weather (X. Li et al., 2008). Surgical technique also seems to influence the risk of CS: The lower the level of division and the smaller the extent of sympathectomy, the lower the incidence of CS (Dewey et al., 2006). Treatment options for severe CS are limited: Some investigators try local injection of botulinum toxine in areas where CS is the most severe (Bechara et al., 2006), others use the clamping method with moderate success. At the end of the nineties, Telaranta successfully performed reconstruction with nerve graft by open thoracotomy for a patient suffering from severe CS (Telaranta, 1998). But it is an individual case and a complex procedure. It should be able to avoid CS, because severity does not change over time in 70% of cases (Dumont, 2008). In Taiwan patients suffering from serious CS have already formed a support group based on an internet discussion forum to request the government to take this problem seriously (Hsu & Y.C. Li, 2005). Therefore surgeons are searching for preoperative measurements to determinate postsympathectomy CS. In 2008 Miller and colleagues developed a new technique of a temporary thoracoscopic sympathetic block of the nerve with a local anesthetic that can hopefully predict severity of postoperative CS (Miller & Force, 2008).

Gustatory sweating (GS) is defined as facial sweating when eating certain foods particularly spicy or acidic food (Licht & Pilegaard, 2006) (Fig. 8). This phenomenon has no real

Surgical Management of Primary Upper Limb Hyperhidrosis – A Review 175

for surgery mostly suffer from combined site hyperhidrosis (Eisenach et al., 2005). Reisfeld requests to establish indication for surgical therapy carefully: Thoracoscopic sympathectomy should only be performed in patients with severe palmar hyperhidrosis, other localisations

Short-term studies on sympathectomy can be detected frequently, they continuously present great outcome depending on primary localisation. But unsatisfactory immediate results can occasionally be detected (de Campos et al., 2003). Causes for persistent postoperative sweating are inadequate knowledge and orientation of the surgeon or unrecognised variances of anatomic structures (D.H. Kim et al., 2005; Reisfeld et al., 2002; Yoon et al., 1999) including Kuntz nerve, a communicating sympathetic ramus crossing the second rib (Chung et al., 2002) (Fig. 9). Therefore some authors recommend extension of the sympathectomy line to about three or five centimetres lateral to the sympathetic chain by coagulating the surface of the corresponding rib, a method first described by Linder and colleagues in 1994 (Linder et al., 1994). Adequacy of sympathectomy is also tried to be detected by perioperative use of monitoring device like measuring skin surface temperature or

should only be treated that way if combined with palmar site (Reisfeld et al., 2002).

plethysmographic blood flow (Lee et al., 1999; Yoon et al., 1999).

Fig. 9. Anatomy of Kuntz nerve (INK= intrathoracic nerve of Kuntz) and rami

local nerve regeneration but has not yet been proven (Lee et al., 1999).

Long-term outcomes of more than 10 years are rarely reported (Zacherl et al., 1998). Investigations show that unfortunately results of sympathectomy deteriorate with time (T.S. Lin & Fang, 1999; Walles et al., 2008). This recurrent postoperative sweating may be due to

communicantes (arrowheads)

explanation, the pathophysiology may be quite complex (Licht et al., 2005). GS is less commonly reported than CS. The reported incidence of GS varies considerably from 0-38% (Dumont, 2008). Except one study published by Licht and Pilegaard in 2006, which analyses the relation between extent of sympathectomy, primary localisation of hyperhidrosis and the incidence of GS (Licht & Pilegaard, 2006), there are only a few investigators dealing with this issue. This occurrence is probably not estimated as very troublesome, both by surgeons and by patients. Furthermore triggers can be easily avoided by patients. Thus treatment options for GS including topical or systemic medications and the injection of botulinumtoxine are rarely performed (Eckardt & Kuettner, 2003).

Fig. 8. Patient suffering from gustatory sweating

Due to unforeseeable and unacceptable complications and unavoidable side effects, careful patient selection is important for surgery. Patients should be fully informed before they decide on surgical treatment (Dumont, 2008).

#### **<IP_ADDRESS> Postoperative results and patient satisfaction**

Literature suggests: Endoscopic thoracic sympathectomy is a safe and effective therapeutic strategy in patients suffering from severe primary hyperhidrosis with excellent results and high rates of patient satisfaction (Henteleff & Kalavrouziotis, 2008).

Postoperative results seem to depend more on severity and primary localisation of hyperhidrosis than on surgical technique: Best results can be achieved in patients with severe palmar hyperhidrosis (Baumgartner & Konecny, 2007). Patients with isolated axillary hyperhidrosis do not benefit sufficiently from sympathectomy (Gossot et al., 2003; Herbst et al., 1994). One possible explanation for the lower success rate may be that there is a combination of eccrine and apocrine sweat glands in the axilla. The eccrine sweat glands are innervated by sympathetic fibres, but the apocrine glands respond primarily to epinephrine. They are not blocked by sympathectomy and continue to function (Licht et al., 2005; Reisfeld et al., 2002). Therefore local surgical axillary procedures should be recommended as first-line therapy. As already mentioned, isolated plantar hyperhidrosis should be treated by endoscopic lumbar extraperitoneal sympathectomy. Individual reports with positive experiences already exist (Wörle et al., 2007). Also patients with facial hyperhidrosis or blushing do not universally and overwhelmingly benefit by sympathectomy., a case-by-case evaluation is required (Baumgartner, 2008). But patients with severe hyperhidrosis presenting

explanation, the pathophysiology may be quite complex (Licht et al., 2005). GS is less commonly reported than CS. The reported incidence of GS varies considerably from 0-38% (Dumont, 2008). Except one study published by Licht and Pilegaard in 2006, which analyses the relation between extent of sympathectomy, primary localisation of hyperhidrosis and the incidence of GS (Licht & Pilegaard, 2006), there are only a few investigators dealing with this issue. This occurrence is probably not estimated as very troublesome, both by surgeons and by patients. Furthermore triggers can be easily avoided by patients. Thus treatment options for GS including topical or systemic medications and the injection of

Due to unforeseeable and unacceptable complications and unavoidable side effects, careful patient selection is important for surgery. Patients should be fully informed before they

Literature suggests: Endoscopic thoracic sympathectomy is a safe and effective therapeutic strategy in patients suffering from severe primary hyperhidrosis with excellent results and

Postoperative results seem to depend more on severity and primary localisation of hyperhidrosis than on surgical technique: Best results can be achieved in patients with severe palmar hyperhidrosis (Baumgartner & Konecny, 2007). Patients with isolated axillary hyperhidrosis do not benefit sufficiently from sympathectomy (Gossot et al., 2003; Herbst et al., 1994). One possible explanation for the lower success rate may be that there is a combination of eccrine and apocrine sweat glands in the axilla. The eccrine sweat glands are innervated by sympathetic fibres, but the apocrine glands respond primarily to epinephrine. They are not blocked by sympathectomy and continue to function (Licht et al., 2005; Reisfeld et al., 2002). Therefore local surgical axillary procedures should be recommended as first-line therapy. As already mentioned, isolated plantar hyperhidrosis should be treated by endoscopic lumbar extraperitoneal sympathectomy. Individual reports with positive experiences already exist (Wörle et al., 2007). Also patients with facial hyperhidrosis or blushing do not universally and overwhelmingly benefit by sympathectomy., a case-by-case evaluation is required (Baumgartner, 2008). But patients with severe hyperhidrosis presenting

botulinumtoxine are rarely performed (Eckardt & Kuettner, 2003).

Fig. 8. Patient suffering from gustatory sweating

decide on surgical treatment (Dumont, 2008).

**<IP_ADDRESS> Postoperative results and patient satisfaction**

high rates of patient satisfaction (Henteleff & Kalavrouziotis, 2008).

for surgery mostly suffer from combined site hyperhidrosis (Eisenach et al., 2005). Reisfeld requests to establish indication for surgical therapy carefully: Thoracoscopic sympathectomy should only be performed in patients with severe palmar hyperhidrosis, other localisations should only be treated that way if combined with palmar site (Reisfeld et al., 2002).

Short-term studies on sympathectomy can be detected frequently, they continuously present great outcome depending on primary localisation. But unsatisfactory immediate results can occasionally be detected (de Campos et al., 2003). Causes for persistent postoperative sweating are inadequate knowledge and orientation of the surgeon or unrecognised variances of anatomic structures (D.H. Kim et al., 2005; Reisfeld et al., 2002; Yoon et al., 1999) including Kuntz nerve, a communicating sympathetic ramus crossing the second rib (Chung et al., 2002) (Fig. 9). Therefore some authors recommend extension of the sympathectomy line to about three or five centimetres lateral to the sympathetic chain by coagulating the surface of the corresponding rib, a method first described by Linder and colleagues in 1994 (Linder et al., 1994).

Fig. 9. Anatomy of Kuntz nerve (INK= intrathoracic nerve of Kuntz) and rami communicantes (arrowheads)

Long-term outcomes of more than 10 years are rarely reported (Zacherl et al., 1998). Investigations show that unfortunately results of sympathectomy deteriorate with time (T.S. Lin & Fang, 1999; Walles et al., 2008). This recurrent postoperative sweating may be due to local nerve regeneration but has not yet been proven (Lee et al., 1999).

Surgical Management of Primary Upper Limb Hyperhidrosis – A Review 177

Baumgartner, F.J. (2008). Surgical approaches and techniques in the management of severe

Bechara, F.G.; Sand, M., Moussa, G., Sand, D., Altmeyer, P., Hoffmann, K. & Schmidt, J.

Cetindag, I.B.; Boley, T.M., Webb, K.N. & Hazelrigg, S.R. (2008). Long-term results and

Chung, I.H.; Oh, C.S., Koh, K.S., Kim, H.J., Paik, H.C. & Lee, D.Y. (2002). Anatomic

de Campos, J.R.; Kauffman, P., Werebe Ede, C., Andrade Filho, L.O., Kusniek, S., Wolosker,

Dewey, T.M.; Herbert, M.A., Hill, S.L., Prince, S.L. & Mack, M.J. (2006). One-year follow-up

Dumont, P. (2008). Side effects and complications of surgery for hyperhidrosis. Review.

Eckardt, A. & Kuettner, C. (2003). Treatment of gustatory sweating (Frey's syndrome) with botulinum toxin A. *Head & Neck,* Vol. 25, No.8, (August 2003), pp. 624-28 Eisenach, J.H.; Atkinson, J.L. & Fealey, R.D. (2005). Hyperhidrosis: evolving therapies for a

Gee, S. & Yamauchi, P.S. (2008). Nonsurgical management of hyperhidrosis. *Thoracic Surgery*

Gossot, D. (1996). Chylothorax after endoscopic thoracic sympathectomy. Case Report.

Gossot, D.; Kabiri, H., Caliandro, R., Debrosse, D., Girard, P. & Grunenwald, D.

Gossot, D.; Galetta, D., Pascal, A., Debrosse, D., Caliandro, R., Girard, P., Stern, J.B. &

Grondin, S.C. (2008). Hyperhidrosis. Preface. *Thoracic Surgery Clinics,* Vol.18, No.2, (May

*The Annals of Thoracic Surgery*, Vol.81, No.4, (April 2006), pp. 1227-32 Duarte, J.B. & Kux, P. (1998). Improvements in video-endoscopic sympathicotomy for the

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variations of the T2 nerve root (including the nerve of Kuntz) and their implications of sympathectomy. *Journal of Thoracic and Cardiovascular Surgery,* Vol.123, No.3,

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treatment of palmar, axillary, facial, and palmar-plantar hyperhidrosis. *European*

well-established phenomenon. Review. *Mayo Clinical Proceedings,* Vol. 80, No.5,

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Today some surgeons offer redo-operations in cause of persistent or recurrent postoperative sweating, also called re-sympathectomies. Usually these procedures can be reperformed by videothoracoscopy, severe pleural adhesions requiring thoracotomy are rarely documented (D.H. Kim et al., 2005; T.S. Lin, 2001). However there is a lack of long-term results too.

