Video-Assisted Thoracoscopic Surgery (VATS) Lobectomy

### **Chapter 2**

## Perspective Chapter: Essentials of Lobectomy under Video-Assisted Thoracoscopic Surgery for Non-Small-Cell Lung Cancer

*Jian Li, Xu Zhu, Jianglun Li, Jian Zhang, Kaiying Wang and Xiaojun Du*

### **Abstract**

The morbidity and mortality of lung cancer rank second and first respectively in malignant solid tumors worldwide. As we all know, surgical resection is the cornerstone of comprehensive treatment of non-small-cell lung cancer (NSCLC). The current National Comprehensive Cancer Network (NCCN) guidelines for NSCLC suggest that for medically operable disease, resection is the preferred local treatment modality, anatomic pulmonary resection is preferred for the majority of patients with NSCLC, and video-assisted thoracoscopic surgery (VATS) or minimally invasive surgery should be strongly considered for patients with no anatomic or surgical contraindications. With many advantages, uniportal VATS (u-VATS) has been widely accepted and used. Therefore, in this article, we attempted to review the essentials of lobectomy under u-VATS for NSCLC.

**Keywords:** non-small-cell lung cancer, video-assisted thoracoscopic surgery, lobectomy, uniportal

### **1. Part 1. General principles**

### **1.1 Introduction**

Currently, the morbidity and mortality of lung cancer rank second and first respectively in malignant solid tumors worldwide [1, 2]. Right upper lobe has the highest incidence of lung cancer (23.8%–47.0%) among the five lung lobes [3–8]. As we all know, surgical resection is the cornerstone of comprehensive treatment of non-small-cell lung cancer (NSCLC). The current National Comprehensive Cancer Network (NCCN) guidelines for NSCLC suggest that for medically operable disease, resection is the preferred local treatment modality, anatomic pulmonary resection is preferred for the majority of patients with NSCLC, and video-assisted thoracoscopic surgery (VATS) or minimally invasive surgery (including robotic-assisted

approaches) should be strongly considered for patients with no anatomic or surgical contraindications [9]. Because VATS, compared with thoracotomy, is associated with reduced length of hospital stay, less postoperative pain, fewer postoperative complications, more rapid recovery to normal life, and less pulmonary injury without compromising oncology principles [10]. Previously, VATS was conventionally performed under multiportal (m-VATS). Compared with m-VATS, uniportal VATS (u-VATS) has the advantages of direct view, easy learning, less operation time and postoperative drainage duration, decreased postoperative pain and hospitalization, diminished inflammatory response, or faster access to chemotherapy [4, 11, 12]. Consequently, u-VATS has been widely accepted and used. Therefore, in this article, we attempted to review the essentials of lobectomy under u-VATS for NSCLC.

### **1.2 Instrument**

Due to the restricted interspace available under u-VATS, the fewer processing instruments used the better. **Figure 1** shows the instruments we commonly use. Among them, the suction with a slightly curved tip is recommended to obtain more operating space and angles. In addition, a manual-control electric hook is recommended to relieve the discomfort caused by standing on one leg when using a footcontrol one too long. Furthermore, the ring forceps clamping a small gauze are used to turn and tow the lobes, instead of clamping the lobes directly, to reduce exudation from the residual lung after surgery. A high-definition thoracoscopic system is recommended too, because most of the procedures of lobectomy have to be finished very precisely. Meanwhile, a thoracoscopy with a freely rotatable optical fiber is also recommended to obtain more viewing angles. Since a three-dimensional thoracoscopic system can provide a high-definition and stereoscopic view, it is highly recommended for beginners. A 5 mm thoracoscope can further reduce the length of the incision;


**Figure 1.** *The instruments commonly used.*

*Perspective Chapter: Essentials of Lobectomy under Video-Assisted Thoracoscopic Surgery… DOI: http://dx.doi.org/10.5772/intechopen.105467*

however, the technical requirements for the surgeon and the assistant holding the thoracoscopy are harder for its smaller view. Finally, the recommended length of the staple cartridge used for vessels and bronchus is 30 mm or 45 mm, so that there is sufficient space and angle to place it into the interstice between the tissues to be cut.

### **1.3 Anesthesia and position**

### *1.3.1 Anesthesia*

Commonly, patients are anesthetized with intravenous coupled with inhaled anesthetics, and ventilation is maintained under contralateral endobronchial intubation with double-lumen endobronchial tube. For experienced surgical teams, tubeless anesthesia under regional combined with general anesthesia can be used.

### *1.3.2 Position for patient*

The patient is placed in the contralateral decubitus position, and then the operating table is adjusted to a jackknife position to widen the intercostal space and elevate the hilum, which would facilitate intraoperative processing (**Figure 2**).

### *1.3.3 Position for surgeon and assistant*

In general, the display screen is placed on the back of the patient near the head end. The surgeon stands on the upper ventral side, while the assistant stands on a lowrise foot stool on the lower ventral side. This position could increase the interspace between the thoracoscopic body and the operating instruments and could further reduce mutual interference (**Figure 3**). In order to facilitate processing, the position of the surgeon and the assistant could be exchanged when cut the lower pulmonary ligament and dissect the groups 8 and 9 lymph nodes. If there are two movable display screens and the assistant is very experienced, the assistant can stand on the back of the patient to further increase the interspace.

### **Figure 2.**

*The position for patient. The patient is placed in the contralateral decubitus position, and then the operating table is adjusted to a jackknife position.*

### **Figure 3.**

*Position for surgeon and assistant. The surgeon stands on the upper ventral side, while the assistant stands on a low-rise foot stool on the lower ventral side.*

### *1.3.4 Incision and orders of placing instruments*

The location of the incision is very important. It directly affects the smoothness and safety of the processing. An optimal choice of incision will make the placement of a stapler smoother under better angle. We generally make all the incision at the fifth intercostal space, except for left upper lobectomy at the fourth, from the anterior axillary to the mid-axillary line. It can not only ensure the smoothness and safety of the processing, but also facilitate the conversion to thoracotomy by lengthening the incision if necessary. Commonly, the incision is made about 3–4 cm in length. For beginners or low volume centers, the length of incision could be appropriately extended and gradually shortened after their experience is mature and stable. This can ensure the operation safe and shorten the learning curve. Incision protective cover is used to reduce staxis and facilitate the entry and exit of instruments. The orders of placing the thoracoscopy and instruments are as follows: the thoracoscopy is always close to the upper border of the incision and fixed with a string or an infusion tube to reduce the fatigue of the assistant. When the lobes need to be towed to expose the operating area, the ring forceps should be close to the lower edge of the thoracoscopy or the lower border of the incision to ensure sufficient operating interspace for the surgeon to avoid mutual interference. The dominant hand of the surgeon holds an energy device (such as an electric hook or an ultrasonic scalpel)

### *Perspective Chapter: Essentials of Lobectomy under Video-Assisted Thoracoscopic Surgery… DOI: http://dx.doi.org/10.5772/intechopen.105467*

with the nondominant hand holding a suction or a long forceps to enter the thoracic cavity through the lower border or middle of the incision. As for whether it is better to hold an electric hook or an ultrasonic scalpel in the dominant hand, and a suction device or a long forceps in the nondominant hand, each has its own advantages and disadvantages. It mainly depended on the experience and habits of the surgeon. However, when in the learning phase, surgeons should try to use a fixed combination mode to shorten the learning curve. The author is used to holding an electric hook in the dominant hand with a suction in the nondominant hand. Because the tip of the electric hook is smaller which can perform a finer anatomy, and because that the suction can not only suck the smog generated by the energy device and the staxis exuded from the operating area in time to maintain a clear vision, but also can expose the operating area. Moreover, in the event of an accidental massive bleeding caused by a major vessel broken, the suction can be used to press it in time to control the bleeding and suck the blood to ensure a clear vision, which could provide a favorable condition for the next treatment (**Figure 4**).

### *1.3.5 Specimen extraction*

The resected lobe is bagged and dragged to the incision. After removing the incision protective cover, two ring forceps are used to drag the lung tissue and pull it out. If the lesion is longer than the incision, scissors are used to cut it into small in the bag. Here, the bag is in a semi-tight state. Then, the scissors are slightly opened with either lateral border close to the inner surface of the bag and slowly interposed to cut the lesion small. It can prevent scissors from cutting through the bag. After extracting the resected lobe, intersegmental, interlobar, and/or hilar lymph nodes are removed in vitro.

### *1.3.6 Systemic mediastinal lymphadenectomy*

The extent of systemic mediastinal lymphadenectomy on the right side includes groups 2R, 3A, 3P, 4R, 7, 8, and 9 and groups 3A, 4 L, 5, 6, 7, 8, and 9 on the left. En bloc resection is used to ensure complete resection and reduce small residues. That is, the lymph nodes and pericentral adipose tissue are completely removed with the

### **Figure 4.**

*Incision and orders of placing instruments. Left, the incision is made at the fifth intercostal space from the anterior axillary to the mid-axillary line. Right, the orders of placing the thoracoscopy and instruments.*

surrounding normal tissue as the boundary. It is relatively difficult to remove the lymph nodes of groups 2, 4, and 7. It is recommended to completely split the mediastinal pleura and use the surrounding normal tissue as the boundary to dissect to the depths layer by layer, rather than tunneling to the depths at one point. This can facilitate the exposure of the view and process. An ultrasonic scalpel can be used to reduce the difficulty of lymph node resection, because it can not only reduce bleeding, but also achieve the functions of dissecting, pulling, and cutting simultaneously, which thereby reduce the use and replacement of other instruments.

