The Realm of Oncological Lung Surgery: From Past to Present and Future Perspectives

*Alexander Maat, Amir Hossein Sadeghi, Ad Bogers and Edris Mahtab*

### **Abstract**

In this chapter, a historical overview as well as an overview of state of the art of the surgical techniques for the treatment of lung cancer is outlined. The chapter focuses on the introduction of open surgery, video-assisted thoracic surgery (VATS), uniportal VATS (UVATS), and robotic-assisted thoracic surgery (RATS) techniques for lung resections. A short introduction on upcoming techniques and modalities is given. The currently available tools as three-dimensional (3D) computed tomography (CT), virtual reality, and endo-bronchial surgery will be discussed. Based on the current development, this chapter attempts to delineate the horizon of oncological lung surgery. The information is generated not only from the available literature, but also from the experiences of surgeons and other physicians as well as co-workers involved in lung cancer treatment around the world. This chapter can be seen as a general introduction to several aspects of oncological lung surgery.

**Keywords:** lung cancer, lung surgery, VATS, UVATS, RATS, thoracotomy, virtual reality, endo-bronchial surgery

#### **1. Introduction**

For centuries, the inside of the chest cavity was a no-go area for complex surgical interventions. The problems of an open pneumothorax were already known by the ancient Greek Celsus around the year 30 AD noted: "as soon as the knife really penetrates to the chest, by cutting through the transverse septum, a sort of membrane which divides the upper from the lower parts, the man loses his life at once" [1].

At that time, drainage of an empyema as described by Hippocrates (approx. 460–375 BC) was the only feasible operation [2]. The first report of a successful lung resection is attributed to Roland of Parma in 1499 who resected the herniating part of a lung, days after a penetrating chest trauma [3]. In 1846, general anesthesia with ether had been introduced by William Morton in Boston, an extremely important step in the history of surgery.

During the mid-nineteenth century, when tuberculosis reached its highest incidence, it was recognized that a state of rigidity of the mediastinum permitted an open pneumothorax. Estlander of Helsingfors was one of the first to describe wide thoracoplasty in order to "rest" a lung affected by tuberculosis ("decostalisation of the chest" in 1879) [4].

#### *Update in Respiratory Diseases*

During the late nineteenth century, many experiments were carried out, mainly in animals, aimed at performing lobectomy and pneumonectomy. Usually these experiments were done in stages, the first procedure aiming at creating a state of fixation of the mediastinum. The world still was not ready yet for primary lung resections.

Further in this chapter, a historical overview and an overview of modern surgical techniques for the treatment of lung cancer are outlined. The focus is on the introduction of open surgery as well as the minimally invasive surgery. In addition, a short introduction to upcoming techniques and modalities is given.

## **2. The evolution of thoracic surgery: a journey through time**

#### **2.1 The first giant steps: aseptic approach, X-ray, and positive pressure ventilation**

During the late nineteenth century, Joseph Lister, based on Louis Pasteur's theory of micro-organisms, introduced the concept of asepsis in 1867. Surgeon's hands, instruments, and surgical wounds were sterilized with 5% carbolic acid (phenol) solution and a mist of phenol was sprayed into the surgical field [5]. This policy led to an extreme reduction of post-operative mortality and for this reason, Lister is regarded as the father of modern surgery. Caroline Hampton, chief nurse and later on the wife of William Halsted, one of the founding fathers of the John's Hopkins Hospital, developed severe dermatitis due to frequent exposure to phenol and mercuric chloride. This provoked Halsted to ask the Goodyear Company to develop rubber gloves to protect the hands of the surgical team. These became available at the end of 1890 and were soon used throughout the world [6].

