Troubleshooting Video-Assisted Thoracic Surgery Lobectomy

Transcription

1 Troubleshooting Video-Assisted Thoracic Surgery Lobectomy Todd L. Demmy, MD, Ted A. James, MD, Scott J. Swanson, MD, Robert J. McKenna, Jr, MD, and Thomas A. D Amico, MD Departments of Thoracic Surgery and Surgical Oncology, Roswell Park Cancer Institute, Buffalo, New York; Department of Thoracic Surgery, Mount Sinai Medical Center, New York, New York; Department of Thoracic Surgery, University of California Los Angeles, Los Angeles, California; and Division of Cardiothoracic Surgery, Duke University Medical Center, Durham, North Carolina Purpose. Surgeons converting their open lobectomy skills to video-assisted thoracic surgery (VATS) techniques have sought traditional technical courses, publications, and physician mentoring. While these are useful in teaching basic principles, it is more difficult to promulgate the numerous advanced techniques or technical tricks that deal with anatomical variations or pathologic changes in the lung tissue. Description. Engineers have simplified the process of rolling out complex technology by using troubleshooting guides. Accordingly, helpful video-assisted lobectomy maneuvers have been categorized according to the specific problems occasionally encountered at different points in the operation. Evaluation. These maneuvers were compiled and reviewed by a panel of thoracic surgeons experienced in video-assisted lobectomies and have been active in teaching and mentoring of thoracic surgeons, residents and fellows. The techniques described have been used successfully by the authors to overcome exposure and instrumentation limitations, to achieve the outcomes reported in their series, and to guide trainees. Conclusions. Troubleshooting guides offer an organized means for surgeons to improve the parts of the video-assisted lobectomy procedure that they find tedious or challenging. (Ann Thorac Surg 2005;79: ) 2005 by The Society of Thoracic Surgeons Since the early 1990s, video-assisted thoracic surgery (VATS) has gained popularity in the management of both benign and malignant pulmonary disease. Although operative resources may be more expensive than traditional open thoracotomy, VATS has shown salutary effects on postoperative pain, pulmonary complications, and hospital stay, particularly in frail patients [1 3]. As widely demonstrated and reported with laparoscopic cholecystectomy, most new surgical procedures are accompanied by a distinct learning curve, and require the incorporation of new operative skills [4, 5]. Performing a VATS lobectomy for primary lung cancer generally follows an orderly sequence. At times the procedure can prove tedious, however, and in some circumstances these difficulties may result in the conversion to an open thoracotomy. The purpose of this paper is to present a basic operative approach for a pulmonary lobe resection using a VATS technique. Moreover, our intent is to present a compilation of tips organized in a troubleshooting Accepted for publication May 3, Address reprint requests to Dr Demmy, Roswell Park Cancer Institute, Elm and Carlton Sts, Buffalo, NY 14263; todd.demmy@ roswellpark.org. approach to be used as a reference guide for practitioners when experiencing technical difficulties. In this way, surgeons of all levels of experience or those who choose their own approach to VATS lobectomy can focus on areas that they find most challenging. Material and Methods Preoperative Evaluation A lobectomy is considered the standard of care in the surgical management of early stage (IA to IIB) primary lung cancer provided that the patient has sufficient cardiopulmonary reserve. This report will focus on the technical aspects of the procedure rather than the physiologic and oncologic preparation of patients. In general, all pulmonary lobectomies in patients with favorable preoperative imaging and sufficient cardiopulmonary reserve can be performed successfully using VATS. The surgeon reviews the computed tomography (CT) images to ensure that the tumor can be extracted through the access incision and that it is a safe distance from the hilar dissection or certain unresectable structures. In certain cases, VATS confirms locally advanced disease (ie, stage IIIB or T4), thus sparing the patient from an unnecessary 2005 by The Society of Thoracic Surgeons /05/$30.00 Published by Elsevier Inc doi: /j.athoracsur