When resect group 2 and 4 lymph nodes, a suction (or other instrument) is used to push the azygos vein up, and ultrasonic scalpel is used to dissect lymph nodes and pericentral adipose tissue with the anterior edge of the trachea, the surface of the pericardium, and the posterior edge of the superior vena cava as the boundary. Then, the mediastinal pleura is split along the superior border of the azygos arch, the posterior border of the superior vena cava, and the anterior border of the trachea in a "△" pattern. After the whole piece of lymph nodes and pericentral adipose tissue being pushed posteriorly and upwardly with suction (or other instrument),

**Figure 5.**

*Cut the posterior horizontal fissure with tunnel technique. A. Tunneling the fissure. B. Stapling the fissure. C. The outcomes after posterior horizontal fissure being cut off.*

### **Figure 6.**

*The procedure of "From posterior inferior to anterior superior." A. Cutting the posterior ascending artery. B. Cutting the right upper bronchus. C. Cutting the remaining upper vessels simultaneously. D. The outcomes after right upper lobe being removed.*

### *Perspective Chapter: Essentials of Lobectomy under Video-Assisted Thoracoscopic Surgery… DOI: http://dx.doi.org/10.5772/intechopen.105467*

ultrasonic scalpel is used to dissect them cephalad gradually until being completely removed. Care should be taken when dissecting is performed near the junction of the vagus nerve and the brachiocephalic artery on right side or arch of aorta on left side, since the recurrent laryngeal nerves come from there. Blunt and sharp dissection is used interchangeably before the vagus nerve and the recurrent laryngeal nerve being clearly identified to avoid nerve damage (**Figure 5**).

When resect group 7 lymph nodes, the middle and lower lobs are first pulled anteriorly and inferiorly at the posterior hilum with a clamped gauze to fully expose the carina area. Then, the mediastinal pleura is split along the superior border of the inferior pulmonary vein, the posterior border of the right main bronchus, and the anterior superior border of the esophagus in a "△" pattern. Suction (or other instrument) is used to push the whole piece of lymph nodes and pericentral adipose tissue backward and upward, and then ultrasonic scalpel is used to completely remove them cephalad (**Figure 6**).

### **1.4 Dealing with special problems**

### *1.4.1 Pleural adhesion*

Pleural adhesion is often seen in diseases such as pleurisy, lobar pneumonia, obstructive pneumonia caused by massive or central lung cancer. In the past, pleural adhesion was considered a contraindication for VATS. But with the accumulation of experience and the improvement of instruments, thoracic surgeons now generally believe that there are more advantageous to dissect pleural adhesion with VATS for better viewing angle, finer dissection, and less bleeding. Of course, in the case of pleural adhesion caused by extensive rind thoracotomy is still recommended. Because the rind is too tough to make interspace for thoracoscopic process. After the incision is made, the adhesion around the incision is bluntly mobilized with fingers so that the thoracoscopy and processing instruments can be placed. Afterward, although the process is time-consuming and needs patience, the pleural adhesion dissecting can be completed with the cooperation of the curved suction and the electric hook. When the adhesion is close to some major vessels, it can remain and does not have to be completely removed, so as to avoid damage to the major vessels to cause massive bleeding or even threaten the patient's life.

### *1.4.2 Massive bleeding*

Massive bleeding caused by broken vessels is a relatively common but serious accident in lobectomy and can occasionally be fatal. It is more common in pulmonary artery injury and rupture, while veins are less likely to rupture due to its good elasticity. It is more common in central lung cancer, lymph node calcification, neoadjuvant radiotherapy, and/or chemotherapy. In such cases, preparations for thoracotomy should be done before surgery and finer dissecting is needed during surgery. Especially when turning and pulling the lobes, it should be gentle to avoid tearing the root of the vessels. When vessel is broken and bleeding, the surgeon should keep calm. First, use suction or gauze to compress the proximal end of the broken vessel to stop bleeding. When suction is used, the location and size of the rupture can be directly observed. Then, the surgeon should decide the next treatment strategy based on the location, size of the rupture, and his or her experience, such as repair with suture, hemo-lock clamp, conversion to thoracotomy, or pulmonary artery trunk blocking, etc. The treatment suggestions are as follows:


### *1.4.3 Difficult hilum*

It refers to the situation that the hilar tissue is difficult to dissect due to the unclear and tough boundary for various reasons. It is more common in central lung cancer, lymph node calcification, neoadjuvant radiotherapy, and (or) after chemotherapy. Faced with such a situation, the surgeon should fully evaluate its resectability before surgery based on CT scan and experience. During operation, surgeon should not persist in a constant order or method of resection, but should treat it flexibly. If intraoperative exploration estimates that thoracoscopic resection is difficult, it should be timely and forwardly converted to thoracotomy, or directly thoracotomy after preoperative evaluation. Generally, it is recommended to deal with the relatively easily resectable tissue first to provide an opportunity for the more difficult one. Sometimes, it might be useful to lower the level of difficulty by splitting the pericardium and then cutting the pulmonary vein off or blocking the pulmonary artery trunk. In addition, for calcified lymph nodes, since it is the pericentral tissue that metastasizes, while itself (especially when it is completely calcified) hardly metastasizes, it is reasonable to resect it partially rather than completely. If the lateral wall of the artery trunk (<1/3 circumference) is invaded or cannot be unbound, a tri-stapler can be used to remove part of the lateral wall and the lesion simultaneously to ensure the safety of the process.

### **1.5 Conversion to thoracotomy**

Although lobectomy under u-VATS has many advantages, thoracotomy is still better from the perspective of surgical safety. Therefore, in order to ensure the safety of patients, under any circumstance, if the surgeon is not fully confident to proceed with the next process or an uncontrollable event has occurred, it must be immediately converted to thoracotomy without hesitation. According to the emergency state when converting, it is divided into planned and forced conversion to thoracotomy. The former is that the surgeon forwardly decides to convert to thoracotomy when he or she estimates that the next process cannot be performed very safely based on their experience. At this time, the condition is relaxed and operations can be performed in an orderly manner. Generally, the anterolateral incision is lengthened to about 10 cm or through which the surgeon can reach the chest cavity with one hand for auxiliary process. Forced conversion to thoracotomy is an emergency that has occurred beyond the capability of the surgeon to handle under u-VATS. In order to save the patient's life, it has to be converted to thoracotomy immediately. It is generally seen in massive bleeding caused by major vessels broken. At this moment, the condition is very tense. The surgeon has to race against time to control the bleeding. According to the state of bleeding, the chest wall can be incised layer by layer or just once.

*Perspective Chapter: Essentials of Lobectomy under Video-Assisted Thoracoscopic Surgery… DOI: http://dx.doi.org/10.5772/intechopen.105467*

### **1.6 Drainage tube placement and incision suture**

At the end of the surgery, another incision is usually made to place drainage tube. However, we could place it at the same incision to minimize invasiveness [13]. First, when the u-VATS was completed, the skin and subcutaneous tissue were pulled up and the intercostal muscle in the same intercostal space was transpierced with a mosquito forceps about 2.0 cm beyond the distal end of the incision site. Second, the drainage tube was clamped and punctured into the cavity, which is as alike as the procedure of doing a chest drainage that is familiar to thoracic surgeons in general. Third, after the drainage tube was placed properly, the subcutaneous tissue was sutured conventionally. Fourth, the drainage tube was anchored about 1.0 cm beyond the incision with a silk thread, which was passed through the subcutaneous suture. Finally, the skin incision was closed by subcutaneous continuous suture with a 3-0 self-retaining suture (Quill TM knotless tissue-closure device, Angiotech Puerto Rico Inc., Vancouver, Canada), which was cut flush to the skin lastly. When removing, one end of the anchoring silk thread was snipped and the drainage tube was pulled out, which just like removing the stiches, and the wound was sealed with Vaseline gauze immediately.

### **1.7 Technological difficulty**

1. U-VATS has higher requirements on assistants. The assistants need to be familiar with the surgeons' habits and to ensure the processing area clearly and sufficient extrathoracic operating space for surgeon by flexibly rotating the angle of thoracoscopic body.

2. Placement of stapler under u-VATS. Compared with multi-portal VATS, the angle is relatively limited when the stapler is placed under u-VATS. Therefore, surgeons need to completely dissect the target organ and its surroundings first and then adjust the relative position of the lobe to achieve a better angle for stapler placement. In addition, a shorter or curved-tip stapler is usually useful to reduce the difficulty of stapler placement.