Lots of investigators use patient satisfaction as a common parameter to describe overall effectiveness of sympathectomy. Some studies reveal that patient dissatisfaction is primarily associated with persistence or recurrence of preoperative symptoms and to a lesser extent with incidence of side effects (Kwong et al., 2005; Walles et al., 2008). But assessment of surgical result using the conventional method patient satisfaction is imprecise and inaccurate (Leão et al. 2003). Main problem in requesting patient satisfaction, mostly based on patients self-report in questionnaires postoperatively, is subjectivity (Shargall et al., 2008). In some series several quality-of-life measures for assessment of improvements in daily life after treatment of hyperhidrosis are already used to get a more objective point of view (de Campos et al., 2003; Tetteh et al., 2009) (Table 7). In combination with quantitative measurements, which are often not practicable in the clinical setting, a precise evaluation of the effectiveness of sympathectomy would be possible (Cetindag et al., 2008).

Table 7. Several tools used for Quality-of-life assessment

## **5. Conclusion**

In literature database hundreds of citations can be identified concerning treatment of primary upper limb hyperhidrosis by thoracic sympathectomy and nearly all investigators suggest that patients can significantly benefit from this procedure.

But fundamental limitations arise: the great majority of currently available studies are retrospective single-centre series. The heterogeneity of study population, the inconsistent definition and terminology of the word sympathectomy, the variety of surgical techniques with the optimal procedure remaining elusive and the lack of uniform measures at both the exposure and outcome levels make comparison and generalisability of these series quite impossible. In future, in addition to standardization, both long-term studies with large numbers of patients and multicentre randomised controlled trials are mandatory to clearly define the role of sympathectomy in treatment of primary hyperhidrosis (Henteleff & Kalavrouziotis, 2008).

## **6. References**

Baumgartner, F. & Konecny, J. (2007). Compensatory hyperhidrosis after sympathectomy: level of resection versus location of hyperhidrosis. *The Annals of Thoracic Surgery,*  Vol.84, No.4, (October 2007), pp.1422

Today some surgeons offer redo-operations in cause of persistent or recurrent postoperative sweating, also called re-sympathectomies. Usually these procedures can be reperformed by videothoracoscopy, severe pleural adhesions requiring thoracotomy are rarely documented (D.H. Kim et al., 2005; T.S. Lin, 2001). However there is a lack of long-term results too. Lots of investigators use patient satisfaction as a common parameter to describe overall effectiveness of sympathectomy. Some studies reveal that patient dissatisfaction is primarily associated with persistence or recurrence of preoperative symptoms and to a lesser extent with incidence of side effects (Kwong et al., 2005; Walles et al., 2008). But assessment of surgical result using the conventional method patient satisfaction is imprecise and inaccurate (Leão et al. 2003). Main problem in requesting patient satisfaction, mostly based on patients self-report in questionnaires postoperatively, is subjectivity (Shargall et al., 2008). In some series several quality-of-life measures for assessment of improvements in daily life after treatment of hyperhidrosis are already used to get a more objective point of view (de Campos et al., 2003; Tetteh et al., 2009) (Table 7). In combination with quantitative measurements, which are often not practicable in the clinical setting, a precise evaluation of

the effectiveness of sympathectomy would be possible (Cetindag et al., 2008).

(HHIQ)

(HDSS)

In literature database hundreds of citations can be identified concerning treatment of primary upper limb hyperhidrosis by thoracic sympathectomy and nearly all investigators

But fundamental limitations arise: the great majority of currently available studies are retrospective single-centre series. The heterogeneity of study population, the inconsistent definition and terminology of the word sympathectomy, the variety of surgical techniques with the optimal procedure remaining elusive and the lack of uniform measures at both the exposure and outcome levels make comparison and generalisability of these series quite impossible. In future, in addition to standardization, both long-term studies with large numbers of patients and multicentre randomised controlled trials are mandatory to clearly define the role of sympathectomy in treatment of primary hyperhidrosis (Henteleff &

Baumgartner, F. & Konecny, J. (2007). Compensatory hyperhidrosis after sympathectomy:

level of resection versus location of hyperhidrosis. *The Annals of Thoracic Surgery,*

General tools Specific hyperhidrosis tools

Table 7. Several tools used for Quality-of-life assessment

Vol.84, No.4, (October 2007), pp.1422

suggest that patients can significantly benefit from this procedure.

12 or 36 (SF-12 or SF-36)

(DLQI)

**5. Conclusion**

Kalavrouziotis, 2008).

**6. References**

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Linder, A.; Friedel, G. & Toomes, H. (1994). Thermometrically controlled thoracoscopic

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427-31

47

13-16

pp. 895-98

967-77

255-67

1214, discussion pp. 1215-16

(November 2002), pp. 682-84

sympathectomy. *The Annals of Thoracic Surgery,* Vol.78, No.2, (August 2004), pp.

sympathectomy for axillary hyperhidrosis: the influence of T4. *The Annals of Thoracic Surgery*, Vol.80, No.2 (August 2005), pp. 455-59, discussion pp. 459-60 Licht, P.B. & Pilegaard, H.K. (2006). Gustatory side effects after thoracoscopic

sympathectomy. *The Annals of Thoracic Surgery,* Vol.81, No.3, (March 2006), pp. 1043-

clipping - a better and reversible operation for treatment of hyperhidrosis palmaris: experience with 326 cases. *European Journal of Surgery*, Supplements 580, (1998), pp.

palmar hyperhidrosis--with emphasis on perioperative management (1,360 case

analysis of 42 cases. *The Annals of Thoracic Surgery,* Vol.72, No.3, (September 2001),

Endoscopic lumbar sympathectomy for women: effect on compensatory sweat.

(2008). Guidelines for the prevention, diagnosis and treatment of compensatory hyperhidrosis. *Jornal Brasileiro de Pneumologia,* Vol.34, No.11, (November 2008), pp.

hyperhidrosis. *The Annals of Thoracic Surgery,* Vol. 85, No.4, (April 2008), pp. 1211-

complication of bilateral cervico-dorsal sympathectomy. *Interactive CardioVascular*

hyperhidrosis and Raynaud's phenomenon of the upper limb and excessive facial blushing: a five year experience. *Postgraduate Medical Journal,* Vol. 78, No.925,

hyperhidrosis: experience with both cauterization and clamping methods. *Surgical Laparoscopy Endoscopy & Percutaneous Techniques,* Vol.12, No.4, (August 2002), pp.

Henteleff, H.J. & Kalavrouziotis, D. (2008). Evidence-based review of the surgical

Herbst, F.; Plas, E.G., Függer, R. & Fritsch, A. (1994). Endoscopic thoracic sympathectomy

Hsu, M.H.; Li, Y.C. (2005). Compensatory sweating after thoracoscopic sympathectomy

Inan, K.; Goksel, O.S., Uçak, A., Temizkan, V., Karaca, K., Ugur, M., Arslan, G., Us, M. &

Kaya, S.O.; Liman, S.T., Bir, L.S., Yuncu, G., Erbay, H.R. & Unsal, S. (2003). Horner's

Kim, D.H.; Paik, H.C. & Lee, D.Y. (2005). Video assisted thoracoscopic re-sympathetic

Krasna, M.J. (2008). Thoracoscopic sympathectomy: a standardized approach to therapy for

Kreyden, O.P. & Burg, G. (2000). Die Giftbehandlung von Schweissperlen. Eine Übersicht

Kwong, K.F.; Hobbs, J.L., Cooper, L.B., Burrows, W., Gamliel, Z. & Krasna, M.J. (2008).

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Lee, D.Y.; Hong, Y.J. & Shin, H.K. (1999). Thoracoscopic sympathetic surgery for hyperhidrosis. *Yonsei Medical Journal* , Vol. 40, No.6, (December 1999), pp. 589-95 Lee, D.Y.; Yoon, Y.H., Shin, H.K., Kim, H.K. & Hong, Y.J. (2000). Needle thoracic

Li, X.; Tu, Y.R., Lin, M., Lai, F.C., Chen, J.F. & Dai, Z.J. (2008). Endoscopic thoracic

*Annals of Thoracic Surgery,* Vol.69, No.1 (January 2000), pp. 251-53

*Thoracic Surgery,* Vol. 24, No.6, (December 2003), pp. 1025-28

*Thoracic Surgery*, Vol. 27, No. 5, (May 2005), pp. 741-44

Vol. 130, No. 29-30, (July 2000), pp. 1084-90

390-93, discussion pp. 393-94

pp. 209-16

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97

1747-51

86-90

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**11**

*China*

Alan D. L. Sihoe

**The Evolution of VATS Lobectomy**

Video-Assisted Thoracic Surgery (VATS) has without doubt been the most significant advance in thoracic surgery over the past half century. No other single innovation has so totally revolutionized the way thoracic surgeons perform their craft, or so greatly improved

In any surgical specialty, patients in the 21st Century are already well aware of the benefits of minimally invasive surgery. Thoracic surgery is no exception. Throughout the world, patients requiring major lung resection surgery are increasingly demanding that they receive VATS. The trend for ever increasing proportions of lung resections being performed with a VATS approach is inexorable. This is true around the globe, from Asia to Europe to North America. It is becoming ever more difficult for thoracic surgeons to justify *not* using a VATS in the face of overwhelming evidence for the benefits of this approach – not only in

Yet behind the hype and glamour of VATS today, there are aspects of the approach that even many experienced thoracic surgeons tend to overlook. It is often forgotten that VATS was first used for major lung resection two decades ago. During its infancy, VATS lobectomy was often dismissed as a gimmick or a fad with only limited niche applicability in thoracic surgery as a whole. The story of how VATS lobectomy matured, developed and evolved over the past 20 years to become the mainstream approach it is today contains many lessons for the modern thoracic surgeon. These include: realizing the importance of accurately defining a minimally invasive surgical approach such as VATS; establishing reliable outcome measures to objectively validate its efficacy; and continuing efforts to

This chapter aims to provide an overview of how VATS lobectomy has evolved over the past two decades from a minor novelty into a fundamental pillar of thoracic surgical practice. The many innovations made and insights gained during the maturation of the VATS approach have had profound influence on how thoracic surgery as a whole is

VATS surgeons worldwide have generally attributed the origination of thoracoscopic therapy to the Swedish physician Hans Christian Jacobaeus (Jacobaeus, 1910; Braimbridge,

the surgical experience for patients undergoing thoracic operations worldwide.

terms of reducing patient morbidity, but also in improving surgical outcomes.

improving its outcomes and affirm its role in modern clinical practice.

**1. Introduction**

practiced today.