2 Ann Thorac Surg DEMMY ET AL 2005;79: VATS LOBECTOMY TROUBLESHOOTING 1745 thoracotomy incision. Additionally, wedge biopsies for diagnosis and lymph node dissection for staging can be carried out by means of VATS. Extensive pleural fibrosis or inabilities to collapse the desired lung are problems that may prevent VATS lobectomy. General Operative Considerations Patients are positioned in the lateral decubitus position and flexed to expand the interspaces for the VATS ports. Selective airway management has several options that are effective, but there should be the capacity to perform bronchoscopy during the thoracic procedure to correct device positioning that enables single lung ventilation. This may be necessary because of incorrect device placement or, commonly, dislodgement that occurs during manipulation of the lung hilum. A feared complication of VATS lobectomy is vascular injury that cannot be controlled before the need of transfusion or resuscitation. Irreparable damage to adjacent lung tissues and other organs are concerns as well. Exposure optimization by using angled or flexible thoracoscopes and correct port placement reduces such complications. Excessive torque applied to the VATS port sites can cause injuries to intercostal neurovascular bundles, resulting in significant postoperative pain. A laparoscopic needle delivers precise intercostal nerve blocks under thoracoscopic guidance. Epidural anesthesia is not required for these patients; however, intrapleural local anesthesia (eg, bolus or continuous 0.25% bupivacaine) helps diminish the considerable discomfort frequently caused by the chest tube. The lung is reinflated under fluid to identify air leaks, particularly from the bronchial stump. The access incision (Fig 1) allows easier air egress and a greater chance of subcutaneous emphysema because no pericostal sutures are used to obliterate the intercostal space. Accordingly, the working incision can be used for a second chest tube when a moderate air leak is expected postoperatively. Otherwise, the working incision can be closed. Associated Procedures While preoperative imaging is usually sufficient, occasionally preoperative localization of the tumor site helps to localize small or deeply seated tumors. Attempts should always be made to directly palpate the lesion intraoperatively. Thoracoscopic lysis of adhesions, pleural exploration for occult metastases, wedge resection for diagnosis, and lymph node dissection are common adjunctive procedures; the latter is often easier to perform after the specimen had been removed. Usually, the incisions used for the associated procedures can be the same as that needed for the VATS lobectomy. Core Procedural Concepts The core concepts that follow represent the preferred approach by the lead author (T.L.D.) and differs somewhat among the other authors [2, 3, 6]. Its rationale is based on an access incision ideally 6 cm or less and two Fig 1. Video-assisted thoracic surgery lobectomy incision placement. The lines represent two different access incision options: the inferior facilitates dissection in the major fissure during lower lobe resections; the superior option allows optimal direct viewing of the superior pulmonary vein and apical pulmonary artery branches during upper lobectomies. Inset shows articulating endoscopic linear cutter essential for this technique. It is important to note that the function of each incision can change throughout the case (see Table 1). For instance, it is sometimes best to manipulate the tissue through the camera port and put the video camera through the access incision. It is important for the working incision to be very anterior and in line with the major fissure. other approximately 1 cm incisions. Posterior incisions are avoided because the interspaces there are tighter and more likely to cause nerve injury. Furthermore, articulating staplers have reduced the need for a posterior hilar approach. In general, it is best to have a camera port that allows multiple-angle views of both the anterior and posterior hilum, a working port in line with the major fissure (about the sixth intercostal space) and as far anterior as possible so that the stapler can be applied perpendicularly with the hilar structures, and an access incision that facilitates direct view of the most difficult to dissect anatomy for that type of resection. A 30-degree thoracoscope (or preferably a flexible tip camera) is needed to provide a range of views greater than open thoracotomy. First, a camera incision in the seventh or eighth intercostal space, midaxillary line is made, and general exploration of the thoracic cavity is performed to detect con-