### **2. Part 2. Right upper lobectomy under u-VATS**

### **2.1 Different orders of hilar cut**

Although some studies have shown that cutting pulmonary vein first might reduce the incidence of recurrence and prolong the survival time [14–18]. However, other studies have claimed that there is no difference in the risk of recurrence and survival time between cutting the pulmonary vein first or later [19–21]. Moreover, the first intraoperative priority is to ensure the safety of the patient and the operation. Therefore, there is no need to subject to a fixed order of hilar cut. The optimal order of hilar cut is only determined by the specific situation during the operation and the surgeon's habits. The general principle is to deal with the simple tissue first and then the more difficult ones. The common orders of hilar cut are as follows:

### *2.1.1 Vein-artery-bronchus (VAB)*

That is, the right upper pulmonary vein is cut off first, then the branches of the artery, and finally, the bronchus. It derives from the experience of thoracotomy and

### *Essentials of Pulmonary Lobectomy*

theoretically minimizes the possibility of hematogenous tumor spread. In addition, when the bronchus is cut off last, the likelihood of massive bleeding, which is caused by tearing the vessels, is minimized. The main process is as follows:


*Perspective Chapter: Essentials of Lobectomy under Video-Assisted Thoracoscopic Surgery… DOI: http://dx.doi.org/10.5772/intechopen.105467*


### *2.1.2 From anterior superior to posterior inferior*

That is, the apical anterior artery of the right upper pulmonary artery is cut off first, followed by the pulmonary vein and arterial variant branches, then the bronchus, and finally, the posterior ascending branch and the incomplete horizontal fissure. This order is particularly useful when the horizontal fissure is incomplete. Since the right upper lobe is always pulled backward and downward throughout the operation, the lungs are mostly prevented from turning. The main process is as follows:


artery is thick (> 3 mm in diameter), it needs to be dissected and cut off separately. Otherwise, it can be stapled with the incomplete fissure using a 60 mm stapler to complete the right upper lobe resection.

### *2.1.3 From posterior inferior to anterior superior*

That is, the posterior ascending artery is first cut off, then the bronchus, and finally, the upper pulmonary vein and the apical anterior artery (including possible variant arterial branches) are cut off simultaneously. It is especially useful when the horizontal fissure is complete. Since most of the procedure is performed with the upper lobe in its natural collapsed status, it is rarely needed to turn it over. The main process is as follows as we reported before [22]:

1.If the horizontal fissure is complete, only the visceral pleura at the horizontal fissure need to be split with an energy device. If not, the "tunnel technique" is used to cut it off. First, the upper lobe is pulled backward and upward using a suction (or other instrument) to expose the anterior hilum, and the mediastinal pleura is split along the upper border of the middle pulmonary vein. Second, the proximal end of the adipose tissue and lymph nodes is dissected and pushed to the distal end of the lung tissue or directly removed until the surface of mid-pulmonary artery trunk is exposed. After that, forceps or ultrasonic scalpel is used to bluntly and sharply dissect the tissues along the

### **Figure 7.**

*Resecting group 2 and 4 lymph nodes. A. a suction is used to push the azygos vein up, and ultrasonic scalpel is used to dissect lymph nodes. B. The mediastinal pleura is split in a "*△*" pattern. C. The whole piece of lymph nodes and pericentral adipose tissue being pushed posteriorly and upwardly with suction. D. The outcomes after group 4 and 2 lymph nodes being removed.*

*Perspective Chapter: Essentials of Lobectomy under Video-Assisted Thoracoscopic Surgery… DOI: http://dx.doi.org/10.5772/intechopen.105467*

surface of the mid-pulmonary artery trunk to make a factitious tunnel. Then, the anterior part of the horizontal fissure was cut off with a stapler through the factitious tunnel (**Figure 7**). After carefully identifying the posterior ascending artery, a stapler is used again to cut the posterior part of the horizontal fissure (**Figure 8**).


### **Figure 8.**

*A. The mediastinal pleura is split in a "*△*" pattern. B. The group 7 lymph nodes and pericentral adipose tissue is pushed backward and upward. C. The outcomes after group 7 lymph nodes being removed.*

### **Figure 9.**

*Cut the anterior horizontal fissure with tunnel technique. A. To expose the mid-pulmonary artery trunk. B. Tunneling the fissure. C and D. Stapling the fissure. E. The outcomes after anterior horizontal fissure being cut off.*

4.After that, the adipose tissue and the proximal end of the lymph nodes are dissected and then pushed to the distal end of the lung tissue or directly removed. If the lymph nodes are covered by possible variant arteries, it can be dissect along the surface of the pericardium posteriorly. Then the right upper lobe is pulled backward and caudalward to continue to dissect the lymph nodes anteriorly. Subsequently, the lymph nodes are pushed to the distal end of the lung tissue or removed directly. Now, the remaining upper pulmonary vessels (including the right upper pulmonary vein, the apical anterior artery, and possible arterial variant arteries) are hollowed out. And, then they are cut off simultaneously with a stapler. Finally, the right upper lobe is completely removed (**Figure 9**).

### **3. Part 3. Right middle lobectomy under u-VATS**

Right middle lobectomy under u-VATS is relatively easy for its hilum is superficial to the mediastinum, especially when the fissures are complete.


### **4. Part 4. Right lower lobectomy with single-direction under u-VATS**

The advantage of lobectomy with single directional is that the whole procedure starts from the shallowest structure of the hilum, proceeds in one direction, and cuts the fissure. This procedure is particularly useful when the oblique fissure is incomplete.

### **4.1 Surgical procedure**

After the right lower lobe is pulled backward and cephalad, the inferior pulmonary ligament is cut to the lower boundary of the lower pulmonary vein with electric *Perspective Chapter: Essentials of Lobectomy under Video-Assisted Thoracoscopic Surgery… DOI: http://dx.doi.org/10.5772/intechopen.105467*

hook (**Figure 1**). And the group 8 lymph node is dissected and pushed to the distal end of the lung tissue or directly removed.

Dissect the inferior pulmonary vein and remove group 9 lymph node or push it to the distal end of the lung tissue, then separate and expand the interspace between the vein and lower bronchus by forceps (**Figure 2**).

Cut the inferior pulmonary vein off with stapler (**Figure 3**).

Dissect the lower bronchus and separate it from the lower pulmonary artery with a forceps by close to the upper boundary of the lower bronchus to avoid injuring the artery (**Figure 4**). Then cut the lower bronchus off with stapler (**Figure 7**).

Remove group 11 lymph node or push it to the distal end of the lung tissue. Then dissect the lower pulmonary artery and suspend it with suture (**Figure 8**).

Cut off the lower lobe artery with stapler (**Figure 9**).

Finally, cut off the oblique fissure with stapler to finish the right lower lobectomy (**Figure 5**).

### **4.2 Essential technology for right lower lobectomy with single direction under u-VATS**

The sheath of the inferior pulmonary vein, especially the surrounding pleura, must be completely split to facilitate the placement of stapler. Moreover, the middle pulmonary vein may sometimes drain into the inferior pulmonary vein, so it needs to be carefully identified during dissecting.

More attention should be paid when separating lower bronchus to avoid injuring vessels. There are often lymph nodes around the bronchus. Sometimes these lymph nodes closely adhere to the bronchus and vessels, making it difficult to separate the interspace between the bronchus and vessels. On this occasion, it is impossible to place the stapler due to insufficient space. Therefore, the lower lobe bronchus should be cut off with scissors and then suture the bronchial stump after removing the lobe. In addition, it should be noted that the dissecting of the upper boundary of the lower bronchus should be performed on the interior of the middle lobe bronchus, because the lower lobe is pushed upward. Otherwise, if the dissecting is too close to the mediastinum, the middle bronchus may be injured or cut accidentally. Furthermore, the lower bronchus should be cut off at an appropriate distance (about 5 mm) to the middle lobe bronchus to avoid the stenosis of the middle lobe bronchus and subsequently postoperative atelectasis or occurrence of bronchopleural fistula.

In most cases, the lower pulmonary artery trunk can be cut off with one stapler. If the dorsal segment artery is far from the basal artery trunk, they need to be cut off respectively. In addition, when dissecting the artery, it should be gentle to avoid massive bleeding caused by tearing it.

### **5. Part 5. Left lower lobectomy under u-VATS**

Left lower lobectomy under u-VATS can be performed as similar as right lower lobectomy reported before. Here, we describe another procedure, which is more commonly used.

1.First, the left lower lobe is pulled backward and cephalad to expose the inferior hilum. The inferior pulmonary ligament is cut to the lower boundary of the lower pulmonary vein with electric hook or ultrasonic scalpel. And the group 8 lymph node is dissected and pushed to the distal end of the lung tissue or directly removed.


### **6. Part 6. Left upper lobectomy under u-VATS**

Left upper lobectomy under u-VATS is comparatively difficult for its special hilar anatomy and more frequent variant artery. Comparing with the right hilum, the left hilum is cephalad higher, and most of the arteries of the left upper division are covered by the upper bronchus. Therefore, the incision is made at the fourth intercostal space to facilitate dissection and placement of stapler.


*Perspective Chapter: Essentials of Lobectomy under Video-Assisted Thoracoscopic Surgery… DOI: http://dx.doi.org/10.5772/intechopen.105467*

distal end of the lung tissue or directly removed. Then, the bronchus is cut off with stapler.

5.The proximal end of the interlobar lymph nodes is dissected and then pushed to the distal end of the lung tissue or directly removed. If the lingular segmental artery is thick (> 3 mm in diameter), it needs to be dissected and cut off separately. Otherwise, it can be stapled with the incomplete fissure using a 60 mm stapler to complete the left upper lobectomy.