**2. Historical background**

*Division of Cardiothoracic Surgery, Department of Surgery, Li Ka Shing Faculty of Medicine, The University of Hong Kong,*

## **The Evolution of VATS Lobectomy**

### Alan D. L. Sihoe

*Division of Cardiothoracic Surgery, Department of Surgery, Li Ka Shing Faculty of Medicine, The University of Hong Kong, China*

#### **1. Introduction**

180 Topics in Thoracic Surgery

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pp. 32-37

pp. 1048-55

274-75

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58

46

81

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übermäßigem Schwitzen. *Deutsches Aerzteblatt International,* Vol.106, No.3, (2009),

sympathectomy for severe hyperhidrosis: impact of restrictive denervation on compensatory sweating. *The Annals of Thoracic Surgery,* Vol.81, No.3, (March 2006),

J., Maddaus, M.A. & Andrade, R.S. (2009). Primary palmoplantar hyperhidrosis and thoracoscopic sympathectomy: a new objective assessment method. *The Annals of Thoracic Surgery,* Vol.87, No.1, (January 2009), pp. 267-74, discussion pp.

surgery for hand sweating. Review. *Annals of Thoracic and Cardiovascular Surgery,*

sympathectomy for essential hyperhidrosis: effects on cardiopulmonary function.

endoscopic thoracic sympathicotomy: survey 10 years after surgery*. Interactive*

G., Perissat, J. *Operative manual of endoscopic surgery.* New York Springer Verlag,

Hyperhidrose. *Journal der Deutschen Dermatologischen Gesellschaft,* Vol.5, No.7, (June

hyperhidrosis. *Asian Cardiovascular & Thoracic Annals,* Vol.7, No.1, (1999), pp. 56-

results of 630 thoracoscopic sympathicotomies for primary hyperhidrosis: the Vienna experience. *European Journal of Surgery,* Supplements 580, (1998), pp. 43-

Video assistance reduces complication rate of thoracoscopic sympathicotomy for hyperhidrosis. *The Annals of Thoracic Surgery*, Vol.68, No.4, (October 1999), pp. 1177Video-Assisted Thoracic Surgery (VATS) has without doubt been the most significant advance in thoracic surgery over the past half century. No other single innovation has so totally revolutionized the way thoracic surgeons perform their craft, or so greatly improved the surgical experience for patients undergoing thoracic operations worldwide.

In any surgical specialty, patients in the 21st Century are already well aware of the benefits of minimally invasive surgery. Thoracic surgery is no exception. Throughout the world, patients requiring major lung resection surgery are increasingly demanding that they receive VATS. The trend for ever increasing proportions of lung resections being performed with a VATS approach is inexorable. This is true around the globe, from Asia to Europe to North America. It is becoming ever more difficult for thoracic surgeons to justify *not* using a VATS in the face of overwhelming evidence for the benefits of this approach – not only in terms of reducing patient morbidity, but also in improving surgical outcomes.

Yet behind the hype and glamour of VATS today, there are aspects of the approach that even many experienced thoracic surgeons tend to overlook. It is often forgotten that VATS was first used for major lung resection two decades ago. During its infancy, VATS lobectomy was often dismissed as a gimmick or a fad with only limited niche applicability in thoracic surgery as a whole. The story of how VATS lobectomy matured, developed and evolved over the past 20 years to become the mainstream approach it is today contains many lessons for the modern thoracic surgeon. These include: realizing the importance of accurately defining a minimally invasive surgical approach such as VATS; establishing reliable outcome measures to objectively validate its efficacy; and continuing efforts to improving its outcomes and affirm its role in modern clinical practice.

This chapter aims to provide an overview of how VATS lobectomy has evolved over the past two decades from a minor novelty into a fundamental pillar of thoracic surgical practice. The many innovations made and insights gained during the maturation of the VATS approach have had profound influence on how thoracic surgery as a whole is practiced today.

#### **2. Historical background**

VATS surgeons worldwide have generally attributed the origination of thoracoscopic therapy to the Swedish physician Hans Christian Jacobaeus (Jacobaeus, 1910; Braimbridge,

The Evolution of VATS Lobectomy 183

can persist in up to 30% of patients at 4 to 5 years after surgery. It has previously been suggested that the pain can result from a combination of skin incision, muscle splitting, rib fracturing, costo-chondral dislocation, pleural injury, diathermy burning, neuroma formation at the wound, and so on. Above all, many surgeons believe that the single most

The rationale for VATS pulmonary resection is that by using video technology to minimize the surgical access required, most of these pain-causing elements can be reduced, particularly rib-spreading. The challenge to the first pioneers of VATS lobectomy, however, was how to negotiate the delicate hilar structures – particularly the pulmonary arteries which can easily tear and bleed. Using the small access ports envisaged, innovative strategies or exquisite sill would be required to tackle the structures situated on the medial

One of the first to report large series of lobectomies for lung cancer using the VATS approach was Dr Ralph Lewis (Lewis et al, 1992; Lewis, 1995). The technique his group described used 4 ports and explicitly called for the avoidance of rib-spreading. The mediastinal lymph nodes are excised, the fissures divided with endoscopic staplers, and the hilar structures skeletalized. The hilar structures (pulmonary artery, pulmonary vein and lobar bronchus) are then simultaneously stapled in their normal anatomic configuration using two firings of a stapler device. This bold but simple technique permitted efficient resection of a lung lobe in the early days of VATS when the intricate skills needed for conventional isolation-ligation of individual hilar structures via the small incision were still being developed. Even in the early 1990s, in his first 200 consecutive patients using this technique, Lewis claimed impressively short average operating times of 79.5 minutes and length of hospital stay of 3.07 days (Lewis & Caccavale, 2000). There was no mortality and minor complications were only noted in 13% of patients. Importantly, no patient developed a bronchopleural fstula despite the use of simultaneous stapling. After a mean follow-up of 34 months, recurrence-free survival was claimed in 141 out of 171 patients with primary lung cancers (even though less than half had post-operative stage I disease), and 7 deaths

However, despite such promising results, Lewis' simultaneous stapling technique met with considerable skepticism from the more traditional-minded thoracic surgeons' community (Pearson, 2000). Although Lewis and colleagues made a very sound argument that simultaneous stapling was a safe and even historically-proven technique for lobectomy (Lewis, 1995; Lewis & Caccavale, 2000), their approach failed to become established into the mainstream in the face of overwhelming conservatism. Since then, VATS lobectomy has generally conformed worldwide to the strategy of individual isolation-ligation of hilar structures. Nonetheless, Lewis' simultaneous stapling technique has never been discredited on clinical evidence. It can achieve a quick and safe means of removing a lobe, and can still play a part in the surgeon's armamentarium for selected patients when an expeditious

The individual isolation-ligation strategy took over as the mainstream for VATS lobectomy subsequently. As the early VATS surgeons tackled the challenge of the hilar structures, the initial instinct was to apply the conventional individual isolation-ligation of open thoracotomy but using smaller wounds. This conventional approach involved dissection of the pulmonary vessels via the interlobar fissure first, then completing the fissures, and finally dividing the bronchus (Roviaro et al, 1993; Kirby et al, 1993; Yim et al, 1996). The

important element is the forcible spreading of the ribs during thoracotomy.

side of the lobe, often buried by overlying parenchyma and fused fissures.

were unrelated to neoplasm.

lobectomy is required.

2000; Sihoe & Yim, 2008). Towards the end of the 19th century, he first used a modified cystoscope to examine the pleural cavity under local anesthesia. Using a simple candle as a light source, Jacobaeus peered through the rigid tube to look inside the chest. He primarily used this technique of direct thoracoscopy technique to lyse adhesions in order to collapse the lungs as this was the prevailing treatment for tuberculosis at the time. This technique was adopted throughout Europe in the early decades of the 20th century. As this method of direct visualization through a tube has now become forever linked to the term 'thoracoscopy', many VATS surgeons today resolutely refer to modern VATS as 'Video-Assisted *Thoracic* Surgery' and never '*thoracoscopic* surgery' (Lewis, 1996).

The introduction of streptomycin in 1945, and ever improving medical treatment of tuberculosis spelled the end of a period of enthusiasm for traditional therapeutic thoracoscopy. It is only in the last few decades that interest in minimally invasive thoracic surgical therapy was rekindled by two key technological developments. First, the marriage of the rod lens with solid state video systems and micro-cameras in the early 1980s allowed a panoramic view of the hemithorax, instead of the previous tunnel-like vision with direct thoracoscopy. Second, the availability of new endoscopic instruments like the linear mechanical stapler opened up new vistas for a spectrum of diagnostic and therapeutic procedures. From these advances, Video-Assisted Thoracic Surgery (VATS) was born. The video-thoracoscope unit with its own light source provides a well-illuminated, magnified operative view of the thorax, providing very high resolution for details surpassing even that provided by conventional headlight and magnifying loops. Although initially used for simpler diagnostic purposes, the tremendous success of laparoscopic cholecystectomy in the mid-1980s gave impetus to surgeons to apply VATS for therapy of intra-thoracic conditions.

Before long, the potential advantage of the VATS approach for reducing post-operative morbidity and pain began gaining widespread notice. The first major meeting on VATS was held in January 1992 in San Antonio, Texas in conjunction with the Society of Thoracic Surgeons meeting, representing the baptism of a newborn technique (Mack et al, 1993). Over the subsequent years, VATS has become established and developed in many centers in North America, Asia, Europe, Australia and South America (Yim et al, 1998a). Its applications as a diagnostic approach and as a therapeutic modality for benign thoracic diseases have now been firmly incorporated into mainstream thoracic surgery. Throughout the 1990s, VATS gradually became the approach of choice for thoracic procedures such as diagnosis of solitary lung nodules, diffuse pulmonary infiltrates and pleural disease; and simpler therapeutic procedures such as for pneumothorax and excisions of mediastinal lesions. With growing experience with the technique, it was inevitable that more complex pulmonary operations were being performed using VATS.

### **3. The genesis of VATS lobectomy**

For one whole century since the first lung resection was performed in 1891 by Tuffier, the posterolateral thoracotomy - and less frequently the median sternotomy and the clam-shell incisions for bilateral pulmonary procedures - have been the preferred modes of surgical access (Braimbridge, 2000). Unfortunately, although these incisions generally provide good surgical exposure, they are also among the most painful incisions in all of surgery. The trauma of access is often described as worse than that of the procedure itself. It has been reported that 5% to 80% of patients experience significant levels of pain at two months or more after a standard thoracotomy (Rogers & Duffy, 2000; Karmakar & Ho, 2004). This pain

2000; Sihoe & Yim, 2008). Towards the end of the 19th century, he first used a modified cystoscope to examine the pleural cavity under local anesthesia. Using a simple candle as a light source, Jacobaeus peered through the rigid tube to look inside the chest. He primarily used this technique of direct thoracoscopy technique to lyse adhesions in order to collapse the lungs as this was the prevailing treatment for tuberculosis at the time. This technique was adopted throughout Europe in the early decades of the 20th century. As this method of direct visualization through a tube has now become forever linked to the term 'thoracoscopy', many VATS surgeons today resolutely refer to modern VATS as 'Video-

The introduction of streptomycin in 1945, and ever improving medical treatment of tuberculosis spelled the end of a period of enthusiasm for traditional therapeutic thoracoscopy. It is only in the last few decades that interest in minimally invasive thoracic surgical therapy was rekindled by two key technological developments. First, the marriage of the rod lens with solid state video systems and micro-cameras in the early 1980s allowed a panoramic view of the hemithorax, instead of the previous tunnel-like vision with direct thoracoscopy. Second, the availability of new endoscopic instruments like the linear mechanical stapler opened up new vistas for a spectrum of diagnostic and therapeutic procedures. From these advances, Video-Assisted Thoracic Surgery (VATS) was born. The video-thoracoscope unit with its own light source provides a well-illuminated, magnified operative view of the thorax, providing very high resolution for details surpassing even that provided by conventional headlight and magnifying loops. Although initially used for simpler diagnostic purposes, the tremendous success of laparoscopic cholecystectomy in the mid-1980s gave impetus to surgeons to apply VATS for therapy of intra-thoracic conditions. Before long, the potential advantage of the VATS approach for reducing post-operative morbidity and pain began gaining widespread notice. The first major meeting on VATS was held in January 1992 in San Antonio, Texas in conjunction with the Society of Thoracic Surgeons meeting, representing the baptism of a newborn technique (Mack et al, 1993). Over the subsequent years, VATS has become established and developed in many centers in North America, Asia, Europe, Australia and South America (Yim et al, 1998a). Its applications as a diagnostic approach and as a therapeutic modality for benign thoracic diseases have now been firmly incorporated into mainstream thoracic surgery. Throughout the 1990s, VATS gradually became the approach of choice for thoracic procedures such as diagnosis of solitary lung nodules, diffuse pulmonary infiltrates and pleural disease; and simpler therapeutic procedures such as for pneumothorax and excisions of mediastinal lesions. With growing experience with the technique, it was inevitable that more complex

For one whole century since the first lung resection was performed in 1891 by Tuffier, the posterolateral thoracotomy - and less frequently the median sternotomy and the clam-shell incisions for bilateral pulmonary procedures - have been the preferred modes of surgical access (Braimbridge, 2000). Unfortunately, although these incisions generally provide good surgical exposure, they are also among the most painful incisions in all of surgery. The trauma of access is often described as worse than that of the procedure itself. It has been reported that 5% to 80% of patients experience significant levels of pain at two months or more after a standard thoracotomy (Rogers & Duffy, 2000; Karmakar & Ho, 2004). This pain

Assisted *Thoracic* Surgery' and never '*thoracoscopic* surgery' (Lewis, 1996).

pulmonary operations were being performed using VATS.