The aftermath of the nineteenth century saw the discovery of X-ray by William Konrad Rontgen in 1895. For the first time in mankind, it became possible to identify large tumors in the chest when not shaded by the heart and other mediastinal structures. At the turn of the twentieth century, the major barrier to enable one stage intrathoracic surgery was that of the open pneumothorax. This is remarkable since the anatomist Vesalius in 1543 had extensively studied respiration and already studied tracheotomy and positive pressure ventilation. His ideas would be dormant for about 3.5 centuries [7]. Based on this concept that there should be a pressure difference between the intra-alveolar pressure and the atmospheric pressure, Sauerbruch, still an assistant of von Mikulicz, developed the negative pressure chamber [8]—a genius idea, but quite unpractical. Only two of these operation theaters were built worldwide, one in Germany and the other one in the German Hospital (today the Lenox-Hill hospital) in New York where the surgeon Willy Meyer, emigrated to the USA from Germany in 1884, added a small positive pressure chamber over the patients head in 1909, this was called the super chamber but it was never clinically used [9]. Willy Meyer would become one of the founding fathers of the American Association for Thoracic Surgery (AATS) in 1918.

In the same year, 1909, and also in New York, Meltzer and his son-in-law Auer launched their concept of positive pressure ventilation, using a flexible silk woven tracheal catheter and a continuous stream of air mixed with ether [10]. Their concept was the birth of modern anesthesia. Recognizing that this was an enormous step forward, Meltzer was invited to become the first president of the AATS. In a speech delivered at the founding meeting of the AATS, Willy Meyers stated: "The thorax was the last fortress to be attacked and it has been laid open safely to the surgeon's knife" [9].

**101**

*The Realm of Oncological Lung Surgery: From Past to Present and Future Perspectives*

Lung cancer was a very rare disease in the beginning of the twentieth century. In 1919, Alton Ochsner, as a medical student was invited with his whole class to witness an autopsy of a patient who died of lung cancer. The pathologist announced that no one in that class would ever again see another such case [11]. It took 17 years before Ochsner, who had become a surgeon, saw his second case, followed by 8 other cases in the 6 following months. All of these patients were male and had served as soldiers in World War I and in the line of duty they had taken up the habit of smoking, provoked by mass advertisements promoting smoking. Ochsner was amongst the first surgeons to correlate smoking to the development of lung cancer [12]. With the lung cancer epidemic which started after World War I, the number of patients with potentially resectable lung cancer increased significantly. Two major surgical items had to be settled; should a lung resection for cancer be a lobectomy or a pneumonectomy and what is the best surgical technique? Is it mass hilar ligation or anatomical dissection? The first report on lobectomy for lung cancer was that of Edward Churchill (Boston) in 1932 [13]. One year later, Evarts Graham, while intending to perform a lobectomy, was forced to perform a pneumonectomy because the tumor was very centrally located in the hilum at the origin of the left upper lobe (bronchoplastic procedures such as sleeve resection had not been developed yet) [14]. For a considerably long period, pneumonectomy was regarded as the golden standard for all lung cancer patients. Lobectomy by many was considered inferior and compared with lumpectomy without resection of loco-regional lymph nodes in breast cancer [15]. Only in 1962, a large case series between pneumonectomy and lobectomy were compared showing that lobectomy was equivalent to pneumonectomy as a cancer operation but with a lower rate of

**2.3 Fundamental steps in the development of state-of-the-art lung surgery**

With respect to surgical technique, there was no consensus on hilar control; mass ligation or anatomical dissection and step-by-step control of the hilar structures. Cadaveric studies performed by Blades and Kent in the early 1940s pushed the world toward the latter, later supported by several publications of Boyes on the

With this knowledge, Clement Thomas Price (London, 1947) introduced the concept of parenchyma sparing operations, having done the first anatomical segmentectomy in a lung cancer patient [18]. The first sleeve resection for bronchogenic carcinoma was performed in 1952 [19]. Consequently, it was around the mid-1950s the four main operations in lung cancer as we know today were in the armamentarium of the thoracic surgeon: pneumonectomy, lobectomy, sleeve

A major step forward was the introduction of double lumen endo-tracheal tube by Carlens in 1949 [20]. With this selective single lung ventilation concept, modern lung surgery is greatly facilitated, particularly, the endoscopic and robotic tech-

Diagnostic techniques were still very primitive in that era compared with today's standards. Besides standard chest X-ray, there was rigid bronchoscopy, bronchography, planography, and cytology. The concept of staging had to be developed yet. Exploratory thoracotomy in "operable patients" was performed with a very low threshold, not to lose time. Some authors reported up to 50% inoperability [21]. In the Amsterdam University Hospital between 1955 and 1960 in a series of 100

*DOI: http://dx.doi.org/10.5772/intechopen.90658*

complications and mortality [16].

lobectomy, and segmentectomy.

intrahilar anatomy of the lung segments [10, 17].

niques used nowadays (discussed later in this chapter).