Sometimes, it is difficult to cut the pulmonary vein first because of insufficient angle for stapler placement (**Figure 6A**) or dense adhesion caused by calcified lymph node. In this case, the abovementioned procedure is reversed (**Figures 6B**–**F** and **10**).


### **Figure 10.**

*Dissecting the inferior pulmonary ligament. IPL, inferior pulmonary ligament. RLL, right lower lobe. Dia, diaphragm. IVC, inferior vena cava.*

### **Figure 11.**

*Dissecting the inferior pulmonary vein. IPV, inferior pulmonary vein. RLL, right lower lobe.*


### **Figure 12.**

*Dissect the inferior pulmonary vein. IPV, inferior pulmonary vein. RLL, right lower lobe.*

**Figure 13.** *Dissect the lower lobe bronchus. RLLB, right lower lobe bronchus. RMLB, right middle lobe bronchus.*

**Figure 14.** *Cut off the lower lobe bronchus. RLL, right lower lobe. RMLB, right middle lobe bronchus.*

*Perspective Chapter: Essentials of Lobectomy under Video-Assisted Thoracoscopic Surgery… DOI: http://dx.doi.org/10.5772/intechopen.105467*


### **Figure 15.**

*Dissect the lower lobe artery. RLLA, right lower lobe artery. RMLA, right middle lobe artery. RLL, right lower lobe. RUL, right upper lobe.*

**Figure 16.** *Cut off the lower lobe artery. RLLA, right lower lobe artery. RLL, right lower lobe. RUL, right upper lobe.*

**Figure 17.** *Cut off the interlobar fissure. RLL, right lower lobe. RUL, right upper lobe.*

### **Figure 18.**

*The reversed procedure for left upper lobectomy. A. Insufficient angle for stapler placement. B. Dissecting the anterior part of the oblique fissure with "tunnel technique." C. Stapling the LSA. D. Dissecting the posterior part of the oblique fissure with "tunnel technique." E. Stapling the lateral subsegmental artery. F. Dissecting the APSA. PA, pulmonary artery. PV, pulmonary vein. BSAT, basal segmental artery trunk. LSA, lingular segmental artery. SSA, superior segmental artery. APSA, apicoposterior segmental artery.*

### **Figure 19.**

*The reversed procedure for left upper lobectomy (continue). A. Dissecting the ASA. B. Stapling the PV. C. The surrounding lymph nodes and adipose tissue are dissected and pushed to the distal end of the lung tissue. D. Stapling the UB. E. The outcomes after left upper lobe being removed. ASA, anterior segmental artery. PV, pulmonary vein. LN, lymph node. UB, upper bronchus.*

*Perspective Chapter: Essentials of Lobectomy under Video-Assisted Thoracoscopic Surgery… DOI: http://dx.doi.org/10.5772/intechopen.105467*

### **Author details**

Jian Li, Xu Zhu, Jianglun Li, Jian Zhang, Kaiying Wang and Xiaojun Du\* Department of Thoracic Surgery, The Affiliated Hospital of Guizhou Medical University, Guiyang, China

\*Address all correspondence to: xj.du@foxmail.com

© 2022 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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[5] Menna C, Poggi C, Andreetti C, Maurizi G, Ciccone AM, D'Andrilli A, et al. Does the length of uniportal video-assisted thoracoscopic lobectomy affect postoperative pain? Results of a randomized controlled trial. Thoracic Cancer. 2020;**11**:1765-1772. DOI: 10.1111/ 1759-7714.13291

[6] Lim CG, Shin KM, Lim JS, Lim JK, Kim HJ, Kim WH, et al. Predictors of conversion to thoracotomy during video-assisted thoracoscopic surgery lobectomy in lung cancer: Additional predictive value of FDG-PET/CT in a tuberculosis endemic region. Journal of Thoracic Diseases. 2017;**9**:2427-2436. DOI: 10.21037/jtd.2017.07.40

[7] Byun CS, Lee S, Kim DJ, Lee JG, Lee CY, Jung I, et al. Analysis of unexpected conversion to thoracotomy during thoracoscopic lobectomy in lung cancer. The Annals of Thoracic Surgery. 2015;**100**:968-973. DOI: 10.1016/j. athoracsur.2015.04.032

[8] Samson P, Guitron J, Reed MF, Hanseman DJ, Starnes SL. Predictors of conversion to thoracotomy for videoassisted thoracoscopic lobectomy: A retrospective analysis and the influence of computed tomography–based calcification assessment. The Journal of Thoracic and Cardiovascular Surgery. 2013;**145**:1512-1518. DOI: 10.1016/j. jtcvs.2012.05.028

[9] Ettinger DS, Wood DE, Aisner D, Akerley W, Bauman JR, Bharat A, et al. NCCN clinical practice guidelines in oncology: Non-small cell lung cancer. Version 5. 2021. Available from: https:// www.nccn.org/guidelines/guidelinesdetail?category=1&id=1450. [Accessed June 16, 2021]

[10] Yao J, Chang Z, Zhu L, Fan J. Uniportal versus multiportal thoracoscopic lobectomy: Ergonomic evaluation and perioperative outcomes from a randomized and controlled trial. Medicine (Baltimore). 2020;**99**:e22719. DOI: 10.1097/MD.0000000000022719

[11] Gonzalez-Rivas D. Uniportal thoracoscopic surgery: From medical thoracoscopy to non-intubated uniportal video-assisted major pulmonary resections. Annals of Cardiothoracic Surgery. 2016;**5**:85-91. DOI: 10.21037/ acs.2016.03.07

[12] Gonzalez-Rivas D, Paradela M, Fernandez R, Delgado M, Fieira E, Mendez L, et al. Uniportal video-assisted thoracoscopic lobectomy: Two years of experience. The Annals of Thoracic

*Perspective Chapter: Essentials of Lobectomy under Video-Assisted Thoracoscopic Surgery… DOI: http://dx.doi.org/10.5772/intechopen.105467*

Surgery. 2013;**95**:426-432. DOI: 10.1016/j. athoracsur.2012.10.070

[13] Du X, Chen G, Tian D, Xie L, Zhou H. Modified tube fixation technique for uniportal video-assisted thoracic surgery. Video-Assisted Thoracic Surgery. 2018;**3**:45-45. DOI: 10.21037/ vats.2018.10.03

[14] Sawabata N, Funaki S, Hyakutake T, Shintani Y, Fujiwara A, Okumura M. Perioperative circulating tumor cells in surgical patients with non-small cell lung cancer: Does surgical manipulation dislodge cancer cells thus allowing them to pass into the peripheral blood? Surgical Today. 2016;**46**:1402-1409. DOI: 10/gnjf9k

[15] Duan X, Zhu Y, Cui Y, Yang Z, Zhou S, Han Y, et al. Circulating tumor cells in the pulmonary vein increase significantly after lobectomy: A prospective observational study. Thoracic Cancer. 2019;**10**:163-169. DOI: 10.1111/1759-7714.12925

[16] Sawabata N, Nakamura T, Kawaguchi T, Watanabe T, Ouji NS, Ito T, et al. Circulating tumor cells detected only after surgery for nonsmall cell lung cancer: Is it a predictor of recurrence? Journal of Thoracic Diseases. 2020;**12**:4623-4632. DOI: 10.21037/ jtd-20-1636

[17] Hashimoto M, Tanaka F, Yoneda K, Takuwa T, Matsumoto S, Okumura Y, et al. Positive correlation between postoperative tumor recurrence and changes in circulating tumor cell counts in pulmonary venous blood (pvCTC) during surgical manipulation in non-small cell lung cancer. Journal of Thoracic Diseases. 2018;**10**:298-306. DOI: 10/gc845x

[18] Long X, Wu B, Zhang W, Lv G, Yu D, Peng J, et al. Effects of vessel interruption sequence during lobectomy for non-small cell lung cancer: A systematic review and meta-analysis. Frontiers in Surgery. 2021;**8**:694005. DOI: 10/gnjf9s

[19] Zhai H-R, Yang X-N, Nie Q, Liao R-Q, Dong S, Li W, et al. Different dissecting orders of the pulmonary bronchus and vessels during right upper lobectomy are associated with surgical feasibility and postoperative recovery for lung cancer patients. China Journal of Cancer. 2017;**36**:53. DOI: 10.1186/ s40880-017-0220-9

[20] Kozak A, Alchimowicz J, Safranow K, Wójcik J, Kochanowski L, Kubisa B, et al. The impact of the sequence of pulmonary vessel ligation during anatomic resection for lung cancer on long-term survival – a prospective randomized trial. Advances in Medical Sciences. 2013;**58**:156-163. DOI: 10/f5bmdf

[21] Refaely Y, Sadetzki S, Chetrit A, Simansky DA, Paley M, Modan B, et al. The sequence of vessel interruption during lobectomy for non–small cell lung cancer: Is it indeed important? The Journal of Thoracic and Cardiovascular Surgery. 2003;**125**:1313-1320. DOI: 10/ fm8sgq

[22] Wang K, Zhang J, Li J, Liu L, Tang Z, Du X. aBVA procedure by uniportal video-assisted thoracoscopic surgery for right upper peripheral lung cancer: A Randomized Trial. Frontiers in Oncology. 2022;**12**:828432. DOI: 10.3389/ fonc.2022.828432

### **Chapter 3**

## Thoracoscopic Lobectomy in Infants and Neonates

*Elisabeth T. Tracy and Steven W. Thornton*

### **Abstract**

Video-assisted thoracic surgery is a well-established approach to managing lung pathology in the adult and adolescent population. This minimally invasive strategy has also gained traction for the care of infants and neonates with congenital lung lesions. Thoracoscopic surgery for infants and neonates requires special attention to these patients' unique physiology. Careful consideration must also be given to lung isolation, the effects of insufflation, and the constraints of small working spaces. Additionally, anomalies such as congenital pulmonary airway malformations have special anatomic considerations including cystic regions and anomalous feeding vessels. However, the basic surgical principles of pulmonary resection apply to infants and children as well as adults.