**3. The genesis of VATS lobectomy**

can persist in up to 30% of patients at 4 to 5 years after surgery. It has previously been suggested that the pain can result from a combination of skin incision, muscle splitting, rib fracturing, costo-chondral dislocation, pleural injury, diathermy burning, neuroma formation at the wound, and so on. Above all, many surgeons believe that the single most important element is the forcible spreading of the ribs during thoracotomy.

The rationale for VATS pulmonary resection is that by using video technology to minimize the surgical access required, most of these pain-causing elements can be reduced, particularly rib-spreading. The challenge to the first pioneers of VATS lobectomy, however, was how to negotiate the delicate hilar structures – particularly the pulmonary arteries which can easily tear and bleed. Using the small access ports envisaged, innovative strategies or exquisite sill would be required to tackle the structures situated on the medial side of the lobe, often buried by overlying parenchyma and fused fissures.

One of the first to report large series of lobectomies for lung cancer using the VATS approach was Dr Ralph Lewis (Lewis et al, 1992; Lewis, 1995). The technique his group described used 4 ports and explicitly called for the avoidance of rib-spreading. The mediastinal lymph nodes are excised, the fissures divided with endoscopic staplers, and the hilar structures skeletalized. The hilar structures (pulmonary artery, pulmonary vein and lobar bronchus) are then simultaneously stapled in their normal anatomic configuration using two firings of a stapler device. This bold but simple technique permitted efficient resection of a lung lobe in the early days of VATS when the intricate skills needed for conventional isolation-ligation of individual hilar structures via the small incision were still being developed. Even in the early 1990s, in his first 200 consecutive patients using this technique, Lewis claimed impressively short average operating times of 79.5 minutes and length of hospital stay of 3.07 days (Lewis & Caccavale, 2000). There was no mortality and minor complications were only noted in 13% of patients. Importantly, no patient developed a bronchopleural fstula despite the use of simultaneous stapling. After a mean follow-up of 34 months, recurrence-free survival was claimed in 141 out of 171 patients with primary lung cancers (even though less than half had post-operative stage I disease), and 7 deaths were unrelated to neoplasm.

However, despite such promising results, Lewis' simultaneous stapling technique met with considerable skepticism from the more traditional-minded thoracic surgeons' community (Pearson, 2000). Although Lewis and colleagues made a very sound argument that simultaneous stapling was a safe and even historically-proven technique for lobectomy (Lewis, 1995; Lewis & Caccavale, 2000), their approach failed to become established into the mainstream in the face of overwhelming conservatism. Since then, VATS lobectomy has generally conformed worldwide to the strategy of individual isolation-ligation of hilar structures. Nonetheless, Lewis' simultaneous stapling technique has never been discredited on clinical evidence. It can achieve a quick and safe means of removing a lobe, and can still play a part in the surgeon's armamentarium for selected patients when an expeditious lobectomy is required.

The individual isolation-ligation strategy took over as the mainstream for VATS lobectomy subsequently. As the early VATS surgeons tackled the challenge of the hilar structures, the initial instinct was to apply the conventional individual isolation-ligation of open thoracotomy but using smaller wounds. This conventional approach involved dissection of the pulmonary vessels via the interlobar fissure first, then completing the fissures, and finally dividing the bronchus (Roviaro et al, 1993; Kirby et al, 1993; Yim et al, 1996). The

The Evolution of VATS Lobectomy 185

By the mid-1990s, the basic technique of VATS lobectomy had become progressively better defined. Certain key concepts were becoming consolidated into the maxim of the VATS surgeon. The ribs were not to be spread. Hilar vessels were to be individually isolated and divided. The sequence of hilar dissection may differ from open surgery. It was also becoming evident that staplers were a quintessential component of a VATS lobectomy, even if conventional ligation and suturing could still be used in some cases. With the key ingredients in place, VATS lobectomy appeared set to take on the thoracic surgery world.

In establishing any new surgical approach, it is first necessary to demonstrate its safety for patients. With VATS lobectomy, the results of early case series universally ranged from good to excellent. The overall surgical mortality of 0-2% for VATS compared favorably to the conventional technique (Yim et al, 1998a; McKenna et al, 1998; Sihoe & Yim, 2008). Major complications and post-operative morbidity from VATS resections are relatively uncommon (Yim & Liu 1996; Walker, 2000), and minor complication rates are no higher than with open thoracotomy. Tumor implantation following VATS was an early concern (Downey et al, 1996). However, even in a series in which wound protection was not routinely carried out, port site recurrence was noted in only 0.26% (Parekh et al, 2001). This already low figure could be further minimized by routine use of a wound protector, gentle handling of tissue, and copious irrigation of the hemithorax prior to closure (Sihoe & Yim, 2008). Early studies further showed that VATS took similar operating times as open surgery, but consistently produced similar or lower levels of blood loss (Demmy & Curtis, 1999; Sugiura et al, 1999). In return for equivalent safety as open surgery, VATS delivered the promise of less postoperative pain for patients. Early evidence confiermed that patients who undergo resections via the VATS approach experience less immediate post-operative pain than those having the thoracotomy approach. This has been documented in several large case controlled studies either by objective assessment in terms of analgesic requirements (Yim et al, 1996; Walker et al, 1996), or subjective assessment in terms of pain scoring, usually in the form of a visual analogue scale (Giudicelli et al, 1994; Yim et al, 1996; Demmy & Curtis, 1999). A trend for reduced post-operative analgesic requirement was also seen in early studies comparing VATS with thoracotomy for lobectomy (Kirby et al, 1995; Sugiura et al, 1999). The reduced pain translated into faster recovery, resulting in significantly shorter hospital stays and earlier return to pre-operative work or activities (Demmy & Curtis, 1999; Sugiura et al,

By the mid to late 1990s, there was already widespread interest in this minimally invasive approach to lung resection surgery. Although relatively few surgeons were actively performing lobectomies this way, the rise of VATS was strikingly reflected in the large volumes of publications in this field. By the turn of the century, the number of papers published in indexed journals on VATS or 'thoracoscopic' lobectomy was being counted in hundreds. It seemed that VATS lobectomy would soon replace open lobectomy in our specialty, so popular was the approach becoming in academic circles. However, this

An early, small, multi-institutional, randomized, prospective study of lobectomy performed through VATS compared to thoracotomy showed no significant benefits for using VATS in terms of pain reduction (Kirby et al, 1995). In another cross-sectional, questionnaire-based study, Landreneau and colleagues reported that the incidence of chronic post-operative pain

**4. The rise and fall of early VATS lobectomy**

honeymoon period was abruptly brought to a halt.

1999).

advantage of this strategy was that it was immediately familiar for conventional thoracic surgeons – all that was required was getting used to doing the same operation via smaller wounds. The anatomy and intra-thoracic views were essentially familiar, and this made it simpler for surgeons to take the leap into the unfamiliar world of video images. Again, early reported results were encouraging with low mortality and short hospital stays.

Fig. 1. Professor Anthony Yim was a pioneer of VATS lobectomy in Asia, developing some of the fundamental techniques of this new surgical approach in the 1990s. His work played a pivotal role in establishing VATS lobectomy as a key pillar of modern thoracic surgery. As seen in this early photo from Hong Kong, the basic elements used in the early days of VATS would remain very familiar to the VATS surgeon of today.

However, it was gradually realized that simply copying the open thoracotomy approach (hilum, then fissure, then bronchus) was not necessarily ideal when performing VATS (Roviaro et al, 2000). In particular, the relatively fixed positions of the delicate hilar vessels made them hazardous to isolate and ligate individually. The rigidity of the ribs, the narrowness of the intercostals spaces, and the lack of angulation of the early staplers meant that stapler insertion around the vessels were often difficult - sometimes perilous undertakings. Some surgeons preferred traditional ligature of the vessels with thread, but this in turn can be limited by the difficulty of intracorporeal knotting through small incisions, especially in patients with deep chests or tight intercostals spaces. The problem is only partly solved with the use of specially designed knot-pushers (Yim & Lee, 1995).

It was only gradually appreciated that the slightly different views and access presented during VATS may require slightly different surgical strategies compared to open thoracotomy. With a conventional postero-lateral thoracotomy, looking straight down into the chest while standing behind the patient made it logically to employ a fissure-first or a posterior-to-anterior dissection strategy. With VATS, where the camera is usually placed at a lower level than the working port(s), this is often more difficult. Instead, working in an anterior-to-posterior direction, tackling vein the artery then bronchus, seemed to work better. The pulmonary vein is almost always easiest to approach first with the videothoracoscope, with little overlying tissue obscuring it. Once divided, the pulmonary artery branches are usually easy to expose without having to dissect laboriously through often fused interlobar fissures. Indeed, adept use of the video-thoracoscope can make this dissection of the arteries from this more medial aspect of the lobe a much more feasible proposition than with open thoracotomy. Dr Robert McKenna was among the first to advocate such a strategy (McKenna, 1994), and the gradual acceptance of this approach as the mainstream meant that most VATS surgeons nowadays tend to stand anterior to the patient when performing a lobectomy, instead of behind the patient as during a lobectomy via postero-lateral thoracotomy.

advantage of this strategy was that it was immediately familiar for conventional thoracic surgeons – all that was required was getting used to doing the same operation via smaller wounds. The anatomy and intra-thoracic views were essentially familiar, and this made it simpler for surgeons to take the leap into the unfamiliar world of video images. Again, early

Fig. 1. Professor Anthony Yim was a pioneer of VATS lobectomy in Asia, developing some of the fundamental techniques of this new surgical approach in the 1990s. His work played a pivotal role in establishing VATS lobectomy as a key pillar of modern thoracic surgery. As seen in this early photo from Hong Kong, the basic elements used in the early days of VATS

However, it was gradually realized that simply copying the open thoracotomy approach (hilum, then fissure, then bronchus) was not necessarily ideal when performing VATS (Roviaro et al, 2000). In particular, the relatively fixed positions of the delicate hilar vessels made them hazardous to isolate and ligate individually. The rigidity of the ribs, the narrowness of the intercostals spaces, and the lack of angulation of the early staplers meant that stapler insertion around the vessels were often difficult - sometimes perilous undertakings. Some surgeons preferred traditional ligature of the vessels with thread, but this in turn can be limited by the difficulty of intracorporeal knotting through small incisions, especially in patients with deep chests or tight intercostals spaces. The problem is only partly solved with the use of specially designed knot-pushers (Yim & Lee, 1995). It was only gradually appreciated that the slightly different views and access presented during VATS may require slightly different surgical strategies compared to open thoracotomy. With a conventional postero-lateral thoracotomy, looking straight down into the chest while standing behind the patient made it logically to employ a fissure-first or a posterior-to-anterior dissection strategy. With VATS, where the camera is usually placed at a lower level than the working port(s), this is often more difficult. Instead, working in an anterior-to-posterior direction, tackling vein the artery then bronchus, seemed to work better. The pulmonary vein is almost always easiest to approach first with the videothoracoscope, with little overlying tissue obscuring it. Once divided, the pulmonary artery branches are usually easy to expose without having to dissect laboriously through often fused interlobar fissures. Indeed, adept use of the video-thoracoscope can make this dissection of the arteries from this more medial aspect of the lobe a much more feasible proposition than with open thoracotomy. Dr Robert McKenna was among the first to advocate such a strategy (McKenna, 1994), and the gradual acceptance of this approach as the mainstream meant that most VATS surgeons nowadays tend to stand anterior to the patient when performing a lobectomy, instead of behind the patient as during a lobectomy

would remain very familiar to the VATS surgeon of today.

via postero-lateral thoracotomy.

reported results were encouraging with low mortality and short hospital stays.