3 1746 DEMMY ET AL Ann Thorac Surg VATS LOBECTOMY TROUBLESHOOTING 2005;79: Fig 2. Video-assisted thoracic surgery lobectomy tools. Endoscopic instruments can be useful in large thoracic cavities; however, standard instruments are good choices because of their availability and familiar handling properties. The retractor shown is only used to spread the soft tissues of the chest wall without rib spreading. A Weitlaner retractor may also be used. A large blunt right-angle clamp is a favorite of the lead author. (a) Large right angle; (b) modified Babcock; (c) pediatric Tuffier; (d) extraction sac (5 8 inches). traindications to VATS resection. The other incisions (access and working) are made based on the guidelines above and are depicted in Figure 1. Deep palpation or fine-gauge needle insertion over the prospective site can help determine the optimum location. Endoscopic linear cutting stapling devices are used to divide all pulmonary structures including the bronchus. Clip application for delicate pulmonary artery branches should be avoided because erratic application forces can tear the vessels or later tissue manipulation can avulse the clips. Standard practice involves using a tough nylon sac to extract the specimen from the thoracic cavity in order to prevent the seeding of tumor cells at the port site. Although endoscopic tools can be used, familiar standard instruments are often better because of better grasping strength and tactile feedback. A large (Herrington) right angle is an extremely useful tool to develop tissue planes (see Fig 2). The angled Babcock clamp can reach many different directions and, because of its angle, its handle will not obscure the direct view when applied through the access incision. Endoscopic staplers generally pass around the target tissue best at full articulation so that the anvil can be delivered through the space completely. That is because the staplers have straight anvils that do not pass around proximate tubular structures as well as angled instruments. A common technique is to secure the cut end of a rubber catheter (8F to 14F) to the anvil of the stapler. That serves to guide the stapler around the pulmonary vessels. Two of the authors (R.J.M. and S.J.S.) believe that moving the camera adds time and possible confusion to the procedure whereas another (T.L.D.) prefers alternate exposures, in particular the anterior view for anteroapical hilar structures. As opposed to open thoracotomies, the surgeon s side is the anterior aspect of the patient (R.J.M.), especially for upper lobe access incisions. None of the authors spreads the ribs, one uses a Weitlaner Table 1. Lobectomy Maneuvers Step Maneuver Instruments Right upper lobe (RUL) resection Mobilize pleura A LB, RA Divide RUL branch(es) of superior vein B 2.0 mm ELC a,ra Divide apical PA branches B or C 2.5 mm ELC Identify PA in major fissure D LB, SF, SS, PD Partially complete fissure between upper and middle lobe peripherally toward hilum E 3.5 mm ELC, RA (stretch lung to chest wall) Identify PA to middle and lower lobe from medial, hilar perspective A PD Use large blunt right angle to develop avascular plane along superior edge of PA from A or D RA, RR medial hilum and exiting in the major fissure near the PA Complete the minor fissure by stapling through the plane created in previous step to expose full course of PA C 3.5 mm ELC, RA

