25 - Thoracic Incisions
Editors: Shields, Thomas W.; LoCicero, Joseph; Ponn, Ronald B.; Rusch, Valerie W.
Title: General Thoracic Surgery, 6th Edition
Copyright 2005 Lippincott Williams & Wilkins
> Table of Contents > Volume I - The Lung, Pleura, Diaphragm, and Chest Wall > Section VII - Pulmonary Resections > Chapter 33 - Video-Assisted Thoracic Surgery for Wedge Resection, Lobectomy, and Pneumonectomy
Chapter 33
Video-Assisted Thoracic Surgery for Wedge Resection, Lobectomy, and Pneumonectomy
Robert J. McKenna Jr.
The expectation for minimally invasive thoracic procedures has been that they would reduce morbidity, mortality, and hospital stay and allow quicker return to regular activities for patients after procedures that formerly required major incisions. This expectation has yet to be conclusively proved, although some of the early results are encouraging. The techniques for lung resection (wedge, lobectomy, and pneumonectomy) with video-assisted thoracic surgery (VATS) are evolving, but this chapter presents details about the current approaches and results.
VIDEO-ASSISTED THORACIC SURGICAL RESECTION OF LUNG NODULES
Currently, lung nodules are more commonly resected with VATS than with thoracotomy. Hazelrigg and associates (1993) showed that, compared with an open procedure, the VATS approach has a shorter hospital length of stay, although the cost savings from a shorter length of stay are equal to the additional cost of the extra equipment for the VATS procedure, and no overall cost savings was demonstrated. The VATS resections in this study were performed with disposable equipment; thus, a cost savings is probably realized if the procedure is performed with reusable instruments.
Some pulmonary masses are more difficult to resect by VATS than by thoracotomy. Lobectomy is appropriate for the diagnosis of certain centrally located masses. Other masses may be amenable to wedge resection. Although proper exposure, traction, and countertraction are more challenging with VATS, it can be done. As in an open procedure, cautery can be used in a VATS procedure to cut into the lung parenchyma to isolate and resect the mass. A small mass ( 5 mm) may be difficult to locate with VATS. VATS wedge resection is usually undertaken for a peripherally located mass between 1 and 5 cm in size.
Operative Technique for Wedge Resection
Under one-lung general anesthesia, the patient is placed in a full lateral decubitus position, as for a posterolateral thoracotomy. A trocar and thoracoscope are placed through the eighth intercostal space to obtain the optimal panoramic view of the thoracic cavity. We prefer to use the 30-degree, 5-mm thoracoscope because the smaller scope causes less trauma to the intercostal nerves and the 30-degree scope allows the surgeon to look around a structure better than the 0-degree scope. Generally, a 1- to 2-cm incision is placed in the fourth or fifth intercostal space in the midaxillary line for palpation of the lung with a finger, and a 1- to 2-cm incision is made in the midclavicular line in the sixth interspace for a stapler. The more anterior location of these latter two incisions is preferable to posteriorly placed incisions, where the interspaces are smaller.
Localization of Lung Nodules by Video-Assisted Thoracic Surgery
Because the small incisions used for VATS limit the surgeon's ability to palpate the lung, a key to successful performance of resection of a lung mass by VATS is the ability to find the lesion. It is, therefore, important for the surgeon to correlate the location of a mass on computed tomographic (CT) scan with the patient's anatomy. An experienced thoracic surgeon can almost always find a lung mass in this fashion. The lung is quite mobile; hence, most areas of the lung can be brought to a finger placed through the incision in the fourth intercostal space in the midaxillary line.
Rarely, preoperative wire localization of a lung nodule is helpful when a lung mass is small (usually smaller than 5 mm) or at least 2 cm below the pleura. Under CT guidance, the radiologist places a hooked wire in or adjacent to the
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nodule. The wire should be cut off at skin level because it does not matter if it retracts into the chest. If the wire has been taped to the chest without being cut, the wire may become dislodged from the mass if the patient develops a pneumothorax. When the wire has been positioned, the patient is then transferred to the operating room for resection of the area of the lung with the wire. The mass can usually be palpated in the specimen without the need for a specimen radiograph to confirm that the mass has been resected. As Mack and colleagues (1993) noted, this technique is associated with minimal complications (e.g., rare dislodgment of the wire or pneumothorax). Wire localization was used more often in the early days of VATS before surgeons realized that it was rarely necessary. This technique has again become more common because screening CT scans identify small nodules that may be difficult to locate with VATS.