By the mid-1990s, the basic technique of VATS lobectomy had become progressively better defined. Certain key concepts were becoming consolidated into the maxim of the VATS surgeon. The ribs were not to be spread. Hilar vessels were to be individually isolated and divided. The sequence of hilar dissection may differ from open surgery. It was also becoming evident that staplers were a quintessential component of a VATS lobectomy, even if conventional ligation and suturing could still be used in some cases. With the key ingredients in place, VATS lobectomy appeared set to take on the thoracic surgery world.

## **4. The rise and fall of early VATS lobectomy**

In establishing any new surgical approach, it is first necessary to demonstrate its safety for patients. With VATS lobectomy, the results of early case series universally ranged from good to excellent. The overall surgical mortality of 0-2% for VATS compared favorably to the conventional technique (Yim et al, 1998a; McKenna et al, 1998; Sihoe & Yim, 2008). Major complications and post-operative morbidity from VATS resections are relatively uncommon (Yim & Liu 1996; Walker, 2000), and minor complication rates are no higher than with open thoracotomy. Tumor implantation following VATS was an early concern (Downey et al, 1996). However, even in a series in which wound protection was not routinely carried out, port site recurrence was noted in only 0.26% (Parekh et al, 2001). This already low figure could be further minimized by routine use of a wound protector, gentle handling of tissue, and copious irrigation of the hemithorax prior to closure (Sihoe & Yim, 2008). Early studies further showed that VATS took similar operating times as open surgery, but consistently produced similar or lower levels of blood loss (Demmy & Curtis, 1999; Sugiura et al, 1999).

In return for equivalent safety as open surgery, VATS delivered the promise of less postoperative pain for patients. Early evidence confiermed that patients who undergo resections via the VATS approach experience less immediate post-operative pain than those having the thoracotomy approach. This has been documented in several large case controlled studies either by objective assessment in terms of analgesic requirements (Yim et al, 1996; Walker et al, 1996), or subjective assessment in terms of pain scoring, usually in the form of a visual analogue scale (Giudicelli et al, 1994; Yim et al, 1996; Demmy & Curtis, 1999). A trend for reduced post-operative analgesic requirement was also seen in early studies comparing VATS with thoracotomy for lobectomy (Kirby et al, 1995; Sugiura et al, 1999). The reduced pain translated into faster recovery, resulting in significantly shorter hospital stays and earlier return to pre-operative work or activities (Demmy & Curtis, 1999; Sugiura et al, 1999).

By the mid to late 1990s, there was already widespread interest in this minimally invasive approach to lung resection surgery. Although relatively few surgeons were actively performing lobectomies this way, the rise of VATS was strikingly reflected in the large volumes of publications in this field. By the turn of the century, the number of papers published in indexed journals on VATS or 'thoracoscopic' lobectomy was being counted in hundreds. It seemed that VATS lobectomy would soon replace open lobectomy in our specialty, so popular was the approach becoming in academic circles. However, this honeymoon period was abruptly brought to a halt.

An early, small, multi-institutional, randomized, prospective study of lobectomy performed through VATS compared to thoracotomy showed no significant benefits for using VATS in terms of pain reduction (Kirby et al, 1995). In another cross-sectional, questionnaire-based study, Landreneau and colleagues reported that the incidence of chronic post-operative pain

The Evolution of VATS Lobectomy 187

operation or frequently chose to peek through the wounds directly? As it turned out, it

In a couple of landmark papers, Shigemura and colleagues compared three well-defined surgical approaches for lobectomy: 'complete' VATS (c-VATS) using purely endoscopic techniques with 100% monitor vision without rib-spreading minithoracotomy; 'assisted' VATS (a-VATS) performing the main procedures via rib spreading and using a minithoracotomy (10 cm long) with both monitor and direct vision; and open thoracotomy (20 cm long) with direct vision only (Shigemura et al, 2004 & 2006). In these studies, the average operative time was longer for c-VATS (246 ± 47 minutes) than for a-VATS (169 ± 27 minutes) or open surgery (159 ± 28 minutes) (P < 0.05), but estimated blood loss was lower for c-VATS (96 ± 65 mL), and there was no significant difference in the number of dissected lymph nodes. Recovery time objectively analyzed by an accelerometer was shorter in patients undergoing c-VATS than in patients undergoing a-VATS or open surgery (p < 0.05). Median length of hospitalization was shorter for patients undergoing c-VATS (11.8 ± 2.7 days) than for patients undergoing a-VATS and open procedures (P < 0.05). It was therefore elegantly demonstrated that strict adherence to a completely endoscopic approach could give measurably better outcomes. In effect, it became no longer possible to consider any compromise in technique (as in a-VATS) as acceptable when describing a proper VATS

As a consequence of this realization, VATS surgeons have now applied much stricter definitions when describing VATS lobectomy. The Cancer and Leukemia Group B (CALGB) 39802 trial of the American Society of Clinical Oncology has produced perhaps the most authoritative and accepted definition of the approach thus far (Swanson et al, 2007). In this trial of the safety and feasibility of c-VATS, VATS lobectomy has been defined by the following criteria: no rib spreading; a maximum length of 8 cm of the access incision for removal of the lobectomy specimen; individual dissection of the vein, arteries, and airway for the lobe in question; and standard node sampling or dissection (identical to an open thoracotomy). All specimens were placed in an impermeable bag and removed through the access incision. This definition carries the key points emphasized by the pioneers of VATS lobectomy to reduce surgical access trauma, filtering out 'pseudo-VATS' techniques that gave compromised results (Yim, 2002; Sihoe & Yim, 2008). However, it also allowed enough flexibility for individual surgeons to adapt the approach to their own tastes – as will be

Once the definition of VATS lobectomy was re-established, it became once more possible to clearly demonstrate the benefits of the minimally invasive approach over thoracotomy. Since the turn of the century, we have witnessed a second burst of publications espousing the virtues of VATS, no less compelling than the first burst of the early to mid 1990s. A large systematic review of 39 papers involving over 6000 patients compared VATS with thoracotomy with the majority of those papers published since the turn of the century (Whitson et al, 2008). Acknowledging the CALGB definition of VATS lobectomy, this study once more reaffirmed that compared with thoracotomy, VATS lobectomy was associated with significantly shorter chest tube duration, shorter length of hospital stay, and improved survival at 4 years after resection. Furthermore, in a secondary analysis of data from the American College of Surgeons Oncology Group Z0030 randomized clinical trial comparing VATS with open lobectomy for lung cancer, it was also found that VATS gave advantages (Scott et al, 2010). In summary, VATS gave less atelectasis requiring bronchoscopy (0% vs 6.3%, P = 0.035), fewer chest tubes draining for longer than 7 days (1.5% vs 10.8%; P = 0.029),

and shorter median length of stay (5 days vs 7 days; P < 0.001).

mattered a great deal.

lobectomy.

discussed below.

at one year following VATS was also not different from thoracotomy (Landreneau et al, 1994). Over the years, these studies have been frequently quoted by opponents of VATS to suggest that the benefits of VATS may not extend to the long-term or were not clinically important. Very soon, a number of similar papers followed suit, questioning whether VATS gave patients any real benefit at all. In a separate study comparing VATS and open lobectomy, no statistical differences could be found in the pain assessment after 1 week, nor were any differences detected between groups with respect to respiratory muscle strength or 6-minute walking distance (Nomori et al, 2001). Without doubt, these reports slowed the general acceptance of VATS lobectomy by surgeons in some countries for a number of years. Unsurprisingly, a survey of the General Thoracic Surgery Club members in 1997 showed that the majority considered this application unacceptable (Mack et al, 1997). In that survey, 60% of respondents used VATS less than 20% of the time and 38.1% expressed concern regarding overuse. In particular, several concerns were raised. First, the safety of fine anatomical dissection of the hilum in an essentially closed chest was questioned. Second, there was skepticism over the adequacy of clearance for oncological lung resections with curative intent. Third, although the short term benefits of VATS to patients were intuitively obvious, its long term advantages over conventional surgery remained unclear. Fourth, the relatively high costs of the endoscopic equipments and VATS-related consumables cast doubt on the cost-effectiveness of this.

Clearly, before VATS lobectomy could progress further as a viable surgical option, these concerns needed to be fully addressed. The pleasant surprise was that not only did the subsequent soul-searching by VATS proponents overcome these obstacles, it also revealed a great deal about the fundamental principles of lung cancer surgery itself.

### **5. Defining VATS lobectomy**

When contemplating why some reports of VATS were emerging showing poorer than expected outcomes, it soon became clear that not all those reports were describing the same operation. Careful comparison of published reports confirmed that the 'VATS lobectomy' being reported was not a unified technique, but several variations existed (Yim et al 1998b; Sihoe & Yim 2008). During the initial scramble to become the first to report results with this new surgical technique, this procedure was developed almost simultaneously at different centers, with each unit carrying its own characteristics (Braimbridge, 2000). Not surprisingly, they did so with little consensus over some details of the technique. For example, how long an incision does one allow for a utility "minithoracotomy" before it becomes a "thoracotomy"? How often should one operate through the minithoracotomy as opposed to the video monitor? How much rib spreading can we afford before the benefits of minimal access surgery are lost?