4 Ann Thorac Surg DEMMY ET AL 2005;79: VATS LOBECTOMY TROUBLESHOOTING 1747 Table 1. Continued Step Maneuver Instruments Divide remaining PA branches to RUL including recurrent branches C 2.5 mm ELC, RA Complete posterior fissure C or E 3.5 mm ELC, RA Dissect and divide RUL bronchus C TR, PD, 4.8 mm ELC Bagging specimen C 5 8 LS, TR Divide inferior ligament C LB Intercostal nerve block C LN Insert chest tube, confirm lung reexpansion, air leak check, possible lung sealant A or C Staple untethered middle lobe to lower lobe to prevent torsion C 3.5 mm ELC Right middle lobe (RML) resection Mobilize pleura C LB, RA Divide ML branch of superior vein B 2.0 mm ELC a,ra Identify and dissect PA in major fissure D LB, SF, SS, PD Partially complete minor fissure peripherally toward hilum (stretch lung to E 3.5 mm ELC, RA chest wall) Identify PA to middle and lower lobe from medial, hilar perspective if not A PD identified from major fissure Use large blunt right angle to develop plane along superior edge of PA from A or D RA, RR medial hilum and exiting in the major fissure near the PA Complete the minor fissure by stapling through the plane created above to C 3.5 mm ELC, RA expose full course of PA Divide PA branches to middle lobe C 2.5 mm ELC, RA Complete anterior fissure with the lower lobe C 3.5 mm ELC, RA Dissect and divide RML bronchus C TR, PD, 4.8 mm ELC Bagging specimen C 5 8 LS, TR Divide inferior ligament C LB Intercostal nerve block C LN Insert chest tube, confirm lung reexpansion, air leak check, possible lung sealant A or C Lower lobe (LL) resections (right or left) Mobilize pleura C LB, RA Identify PA in major fissure D LB, SF, SS, PD Divide PA branches to lower lobes sparing branches to upper lobe segments C 2.5 mm ELC, RA Divide inferior ligament C LB Divide inferior vein C 2.0 mm ELC a,ra Complete anterior and posterior fissures C and/or 3.5 mm ELC, RA E Dissect and divide LL bronchus C TR, PD, 4.8 mm ELC Bagging specimen C 5 8 LS, TR Intercostal nerve block C LN Insert chest tube, confirm lung reexpansion, air leak check, possible lung sealant A or C Left upper lobe (LUL) resections Mobilize pleura A LB, RA Divide superior vein B 2.0 mm ELC a,ra Divide apical PA branches B or C 2.5 mm ELC, RA Identify PA in major fissure D LB, SF, SS, PD Complete posterior fissure C 3.5 mm ELC, RA Divide remaining PA branches to LUL including lingular branch C 2.5 mm ELC, RA Complete anterior fissure C or E 3.5 mm ELC, RA Dissect and divide LUL bronchus C TR, PD, 4.8 mm ELC Bagging specimen C 5 8 LS, TR Divide inferior ligament C LB Intercostal nerve block C LN Insert chest tube, confirm lung reexpansion, air leak check, possible lung sealant A or C a A 2.5 mm vascular load may be used on the pulmonary veins particularly if thickened. The letters in the middle three columns refer to the maneuvers in Figure 3. Direct viewing always can be performed through the access incision and camera viewing is usually done through the midaxillary incision but can be done through others by swapping the instruments. Generally one other incision is needed to grasp the lung to place it into the proper exposure and the remaining accomplishes the intended dissection with the proper instrument. ELC endoscopic linear cutter; LB long cautery tip; LN laparoscopic needle; LS laparoscopic extraction sac (heavy nylon); PA pulmonary artery; PD peanut dissector; RA right angle; RR red rubber catheter; SF standard forceps; SS standard scissors; TR triangular (5 mm liver-type) retractor.

5 1748 DEMMY ET AL Ann Thorac Surg VATS LOBECTOMY TROUBLESHOOTING 2005;79: Fig 3. Selected video-assisted thoracic surgery lobectomy maneuvers. For practicality, all the maneuvers are shown with the patient positioned in the left lateral decubitus position as if to undergo a right-sided procedure. The same maneuvers can be performed mirror-image for leftsided work. At least one example of an interior view is provided for each. (A) Medial viewing and inferior holding of lung to allow dissection through the access incision. Example shows dissection of the apical hilum. (B) Medial viewing and access holding of lung to allow stapling of hilar structures from below. Example shows division of the apical pulmonary artery trunk to the right upper lobe (upper lobe branch of vein divided and reflected away). (C) Standard viewing and use of working port to dissect and divide structures while lung is retracted through access incision. Example shows use of stapler to divide pulmonary artery to right lower lobe. (D) Standard viewing and use of working port to retract lung and access incision to dissect structures; this is commonly used to dissect the pulmonary artery in the major fissure. Example shows inferior pulmonary vein after the pulmonary ligament was divided by this maneuver. (E) Standard viewing and use of access incision to deliver stapler to divide fissures. Example shows division of the posterior fissure between the right lower lobe and the upper lobe.