Wedge Resection
The use of endoscopic staples is the most common method for wedge resection of a lung nodule. Ring forceps through two incisions position the mass for the stapler. Often, the stapler is fired through different incisions to complete the resection (Fig. 33-1).
Alternatively, electrocautery or laser can be used to resect the mass. In this case, the lung parenchyma is sutured. A fourth incision is often made for another instrument to provide good traction and countertraction on the lung for optimal function of the electrocautery. Smoke from the electrocautery can be problematic. Suction in the thoracic cavity causes the lung to reexpand unless air can flow into the thoracic cavity through at least one of the incisions. Many thoracic surgeons find endoscopic suturing difficult; therefore, this approach is less common than wedge resection with staples.
Cancer has implanted in thoracoscopy incisions after biopsy, as noted by Downey and associates (1996) in a review of 21 cases in which this problem occurred. If the lung mass could be a malignancy, it should be placed in a bag for removal to minimize the risk for recurrence in the incision. Several endoscopic bags are available for removal of the usual wedge resection (e.g., Endocatch, U.S. Surgical, Norwalk, CT, U.S.A.).
GENERAL APPROACH TO A VIDEO-ASSISTED THORACIC SURGICAL LOBECTOMY
A VATS lobectomy should be the same procedure that is performed with an open operation. This includes the individual
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ligation of the vessels and bronchus for the lobectomy and a lymph node dissection or sampling as recommended by the author (1995). The indications and contraindications for the procedure (Tables 33-1 and 33-2) are similar to the indications for lobectomy by means of thoracotomy. The tumor must be small enough for removal through the VATS incisions. The author (1994) reported that a lobectomy by VATS might be easier for older patients than a lobectomy by thoracotomy. The author and associates (1996) also showed that the combination of VATS lung volume reduction surgery and VATS lobectomy allows a complete cancer operation for some patients who otherwise would not be candidates for resection because of poor pulmonary function. Centrally located tumors may require a thoracotomy to determine whether sleeve resection or a pneumonectomy is appropriate. The dissection around the vessels and in the mediastinum is more difficult after chemotherapy or radiation; thus, a thoracotomy is usually necessary. This section first describes the techniques that are common to all VATS lobectomies and then some features that are unique to resection of specific lobes.
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Fig. 33-1. The stapler is fired first in a cephalad direction (A) and then in a posterior direction (B) |
Table 33-1. Indications for Video-Assisted Thoracic Surgical Lobectomy | |
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One-Lung Ventilation
After induction of general anesthesia with one-lung ventilation, the patient is placed in a full lateral decubitus position. To allow the maximal time possible for the lung to collapse, one-lung ventilation is instituted while the patient is positioned and the surgeon goes to the scrub sink. If the lung has not collapsed enough when the procedure begins, the bronchoscope is passed into the ipsilateral main-stem bronchus for suctioning to encourage further atelectasis.
Incisions
Proper placement of incisions is critical (Fig. 33-2; see Color Fig. 33-2) to the ease of performing a lobectomy by VATS. The trocar and thoracoscope are placed in the eighth intercostal space in the midaxillary line on the right or posterior axillary line on the left to avoid obstruction of vision by the pericardial fat pad. This provides the best panoramic view of the thoracic cavity. The 30-degree lens allows the surgeon to see around structures in the hilum better than the 0-degree lens. The camera incision is usually placed over a rib and angled superiorly to the interspace to reduce irritation of the intercostal nerve when the trocar is rotated. All other incisions are made directly over an interspace.
Table 33-2. Contraindications for Video-Assisted Thoracic Surgical Lobectomy | |
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Fig. 33-2. The incisions for our approach to video-assisted thoracic surgical lobectomy including the following: (1) an incision for the trocar and the thoracoscope, (2) an incision in the auscultatory triangle for an assistant's instrument, (3) the utility thoracotomy incision, and (4) an incision in the midclavicular line for the stapler. (See Color Fig. 33-2.) |
Through a 1- to 2-cm incision in the auscultatory triangle, a curved ring forceps manipulates the lung for inspection of the pleura and exposure of the hilum to determine the proper position for the other incisions. Lower placement of this posterior incision improves the angle of the stapler for the superior pulmonary vein and assists with a lower lobectomy. Slightly higher placement of the incision helps
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with paratracheal node dissection but makes the angle for the stapler on the pulmonary vein more difficult.
