Video-Assisted Thoracoscopic Pneumonectomy: The Edinburgh Posterior Approach

Video-assisted thoracoscopic surgery (VATS) is now well established as an alternative to open thoracotomy for major pulmonary resections of bronchogenic carcinoma and benign disease (1,2). Compared to open surgery, the minimally invasive approach has a number of benefits in the immediate post-operative period that include reduced pain, better pulmonary function, shorter hospital stay, improved cosmesis and lower risk of developing pneumonia (3-7). VATS lobectomy is equivalent to open surgery in terms of oncological outcomes, is less immunomodulatory and enables more patients to commence and complete adjuvant chemotherapeutic regimens (7-10). Furthermore, minimally invasive techniques are cost effective and at least equivalent to open techniques in terms of long-term survival (11-13). Whilst the anterior approach is preferred by many surgeons, the main advantages of the posterior approach in our experience is the excellent view that is obtained of the posterior hilum which facilitates dissection of the bronchi and branches of the pulmonary artery. In addition, the mediastinal node packets are clearly seen, allowing thorough lymphadenectomy. Importantly, in the posterior approach the tips of the instruments come towards the camera and are therefore easily seen whilst in use increasing the safety of dissection. More than 800 VATS major pulmonary resections have been performed in our centre over the last 20 years (Video 1) and we here describe our method for fissure-based VATS lobectomy using a posterior approach. Video 1 Video-assisted thoracoscopic lobectomy - The Edinburgh posterior approach Pre-operative assessment Selection criteria We have adopted VATS resecetion as the surgical strategy of choice for all cases of peripheral carcinoma of 5 cm or less in diameter and for suitable benign disease. Lobectomy and anatomic segmentectomy are standard procedures. It is possible to utilise VATS techniques in patients with more advanced disease such as moderate chest wall or pericardial involvement and, rarely, for pneumonectomy in patients with low bulk hilar involvement. However with the trend towards lung conservation strategies, we now reserve pneumonectomy for rare individuals in whom broncho-vascular reconstruction is not feasible.