As a result of this lack of standardization in defining the VATS lobectomy procedure, some authors had been loosely applying the term "VATS" to describe any thoracic surgery in which a video-thoracoscope is prepared, often for little more than illumination of the thoracic space while the operation is performed essentially via an open approach (Yim et al 1998b). In some instances, some authors were even tolerating a degree of rib-spreading when performing supposed 'VATS lobectomy' (Nomori et al, 2001). The number and position of ports used also varied considerably between centers. At first, the VATS community was very tolerant of such variations (Sihoe & Yim 2008). After all, the thinking went, how did it matter whether the surgeon was looking at the monitor throughout the

at one year following VATS was also not different from thoracotomy (Landreneau et al, 1994). Over the years, these studies have been frequently quoted by opponents of VATS to suggest that the benefits of VATS may not extend to the long-term or were not clinically important. Very soon, a number of similar papers followed suit, questioning whether VATS gave patients any real benefit at all. In a separate study comparing VATS and open lobectomy, no statistical differences could be found in the pain assessment after 1 week, nor were any differences detected between groups with respect to respiratory muscle strength or 6-minute walking distance (Nomori et al, 2001). Without doubt, these reports slowed the general acceptance of VATS lobectomy by surgeons in some countries for a number of years. Unsurprisingly, a survey of the General Thoracic Surgery Club members in 1997 showed that the majority considered this application unacceptable (Mack et al, 1997). In that survey, 60% of respondents used VATS less than 20% of the time and 38.1% expressed concern regarding overuse. In particular, several concerns were raised. First, the safety of fine anatomical dissection of the hilum in an essentially closed chest was questioned. Second, there was skepticism over the adequacy of clearance for oncological lung resections with curative intent. Third, although the short term benefits of VATS to patients were intuitively obvious, its long term advantages over conventional surgery remained unclear. Fourth, the relatively high costs of the endoscopic equipments and VATS-related consumables cast

Clearly, before VATS lobectomy could progress further as a viable surgical option, these concerns needed to be fully addressed. The pleasant surprise was that not only did the subsequent soul-searching by VATS proponents overcome these obstacles, it also revealed a

When contemplating why some reports of VATS were emerging showing poorer than expected outcomes, it soon became clear that not all those reports were describing the same operation. Careful comparison of published reports confirmed that the 'VATS lobectomy' being reported was not a unified technique, but several variations existed (Yim et al 1998b; Sihoe & Yim 2008). During the initial scramble to become the first to report results with this new surgical technique, this procedure was developed almost simultaneously at different centers, with each unit carrying its own characteristics (Braimbridge, 2000). Not surprisingly, they did so with little consensus over some details of the technique. For example, how long an incision does one allow for a utility "minithoracotomy" before it becomes a "thoracotomy"? How often should one operate through the minithoracotomy as opposed to the video monitor? How much rib spreading can we afford before the benefits of

As a result of this lack of standardization in defining the VATS lobectomy procedure, some authors had been loosely applying the term "VATS" to describe any thoracic surgery in which a video-thoracoscope is prepared, often for little more than illumination of the thoracic space while the operation is performed essentially via an open approach (Yim et al 1998b). In some instances, some authors were even tolerating a degree of rib-spreading when performing supposed 'VATS lobectomy' (Nomori et al, 2001). The number and position of ports used also varied considerably between centers. At first, the VATS community was very tolerant of such variations (Sihoe & Yim 2008). After all, the thinking went, how did it matter whether the surgeon was looking at the monitor throughout the

great deal about the fundamental principles of lung cancer surgery itself.

doubt on the cost-effectiveness of this.

**5. Defining VATS lobectomy**

minimal access surgery are lost?

operation or frequently chose to peek through the wounds directly? As it turned out, it mattered a great deal.

In a couple of landmark papers, Shigemura and colleagues compared three well-defined surgical approaches for lobectomy: 'complete' VATS (c-VATS) using purely endoscopic techniques with 100% monitor vision without rib-spreading minithoracotomy; 'assisted' VATS (a-VATS) performing the main procedures via rib spreading and using a minithoracotomy (10 cm long) with both monitor and direct vision; and open thoracotomy (20 cm long) with direct vision only (Shigemura et al, 2004 & 2006). In these studies, the average operative time was longer for c-VATS (246 ± 47 minutes) than for a-VATS (169 ± 27 minutes) or open surgery (159 ± 28 minutes) (P < 0.05), but estimated blood loss was lower for c-VATS (96 ± 65 mL), and there was no significant difference in the number of dissected lymph nodes. Recovery time objectively analyzed by an accelerometer was shorter in patients undergoing c-VATS than in patients undergoing a-VATS or open surgery (p < 0.05). Median length of hospitalization was shorter for patients undergoing c-VATS (11.8 ± 2.7 days) than for patients undergoing a-VATS and open procedures (P < 0.05). It was therefore elegantly demonstrated that strict adherence to a completely endoscopic approach could give measurably better outcomes. In effect, it became no longer possible to consider any compromise in technique (as in a-VATS) as acceptable when describing a proper VATS lobectomy.

As a consequence of this realization, VATS surgeons have now applied much stricter definitions when describing VATS lobectomy. The Cancer and Leukemia Group B (CALGB) 39802 trial of the American Society of Clinical Oncology has produced perhaps the most authoritative and accepted definition of the approach thus far (Swanson et al, 2007). In this trial of the safety and feasibility of c-VATS, VATS lobectomy has been defined by the following criteria: no rib spreading; a maximum length of 8 cm of the access incision for removal of the lobectomy specimen; individual dissection of the vein, arteries, and airway for the lobe in question; and standard node sampling or dissection (identical to an open thoracotomy). All specimens were placed in an impermeable bag and removed through the access incision. This definition carries the key points emphasized by the pioneers of VATS lobectomy to reduce surgical access trauma, filtering out 'pseudo-VATS' techniques that gave compromised results (Yim, 2002; Sihoe & Yim, 2008). However, it also allowed enough flexibility for individual surgeons to adapt the approach to their own tastes – as will be discussed below.

Once the definition of VATS lobectomy was re-established, it became once more possible to clearly demonstrate the benefits of the minimally invasive approach over thoracotomy. Since the turn of the century, we have witnessed a second burst of publications espousing the virtues of VATS, no less compelling than the first burst of the early to mid 1990s. A large systematic review of 39 papers involving over 6000 patients compared VATS with thoracotomy with the majority of those papers published since the turn of the century (Whitson et al, 2008). Acknowledging the CALGB definition of VATS lobectomy, this study once more reaffirmed that compared with thoracotomy, VATS lobectomy was associated with significantly shorter chest tube duration, shorter length of hospital stay, and improved survival at 4 years after resection. Furthermore, in a secondary analysis of data from the American College of Surgeons Oncology Group Z0030 randomized clinical trial comparing VATS with open lobectomy for lung cancer, it was also found that VATS gave advantages (Scott et al, 2010). In summary, VATS gave less atelectasis requiring bronchoscopy (0% vs 6.3%, P = 0.035), fewer chest tubes draining for longer than 7 days (1.5% vs 10.8%; P = 0.029), and shorter median length of stay (5 days vs 7 days; P < 0.001).

The Evolution of VATS Lobectomy 189

surgeons using a simultaneous stapling technique (Lewis et al, 1992; Lewis, 1995). Even the extent of lymph node dissection is not the critical issue, as similar outcomes in terms of morbidity are seen regardless of how much dissecting is done (Sagawa et al, 2002; Watanabe et al, 2005; Denlinger et al, 2010). What is left of the CALGB criteria is therefore perhaps the

It has been demonstrated that pain or aching can occur in up to 50-70% of patients at two months or more after thoracotomy (Rogers & Duffy, 2000; Karmakar & Ho, 2004). In 5% of these patients, the pain has been described as 'severe and disabling,' and over 40% of patients may still have some degree of pain at one year after surgery. Patients with such post-thoracotomy pain typically describe their pain as being burning, aching, electrical and/or shock-like in quality (Benedetti et al, 1998a; Rogers & Duffy, 2000), and responding poorly to the use of opiates (Benedetti et al, 1998b).These characteristics are the same as those of recognized neuropathic pain syndromes, such as post-herpetic neuralgia and diabetic peripheral neuropathy (Nicholson, 2000; Laird & Gidal, 2000). These all suggest that one of the key mechanisms of post-thoracotomy pain may be neuropathic. Specifically, the rib-spreading during thoracotomy may be causing substantial compression and hence neuropraxic damage to the intercostals nerves. Emerging physiological studies are now gradually confirming this hypothesis (Benedetti et al, 1998a; Rogers et al, 2002; Maguire et al, 2006; Bolotin et al, 2007). In turn, this means that the benefits of VATS over thoracotomy may to a large degree be explained by the eschewing of rib-spreading and intercostals nerve

This understanding not only helps in lowering morbidity after thoracotomy (such as by increasing use of VATS), but also in improving outcomes after VATS itself. This is because VATS does not absolutely eliminate intercostal nerve trauma as will be discussed below, and this understanding gained by simply appreciating the fundamental definition of VATS

Besides honing of the definition of VATS lobectomy, another key factor in the resurgence of this surgical approach since the 1990s has been the improvement in quality of the clinical

Following from the early success of laparoscopy in abdominal surgery, initial reports on VATS focused on the benefits it promised in terms of reduced pain with the smaller wounds. But how can pain be accurately assessed? Most clinical studies even today use patient self-reporting of levels of pain. The most common self-reporting tools are the Visual-Analog Scale or a simple 10-point numeric score. These are very simple to use and readily understood by both patients and fellow clinicians. However, they are well recognized to be subject to a wide range of confounding variables. For example, these may include patient socio-economic factors, chronic pain or analgesic use pre-operatively, other sources of postoperative satisfaction or dissatisfaction, and so on. The result is both a certain degree of unreliability and considerable variance in the scores collected. The latter in particular may have contributed to some of the more negative findings about VATS in the aforementioned studies of the mid and late 1990s (Landreneau et al, 1994; Kirby et al, 1995; Nomori et al, 2001). Other methods to quantify pain directly are also problematic. More sophisticated pain scores – such as the McGill Pain Scale – have been suggested. However, these are not

**6. Improving the validation of outcomes following VATS lobectomy**

most important: avoidance of rib-spreading.

trauma.

may also help in its treatment.

research published to investigate its worth.

Fig. 2. It is actually not difficult for the casual observer to distinguish whether 'complete' VATS or 'assist' VATS is being performed, even if the wounds appear very similar in size at the end of the operation. In 'complete' VATS (A), the surgeon operates using monitor vision exclusively and can therefore stand comfortably upright throughout the operation. Only gentle skin retraction is occasionally used at the utility port. In 'assisted' VATS (B), the surgeon operates some or most of the time using direct vision via the utility port and consequently is often seen stooping over the patient to 'peek in'. To allow enough room for both direct vision and instrumentation through that port, some degree of rib retraction must typically be used.

It is therefore confirmed that VATS gives clinical advantages once clearly defined. However, this in turn raises the question: 'why?' What is so special about the criteria used for defining VATS that they can significantly impact on outcomes?

Looking at the four listed criteria of the CALGB definition, it is clear that the length of the main incision is not that important. Even when a large number of reports using a large range of wound lengths are considered together, the advantage of VATS over thoracotomy is well maintained (Whitson et al, 2008). Neither is the use of individual isolation-ligation of the hilar structures that important – as evidenced by the excellent results reported by

Fig. 2. It is actually not difficult for the casual observer to distinguish whether 'complete' VATS or 'assist' VATS is being performed, even if the wounds appear very similar in size at the end of the operation. In 'complete' VATS (A), the surgeon operates using monitor vision exclusively and can therefore stand comfortably upright throughout the operation. Only gentle skin retraction is occasionally used at the utility port. In 'assisted' VATS (B), the surgeon operates some or most of the time using direct vision via the utility port and consequently is often seen stooping over the patient to 'peek in'. To allow enough room for both direct vision and instrumentation through that port, some degree of rib retraction must

It is therefore confirmed that VATS gives clinical advantages once clearly defined. However, this in turn raises the question: 'why?' What is so special about the criteria used for defining

Looking at the four listed criteria of the CALGB definition, it is clear that the length of the main incision is not that important. Even when a large number of reports using a large range of wound lengths are considered together, the advantage of VATS over thoracotomy is well maintained (Whitson et al, 2008). Neither is the use of individual isolation-ligation of the hilar structures that important – as evidenced by the excellent results reported by

typically be used.