**2.2 Smoking induced global lung cancer epidemic**

*The Realm of Oncological Lung Surgery: From Past to Present and Future Perspectives DOI: http://dx.doi.org/10.5772/intechopen.90658*

#### **2.2 Smoking induced global lung cancer epidemic**

*Update in Respiratory Diseases*

resections.

**ventilation**

During the late nineteenth century, many experiments were carried out, mainly in animals, aimed at performing lobectomy and pneumonectomy. Usually these experiments were done in stages, the first procedure aiming at creating a state of fixation of the mediastinum. The world still was not ready yet for primary lung

Further in this chapter, a historical overview and an overview of modern surgical techniques for the treatment of lung cancer are outlined. The focus is on the introduction of open surgery as well as the minimally invasive surgery. In addition,

a short introduction to upcoming techniques and modalities is given.

**2. The evolution of thoracic surgery: a journey through time**

able at the end of 1890 and were soon used throughout the world [6].

The aftermath of the nineteenth century saw the discovery of X-ray by William Konrad Rontgen in 1895. For the first time in mankind, it became possible to identify large tumors in the chest when not shaded by the heart and other mediastinal structures. At the turn of the twentieth century, the major barrier to enable one stage intrathoracic surgery was that of the open pneumothorax. This is remarkable since the anatomist Vesalius in 1543 had extensively studied respiration and already studied tracheotomy and positive pressure ventilation. His ideas would be dormant for about 3.5 centuries [7]. Based on this concept that there should be a pressure difference between the intra-alveolar pressure and the atmospheric pressure, Sauerbruch, still an assistant of von Mikulicz, developed the negative pressure chamber [8]—a genius idea, but quite unpractical. Only two of these operation theaters were built worldwide, one in Germany and the other one in the German Hospital (today the Lenox-Hill hospital) in New York where the surgeon Willy Meyer, emigrated to the USA from Germany in 1884, added a small positive pressure chamber over the patients head in 1909, this was called the super chamber but it was never clinically used [9]. Willy Meyer would become one of the founding

fathers of the American Association for Thoracic Surgery (AATS) in 1918.

In the same year, 1909, and also in New York, Meltzer and his son-in-law Auer launched their concept of positive pressure ventilation, using a flexible silk woven tracheal catheter and a continuous stream of air mixed with ether [10]. Their concept was the birth of modern anesthesia. Recognizing that this was an enormous step forward, Meltzer was invited to become the first president of the AATS. In a speech delivered at the founding meeting of the AATS, Willy Meyers stated: "The thorax was the last fortress to be attacked and it has been laid open safely to the

**2.1 The first giant steps: aseptic approach, X-ray, and positive pressure** 

During the late nineteenth century, Joseph Lister, based on Louis Pasteur's theory of micro-organisms, introduced the concept of asepsis in 1867. Surgeon's hands, instruments, and surgical wounds were sterilized with 5% carbolic acid (phenol) solution and a mist of phenol was sprayed into the surgical field [5]. This policy led to an extreme reduction of post-operative mortality and for this reason, Lister is regarded as the father of modern surgery. Caroline Hampton, chief nurse and later on the wife of William Halsted, one of the founding fathers of the John's Hopkins Hospital, developed severe dermatitis due to frequent exposure to phenol and mercuric chloride. This provoked Halsted to ask the Goodyear Company to develop rubber gloves to protect the hands of the surgical team. These became avail-

**100**

surgeon's knife" [9].