**Keywords:** pulmonary resection, wedge resection, segmentectomy, lobectomy, thoracoscopic, video-assisted thoracic surgery, children, infants, neonates, pediatrics

### **1. Introduction**

Thoracoscopic surgery is a minimally invasive approach to thoracic surgery wherein large intercostal incisions, rib spreading, and rib resection are avoided. Visualization for these cases depends entirely upon video monitors. There are also modified approaches to thoracoscopy where the thoracoscope is used as an adjunct to rib spreading. These approaches are known as video-assisted thoracotomy.

Minimally invasive thoracic surgery dates back to 1910 when Jacobeus treated a patient with tuberculosis by using a cystoscope to induce a therapeutic pneumothorax [1]. The field took a leap forward in 1993 with the use of thoracoscopic surgery for an anatomic lobectomy in a patient with malignancy [2]. Several large series comparing thoracoscopic surgery to open resection were completed during the early 2000s, which demonstrated feasibility, safety, and comparable outcomes—primarily in adult patients with pulmonary malignancy [3–5]. Later, Steve Rothenberg described a technique for thoracoscopic surgery in infants, which has since proved to be safe and reproducible [6, 7]. This led to the adoption of such techniques by pediatric surgeons, who now regularly make use of smaller instruments and gentle insufflation to achieve good outcomes.

Theoretical benefits to thoracoscopy include decreased postoperative pain, shorter chest tube durations, reduced length of stay, and improved cosmesis. Thus, although

traditional surgical approaches such as posterolateral thoracotomy, muscle-sparing thoracotomy, trans-sternal thoracotomy, and median sternotomy remain viable options, thoracoscopy is considered the standard approach in adults when possible. A recent analysis of the Society of Thoracic Surgeons (STS) database demonstrates that thoracoscopic lobectomies account for 45% of all lobectomies performed [8]. Comparable, robust data on the prevalence of thoracoscopic approaches in infants and neonates are not available, but the approach continues to gain favor as the field of pediatric surgery advances.

### **2. Indications for pulmonary resection in infants and children**

### **2.1 Congenital lung anomalies**

Congenital lung anomalies are altogether uncommon, though when present they represent a common indication for surgical intervention in the infant or neonatal chest. Lesions of the lung, which are potentially amenable to surgery, include congenital pulmonary airway malformations, bronchopulmonary sequestrations, hybrid lesions, and congenital lobar emphysema. As prenatal imaging has improved, early identification of each of these lesions has increased, and the literature guiding their treatment has grown. However, specific practice guidelines are lacking, and surgeon judgment remains the driving factor in decision-making. Ultimately, the prognosis of most children with congenital lung lesions is good, and many are candidates for thoracoscopic resection as an alternative to thoracotomy.

### *2.1.1 Congenital pulmonary airway malformations*

Congenital pulmonary airway malformations (CPAMs) are benign cystic masses of abnormal lung tissue in infants and children (**Figure 1**). They were previously referred to as congenital cystic adenomatoid malformations, or CCAMs, but the name was revised as pathologists began documenting that many of the lesions were neither cystic nor adenomatoid. Now, CPAM is an umbrella term, which includes CCAMs along with sequestrations and hybrid lesions (**Figure 2**). CPAMs are the most encountered congenital lesions of the lung. They range in severity from those that remain asymptomatic indefinitely to those that cause hydrops fetalis and fetal demise from pulmonary hypoplasia.

### **Figure 1.**

*A) Congenital pulmonary airway malformation (CPAM) (\*) on the pleural surface B) without arterial vascular supply in the ligamentous attachment (\*\*).*

*Thoracoscopic Lobectomy in Infants and Neonates DOI: http://dx.doi.org/10.5772/intechopen.105431*

**Figure 2.** *A) Congenital cystic adenomatous malformation (CCAM) and B) intralobar hybrid lesion with a systemic feeding vessel.*

CCAMs are most frequently classified into five groups. Type 0 lesions are exceedingly rare and typically lethal. Here the cysts arise within the trachea or bronchus [9]. Type 1 lesions are the most common, occurring in over 50% of cases, and result from the development of cystic tissue in the distal bronchus or proximal bronchiole. They can become quite large and thus may lead to the development of hydrops [10]. Type 2 lesions are found in roughly a quarter of cases and are frequently associated with congenital anomalies of other organ systems. The extent to which other organ systems are affected defines the prognosis of type 2 lesions. Type 3 lesions occur in less than 10% of cases and are believed to arise from acinar-like tissue. Type 4 lesions are found in about 10% of cases and have been associated with pleuropulmonary blastoma. These lesions are alveolar in origin [11]. Prior to birth, lesions may be classified based on cyst size. Those smaller than 5 mm are termed microcytic, whereas those larger are termed macrocytic. Microcytic lesions are associated with worse outcomes. Types 1, 2, and 4 may present as macrocytic or have elements of both. Type 3 lesions are universally microcytic [12].

CPAM size is an important predictor of outcome. The most used metric is the CPAM volume ratio, CVR. This is the ratio of CPAM/fetal head circumference, where higher ratios are correlated with hydrops fetalis and perinatal morality [13]. Although fetal hydrops is a devastating complication, most patients will be asymptomatic in the fetal and perinatal period. More commonly, patients will be asymptomatic or develop a range of symptoms including respiratory distress, pneumothorax, air leak, pneumonia, empyema, or others contributing to pulmonary abscesses. Up to 25% of initially asymptomatic lesions are expected to become symptomatic, with most of these developing around 6 or 7 months of age [14]. CPAMs may also predispose to, or conceal, malignancy, an outcome that can occur well into adulthood [15].

Symptomatic lesions necessitate surgical intervention. The management of asymptomatic CPAMs, however, is controversial and the potential for these lesions to become symptomatic or mask malignancy must be considered. The objective when operating on an asymptomatic patient is to prevent the development of functional symptoms, pneumonia, or abscess and to mitigate the risk of malignancy.

A 2017 systematic review from the American Pediatric Surgeons Association Committee on Evidence-Based Practice found extensive practice heterogeneity. Most surgeons agreed on the importance of postnatal chest X-ray and CT scan, but consensus could not be reached on optimal timing. Some advised neonatal imaging as early as 6 weeks, whereas others planned for radiographic studies between 3 and 12 months. Resection practices varied as well. Twenty-one percent advise universal resection of asymptomatic CPAMs, 24% recommend observation only for asymptomatic lesions, and the remainder make their recommendation based on lesion size, location, parental preferences, and their suspicion for malignancy [16]. It should be noted that the malignant potential of CPAMs is widely debated. Type 4 CPAMs most strongly predispose to malignancy, though the transformation potential of hybrid lesions and other CPAMs is not well defined [17]. Although there are older studies exploring this topic, the advent of improved prenatal imaging renders them obsolete as we now detected lesions that would have previously gone undetected except at autopsy. In the absence of robust practice guidelines, we favor the latter approach, where the unique presentation of each patient and surgeon judgment are prioritized.

For patients undergoing operative management, anatomic resection is the most common approach for anomalies confined to a single lobe. Early studies suggested that thoracoscopy was a safe and feasible approach that achieved comparable outcomes and shorter length of hospitalization compared with open resection [18]. More recent literature also suggests that thoracoscopic excision may reduce total complication rates [19]. It also mitigates the risk of chest wall deformity, which unlike in the adult population is a real concern for infants undergoing thoracotomy. There is evidence to support the claim the thoracoscopic approach results in less postoperative pain, fewer wound infections, and less long-term musculoskeletal sequelae [20–22]. These findings should be interpreted with caution, though, as the sample sizes are small. This is a common challenge in pediatric surgery, and ultimately, the surgeons' skill and judgment should play an important role in selecting the operative approach.

Removal of the cystic tissue allows the normal pulmonary tissue to function at capacity, and for the pathologist to obtain a definitive tissue diagnosis in patients for whom the concern for malignancy is high. It also mitigates the risk of infections in a population predisposed to recurring pneumonia. Although anatomic resection is most common, there are reports of lung sparing (LSR) resections (i.e., wedge resections or segmentectomies). The LSR approach is generally considered feasible and safe, though studies examining long-term outcomes are limited. It offers theoretical benefit over anatomic resection as the infant's alveoli continue to develop for the first 1–2 years of life [23]. As a result, lung resection during infancy is thought to be less morbid than in adults. No studies to date have examined the theoretical benefit of LSR on pulmonary function, though, and there is no evidence to suggest that the approach is superior to lobectomy for a single, asymptomatic lobar CPAM with regard to either perioperative morbidity or long-term pulmonary function [16]. We thus prefer the lobectomy for its anatomic simplicity and ensuring that the entire lesion is excised.