The 4- to 6-cm utility thoracotomy incision is made from the anterior edge of the latissimus dorsi muscle to the anterior axillary line. It is directly lateral to the superior pulmonary vein for an upper lobectomy or one interspace lower for a middle or lower lobectomy. The ribs are not spread, but a Weitlaner retractor may be used to hold the soft tissues of the chest wall open for easier passage of instruments and to prevent the lung from expanding when suctioning in the chest. The hilar structures are easily accessible for dissection through this incision. Hilar vessels can be tied just as with an open procedure because a finger can usually reach through this incision to the vessels.
A 2-cm incision is made in the midclavicular line in the largest interspace close to the costal margin. This incision is placed as far inferiorly and medially as possible. A ring forceps through this incision can depress the diaphragm for visualization of the inferior pulmonary ligament or retraction of the lung for various steps of the lobectomy.
Position of the Surgeon
The surgeon usually stands to the front of the patient, and the dissection begins in the hilum. This is the same approach used for lung resection through an anterolateral muscle-sparing thoracotomy. This makes the procedure much easier than trying to perform the procedure with the approach for a posterolateral thoracotomy (see Right Upper Lobectomy, later in this chapter).
Hilar Dissection
Vessels in the hilum are dissected sharply through the utility thoracotomy incision with standard thoracotomy instruments, such as Metzenbaum scissors and DeBakey pickups. Hilar lymph nodes are removed as separate specimens to facilitate pathologic staging and because it enhances mobilization of the vessels for passage of the nonarticulating endoscopic stapler (EZ 35, Ethicon, or Endo-GIA, U.S. Surgical) across the pulmonary vessels. Spreading widely with the right angle clamp makes it much easier to pass the stapler around a vessel.
Stapling Devices
The fissure, bronchus, and pulmonary vessels larger than 5 mm are transected with surgical, usually endoscopic, staples (Figs. 33-3, 33-4 and 33-5; see Color Figs. 33-3, 33-4 and 33-5). Vascular (20-mm) staples are used for the vessels, and the green cartridge (48-mm) staples are used on the fissure and the bronchus. Elevating the vessel with a tie aids placement of the stapler across the vessels. Articulation of the stapling devices is not necessary if the incisions are placed properly. The incision that offers the best angle for stapling these structures is presented in Table 33-3.
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Fig. 33-3. A right-angle clamp pulls a tie around the middle lobe bronchus. (See Color Fig. 33-3.) |
Completeness of the Fissure
The fissure is usually completed after the vessels and bronchus are transected. The completeness of the fissure is, therefore, not a factor in determining the feasibility of performing a VATS lobectomy through an anterior approach.
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Fig. 33-4. A right-angle clamp mobilizes the right middle lobe artery. (See Color Fig. 33-4.) |
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Fig. 33-5. The endoscopic stapler is across the right middle lobe artery. (See Color Fig. 33-5.) |
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Specimen Removal
To minimize the risk for contaminating the incision with malignant cells, the lung specimen is placed in a bag for removal through the utility thoracotomy incision. An Endocatch may be large enough for a middle lobe. Removal of the other lobes or the entire lung requires the LapSac (Cook Urological, Bloomington, IN, U.S.A.) because it is a larger bag. Some specimens are difficult to remove through the small utility thoracotomy incision. The lobes usually have a pyramidal shape. Removal of the lobe is easier if the narrow part of the lobe is removed first. Rarely, the ribs must be spread for larger tumors or lobes.
Table 33-3. The Incision through which the Stapler Is Usually Passed for Transection of the Arteries, Veins, Bronchi, and Fissures | ||||||||
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Lymph Node Dissection
Both mediastinal node sampling and a complete lymph node dissection can be performed by VATS (Fig. 33-6; see Color Fig. 33-6). Paratracheal node dissection is easier if the azygos vein is first transected with an endoscopic vascular stapler. The posterior ring forceps lifts the pleura and the paratracheal nodes as the surgeon dissects in the planes along the superior vena cava, trachea (with preservation of the vagus nerve), and pericardium over the ascending aorta, from the pulmonary artery to the innominate artery. This exposure is easiest after a right upper lobectomy. After a middle or lower lobectomy, a ring forceps through the midclavicular incision should retract the upper lobe out of the visual field.