Lung cancer was a very rare disease in the beginning of the twentieth century. In 1919, Alton Ochsner, as a medical student was invited with his whole class to witness an autopsy of a patient who died of lung cancer. The pathologist announced that no one in that class would ever again see another such case [11]. It took 17 years before Ochsner, who had become a surgeon, saw his second case, followed by 8 other cases in the 6 following months. All of these patients were male and had served as soldiers in World War I and in the line of duty they had taken up the habit of smoking, provoked by mass advertisements promoting smoking. Ochsner was amongst the first surgeons to correlate smoking to the development of lung cancer [12]. With the lung cancer epidemic which started after World War I, the number of patients with potentially resectable lung cancer increased significantly. Two major surgical items had to be settled; should a lung resection for cancer be a lobectomy or a pneumonectomy and what is the best surgical technique? Is it mass hilar ligation or anatomical dissection? The first report on lobectomy for lung cancer was that of Edward Churchill (Boston) in 1932 [13]. One year later, Evarts Graham, while intending to perform a lobectomy, was forced to perform a pneumonectomy because the tumor was very centrally located in the hilum at the origin of the left upper lobe (bronchoplastic procedures such as sleeve resection had not been developed yet) [14]. For a considerably long period, pneumonectomy was regarded as the golden standard for all lung cancer patients. Lobectomy by many was considered inferior and compared with lumpectomy without resection of loco-regional lymph nodes in breast cancer [15]. Only in 1962, a large case series between pneumonectomy and lobectomy were compared showing that lobectomy was equivalent to pneumonectomy as a cancer operation but with a lower rate of complications and mortality [16].

#### **2.3 Fundamental steps in the development of state-of-the-art lung surgery**

With respect to surgical technique, there was no consensus on hilar control; mass ligation or anatomical dissection and step-by-step control of the hilar structures. Cadaveric studies performed by Blades and Kent in the early 1940s pushed the world toward the latter, later supported by several publications of Boyes on the intrahilar anatomy of the lung segments [10, 17].

With this knowledge, Clement Thomas Price (London, 1947) introduced the concept of parenchyma sparing operations, having done the first anatomical segmentectomy in a lung cancer patient [18]. The first sleeve resection for bronchogenic carcinoma was performed in 1952 [19]. Consequently, it was around the mid-1950s the four main operations in lung cancer as we know today were in the armamentarium of the thoracic surgeon: pneumonectomy, lobectomy, sleeve lobectomy, and segmentectomy.

A major step forward was the introduction of double lumen endo-tracheal tube by Carlens in 1949 [20]. With this selective single lung ventilation concept, modern lung surgery is greatly facilitated, particularly, the endoscopic and robotic techniques used nowadays (discussed later in this chapter).

Diagnostic techniques were still very primitive in that era compared with today's standards. Besides standard chest X-ray, there was rigid bronchoscopy, bronchography, planography, and cytology. The concept of staging had to be developed yet. Exploratory thoracotomy in "operable patients" was performed with a very low threshold, not to lose time. Some authors reported up to 50% inoperability [21]. In the Amsterdam University Hospital between 1955 and 1960 in a series of 100

exploratory thoracotomies in patients who were found to be inoperable, 54% of patients had complications and 9 of the 100 patients died due to post-operative complications [22]. In 63% of the cases, mediastinal ingrowth or large irresectable nodes were found. In 23%, there was in growth in heart and/or major vessels, 12% ingrowth into the thoracic wall, 1% in growth in the diaphragm, and 1% pleural carcinomatosis. By far, mediastinal involvement was the leading cause of inoperability. In 1959, Carlens had published his experience with 100 mediastinoscopies [20]. The morbidity of this technique was 2.5% and the mortality was less than 0.5%, way better then exploratory thoracotomy. The Amsterdam team embraced mediastinoscopy and combined this in a series of operable patients with bronchoscopy and on indication diagnostic pneumothorax. Due to the mediastinoscopy findings, the resection rate in Amsterdam rose from 60 to 94% with 12% false positive mediastinoscopies [20]. Years later, in 1984, Griffith Pearson published a landmark paper showing that when positive mediastinal nodes were found, any subsequent lung resection would not cure a patient [23].