6 Ann Thorac Surg DEMMY ET AL 2005;79: VATS LOBECTOMY TROUBLESHOOTING 1749 Table 2. Troubleshooting Problem Exposure problems Trouble selecting port sites Camera Anterior working Access incision Upper lobe Lower lobe Trouble viewing area of dissection Camera maneuvers Patient position Retraction Lung maneuvers Access incision Trouble keeping lens clean Dissection and division problems Trouble exposing desired structures General Possible Solutions Use midaxillary 8 th intercostal space. Use camera port to guide placement, needle or digital testing. Try 6 th intercostal space, anterior. The more anterior and in line with major fissure the better. Keep the anterior incision as anterior as possible to improve the angle of entry for the stapler. Use 4 8 cm (typically 5 cm) incision, guided by camera, needle, or digital testing. Try 4 th intercostal space, anterior axillary line for exposure to dissect upper lobe venous and superior arterial branches. Try 5 6 th intercostal space, midaxillary line directly over pulmonary artery in fissure. Avoid injury to long thoracic nerve if wound is extended. Select another port site or access incision to place scope. Use 30 degree or flexible thoracoscope. Train your scope holding assistant thoroughly before embarking on VATS lobectomy. Try reverse Trendelenberg to lower diaphragm. Try tilting table to move lung tissue off field. Position the patient slightly posterior, or roll the table posterior to improve the anterior visualization. Try internal retraction stitch on sturdy (tendon) portion of diaphragm to pull it out of way of the camera. Usea5mmretractor through the working port along side the dissection tool to push the diaphragm out of the way. Alternatively, another 5 mm port site may be created. Place red rubber catheter around hilum and retract through access incision. Use 5 mm loop liver retractor through anterior working port and create loop around lung parenchyma. This is very helpful in lifting the entire lung away from the rest of the hilar structures near the end of the case to be sure that there are no more vascular connections. Try angled instrument like bent Babcock through access incision. Try any fan-type retractor. Collapse by mild airway suction or blunt compression. Release adhesions limiting control of hilum. Move hilum toward access incision to dissect. Try partially dividing fissures. Reduce the tidal volume so that the mediastinum drops, improving the effective working area. Consider using pressure competent trocar ports and gentle carbon dioxide insufflations to assist in collapse of lung. Don t complete minor fissure prematurely during right upper lobe resections to prevent right middle lobe from flopping in the way. Use pediatric retractor to open wound soft tissue but not spread ribs. Change table position to improve viewing angle. Increase width of access incision (up to 8 cm considered minimally invasive). Use transverse self-retaining narrow blade (eg, anal) retractor. Use different port. Clean lens through access incision with squirt of saline. Place corner of cotton sponge into trocar port site to act as a wick for oozing blood, then replace port. Use angled scope. Clean inside of port with cotton-tipped applicator. Dissect pleura from hilum as first step. Start with veins, then arteries, then bronchus. Use Kittner (peanut) retractor through access or other incision. Tether peanut dissection sponge with suture to prevent loss. Use different port exposure or retraction if tedious. Try dividing part or all of fissure. Add another (perhaps more posterior) port. For example, this is useful for left level 7 lymph node exposure.

7 1750 DEMMY ET AL Ann Thorac Surg VATS LOBECTOMY TROUBLESHOOTING 2005;79: Table 2. Continued Problem Inferior ligament Major fissure structures Anterosuperior hilum Posterior hilum Trouble encircling vessels Trouble passing anvil of stapler around structures General Superior vein Inferior vein Apical PA branches Major fissure PA Bronchus Trouble with adhesions Trouble with mild bleeding Trouble with more serious bleeding Possible Solutions Use as many curved instruments as possible. Do all the posterior dissection first to obviate flipping the lung forward during the anterior dissection. Use another low-profile instrument, eg, endoscopic Kittner alongside camera to aid dissection or exposure. Try 30-degree scope downward view. Can use cautery from medial port to start then finish from access port. Retract diaphragm from medial port. Avoid cautery of pericardium. Dissect by direct view through access incision. Move hilum under access incision by retractor from medial port. Try 30-degree scope or 0-degree scope from medial port. Divide upper vein to access pulmonary artery for upper lobectomies. Spare vein branch to middle lobe for right upper lobectomy. Try 30-degree scope viewing medially. Use peanut dissector to increase effective length of vessel. Use standard or large (eg, Herrington) right-angle clamps. Try passing right angle through anteromedial port. Separate fissure to increase dissection room. Use different port to view dissection. Use articulating stapler fully angled rotate slightly after behind structure to facilitate passage. Attach 8 14F red rubber catheter with excess