Anterior retraction of the lung through the utility thoracotomy incision or the low midclavicular incision provides exposure for subcarinal node dissection. This begins by incising the pleura posterior to the inferior pulmonary vein and proceeds superiorly. A ring forceps from posteriorly lifts the pleura over the nodes so the pleura can be incised along the intermediate bronchus and pericardium. Clips are applied to any tissue that does not easily separate when spreading along the bronchus and pericardium. The vagus nerve and esophagus are identified and preserved.
Aortopulmonary window and hilar lymph nodes usually are resected before left upper lobectomy because it makes mobilization of the arterial branches easier. Standard thoracotomy instruments perform this dissection through the utility thoracotomy incision. The pleura is cut parallel to the phrenic nerve and along the superior margin of the superior pulmonary vein from the pericardium and laterally along the apical vein as it crosses the anterior trunk. The nodes and pleura are then lifted to mobilize the tissue from the pulmonary artery. The pleura is incised along the vagus nerve. The recurrent laryngeal nerve is identified and preserved. The lymph node tissue is then dissected off the aorta.
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Fig. 33-6. The aortopulmonary window lymph nodes are elevated. This exposes the aorta, vagus nerve, and recurrent laryngeal nerve. (See Color Fig. 33-6.) |
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Simultaneous Stapling Lobectomy
Lewis and Caccavale (1998) have reported thoracoscopic lobectomy with simultaneous individual stapling of the vessels and bronchus, rather than individual ligation, as described previously. This procedure has created considerable controversy because some surgeons view this as a large wedge resection. With this technique, the lobe is mobilized by partially completing the fissure. A TA stapler, used for open procedures, is fired across the remaining fissure, vessels, and bronchus. Most surgeons do not agree with this technique because they believe that the vessels should be individually ligated for a true anatomic lobectomy.
Techniques for Specific Lobectomies
Right Upper Lobectomy
The anterior approach for a right upper lobectomy begins in the hilum. Removal of hilar nodes defines the middle lobe vein and the upper lobe vein. This helps determine where the stapler should be placed to complete the minor fissure. The stapler goes through either the utility thoracotomy incision or the midclavicular incision. Completion of the minor fissure creates a pathway through which a vascular stapler passes from the posterior incision to transect the vein. Removal of lobar nodes along the artery provides exposure of the arterial branches to the upper lobe. The best angle for the stapler to reach the anterior trunk is provided by the incision in the auscultatory triangle. Additional smaller arterial branches are tied or clipped. Some thoracic surgeons may be unaccustomed to locating the posterior ascending artery anteriorly as it courses between the upper lobe and intermediate bronchus. Through the utility thoracotomy incision, the bronchus is mobilized and stapled. The final maneuver is completion of the remaining fissure with the stapler through the midclavicular incision.
Middle Lobectomy
Middle lobectomy begins with hilar dissection to remove hilar lymph nodes and mobilize the middle lobe vein. A vascular stapler through the posterior incision transects the vein. This maneuver may be easier if the middle lobe is first mobilized by partially completing the fissure between the middle lobe and the lower lobe from inferiorly.
After transection of the vein, further completion of the major fissure with the stapler through the anterior midclavicular incision exposes the bronchus. A second artery to the middle lobe may be found posterior to the bronchus. If present, this artery is transected before addressing the bronchus. The posterior incision provides the best angle for stapling the middle lobe bronchus. This exposes the middle lobe artery that is usually small; hence, it can be tied or clipped. The final maneuver is stapling the minor fissure through the utility thoracotomy incision.
Lower Lobectomy
The approach for a lower lobectomy depends on the completeness of the fissure. The operation is simpler when the fissure is well developed. The pleura is incised so that the artery can be mobilized in the fissure and transected with a stapler through the midclavicular incision. Through the same incision, a stapler completes the major fissure inferiorly between the middle lobe and the lower lobe to the level of the transected artery. The pulmonary ligament is taken down, and level 7 and 9 nodes are harvested. This mobilizes the inferior pulmonary vein so that the stapler can transect the vein through either the utility thoracotomy incision or the midclavicular incision. Removal of the lobar lymph nodes between the bronchus and artery exposes the bronchus for a stapler through the midclavicular incision. Finally, the remainder of the fissure between the superior segment of the lower lobe and the posterior segment of the upper lobe is completed from inferiorly.