The world was waiting for methods to better identify loco-regional progression and distant metastases. Hounsfield, by combining tomography images with the calculating power of a computer, constructed the first computed tomography (CT) scanner, first for brain scans only, but in 1975 he and his team built the first whole body scanner. The computed tomography (CT) scanner was soon to be followed by the magnetic resonance imaging (MRI) scanner in 1977, while the next big step was the combination of positron emission tomography (PET) and CT scanners in 1991. The use of mediastinoscopy has declined after the introduction of ultrasoundguided examinations of the mediastinum and the hilum (endo-esophageal ultrasound (EUS) and endo-bronchial ultrasound bronchoscopy (EBUS)), but is still used on a regular base when the latter techniques fall short.

#### **2.4 The rise of minimally invasive lung surgery**

For decades, postero-lateral thoracotomy has been the preferred entrance for most lung resections (**Figure 1A**). However, the price of an excellent exposure to the lung hilum came with high percentages of long standing post-operative pain, discomfort, and functional loss.

The Swedish internist Jacobeus is often positioned as the founding father of thoracoscopy but in fact, it was the British surgeon Francis Richard Cruse who already had published this technique in 1865 [24].

The first thoracoscopic resections were not immediately embraced by the surgical community. Ralph Lewis was the first one to publish a series of 100 lobectomies done thoracoscopically [25]. Lacking experience, tailor-made instruments, and specific endo-staplers, these resections were performed using a mass stapling technique. In Los Angeles, Robert McKenna worked out a standardized approach for video-assisted thoracic surgery (VATS) lobectomy (**Figure 1B**), working through the hilum from anterior to posterior; in 2006, he published a series of 1100 cases [26].

This provoked surgeons around the world to adapt this technique and today in many hospitals, it is the preferred approach for the majority of cases. In 2019, Eric Lim published the results of the VIOLET trial, a prospective randomized trial between VATS and thoracotomy in lung cancer patients. VATS showing to be superior with respect to major adverse events, less pain on post-operative day 2 and shorter median hospital stay with an equal oncological outcome (number of lymph nodes harvested and upstaged and R-0 resections) [27].

Studies on chronic pain (pain for which patients visit a doctor 3 months postoperative), however, did not show a major difference in pain between thoracotomy

**103**

(**Figure 1C**).

**Figure 1.**

with a subxiphoid approach [32].

*The Realm of Oncological Lung Surgery: From Past to Present and Future Perspectives*

patients and VATS patients 3–6 months post-operatively [28]. Chronic pain after VATS is often contributed to the insult of multiple intercostal nerves by trocars and instruments. It has to be seen whether the explanation is that simple, however, it moved surgeons to search for even less invasive methods, eventually leading to the concept of uniportal VATS (UVATS), first proposed by Rocco in 2004 [29]

*Overview of the surgical approaches for treatment of lung cancer. (A) Postero-lateral thoracotomy, (B) 3 ports, video-assisted thoracic surgery (VATS), (C) uniportal video-assisted thoracic surgery (UVATS), (D) robotic-*

There is still no proof that an UVATS approach leads to less pain, discomfort,

With the idea of intercostal nerve damage in mind, surgeons have also explored other VATS-assisted intrathoracic pathways like subxiphoid and cervical approaches [30, 31]. Others are exploring a hybrid approach, combining 5 mm intercostal ports

and loss of functionality compared with multiple port VATS.

*assisted thoracic surgery (RATS), and (E) endo-bronchial surgery.*

*DOI: http://dx.doi.org/10.5772/intechopen.90658*

*The Realm of Oncological Lung Surgery: From Past to Present and Future Perspectives DOI: http://dx.doi.org/10.5772/intechopen.90658*

#### **Figure 1.**

*Update in Respiratory Diseases*

resection would not cure a patient [23].

used on a regular base when the latter techniques fall short.