flange trimmed to anvil pass catheter first with large right angle clamp then use catheter to guide anvil. Do not to pull catheter hard or out of line with anvil. Pushing anvil will self-guide it. Dissect excess tissue away from structure. Be sure additional unseen, undesired structures are not included. Use appropriate cartridge size with desired tissue. Try passing stapler through camera port. Try passing stapler through medial port. Try passing stapler through medial port or camera port. Try passing stapler through medial port. Take care not to accidentally divide superior segmental artery to lower lobe. Be sure there are no missed pulmonary artery branches. Try passing stapler through medial port (lower) or camera port (upper). Use red rubber catheter (or similar device) looped around distal bronchus and retracted through access incision to expose proximal bronchus for division. Try routine open bronchus stapler (standard or articulating, eg, TA-30, 4.8 mm) directed through access incision. Cut bronchus with #15 blade on long handle. Use camera to guide cutting. Can use red rubber catheter to pass this type of stapler as well. Partially inflate remaining lobe before firing stapler. Start with blunt dissection with blunt clamp through camera port to create pocket. Once pocket created, insert camera. Use camera to separate loose adhesions. Place port into pocket of free pleural space. Use ports to pass cautery and other dissection tools. Use angled tools. Connect two ports working from each port, then it becomes easier. Place thrombostatic material, rotate tissue over it to compress; dissect somewhere else for several minutes. Try biological sealant. Try Harmonic scalpel on friable tissue. If any question, enlarge access incision to obtain direct control. Reapply stapler as a clamp if occurs while removing stapler. Apply peanut retractor to tamponade. Apply ring forcep/sponge if massive bleeding while converting to open thoracotomy. Apply clip (standard or endoscopic) if appropriate. a Suture with 4 0 Prolene and use small clips to lock knot. Avoid placing clamps.

8 Ann Thorac Surg DEMMY ET AL 2005;79: VATS LOBECTOMY TROUBLESHOOTING 1751 Table 2. Continued Problem Miscellaneous Trouble getting lobe into extraction sac Trouble extracting sac through wound Trouble with air leaks or residual space General Large residual spaces Subcutaneous emphysema Trouble with postoperative pain Possible Solutions Triangulate opening with heavy sutures passed through bag, then bring out camera and medial or extra ports. One corner of triangle can be grasped by instrument through access incision. Alternatively, a5mmtriangular liver retractor can help hold open the bag. Insert small end of specimen first, roll rest of specimen into sac with alternating instrument movements, always maintaining a grasp on the specimen. Fill sac with saline to hold it open. Make sure correct lobe is being inserted. Suture sac edges to self-expanding loop of propriety extraction device. Orient sac in direction so that other tissue does not impede progress. Use large (8 10 ) sacs for big resections. Aspirate fluid from sac first, make sure sac is open during extraction for air and fluid to egress. Remove any retractor from access incision. Orient sac with seams parallel to ribs. Reorient specimen in sac so that thinner portion of lobe leads. Pull alternately on one side seam then the other (or in circular motion); may take several minutes for tissue to extrude through. Steady chest with countertraction. Rarely skin or intercostal incision will require expansion. Inflate residual lung under pool of water or saline. Staple, suture, or apply lung sealant to sites of leak. Inspect stump at 20 cm water sustained airway pressure. Use stream of fluid to find air leaks. Check water seal chamber for rate of leak while closing or ask anesthesiologist to estimate leak. Use large enough chest tube to allow air to drain easily without too much suction. Consider using medial port for second chest tube. May need to create longer tunnel for chest tube path. Find pulmonary artery in superficial location in major fissure or anterior hilum and use this as dissection plane beneath parenchyma before division. Use thick ( green, 4.2 to 4.8 mm for very thick) staple load for the bronchus and avoid double firings on bronchus by careful stapler application and use of 60 mm length load. Divide inferior ligament. Consider apical tent. Consider pneumoperitoneum if air leak large. Consider suturing local tissue or patch over access incision to reduce free movement of pleural air into tissues (since intercostal space is not obliterated as after a standard thoracotomy). Do transpleural or posterior intercostal nerve block. Use local anesthesia chest tube. Avoid rib spreading or over torque of instruments in ports. Use Toradol or other nonsteroidal analgesic rather than narcotics. a Authors do not advocate the routine use of clips, because their application can be hazardous. retractor preferentially (R.J.M.), and one uses no retractor (S.J.S.). Lobe-Specific Steps Surgical atlases describe procedural steps assuming a wide exposure once the incision has been made. For each step in a VATS case, the preferred routes for exposure (camera, lung manipulation, and dissection tools) often change. To avoid written tedium, the lobe dissection steps considering these issues are described in a table format (Table 1) citing five maneuvers used commonly by one author (T.L.D.; see Fig 3). Surgeons will find these steps and their own variations intuitively over time, but the table format, like the troubleshooting guide, can be a useful reference when starting out. Additional ports can be used if necessary, although this