The optimal timing of surgery in asymptomatic patients has always been controversial. It is theoretically easier to operative in the thorax prior to the development of CPAM complications as they cause inflammatory changes, which result in a hostile operative field [24]. As a consequence, elective resection is associated with better outcomes compared with emergent surgery [25, 26]. Another important consideration for operative timing is that lung growth continues during the early childhood period. This allows for compensatory lung development after resection. So, although immediate postnatal resection is not required, there are advantages to early intervention. The single largest study examining this topic found increased morbidity associated with resection in younger than 3 months of age or less than 5 kg and increased

*Thoracoscopic Lobectomy in Infants and Neonates DOI: http://dx.doi.org/10.5772/intechopen.105431*

operative time for infants older than 9 months. Thus, the authors recommended deferring elective CPAM resection until the infant was at least 3 months of age, but no older than 9 months [26].

There are also limited reports of fetal pulmonary lobectomy in fetuses with hydrops, though the significant risk of preterm labor and premature delivery must be considered. Other interventions such as pleuro-amniotic shunts can also be completed prenatally, but these operations are only offered at specialized fetal centers [16].

Given the variation in institution and surgeon practice, a robust multicenter study examining risk adjusted outcomes in CPAM patients undergoing resection would be beneficial. The overall rarity of the condition, as is often the case in pediatric surgery, makes this difficult.

### *2.1.2 Bronchopulmonary sequestrations*

Bronchopulmonary sequestrations (BPSs) are masses of lung tissue supplied by anomalous systemic arteries, which do not participate in gas exchange as they are not connected to the tracheobronchial tree. These are the second most common type of congenital pulmonary lesion.

A BPS may be either extra- or intra-lobar depending on their relationship to functional lung tissue. Extra-lobar BPSs are fully separated from the functional lung and are surrounded by their own pleural cover. Intra-lobar BPSs are incorporated *into* the functioning lung. These lesions are compared in **Table 1**. BPSs may be identified on prenatal ultrasonography, incidentally during extra-pulmonary surgical intervention, with the development of recurrent pneumonia or abscess. There are also reports of BPS torsion presenting with sudden abdominal or chest pain necessitating immediate resection in a previously well child [27].

Like CPAMs, BPSs appear as a well-defined homogenous, echo-dense mass on prenatal ultrasonography. They can be distinguished from CPAMs by the presence of doppler flow from a systemic artery to the lesion. This finding, however, is not universally demonstrated on ultrasound, and an MRI may be necessary to distinguish between the two. CT may also be indeterminate (**Figure 3**).

Like CPAMs, the management of asymptomatic lesions remains controversial. It should be noted that intra-lobar lesions have an increased risk of developing


### **Table 1.**

*Comparison of intra- and extra-lobar pulmonary sequestrations.*

### **Figure 3.** *A) Axial and B) coronal CT imaging of a prenatally diagnosed pulmonary lesion of unknown etiology.*

symptoms, particularly those related to infection, as their connection to the functional lung tissue and the bronchopulmonary tree allows for sequestration of infectious material. Additionally, intra-lobar sequestrations are fed by arterial vessels, which most commonly arise from the abdominal aorta and may require repair of a diaphragmatic defect if traversed (**Figure 4**). These can, in some unfortunate cases, result in pulmonary overcirculation or symptomatic shunting. Both scenarios are indications for resection and preoperative embolization should be considered to mitigate intraoperative bleeding risk.

Ultimately, BPSs are monitored and managed similarly to CPAMs, with comparable variations in practice between surgeons and institutions [28, 29]. Though special attention must be paid to resection and ligation of the feeding vessels when pursuing surgery. These technical details are described in detail later in the chapter.

When surgery is performed by a surgeon well versed in thoracoscopy, outcomes with thoracoscopic surgery are comparable to thoracotomy in this population [30]. And recent evidence demonstrates the safety of this approach when applied by appropriately supervised trainees [7]. There are limited reports of a hybrid and endovascular approach to management as well, though surgical resection remains the gold standard when intervention is indicated. As prenatal imaging continues to

### **Figure 4.**

*A) Intralobar sequestration (\*) with aortic vascularization (\*\*) before and B) after transection with subsequent repair of diaphragmatic defect (\*\*\*).*

improve, rigorous practice guidelines should be developed to guide management of these increasingly diagnosed lesions.

### *2.1.3 Hybrid lesions*

Pulmonary lesions with findings suggestive of both CPAM and BPS are possible. These are referred to as hybrid lesions, and as with the constituent defects they represent, evidence-based guidelines for management are scarce. Surgeon judgment and patient presentation are the dominant forces driving management. Consideration should be given to what has been previously described about CPAMs and BPSs.

### *2.1.4 Congenital lobar emphysema*

Congenital lobar emphysema (CLE) is the overdistention of pulmonary tissue resulting from airway obstruction. This may affect a segment, portion of a lobe, or an entire lobe. As with the other lesions described in this chapter, CLE may be diagnosed on antenatal imaging, or be identified in the setting of a symptomatic child. Half of patients are symptomatic at birth and almost all the remainder develop symptoms within the first 6 months of life. It is uncommon to identify CLE in an asymptomatic child.

The infant with congenital lobar emphysema presents with acute, life-threatening respiratory distress. CLE has a 3:1 predominance for male infants with implication of the upper lobe being most common. Only infrequently are the lower lobes involved. Bi-lobar involvement is rare but described [31]. Chest X-ray is usually diagnostic and demonstrates hyperinflation of the involved lobe with compression of the contralateral lung and mediastinal shift [32].

Management of CLE depends on severity of presentation. Nonoperative management is recommended in patients with mild to moderate symptomatology. In the presence of severe pulmonary disfunction or ongoing clinical progression, the gold standard approach to management is a lobectomy. Transient lobar occlusion with balloon endoscopic balloon dilation has been suggested as a mechanism for evaluating the impact of surgical resection *a priori* in patients for whom surgical management is equivocal [31].

It is important to state that CLE must not be confused with a tension pneumothorax, as placement of a chest tube into the overinflated lung can be disastrous. Additionally, since the respiratory distress is of obstructive rather than restrictive etiology, intubation and positive pressure ventilation can worsen respiratory function by forcing more air into the lungs and further expanding them. Expert neonatologists and anesthesiologists should be involved in the care of these infants, who are often managed non-operatively.

Unique from the previously discussed congenital lung lesions, thoracoscopic management is actually contraindicated for CLE as the overinflated lobe limits access to the chest. This makes thoracoscopic dissection in the neonate difficult and dangerous for patients with these lesions [22, 33, 34].

### **2.2 Malignancies**

Malignancy of the pediatric chest is a rare event that when present should prompt consideration of pulmonary resection along with adjuvant therapy, the latter of which is beyond the scope of this text. Malignancies can be primary, most often pleuropulmonary blastoma, or more frequently metastatic. Metastatic disease most often results from osteosarcoma, Wilms tumor, and hepatoblastoma. Thoracoscopic

intervention has been compared with open resection in this population, with thoracoscopic wedge resection now representing the most common therapeutic modality.

### *2.2.1 Pleuropulmonary blastoma*

Pleuropulmonary blastomas (PPBs), though infrequently occurring (estimated incidence is 25–50 cases per year in the United States), are the most common primary pediatric pulmonary malignancy. They are associated with DICER1-related disorders, which have been described in detail elsewhere [35]. For the purposes of this text, it should be noted that this affiliation can result in concurrent primaries outside of the lungs and that all children with PPBs should undergo a thorough workup for additional malignancy, which includes genetic testing for a DICER1 mutation. Children with PPBs present with nonspecific findings that most frequently include respiratory distress, chest pain, and fever. It is uncommon to identify a PPB in the asymptomatic child.

PPBs progress through well-defined stages, which allows for them to be categorized into three unique types, where each corresponds to a different prognosis (**Table 1**). They are categorized based on the presence of cystic and solid components. There is some debate as to whether a type 1 lesion may regress (Type 1r) through the loss of malignant tissue. The controversy is that it is unclear whether these masses ever possessed a malignant component to begin with. Regardless, these lesions seem to be clinically insignificant, as the small number of patients who died after detection of a Type 1 mass experienced progression to Type 2 or 3 rather than Type 1r. No such regression has ever been described in Type 2 or 3 lesions (**Table 2**).

In comprehensive analyses of the PPB Registry, only type and metastases were identified as prognostic factors. Smaller cohort series have also suggested that the ability to achieve complete surgical resection may be prognostic, though this is debated. DICER1 mutations, found in up to two-thirds of patients, are common but definitively not prognostic. Nearly one-third of patients have a family member with a diagnosis within the DICER1 syndrome, including Wilms tumor, stromal tissue tumors, thyroid malignancy, cervical rhabdomyosarcoma, renal sarcoma, and pulmonary sequestration, to name a few [36].