**2.4 The rise of minimally invasive lung surgery**

discomfort, and functional loss.

had published this technique in 1865 [24].

nodes harvested and upstaged and R-0 resections) [27].

exploratory thoracotomies in patients who were found to be inoperable, 54% of patients had complications and 9 of the 100 patients died due to post-operative complications [22]. In 63% of the cases, mediastinal ingrowth or large irresectable nodes were found. In 23%, there was in growth in heart and/or major vessels, 12% ingrowth into the thoracic wall, 1% in growth in the diaphragm, and 1% pleural carcinomatosis. By far, mediastinal involvement was the leading cause of inoperability. In 1959, Carlens had published his experience with 100 mediastinoscopies [20]. The morbidity of this technique was 2.5% and the mortality was less than 0.5%, way better then exploratory thoracotomy. The Amsterdam team embraced mediastinoscopy and combined this in a series of operable patients with bronchoscopy and on indication diagnostic pneumothorax. Due to the mediastinoscopy findings, the resection rate in Amsterdam rose from 60 to 94% with 12% false positive mediastinoscopies [20]. Years later, in 1984, Griffith Pearson published a landmark paper showing that when positive mediastinal nodes were found, any subsequent lung

The world was waiting for methods to better identify loco-regional progression and distant metastases. Hounsfield, by combining tomography images with the calculating power of a computer, constructed the first computed tomography (CT) scanner, first for brain scans only, but in 1975 he and his team built the first whole body scanner. The computed tomography (CT) scanner was soon to be followed by the magnetic resonance imaging (MRI) scanner in 1977, while the next big step was the combination of positron emission tomography (PET) and CT scanners in 1991. The use of mediastinoscopy has declined after the introduction of ultrasoundguided examinations of the mediastinum and the hilum (endo-esophageal ultrasound (EUS) and endo-bronchial ultrasound bronchoscopy (EBUS)), but is still

For decades, postero-lateral thoracotomy has been the preferred entrance for most lung resections (**Figure 1A**). However, the price of an excellent exposure to the lung hilum came with high percentages of long standing post-operative pain,

The Swedish internist Jacobeus is often positioned as the founding father of thoracoscopy but in fact, it was the British surgeon Francis Richard Cruse who already

The first thoracoscopic resections were not immediately embraced by the surgical

community. Ralph Lewis was the first one to publish a series of 100 lobectomies done thoracoscopically [25]. Lacking experience, tailor-made instruments, and specific endo-staplers, these resections were performed using a mass stapling technique. In Los Angeles, Robert McKenna worked out a standardized approach for video-assisted thoracic surgery (VATS) lobectomy (**Figure 1B**), working through the hilum from anterior to posterior; in 2006, he published a series of 1100 cases [26]. This provoked surgeons around the world to adapt this technique and today in many hospitals, it is the preferred approach for the majority of cases. In 2019, Eric Lim published the results of the VIOLET trial, a prospective randomized trial between VATS and thoracotomy in lung cancer patients. VATS showing to be superior with respect to major adverse events, less pain on post-operative day 2 and shorter median hospital stay with an equal oncological outcome (number of lymph

Studies on chronic pain (pain for which patients visit a doctor 3 months postoperative), however, did not show a major difference in pain between thoracotomy

**102**

*Overview of the surgical approaches for treatment of lung cancer. (A) Postero-lateral thoracotomy, (B) 3 ports, video-assisted thoracic surgery (VATS), (C) uniportal video-assisted thoracic surgery (UVATS), (D) roboticassisted thoracic surgery (RATS), and (E) endo-bronchial surgery.*

patients and VATS patients 3–6 months post-operatively [28]. Chronic pain after VATS is often contributed to the insult of multiple intercostal nerves by trocars and instruments. It has to be seen whether the explanation is that simple, however, it moved surgeons to search for even less invasive methods, eventually leading to the concept of uniportal VATS (UVATS), first proposed by Rocco in 2004 [29] (**Figure 1C**).

There is still no proof that an UVATS approach leads to less pain, discomfort, and loss of functionality compared with multiple port VATS.