9 1752 DEMMY ET AL Ann Thorac Surg VATS LOBECTOMY TROUBLESHOOTING 2005;79: is unusual. Frequently, skipping steps is useful to perform simpler steps that often facilitate the difficult ones. Frequently, partial division of the fissures clarifies the view and eases tissue manipulation. Troubleshooting Guide Common problems encountered while performing VATS lobectomy are illustrated in Table 2, which provides suggestions for overcoming these technical issues. The table is divided into separate stages of the operation: exposure, dissection, division, and miscellaneous problems generally occurring at the end of the procedure, including some suggestions for postoperative management. Each stage then has a list of specific problems with solutions. More than one solution may be listed for a particular problem, and one or any number of solutions may be required to rectify the trouble being experienced. No particular order has been assigned to the solutions. Results The authors have used these techniques to prove the feasibility and safety of VATS lobectomy at their own institutions as well as studies done in multi-institutional settings [7]. Life-threatening intraoperative complications are very uncommon, and overall hospital mortality (0.5% to 3.6%) and conversion rates (2% to 13%) are low [2, 3, 6, 7]. The results for a complex or high-risk population are better than those for open thoracotomy and are improving [1, 8]. The reduction in pain, shorter hospitalizations, and improvement in function has not come at the cost of oncologic efficacy. In fact, there are indications that the long-term survival is at least as good as that for traditional surgical results for early stage lung cancer [9]. Operations performed with VATS cause less perturbation of the immune system, which can thereby deal better with minimal residual disease left after resection of aggressive malignancies [10, 11]. Comment The approaches outlined in Tables 1 and 2 offer concise ways for surgeons to convert their considerable open thoracic experience with lung resections to VATS. Application of VATS lobectomy has lagged behind easily learned procedures like wedge biopsy that rapidly became the standard for the thoracic surgical profession because of improved morbidity. Part of the reason for this lag was the need for better optics and dissection tools. Now that these exist, dissemination of the experience seems to be the limiting factor. To some extent, this requires relearning procedures. While didactic courses and mentoring can impart a basic skill set, the subtle technical modifications that are forced by patient variability are learned over a longer time period such as occurs in a surgical residency or years of practice. A troubleshooting guide represents a different form of surgical education borrowed from the engineering profession. Compiling technical tricks like those taught to us by our mentors, or learned through personal experience, or at the occasional meeting into a central source may help compress the time needed to learn more complex skills. The information presented is intended to help the interested surgeon reduce complexity (or conversion rates) and expedite operative times. Disclosures and Freedom of Investigation All funds used to buy the approved instruments and develop the techniques described in this paper came from hospital operating revenue during the course of clinical surgical practice. Although no new data are supplied in this consensus document, all authors had full ability to contribute to the written report and differences in approaches were noted in the manuscript accordingly. The contributing authors whose earlier works were cited had full control of the designs of the studies, methods used, outcome indicators, analyses of data, and productions of the written reports. References 1. 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Results of CALGB 39802: feasibility of video-assisted thoracic surgery (VATS) lobectomy for early stage lung cancer [Abstract]. Proc Am Soc Clin Oncol 2002;21:290a. 8. Demmy TL. VATS lobectomy for frail or complex patients. Chest Meet Abstracts 2003;124(Suppl):234S. 9. Sugi K, Kaneda Y, Esato K. Video-assisted thoracoscopic lobectomy achieves a satisfactory long-term prognosis in patients with clinical stage IA lung cancer. World J Surg 2000;24: Yim APC, Wan S, Lee TW, Arifi AA. VATS lobectomy reduces cytokine responses compared with conventional surgery. Ann Thorac Surg 2000;70: Coffey JC, Wang JH, Smith MJ, et al. Excisional surgery for cancer cure: therapy at a cost. Lancet Oncol 2003;4: Disclaimer The Society of Thoracic Surgeons, the Southern Thoracic Surgical Association, and The Annals of Thoracic Surgery neither endorse nor discourage use of the new technology described in this article.