VATS that they can significantly impact on outcomes?

surgeons using a simultaneous stapling technique (Lewis et al, 1992; Lewis, 1995). Even the extent of lymph node dissection is not the critical issue, as similar outcomes in terms of morbidity are seen regardless of how much dissecting is done (Sagawa et al, 2002; Watanabe et al, 2005; Denlinger et al, 2010). What is left of the CALGB criteria is therefore perhaps the most important: avoidance of rib-spreading.

It has been demonstrated that pain or aching can occur in up to 50-70% of patients at two months or more after thoracotomy (Rogers & Duffy, 2000; Karmakar & Ho, 2004). In 5% of these patients, the pain has been described as 'severe and disabling,' and over 40% of patients may still have some degree of pain at one year after surgery. Patients with such post-thoracotomy pain typically describe their pain as being burning, aching, electrical and/or shock-like in quality (Benedetti et al, 1998a; Rogers & Duffy, 2000), and responding poorly to the use of opiates (Benedetti et al, 1998b).These characteristics are the same as those of recognized neuropathic pain syndromes, such as post-herpetic neuralgia and diabetic peripheral neuropathy (Nicholson, 2000; Laird & Gidal, 2000). These all suggest that one of the key mechanisms of post-thoracotomy pain may be neuropathic. Specifically, the rib-spreading during thoracotomy may be causing substantial compression and hence neuropraxic damage to the intercostals nerves. Emerging physiological studies are now gradually confirming this hypothesis (Benedetti et al, 1998a; Rogers et al, 2002; Maguire et al, 2006; Bolotin et al, 2007). In turn, this means that the benefits of VATS over thoracotomy may to a large degree be explained by the eschewing of rib-spreading and intercostals nerve trauma.

This understanding not only helps in lowering morbidity after thoracotomy (such as by increasing use of VATS), but also in improving outcomes after VATS itself. This is because VATS does not absolutely eliminate intercostal nerve trauma as will be discussed below, and this understanding gained by simply appreciating the fundamental definition of VATS may also help in its treatment.

## **6. Improving the validation of outcomes following VATS lobectomy**

Besides honing of the definition of VATS lobectomy, another key factor in the resurgence of this surgical approach since the 1990s has been the improvement in quality of the clinical research published to investigate its worth.

Following from the early success of laparoscopy in abdominal surgery, initial reports on VATS focused on the benefits it promised in terms of reduced pain with the smaller wounds. But how can pain be accurately assessed? Most clinical studies even today use patient self-reporting of levels of pain. The most common self-reporting tools are the Visual-Analog Scale or a simple 10-point numeric score. These are very simple to use and readily understood by both patients and fellow clinicians. However, they are well recognized to be subject to a wide range of confounding variables. For example, these may include patient socio-economic factors, chronic pain or analgesic use pre-operatively, other sources of postoperative satisfaction or dissatisfaction, and so on. The result is both a certain degree of unreliability and considerable variance in the scores collected. The latter in particular may have contributed to some of the more negative findings about VATS in the aforementioned studies of the mid and late 1990s (Landreneau et al, 1994; Kirby et al, 1995; Nomori et al, 2001). Other methods to quantify pain directly are also problematic. More sophisticated pain scores – such as the McGill Pain Scale – have been suggested. However, these are not

The Evolution of VATS Lobectomy 191

injury to the long thoracic nerve, and as a result of the significant post-operative pain from the wound. By reducing such surgical trauma and post-operative pain, VATS lung resections may reduce the incidence of post-operative shoulder dysfunction. Previous studies have reported that the strengths of the lattisimus dorsi and serratus anterior muscles may be better preserved following VATS when compared to thoracotomy (Landreneau et al, 1993; Giudicelli et al, 1994). In a prospective study, Li et al reported that short-term shoulder strength and range of movement were significantly better in patients who received VATS pulmonary resection than those who received thoracotomy (Li et al, 2003). Again, such

There is emerging evidence that VATS causes less depression of pulmonary function after lung resection surgery than thoracotomy. Kaseda reported that both the forced expiratory volume in one second (FEV1) and forced vital capacity (FVC) values measured at three months post-operatively were significantly preserved relative to pre-operative values in patients who underwent lobectomy by a VATS approach compared to those receiving a thoracotomy approach (p<0.0001) (Kaseda et al, 2002). In another similar study, postoperative PaO2, SaO2, peak flow rates, FEV1 and FVC were all found to be better on postoperative days 7 and 14 in patients who had VATS rather than thoracotomy for lung resection (Nakata et al, 2000). Blood oxygenation, lung diffusion capacities, 6-minute walk test results, and recovery of vital capacity and cardio-pulmonary function after surgery all tend to be better after VATS than after various forms of open thoracotomy for pulmonary

The most exciting attempt to prove that VATS causes less trauma than thoracotomy have come from studies looking at the impact of surgery on inflammatory and immune markers. There is now a wealth of literature showing that the body's immune function is better preserved following laparoscopic surgery compared to its open counterparts in general abdominal surgery. In thoracic surgery, one study has now demonstrated that patients with clinical stage I lung cancer undergoing VATS lobectomy had significantly reduced post-operative release of both pro-inflammatory (interleukins 6 and 8) and antiinflammatory cytokines (interleukin 10) into the plasma compared to those having conventional resection (Yim et al, 2000a). Similar findings were also reported in a smaller Japanese study which showed significantly reduced cytokine release (interleukins 6 and 8) into the pleural fluid in the VATS lobectomy group compared to the open group (Sugi et al, 2000a). In a small randomized, prospective study from Edinburgh, it was also shown that VATS lobectomy was associated with a lesser effect on the post-operative fall in circulating T (CD4) cells and natural killer (NK) cells (Leaver et al, 2000). Lymphocyte oxidation was also less suppressed by VATS compared to open surgery. The same group also found that a range of acute phase responses – including C-reactive protein, interleukin 6, tumor necrosis factor, P-selectin, and oxygen free radical activity – were also significantly less amongst the VATS patients (Craig et al, 2001). A separate Hong Kong study found that NK cell levels were suppressed to similar degrees on the first postoperative day following both VATS and thoracotomy lung resections for non-small cell lung cancer, but that T lymphocyte numbers were significantly more reduced following thoracotomy (Ng et al, 2005). The levels of NK cells subsequently rose more quickly in the VATS group. These results suggest that the VATS approach was associated with less, and quicker recovery from, post-operative immunosuppression following lung resection

studies provide more objective evidence of morbidity reduction after VATS.

resections(Nagahiro et al, 2001; Nomori et al, 2002 & 2003a).

surgery than the thoracotomy approach.

tailored for use in post-operative patient, and they are often too complex and unwieldy to use in the setting of an acute surgical ward. Counting the use of analgesics is also not ideal. If a standardized post-operative protocol of regular analgesic is used, not enough difference may be shown between VATS and open patients. However, if a very flexible 'as required' analgesic regimen is used the results will again will be confounded by factors such as individual patient pain thresholds and prejudices about taken medications. Early reports describing such results also demonstrated that it is hard to compare results sometimes between different cohorts or studies. For example, does a VATS patient taking two tablets of a non-steroidal anti-inflammatory drug daily have more or less pain than a thoracotomy patient taking a total of 10 tablets of a mild opiate over five days? For all these reasons, early studies reporting the alleged benefits of VATS lobectomy came in for considerable criticism over the years.

Learning from these lessons, VATS surgeons have taken to using surrogate measures of reduced morbidity. If pain is reduced, would this not be reflected in shorter hospital stays and earlier return to work? Again, almost every clinical study on VATS suggests that the minimally invasive approach shortens lengths of stay, but again such results are prone to bias. Although chest drain durations can be crudely regulated by defining drainage volume and air leak cessation criteria triggering removal, lengths of stay are much more subject to confounding variables such as clinician desire to send a VATS patient home or patient keenness or reluctance to leave hospital just days after major surgery. It is already recognized that, for example, that in general, the hospital length of stay in Asian institutions is longer than in North American institutions, reflecting the influence of cultural factors that undermines the usefulness of this outcome measure (Whitson et al, 2008). The same can apply to early reports using return to work to demonstrate the benefit of VATS.

Further efforts to display the morbidity reduction with VATS are now coming to fruition though. One of the methods is to compare pre- and post-operative Quality of Life (QoL). There is increasing realization that post-operative QoL is very important to the cancer patient. It has been shown that patients tend to be more concerned about post-operative functional status and performance in activities of daily living than in abstract survival statistics (Cykert et al, 2000). On a more practical leveler for VATS researchers, many excellent and well-validated QoL assessment tools are widely available. One detailed survey used the EORTC QLQ-C30 and EORTC QLQ-LC13 questionnaires designed to assess QoL in lung cancer patients, supplemented by a self-designed, nine-item surgery-specific questionnaire (Li et al, 2002). The survey was conducted on patients who received lung resections with curative intent for early stage lung cancer either by a VATS approach (median follow-up time of 33.5 months) or by an open thoracotomy approach (39.4 months). Statistically comparable levels of QoL and functional status were noted in both groups, although there was a trend for the VATS group to show better QoL scores and lower incidences of fatigue, dyspnea, coughing, and pain. Since then, an increasing number of papers have confirmed that VATS offers patients better QoL following lobectomy than thoracotomy, providing a much more reliable, quantifiable proof of its advantage (Handy et al, 2010; Rueth & Andrade, 2010).

Another important but often overlooked measure of both post-operative pain and QoL after thoracic surgery is the impairment of shoulder function following thoracic surgery. Shoulder function can be impaired following a thoracotomy by a combination of neurological injury during patient positioning, division of shoulder girdle muscles, direct

tailored for use in post-operative patient, and they are often too complex and unwieldy to use in the setting of an acute surgical ward. Counting the use of analgesics is also not ideal. If a standardized post-operative protocol of regular analgesic is used, not enough difference may be shown between VATS and open patients. However, if a very flexible 'as required' analgesic regimen is used the results will again will be confounded by factors such as individual patient pain thresholds and prejudices about taken medications. Early reports describing such results also demonstrated that it is hard to compare results sometimes between different cohorts or studies. For example, does a VATS patient taking two tablets of a non-steroidal anti-inflammatory drug daily have more or less pain than a thoracotomy patient taking a total of 10 tablets of a mild opiate over five days? For all these reasons, early studies reporting the alleged benefits of VATS lobectomy came in for considerable criticism

Learning from these lessons, VATS surgeons have taken to using surrogate measures of reduced morbidity. If pain is reduced, would this not be reflected in shorter hospital stays and earlier return to work? Again, almost every clinical study on VATS suggests that the minimally invasive approach shortens lengths of stay, but again such results are prone to bias. Although chest drain durations can be crudely regulated by defining drainage volume and air leak cessation criteria triggering removal, lengths of stay are much more subject to confounding variables such as clinician desire to send a VATS patient home or patient keenness or reluctance to leave hospital just days after major surgery. It is already recognized that, for example, that in general, the hospital length of stay in Asian institutions is longer than in North American institutions, reflecting the influence of cultural factors that undermines the usefulness of this outcome measure (Whitson et al, 2008). The same can