With the idea of intercostal nerve damage in mind, surgeons have also explored other VATS-assisted intrathoracic pathways like subxiphoid and cervical approaches [30, 31]. Others are exploring a hybrid approach, combining 5 mm intercostal ports with a subxiphoid approach [32].

#### *Update in Respiratory Diseases*

Almost parallel with the introduction and evolution of VATS, the world saw the introduction of robotic-assisted thoracic surgery (RATS), first published by Franca Melfi and her team [33] (**Figure 1D**).

Up till now, no significant differences have been shown in complications and outcome between VATS, UVATS, and RATS [34]. The major reason that the introduction of RATS lagged behind in many institutions is a financial reason; it is not cost-efficient. In the meantime, VATS has evolutionized to three-dimensional VATS (3D VATS) and robotic-like instruments have become available for laparoscopic and VATS procedures.

## *2.4.1 Sub-lobar resection: the rise of segmentectomy*

During the last decade, there is a growing interest in lung parenchyma-sparing resections. This need is more highlighted by the results of the two largest population based national screening studies (NLST, 2011 and NELSON, 2018) showing that discovery and resection of early stage lung cancer through screening programs lead to significantly better survival of patients [35, 36]. The NLST study showed a reduction of 20% in lung cancer mortality for annual screening over 3 years with low-dose CT with a greater benefit for screening in women. The NELSON study showed for screening with low-dose CT, a 26% reduction of lung cancer mortality in high-risk men and up to 61% reduction of lung cancer mortality in high-risk women over a 10-year period. Nowadays, there is a trend toward sub-lobar resection as segmentectomy, making the oncological lung surgery even more challenging. Moreover, this makes the role of peri-operative diagnostic tools as fluorescent indocyanine green (ICG) [37], 3D-CT modalities, and (navigational) bronchoscopy interventions (next section, **Figure 1E**) indispensable. Because of its anatomical complexity, many surgeons hesitate to perform segmentectomy. For this reason, in 2012, Hiroaki Nomori and Morihito Okada published the book "Illustrated Anatomical Segmentectomy for Lung Cancer" which is an essential book for surgeons starting a segmentectomy program at their centers. In 2019, segmentectomy is mostly performed in countries of Eastern Asia, such as Japan, followed by few centers in the USA and Western Europe.

## **3. Advances in thoracic imaging facilitating minimally invasive lung surgery: a brief outlook into the future**

Over the past few decades, imaging modalities such as CT, PET-CT, and standard chest X-ray imaging have played a key role in the non-invasive diagnostic work-up of thoracic disease. In addition, these imaging modalities are an essential part of the preoperative planning process of thoracic surgical procedures. Even though there is a broad range of clinical indications for various thoracic imaging modalities and the information provided by all different modalities is different, the purpose of this section is not to undertake a comprehensive evaluation of the characteristics of these imaging modalities. Specifically, this section will focus on innovative preoperative and intraoperative imaging modalities as a surgical planning and navigation tools and provide a brief overview of new developments in medical imaging, especially in the context of (oncologic) pulmonary resections.

#### **3.1 Three-dimensional computed tomography (3D-CT)**

In the setting of oncologic thoracic surgery, a standard chest CT scan can be used to evaluate the extensiveness of disease in terms of pleural, mediastinal, chest

**105**

*The Realm of Oncological Lung Surgery: From Past to Present and Future Perspectives*

wall, or vascular involvement. In addition, the CT scan is used to study the surgical anatomy of the pulmonary artery (and its major branches), pulmonary vein, and bronchial structures when a resection of the lung parenchyma is planned. Due to the establishment and development of more modern multislice CT scanners, it has become easier to detect smaller peripheral tumors. While this has enabled more diagnostic accuracy, it has resulted in an increased clinical use of sublobar anatomic resections. Specifically, in the setting of anatomic segmental pulmonary resections, which are technically and anatomically more demanding and complex, there is a need for more accurate imaging modalities that enables better preoperative knowledge of the surgical anatomy (such as bronchial and vascular anatomy in sublobar/ segmental levels). Recently, an increasing number of scientific reports have been published on the use of preoperative three-dimensional (3D)-CT reconstruction as a surgical planning tool before anatomic resection of pulmonary segments or lobes [38–42]. According to some of these studies, the preoperative use of 3D-CT reconstructed images is feasible and safe and, in some cases, associated with shorter operative time due to better preoperative understanding of surgical anatomy [38, 42]. In order to obtain 3D-CT image reconstructions, different methods are described and various (free open-source) software packets are available [42–44]. However, there are also limitations regarding the utility of software to reconstruct 3D images of CT scans. For example, the identification and separation of the pulmonary artery and vein may be a challenging and time-consuming process. Moreover, in some cases, a contrast-enhanced CT scan is required to create 3D-simulations, which increases the risks of radiation exposure. In addition, the reconstruction commonly requires technical support and the assistance of radiology and information and communica-

