Mini‐invasive surgery in lung cancer: Current status and future considerations

摘要

The modern concept of mini-invasive thoracic surgery in lung cancer aims at minimizing chest wall access-related trauma using proper techniques while delivering treatment of intrathoracic lesions as radically as in conventional thoracotomy, thereby resulting in modest trauma and injury to the human body.1, 2 Compared with the open modality, mini-invasive thoracic surgery is characterized by, but not only, dimensionally small incisions. Altered function of the heart, lung, liver, kidney, and neuromuscular system arising from mini-invasive thoracic surgery is generally minimal.3-5 Practically, mini-invasive thoracic surgery involves vision-guided, foot-and-hand-coordinated manipulation of target tissues or organs using devices through small incisions, which may be hand-assisted when necessary.6, 7 Today, mini-invasive thoracic surgery for lung cancer includes three approaches – video assisted thoracic surgery (VATS), video-assisted hybrid VATS and hand-assisted VATS – and is technically performed with slender instruments for resection or reconstruction deep inside the thoracic cavity under the navigation by stereoscopic images of direct vision and 2-D images from the thoracoscope.6 Over the past decade, techniques in mini-invasive thoracic surgery have been developing rapidly and increasingly acceptable to the community. Endoscopic surgical instruments have been improved or updated more and more quickly, used in a wider spectrum of surgical conditions, and available to more and more skillful hands. Apart from the thoracoscope, novel tools such as surgical robots are unceasingly added to the armamentarium of mini-invasive thoracic surgery. These instruments tend to be safe and multipotent, mimic the specific functions of those used in open surgery, and are well adapted for the small size of surgical incisions. Aided by emerging techniques and tools, mini-invasive thoracic surgery has found itself in widespread use for treatment of thoracic diseases, and lung cancers in particular.8, 9 Mini-invasive thoracic technique can be safely used for lung biopsy, lobectomy, partial or whole lung resection, segmentectomy, sleeve lobectomy and bronchoplasty in patients with pulmonary neoplasms.10-12 However, the role of mini-invasive surgery in these procedures largely depends on the group and severity of diseases, as well as on expertise of the surgeon. Lung biopsy and partial resection are procedures that simply remove a small fraction of lung tissue for definite diagnosis and sometimes for direct treatment. Among others, these procedures yield the least amount of removed tissue, require the lowest level of surgical skill, and are therefore most commonly performed with mini-invasive thoracic surgery with obvious advantages over the open approach. Biopsy of a pulmonary nodule is an example of this. Traditionally, the procedure may need two or three incisions (one view port plus one or two ports for instruments). Along with advances in specific instruments and surgical techniques, the operation is now performed with only one incision using a single-port trocar. Use of a fine needle-type thoracoscope would improve the mini-invasiveness of the surgery even more. Procedures requiring removal of a larger piece of lung tissue are usually performed after a confirmed diagnosis. These surgeries may include wedge resection and segmentectomy, usually performed in patients with lung cancer who cannot tolerate pulmonary lobectomy.11 Techniques involved in these procedures are not sophisticated – usually including the successive resection of lung tissue rarely with manipulation of single pulmonary vessels and bronchi – and are easily completed with continuous actions of an endoscopic suture knotting instrument. As always, mini-invasive surgery displays significant advantages and is commonly used in this setting. Certain cases of lung cancer require anatomy-based lobectomy which inevitably requires dissection and management of blood vessels and bronchi. As