Further efforts to display the morbidity reduction with VATS are now coming to fruition though. One of the methods is to compare pre- and post-operative Quality of Life (QoL). There is increasing realization that post-operative QoL is very important to the cancer patient. It has been shown that patients tend to be more concerned about post-operative functional status and performance in activities of daily living than in abstract survival statistics (Cykert et al, 2000). On a more practical leveler for VATS researchers, many excellent and well-validated QoL assessment tools are widely available. One detailed survey used the EORTC QLQ-C30 and EORTC QLQ-LC13 questionnaires designed to assess QoL in lung cancer patients, supplemented by a self-designed, nine-item surgery-specific questionnaire (Li et al, 2002). The survey was conducted on patients who received lung resections with curative intent for early stage lung cancer either by a VATS approach (median follow-up time of 33.5 months) or by an open thoracotomy approach (39.4 months). Statistically comparable levels of QoL and functional status were noted in both groups, although there was a trend for the VATS group to show better QoL scores and lower incidences of fatigue, dyspnea, coughing, and pain. Since then, an increasing number of papers have confirmed that VATS offers patients better QoL following lobectomy than thoracotomy, providing a much more reliable, quantifiable proof of its advantage (Handy et

Another important but often overlooked measure of both post-operative pain and QoL after thoracic surgery is the impairment of shoulder function following thoracic surgery. Shoulder function can be impaired following a thoracotomy by a combination of neurological injury during patient positioning, division of shoulder girdle muscles, direct

apply to early reports using return to work to demonstrate the benefit of VATS.

over the years.

al, 2010; Rueth & Andrade, 2010).

injury to the long thoracic nerve, and as a result of the significant post-operative pain from the wound. By reducing such surgical trauma and post-operative pain, VATS lung resections may reduce the incidence of post-operative shoulder dysfunction. Previous studies have reported that the strengths of the lattisimus dorsi and serratus anterior muscles may be better preserved following VATS when compared to thoracotomy (Landreneau et al, 1993; Giudicelli et al, 1994). In a prospective study, Li et al reported that short-term shoulder strength and range of movement were significantly better in patients who received VATS pulmonary resection than those who received thoracotomy (Li et al, 2003). Again, such studies provide more objective evidence of morbidity reduction after VATS.

There is emerging evidence that VATS causes less depression of pulmonary function after lung resection surgery than thoracotomy. Kaseda reported that both the forced expiratory volume in one second (FEV1) and forced vital capacity (FVC) values measured at three months post-operatively were significantly preserved relative to pre-operative values in patients who underwent lobectomy by a VATS approach compared to those receiving a thoracotomy approach (p<0.0001) (Kaseda et al, 2002). In another similar study, postoperative PaO2, SaO2, peak flow rates, FEV1 and FVC were all found to be better on postoperative days 7 and 14 in patients who had VATS rather than thoracotomy for lung resection (Nakata et al, 2000). Blood oxygenation, lung diffusion capacities, 6-minute walk test results, and recovery of vital capacity and cardio-pulmonary function after surgery all tend to be better after VATS than after various forms of open thoracotomy for pulmonary resections(Nagahiro et al, 2001; Nomori et al, 2002 & 2003a).

The most exciting attempt to prove that VATS causes less trauma than thoracotomy have come from studies looking at the impact of surgery on inflammatory and immune markers. There is now a wealth of literature showing that the body's immune function is better preserved following laparoscopic surgery compared to its open counterparts in general abdominal surgery. In thoracic surgery, one study has now demonstrated that patients with clinical stage I lung cancer undergoing VATS lobectomy had significantly reduced post-operative release of both pro-inflammatory (interleukins 6 and 8) and antiinflammatory cytokines (interleukin 10) into the plasma compared to those having conventional resection (Yim et al, 2000a). Similar findings were also reported in a smaller Japanese study which showed significantly reduced cytokine release (interleukins 6 and 8) into the pleural fluid in the VATS lobectomy group compared to the open group (Sugi et al, 2000a). In a small randomized, prospective study from Edinburgh, it was also shown that VATS lobectomy was associated with a lesser effect on the post-operative fall in circulating T (CD4) cells and natural killer (NK) cells (Leaver et al, 2000). Lymphocyte oxidation was also less suppressed by VATS compared to open surgery. The same group also found that a range of acute phase responses – including C-reactive protein, interleukin 6, tumor necrosis factor, P-selectin, and oxygen free radical activity – were also significantly less amongst the VATS patients (Craig et al, 2001). A separate Hong Kong study found that NK cell levels were suppressed to similar degrees on the first postoperative day following both VATS and thoracotomy lung resections for non-small cell lung cancer, but that T lymphocyte numbers were significantly more reduced following thoracotomy (Ng et al, 2005). The levels of NK cells subsequently rose more quickly in the VATS group. These results suggest that the VATS approach was associated with less, and quicker recovery from, post-operative immunosuppression following lung resection surgery than the thoracotomy approach.

The Evolution of VATS Lobectomy 193

done by a minimally invasive or open approach. How is it possible to demonstrate whether a lobe resected by VATS is any more or less a lobe than one removed via thoracotomy? Instead, the battle of the adequacy of VATS is being waged not over the quantity of the lobe itself, but over the amount of lymph node tissue being resected. Opponents of VATS have long suggested that even if a lobe can be removed by VATS, the approach does not allow radical nodal clearance. The debate over the relative merits of lymph node sampling versus lymph node dissection after lung cancer resection is ongoing and beyond the scope of this chapter. However, even if radical nodal dissection is desired, there is now growing evidence that the adequacy of VATS radical lymphadenectomy approaches that of open surgery both in terms of number and mass of nodal tissue removed. In one study, an open thoracotomy immediately after VATS nodal dissection in the same patient could yield only 3% more nodal tissue – an insignificant amount (Sagawa et al, 2002). Two retrospective studies on non-contemporary cohorts of VATS and thoracotomy patients found that VATS gave similar or slightly less nodal tissue, but survival and staging were not affected (Watanabe et al, 2005; Denlinger et al, 2010). In a more recent prospective study of contemporary VATS and thoracotomy cohorts, VATS was confirmed to yield at least as much nodal tissue as thoracotomy regardless of side, lobe or stage of the lung cancer (Sihoe et al, 2011). In addition, VATS gave higher yields at traditionally 'trickier' nodal stations such as the subcarinal nodes (possibly because of the better view VATS afforded in such areas), and the 2-year recurrence-free survival was also higher with VATS. It therefore appears that anatomically-speaking there is no longer a case to suggest VATS is not as oncologically

The last bastion of resistance against the adequacy of VATS lobectomy must therefore be long-term survival rates. Ultimately, any quantifiably proven similarity between VATS and thoracotomy intra-operatively must be translated into similar 'cure' rates post-operatively. Thankfully, a large volume of evidence has been accumulated over the past two decades in this regard. These have consistently demonstrated similar survival rates between VATS and open lobectomy patients (Sugi et al, 2000b; Rueth & Andrade, 2010). However, a trend has long been noticed by VATS surgeons for a trend of longer survival amongst VATS patients. Studies from Japan have time and again reported remarkable 5-year survival rates of around 90% for stage IA lung cancer patients receiving VATS lobectomy (Sugi et al, 2000b; Kaseda et al, 2002; Watanabe et al, 2005). In a 2008 systematic review of 39 studies comparing VATS with open lobectomy, patients who underwent VATS lobectomy were finally confirmed to have improved survival versus patients with open lobectomy (88.4% vs 71%; p = 0.003) (Whitson et al, 2008). More recently, another similar systematic review reported that 5-year survival was significantly improved for patients who undergo VATS lobectomy for earlystage NSCLC (VATS relative risk, 0.72; p = 0.04), further suggesting that VATS lobectomy is

It is still premature to declare with certainty that VATS gives better survival than open lobectomy. Nonetheless, many surgeons have already begun to speculate over reasons why this phenomenon should be possible. The theory gaining most recent attention is that of the effect of VATS on peri-operative immuno-surveillance. It has been shown that tumor cells may be shed into the circulation during lung cancer surgery (Yamashita et al, 2000). In other surgical specialties, it has been demonstrated that the body's own immune system can help kill or remove such circulating tumor cells – a process often called 'immuno-surveillance' (Shariat et al, 2002; Wu et al, 2002). In theory, if the body's immune function is somehow impaired this

complete as open thoracotomy for lung cancer surgery.

at least oncologically equivalent to open lobectomy (Yan et al, 2009).

In essence, there is evidence now to believe that VATS is associated with less perturbation in both the humoral and cellular immune functions compared to open surgery, at least in the short term (Walker et al, 2000). So far, there have been no reports demonstrating that VATS pulmonary resection confers a lower incidence of post-operative infection than the open approach. It has also been hypothesized that as immunosurveillance may play an important role in the progression of cancer, surgically induced immunosuppression may predispose to increased tumor growth or recurrence. Whether better preservation of the immune system by VATS may lead to improved long term survival is unclear but certainly deserves further investigation (Yim, 2002).

The ongoing quest to show the advantages of VATS lobectomy over open surgery has succeeded not only in emphatically meeting this primary objective, but also in teaching thoracic surgeons some valuable lessons. The need to find more reliable assessors for perioperative morbidity has been underscored. This in turn has focused attention on matters important to the patient – such as QoL and post-operative function – rather than just abstract statistics interesting to the surgeon. The extension of the quest to demonstrate less physiological harm to the body using VATS has also begun to highlight the potential oncologic advantage of VATS lobectomy – as will be discussed below.

#### **7. The oncologic efficacy of VATS lobectomy**

Critics of the VATS approach for lung cancer research will say – quite rightly – that all the above benefits of VATS are meaningless if the operation cannot fulfill its primary obligation to provide effective oncologic treatment. As mentioned above, the focus of these early doubts on the oncologic efficacy of VATS lobectomy included: whether VATS allowed fine anatomical dissection for individual isolation-ligation of the hilar structures; whether VATS was a cost-effective means of delivering oncologic therapy; and whether VATS gave adequate clearance for oncological lung resections (Mack et al, 1997). The concern over the ability of VATS to allow lobectomy using an individual isolation-ligation strategy has been resoundingly answered by almost two decades of successful surgery around the world.

The question of cost-effectiveness arose because many centers initially baulked at the high consumables costs and potentially longer operating times involved in a typical VATS lobectomy. However, by choosing the right patients for this technique, using mainly conventional instruments, and relying on ligation and suturing in preference to staplers where possible, the consumable costs could be minimized (Yim, 1996). More importantly, VATS promises shorter hospital stays and fewer complications. The savings gained by the shorter stays and having to treat fewer complications tend to offset the higher consumables costs. One study comparing VATS versus open resections for cancer showed that the overall hospital charges were therefore possibly even lower when VATS is used(Nakajima et al, 2000). In experienced hands, VATS major resection could also be as quick an operation as the open approach because less time is needed to open and close the chest. Most centers regularly performing VATS lobectomy no longer find any significant difference in operating times between VATS and open lobectomies (Sihoe & Yim, 2008). Nowadays, the challenge facing VATS lobectomy is ironically not the fear of higher consumables costs, but rather the expectation by patients and/or insurers of lower overall costs – which may even affect compensation for the surgeon in some regions.

The question about whether VATS gives adequate oncologic clearance requires a more complex answer. After all, an anatomic lobectomy is an anatomic lobectomy whether it is

In essence, there is evidence now to believe that VATS is associated with less perturbation in both the humoral and cellular immune functions compared to open surgery, at least in the short term (Walker et al, 2000). So far, there have been no reports demonstrating that VATS pulmonary resection confers a lower incidence of post-operative infection than the open approach. It has also been hypothesized that as immunosurveillance may play an important role in the progression of cancer, surgically induced immunosuppression may predispose to increased tumor growth or recurrence. Whether better preservation of the immune system by VATS may lead to improved long term survival is unclear but certainly deserves further