A consensus on surgical management is not currently available, but reviews exist to guide the surgeon's approach and surveillance. Consideration should be given to the fact that these lesions may be mistaken for the previously described benign CPAMs, and that PPBs may progress from surgically amenable cystic masses (Type 1) to lethal metastatic disease with solid components (Type 2 or 3) if not managed promptly. The clinical feature best used for distinguishing CPAM from PPB is a systemic feeding vessel. But as has been stated previously, this not always found on imaging. Prenatal detection and pulmonary hyperinflation have also been suggested for their association with CPAM over PPB. On the other hand, multi-lobar or bilateral abnormalities,


**Table 2.**

*Comparison of pleuropulmonary blastoma types.*

*Thoracoscopic Lobectomy in Infants and Neonates DOI: http://dx.doi.org/10.5772/intechopen.105431*

complex cystic tissue, and mediastinal shift are all associated with PPB over CPAM. All children with cystic lung lesions should be considered for DICER1 testing to further assess their risk [37].

Patients with Type 1 disease are curatively managed with surgery alone when resection with negative margins and no tumor spillage is achieved. A wedge resection is most common, though lobectomy or other larger resections may be indicated for lesions with central, hilar, or multifocal involvement. Most authors have advocated for an open approach to the management of these lesions given the risk associated with tumor spillage. Smaller lesions, however, can be approached thoracoscopically by the surgeon adept in minimally invasive techniques [38].

Patients with Type 2 or 3 malignancy will often require adjuvant chemotherapy to minimize the resection necessary to achieve local control. Fortunately, PPBs are highly chemosensitive tumors, and neoadjuvant therapy can achieve a dramatic reduction in tumor size in patients for whom upfront surgery is deemed inappropriate. In general, the literature advocates for open resection in this population as increased size and tumor complexity make achieving a negative margin and spill-free resection difficult via a thoracoscopic approach. Lobectomy or pneumonectomy may be necessary to achieve adequate margins, and pleural surfaces should be taken *en bloc* with the implicated lung tissue.

In cases with extensive pleural spread, extra-pleural pneumonectomy may be necessary. This requires careful resection of the pleural surfaces, pericardium, diaphragm, and phrenic nerve along with division of the pulmonary hilar vessels. Children undergoing such extensive resection have a high rate of postoperative complications, most notably post-pneumonectomy syndrome. Unfortunately, PPB can progress or recur in patients with Type 2 or 3 disease, and both result in dramatically reduced survival [37].

The low incidence of childhood cancers is a defining challenge for the teams that manage them. A lack of robust clinical trials means that treatment algorithms are often driven by expert opinion and physician judgment based on retrospective and registry data. For PPB specifically, treatment options include surgery and chemotherapy as outlined here. The timing for each depends on the type and complexity of PPB. Ultimately, complete surgical resection is required for cure. Advancing the care and understanding of children with PPB will require cooperation across international study groups to organize prospective clinical trials.

### *2.2.2 Pulmonary metastatic disease*

In addition to primary malignancy of the lung, pulmonary metastatic disease is an indication for surgical intervention of the infant or neonate. In fact, this is far *more* common than primary pulmonary malignancy. The most frequently implicated primaries are osteosarcoma, Wilms tumor, and hepatoblastoma (**Figure 5**). Metastasectomy has shown benefit for children with each of these malignancies, though pulmonary resection itself is not benign. The presence of uncontrolled primary disease and an inability to maintain adequate lung function after pulmonary resection are absolute contraindications to metastasectomy, regardless of primary.

Historically speaking, outcomes for children requiring pulmonary metastasectomy have been poor and difficult to study. Early literature was limited by its histologic heterogeneity, but more recent studies have illuminated some key points. We now know that staged bilateral resections are well tolerated and that the extent of metastasis is not an absolute contraindication to metastasectomy. This is largely the result

### **Figure 5.**

*A) Wilms tumor of the right kidney with B) blue vessel loops encircling the tumor's venous outflow.*

of the now frequently utilized pulmonary wedge resection, which permits multiple lesions from both lungs to be excised while preserving non-diseased lung tissue. From a diagnostic perspective, CT has long been the gold standard for detecting pulmonary nodules. CT, however, lacks specificity and is unable to distinguish benign from malignant nodules. In the absence of tissue biopsy, this can lead to false positives and unnecessary surgical interventions [39]. Thus, thoracoscopy has a role in both therapy and diagnostic biopsy.

Wilms tumor is the most common pediatric solid tumor malignancy. Despite overall excellent outcomes for children with this diagnosis, patients with pulmonary metastasis fare poorly. Wilms tumor is responsive to radiotherapy, so whole lung radiation is commonly used for the management of pulmonary metastasis. In patients who do not respond to initial chest radiation, the Children's Oncology Group (COG) advocates diagnostic biopsy of lung nodules to minimize further exposure to toxic therapy in the cohort of patients with benign lesions. Minimally invasive approaches to metastasectomy are widely accepted in this cohort.

Hepatoblastoma also has dramatically decreased survival in children with pulmonary metastasis. Hepatoblastoma is sensitive to chemotherapy, and metastasectomy has been shown to be effective. Thus, the COG recommends a combined approach with neoadjuvant chemotherapy and subsequent total resection of the primary tumor and any pulmonary metastasis. Minimally invasive approaches to metastasectomy are widely accepted.

High-grade osteosarcoma accounts for roughly 5% of childhood malignancy. An important predicator of survival in this population is the presence of metastasis, and the lungs are the most common site for distant spread of malignancy. Though up to 10% of pulmonary metastasis are expected to regress with neoadjuvant chemotherapy, the remainder require surgical resection [40]. Interestingly, the timing of pulmonary metastasis is an important prognostic factor in children with osteosarcoma. Patients who experience pulmonary metastasis during chemotherapy have the worst survival [41].

### *Thoracoscopic Lobectomy in Infants and Neonates DOI: http://dx.doi.org/10.5772/intechopen.105431*

Unlike metastasectomy for Wilms tumor or hepatoblastoma, there has historically been vigorous debate about the use of thoracoscopic resection in patients with osteosarcoma. The discussion has hinged on the fact that direct palpation of the lung via thoracotomy had been shown to detect osteosarcoma metastases that were not identified on CT. The impact of such lesions on survival, however, was not well understood and most treatment was based on surgeon judgment.

Recently, though, a multi-institutional collaborative group compared overall and disease-free survival in patients with metastatic osteosarcoma undergoing thoracoscopy and thoracotomy. They found equivalent overall and pulmonary disease-free survival in patients with oligometastatic pulmonary disease. Thoracoscopy, however, was associated with inferior overall survival when including patients with greater pulmonary burden. Ultimately, further investigation is still needed to determine the best strategy for treating osteosarcoma patients with pulmonary metastasis [42, 43]. Work in this area is ongoing, and the Children's Oncology Group has launched a randomized controlled trial comparing thoracoscopic interventions with bilateral staged thoracotomies in children and adolescents with oligometastatic osteosarcoma [44].

In conclusion, though children with solid tumors fare much better than in decades prior, pulmonary metastases still portend worse outcomes, regardless of primary histology. Surgery has a role to play in both diagnostic and therapeutic settings. Thoracoscopy is widely accepted for most metastasectomies, but evidence is limited on the potential benefits of lung palpation via thoracotomy in patients with osteosarcoma who may have radiographically undetectable pulmonary lesions.

### **2.3 Diagnostic dilemmas**

In some groups of children, pulmonary resection is indicated due to diagnostic dilemmas. These typically occur when nodules or consolidations of unknown etiology develop and may represent malignancy or infection. This is observed in children requiring hematopoietic stem cell transplantation and immunosuppression. In these patients, such radiographic findings could result from infectious complications from their immunotherapy, progressive disease burden, or less frequently graft-versus-host disease. Thoracoscopic wedge resection with pathologic investigation of such ambiguous lesions is appropriate, as the potential for infection and malignancy have been described throughout this chapter [16, 19, 23, 25].

Another challenging situation occurs in the neonate suspected to have alveolar capillary dysplasia with misalignment of the pulmonary veins (ACD/MPV), which results from premature arrest of pulmonary development [45]. Although rare, the diagnosis should be considered in a neonate with unexplained persistent pulmonary hypertension (PPHN) [46]. Presentation is variable, but most infants have early onset respiratory distress [47]. Others will have a delayed presentation weeks to months after delivery [48]. A variety of coincidental defects in the cardiovascular, gastrointestinal, and urogenital systems have been documented [49]. Chest radiographs may demonstrate diffuse haziness or ground glass opacities but are frequently read as normal [50]. Echocardiograms can be useful for evaluation potential cardiac causes of PPHN.

Children with early onset symptoms typically demonstrate transient response to vasodilators, mechanical ventilation, and extra-corporeal membrane oxygenation but ultimately deteriorate and succumb to their disease without a transplantation [51–53]. Definitive diagnosis depends on surgical biopsy and tissue review by an experienced pediatric pathologist. Diagnostic clarity is essential in these cases as the prognosis is poor and early goals of care conversations are required.

### **3. Lobectomy considerations for infants and neonates**

Thoracoscopic pulmonary resections are a well-described alternative to more invasive approaches to lung surgery in the adult and adolescent population. As has been described throughout this chapter, there is broad applicability of this approach to the infant and neonatal population with congenital or malignant abnormalities of the chest. Many of the same considerations from adult surgery apply, but a few are unique to the pediatric population. They are outlined here.

