But even though the benefits of the technique have been documented over the past decade - shorter recovery times and hospitalizations, reduced pain, and improved quality of life, for example - it is currently used in only about five percent of the 40,000 lobectomies performed each year in the United States.
An article describing the study appears in the February 2006 issue of The Annals of Thoracic Surgery. It is a follow-up article to one published in the same journal in 1998 that reported on results of video-assisted thoracoscopic surgery (VATS) in 298 patients. Thoracic surgeon Robert McKenna Jr., M.D., surgical director of the Center for Chest Diseases and medical director of Thoracic Surgery and Trauma at Cedars-Sinai, is the principal investigator and senior author.
Instead of making an eight- to 10-inch incision, as is done in a typical thoracotomy, VATS requires only four small incisions through which instruments and a thoracoscope are placed. A camera lens at the tip of the scope feeds high-resolution images to a video monitor, providing the surgeon with a detailed, magnified view of the surgical site. A segment, lobe or entire lung can be removed, depending on the patient's condition and the extent of the cancer.
"At Cedars-Sinai, we now perform 90 percent of our lobectomies by VATS," said McKenna. "This is the highest percentage of major pulmonary resections done by VATS anywhere in the world. Our data show that it can be safe and our long-term follow-up shows that it results in standard cancer survival. Whether you get access through a big hole or a little hole doesn't matter. What matters is survival, and survival is the standard survival that you expect for patients after a lobectomy done for cancer."
Although the size of the incisions may not affect survival, the authors cite a number of recent studies indicating that the minimally invasive approach does result in reduced postoperative pain, better postoperative pulmonary function, and a higher level of patient quality of life. Still, some surgeons have expressed concern about the risk of blood loss with the VATS procedure, as well as the surgeon's ability to deal with any bleeding that should occur, but studies have actually shown the VATS procedure to result in less blood loss, and according to the Annals article, only seven of the 1,100 cases were converted to an open surgery to control bleeding.
McKenna, whose thoracic surgery group may be the most active in the western United States, suggests that one reason the VATS technique has yet to become the standard of practice is that it can be technically challenging for surgeons who are not accustomed to performing videoscopic procedures and those who do not specialize in chest and lung surgery. A thoracic surgeon since 1982, McKenna is a pioneer in the videoscopic technology and technique. Well known for his research and involvement in National Institutes of Health-funded studies, he has performed and written about VATS procedures since 1992.
"Surgeons who do not have the volume of cases to do pulmonary procedures consistently and regularly will have difficulty developing the skills and routine to do lung surgery this way," he said. "But we are seeing an increase in the number of institutions and surgeons who are adopting this approach, and thoracic surgeons from around the world come here to learn how to do their lung operations this way."
Of the 1,100 patients included in the study, 595 were women, 505 were men. The average age was 71 years, with 160 patients being 80 years of age or older. The mortality rate was less than one percent, fewer than five percent of patients needed to go to the intensive care unit, and the median length of hospital stay was three days. All operations were performed between February 1992 and December 2004.
"About 20 percent of our patients go home from the hospital on either the first or second day following lobectomy for lung cancer," McKenna said. "The VATS procedure is not a pain-free surgery. It does hurt; but it does hurt considerably less than standard open procedures. Most patients will be tired and sore for a month or two but VATS tremendously shifts the recovery rate and reduces the pain compared to the standard operation. We have had two patients who played tennis five and six days after having lobectomies this way and two patients who played golf seven days after having lobectomies this way."