The operation for a lower lobectomy is different when the fissure is poorly developed. First, the pulmonary ligament is taken down. Removal of the subcarinal lymph nodes exposes the inferior pulmonary vein for transection. Staples complete the fissure between the middle lobe and the lower lobe. The bronchus and the artery can then be identified inferiorly by retracting the lower lobe superiorly. Inferiorly, dissection along the anterior and lateral surfaces of the artery elevates the parenchyma of the incomplete fissure off the artery. A stapler from the midclavicular incision completes this part of the fissure to provide good exposure for dissection of the artery. Lobar lymph nodes are removed. The artery and the bronchus can then be individually stapled. Finally, the fissure by the superior segment is completed with the stapler through the midclavicular incision.
Left Upper Lobectomy
The technique for a left upper lobectomy is similar to that for a right upper lobectomy. The approach begins anteriorly with hilar dissection and stapling of the superior pulmonary vein and anterior trunk of the artery. A stapler through the midclavicular incision is fired on the major fissure to expose the lingular artery that can then be tied from anteriorly or stapled from posteriorly. The bronchus is thus exposed. The most dangerous part of a left upper lobectomy is mobilization of the bronchus because a right angle clamp must be passed between the bronchus and the artery. After mobilization, the bronchus is stapled from posteriorly. The remaining branches of the artery can then be seen. Dissection through the utility thoracotomy incision mobilizes these arteries to tie or clip them. Finally, the fissure is completed
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with multiple firings of the stapler through the midclavicular incision.
Left Lower Lobectomy
A left lower lobectomy is performed with the same technique as is used for a right lower lobectomy.
PNEUMONECTOMY
A pneumonectomy on either side is simpler than a lobectomy. The superior pulmonary vein is mobilized through the utility thoracotomy incision and stapled through the midclavicular incision. This exposes the artery. Because there are reports of endoscopic staples cutting without stapling the vessel, it is advisable to either use an endoscopic stapler with the knife removed or an open stapler (TX, Ethicon or Endo-GIA, TA, U.S. Surgical). The inferior pulmonary vein is stapled from anteriorly. Removal of the subcarinal lymph nodes provides access to the main-stem bronchus at the level of the carina. Through the utility thoracotomy incision, a 30-mm TA stapler is then fired on the bronchus. An entire lung can usually be removed through the same-size incision as a lobe if the apex of the lung is passed through the incision first.
RESULTS OF VIDEO-ASSISTED THORACIC SURGICAL RESECTION
The results of the larger published series of VATS lobectomy and pneumonectomy compare favorably with the results expected with a lung resection by thoracotomy (Table 33-4). Seven (0.6%) deaths in 1,120 patients were caused by venous mesenteric infarction, myocardial infarction, respiratory failure, or unknown reasons.
In these series, complications occurred in 10% to 22% of the patients after VATS lobectomy. These included prolonged air leak (5% to 10%), arrhythmias, pneumonia, and respiratory failure. Transfusions were necessary in 0% to 3% of patients. Bronchial stump leak requiring surgical repair occurred in only four cases (0.36%). The postoperative hospital length of stay averaged about 5 days.
Conversion to Thoracotomy
Conversion from VATS to thoracotomy was necessary in 0% to 19.5% of patients in the collected series. Overall, 119 of 1,120 operations were converted to thoracotomy (11.6%). Most commonly, oncologic reasons, such as centrally located tumors requiring vascular control, a sleeve resection, or unsuspected T3 tumors, attached to the chest wall, diaphragm, or superior vena cava, prompted the conversion. If a sleeve lobectomy might be required, conversion to thoracotomy may be needed to evaluate the relationship of the tumor to the artery. Abnormal hilar nodes with granulomatous or metastatic disease adherent to the superior pulmonary vein may be better evaluated and more safely resected with thoracotomy. About 30% of the conversions to thoracotomy were for nononcologic reasons, such as pleural symphysis.
Intraoperative Hemorrhage
Bleeding from a pulmonary vessel during a VATS procedure can be troublesome and dangerous because access is limited. However, this occurs infrequently when an experienced surgeon performs the procedure. A sponge stick should be available to apply pressure immediately for controlling hemorrhage if bleeding occurs. With the bleeding thus controlled, a decision is made as to whether a thoracotomy is needed.
In the collected series, bleeding led to conversion to a thoracotomy in 10 cases (0.9%). No deaths resulted from the bleeding episodes, and not all patients required transfusion. The incidence and the morbidity of this complication, therefore, are low for surgeons experienced with VATS lobectomy. A multiinstitutional survey of 1,560 VATS lobectomies reported by Mackinlay (1997) found that the only intraoperative death was related to an intraoperative myocardial infarction and not to bleeding.