### **3.1 Lung isolation**

Single lung ventilation is often necessary for successful thoracoscopic intervention as the lung is unable to be manually retracted. In adults and adolescents, there are a variety of options available to achieve this, including selective mainstem intubation, double lumen endotracheal tubes, Univent endotracheal tubes, and bronchial blockers. Neonates and infants, however, have smaller thoracic anatomy, which precludes the use of double lumen endotracheal or Univent tubes. Thus, selective mainstem intubation or bronchial blockers are required, though neither provides the same effectiveness as double lumen endotracheal tubes [54].

A major limitation to mainstem intubation is that the anesthesiologist cannot quickly change between single and two-lung ventilation as can be done with a double lumen device. Instead, they must reposition the endotracheal tube, which can result in accidental extubation. It should also be noted that mainstem intubation is particularly difficult on the left side, owing to the more acute angle of this bronchus.

Bronchial blockers can be used as an alternative to mainstem intubation. There are several candidate devices, including Fogarty catheters, pulmonary artery catheters, or the Arndt endobronchial blocker. Each of these can be used to occlude the bronchus on the operative side. The risk here is that the device becomes dislodged during the operation and occludes the tracheal lumen causing inadequate ventilation.

These considerations, although important, should not be prohibitive. Just as we advocate for neonatal thoracoscopic intervention in the hands of a skilled minimally invasive surgeon, so too attention should be placed on selecting an appropriately trained anesthesia staff with skills in neonatal intraoperative management. Such circumstances are a prerequisite for success during minimally invasive thoracic surgery of the infant or neonate [54].

### **3.2 Anatomic principles of lobectomy**

In general, the anatomic principles of lobectomy are similar in neonates, adolescents, and adults. Only the necessary amount of lung for negative margins should be resected to maintain pulmonary function. Care should be taken to operate in an atraumatic fashion and to achieve hemostasis before closure. Respect for the anatomic boundaries and plains of the lungs is paramount. The neonatal circulation has a much smaller overall blood reserve, so volume losses can be detrimental. It is generally safer to take vessels at the segmental level instead of main trunks, and this is more easily done thoracoscopically.

In patients undergoing nonanatomic resections, either due to incorporation of multiple lobes into the lesion, or the presence of fissure fusion, the Ligasure has been recommended to complete a multi-segmentectomy [6].

### **3.3 Thoracoscopic techniques**

Thoracoscopic lobectomy was first described in children by Steve Rothenberg for management of neonates with asymptomatic prenatally diagnosed lesions. He demonstrated that the skilled minimally invasive surgeon could safely and efficaciously apply thoracoscopic surgery to the small child in need of therapeutic lobectomy. Prior to this, the small size of young infants left surgeons unsure if their working space would be adequate for the large instrumentation required to complete a thoracoscopic resection.

His initial discussion of the thoracoscopic approach to neonatal lobectomy was limited to the previously discussed congenital lung malformations, but it now has broader applicability to the malignancies also mentioned in this chapter. Here we outline the modern technical details, which are built on his original approach [7].

Patients are placed in the lateral decubitus position and single lung ventilation is achieved via any of the approaches previously described for neonates. The surgeon and their assistant stand anterior to the patient while facing the surgical monitor. The first trocar is inserted, typically with an open technique, via the appropriate intercostal space based on the planed resection. As with other forms of minimally invasive surgery, the surgeon should attempt to "triangulate" their target for maximum maneuverability with the thoracoscopic instruments (**Figure 6**). If necessary, pneumothorax can be induced via insufflation with CO2. Two to three additional ports are placed under video guidance based on appropriate surgical planning. These will be used for the dissection instruments and sealing device, typically a curved bipolar.

The relevant fissures and lobar vessels are dissected and sealed using the electrocautery. Endoclips should be considered if the patient has a pulmonary sequestration, as care must be taken to ligate the systemic feeding artery. The bronchus is sharply divided and closed intracorporeally using the surgeon's preferred approach. This may include suturing or stapling. The former requires adeptness with intracorporal suturing, though the latter necessitates a larger incision. After completing the lobectomy, the upper incision is lengthened, and the lobe is withdrawn. If the specimen contains malignancy, special attention is given to avoid spillage. A chest tube is left in place.

**Figure 6.** *A) Port placement for upper and B) lower lobectomy.*

### **4. Pneumonectomy and other anatomic resections**

### **4.1 Surgical principles**

The principles of pneumonectomy, other anatomic resections, and wedge resections are similar in adults and children. Indications, as described above, include congenital pulmonary airway malformations, bronchopulmonary sequestrations, emphysema, and primary or metastatic malignancy. Lobectomy with en bloc tumor resection is the standard for patients with resectable cancers. Less extensive resections such as segmentectomy are chosen for patients who cannot tolerate lobectomy due to concern for limited pulmonary reserve [55].

The surgery is completed with the patient in the lateral decubitus position and the pleural space is entered through a posterolateral incision to provide exposure of the lung hilum. Inspection of the pleural space is performed; cytology and culture of any pleural fluid are completed as indicated. Arterial and venous supplies are identified, dissected, and divided at the hilum. Care should be taken not to injure the phrenic nerve when operating in the anterior hilum. Chest tubes are placed to drain residual fluid and support expansion of the residual lung.

### **4.2 Redo surgery**

Redo thoracoscopic surgery is fraught with challenges and requires a special attention to relevant anatomy [56]. Adhesions and scar tissue contribute to a difficult operative field, just as in the adult population [57, 58]. There is precedent for approaching redo operations of the neonatal chest thoracoscopically, and we support such a strategy based on individual surgeon judgment. Still, preparations should be in place in the event that the case must be converted to open [59]. In rare circumstances, an intrapericardial approach to lobectomy or pneumonectomy can be considered in the extremely hostile reoperative chest [60, 61].

### **5. Perioperative complications of thoracoscopic surgery in neonates and infants**

The feasibility and safety of thoracoscopic intervention have been rigorously reviewed in the adolescent population. It has been shown that the approach is not associated with increased risk compared with open surgery, while maintaining the previously described benefits of minimally invasive surgery. It is less thoroughly described in the infant and neonatal population, though we have discussed the common indications and emerging body of evidence, which supports its use in appropriate circumstances.

Reports of major complications from infant and neonatal thoracoscopy are limited but are summarized by a 2018 review published in the European Journal of Pediatric Surgery. Limited reporting of complications, small sample sizes, and study heterogeneity prevent the calculation of definitive complication rates in this population. Reported rates likely underestimate the true incidence due to reporting bias. Increased reporting of complications along with longitudinal patient series is encouraged to promote increased understanding of outcomes in this area and to guide decision-making when operative indications are equivocal [62].

*Thoracoscopic Lobectomy in Infants and Neonates DOI: http://dx.doi.org/10.5772/intechopen.105431*

### **5.1 Bleeding**

Bleeding is one of most common complications in infants and neonates undergoing thoracoscopic surgery. This is of particular importance in the pediatric population given the limited total blood volume. Careful communication with anesthesia is essential to ensure that appropriate blood volume is available at the beginning of a case. There are also several instruments available for management of the bleeding vessel or tissue, including Heme-o-lok clips, pretied ligatures such as the ENDOLOOP, and stapling devices. Energy sources can also be used to achieve hemostasis, with LigaSure, HARMONIC, and Ultrasonic shears being common examples. Care should be given to not damage surrounding tissue when achieving hemostasis with the application of heat, as this can result in its own set of complications, which ironically enough can include additional bleeding. Intracorporeal suturing is also an option [7]. Whatever the approach, rapid control of bleeding is essential and proceeding with a large open thoracotomy is sometimes necessary.

### **5.2 Air leak**

Persistent air leak is another commonly encountered complication of thoracoscopic surgery in neonates and infants. There are no evidence-based guidelines available for the management of this problem. Individual reports have demonstrated success with insertion of a secondary surgical chest tube, which has typically resulted in air leak resolution within a few days. In cases where the air leak has continued, reoperation with closure of a defect may be required. Chemical pleurodesis is well described in the adult population, but use of such toxic agents is discouraged in the pediatric population. There are limited reports of "autologous blood patching" wherein a bolus of the patient's own blood is injected into the pleural cavity through their chest tube [63]. Finally, there is a report of endobronchial occlusion of valves [64].

### **5.3 Conversion to open**

Conversion is an outcome that must be considered in all approaches to minimally invasive surgery, including thoracoscopy. Bleeding, poor visualization, lesion size, pulmonary congestion, dissection difficulty, and the presence of unexpected lesions are all potential causes of conversion [62].

### **6. Conclusions**

Thoracoscopic lobectomy is a strategy for surgical management of a wide range of pulmonary diseases in infants and children. These include congenital malformations, malignancies, and infections. There are similarities to resection in the adult population, but important differences exist too. The unique anatomic and physiologic principles of pediatric patients must be considered during surgical planning. The outcomes of these resections depend primarily on the underlying pathology.

### **Conflict of interest**

The authors declare no conflict of interest.

*Essentials of Pulmonary Lobectomy*

### **Author details**

Elisabeth T. Tracy1 \* and Steven W. Thornton2

1 Division of Pediatric Surgery, Duke University Department of Surgery, Durham, North Carolina, USA

2 Duke University Department of Surgery, Duke University School of Medicine, Durham, North Carolina, USA

\*Address all correspondence to: elisabeth.tracy@duke.edu

© 2022 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

*Thoracoscopic Lobectomy in Infants and Neonates DOI: http://dx.doi.org/10.5772/intechopen.105431*

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## Section 3