Table 33-4. Major Published Series of Video-Assisted Thoracic Surgical Lobectomy and Pneumonectomy | |||||||||||||||||||||||||||||||||||||||||||||
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Postoperative Pain
Patients generally appear to have less pain after a VATS lobectomy than after a lobectomy by thoracotomy. Walker and associates (1996) compared the requirement for narcotic pain medicine in 83 VATS resections versus 110 patients who underwent thoracotomy during the same time period. The VATS group averaged less morphine than the thoracotomy group (57 vs. 83 mg of morphine; p < 0.001). In a randomized, prospective trial of lobectomy in 67 patients (47 by VATS and 23 by muscle-sparing thoracotomies), Giudicelli and colleagues (1994) reported that postoperative pain was significantly less (p < 0.02) after a VATS procedure. The incidence of postthoracotomy pain syndrome after VATS lobectomy (2.2%) reported by the author (1995) is lower than expected after thoracotomy.
Landreneau and associates (1994) prospectively evaluated daily narcotic requirements, hospital stay, and a visual analogue pain scale in 165 patients after muscle-sparing thoracotomy compared with 178 patients after VATS. The VATS group experienced less pain and greater shoulder strength in the first 6 months postoperatively, but there was no difference after 1 year.
Tumor Seeding of the Incision
Seeding of the VATS incisions occurred in 3 of 934 (0.35%) lobectomies performed for cancer. The risk for tumor recurrence in a VATS incision, therefore, appears to be low and can perhaps be even lower with the use of proper bags to protect the incisions during removal of specimens.
Immunologic Effect of VATS Versus Thoracotomy
Walker (1998) compared the immunologic effect ot VATS (n = 83) with thoracotomy (n = 110) for lobectomy. In the VATS cases, there was a reduced stress response, reduced postoperative C-reactive protein, reduced interleukin-6 levels, and better cellular immune function.
Adequacy of Cancer Operation
In an international survey of 1,560 VATS lobectomies by 23 surgeons who had performed at least 20 VATS lobectomies, Mackinlay (1997) showed that the mediastinal nodes were biopsied with mediastinoscopy alone (22.7%), mediastinoscopy and lymph node sampling (32%), or lymph node dissection (45.5%). Kaseda and associates (1998) reported that lymph node dissection with VATS lobectomy yielded an average of 23 lymph nodes (range, 10 to 51).
Long-term disease-free survival is the ultimate measure for the adequacy of any cancer operation. Kaseda and colleagues (1998) reported a 94% 4-year survival rate in patients with stage I lung cancer resected with VATS lobectomy. Lewis and Caccavale (1998) found a 94% 3-year survival rate for stage I, 57% for stage II, and 25% for stage III. The cure rate for lung cancer does not seem to be compromised when a complete cancer operation is performed by VATS.
ROBOTICS IN CARDIOTHORACIC SURGERY
Robotics have been used for a variety of cardiothoracic surgical procedures. Performing off-pump coronary bypass procedures through several 5-mm incisions may be the future of the coronary artery bypass graft (CABG) procedure. Lobectomies using robotics have been performed in the laboratory and in humans. A 4-to 6-cm skin incision must be made to remove the specimen intact; thus, the advantage of the robotics for lobectomy is less clear at the present time. Currently, a lobectomy is a more complex procedure than a CABG because it requires many more instrument changes and the introduction of several applications of the stapler. Further technical developments are needed to make lobectomy with robotics a viable procedure.
SUMMARY
The experience and techniques for minimally invasive thoracic procedures have progressed. With VATS, thoracic surgeons can perform the same major lung resections with the same long-term results as with thoracotomy, whereas VATS may offer patients some short-term benefits.
REFERENCES
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McKenna RJ Jr, et al: Video-assisted thoracic surgery (VATS) lobectomy for bronchogenic cancer. Semin Thorac Cardiovasc Surg 10:321, 1998.
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Reading References
Kirby TJ, et al: Lobectomy-video-assisted surgery versus muscle sparing thoracotomy. A randomized trial. J Thorac Cardiovasc Surg 109:997, 1995.
Leaver HA, et al: Phagocyte activation after minimally invasive and conventional pulmonary lobectomy. Eur J Clin Invest 26(Suppl 1):210, 1996.
Roviaro G, et al: Videothoracoscopic staging and treatment of lung cancer. Ann Thorac Surg 59:971, 1995.
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