Oizumi et al. reported a study on the use of 3D reconstruction of multidetector CT (MDCT) images in order to plan and guide pulmonary segmentectomy preoperatively and during surgery [38]. It was noted that after the introduction of 3D-CT reconstruction, the number of (fairly) difficult classified segmentectomies that have been performed increased significantly, suggesting that preoperative 3D-CT simulation contributes fairly to the efficacy of surgical planning of complex segmentectomies. In addition, in a retrospective analysis of patients undergoing thoracoscopic segmentectomy reported by Xue et al., the authors found that when preoperative 3D-CT reconstruction was used to make operation plans, in 19% of the cases, the operation plan was changed due to the results of 3D simulation [42]. The original surgical plan of these cases was changed due to the expectation of an inadequate resection margin distance, based on pre-operative simulation results. This indicates that preoperative 3D simulation not only contributes to technical feasibility and efficacy of surgery, but also to the decision-making process from an oncological point of view. Even though an increasing number of studies on the use of 3D-CT simulation are being published, the majority of them do not report on the differences in parameters of clinical outcome (such as perioperative blood loss, post-operative stay, and conversion rates to thoracotomy) but focus more on technical aspects and feasibility of 3D-simulation and surgery. However, the majority of reports do recognize the following advantages of preoperative 3D-simulation in the context of (sub-)lobar pulmonary resection: (1) classification and identification of anatomical (vascular and bronchial) abnormalities; (2) identification of unsuitable surgical cases for segmentectomy; (3) training of less experienced thoracic surgeons and surgical residents; (4) preoperative estimation of proper surgical resection margin; (5) a stepwise preoperative surgical planning; and (6) intraoperative navigation for identifica-

3D-CT-mediated preoperative surgical planning and intraoperative guidance of (oncological) pulmonary surgery could contribute significantly to the development

*DOI: http://dx.doi.org/10.5772/intechopen.90658*

tion technology (ICT) experts.

tion of anatomical structures [38, 40–42].

#### *The Realm of Oncological Lung Surgery: From Past to Present and Future Perspectives DOI: http://dx.doi.org/10.5772/intechopen.90658*

wall, or vascular involvement. In addition, the CT scan is used to study the surgical anatomy of the pulmonary artery (and its major branches), pulmonary vein, and bronchial structures when a resection of the lung parenchyma is planned. Due to the establishment and development of more modern multislice CT scanners, it has become easier to detect smaller peripheral tumors. While this has enabled more diagnostic accuracy, it has resulted in an increased clinical use of sublobar anatomic resections. Specifically, in the setting of anatomic segmental pulmonary resections, which are technically and anatomically more demanding and complex, there is a need for more accurate imaging modalities that enables better preoperative knowledge of the surgical anatomy (such as bronchial and vascular anatomy in sublobar/ segmental levels). Recently, an increasing number of scientific reports have been published on the use of preoperative three-dimensional (3D)-CT reconstruction as a surgical planning tool before anatomic resection of pulmonary segments or lobes [38–42]. According to some of these studies, the preoperative use of 3D-CT reconstructed images is feasible and safe and, in some cases, associated with shorter operative time due to better preoperative understanding of surgical anatomy [38, 42]. In order to obtain 3D-CT image reconstructions, different methods are described and various (free open-source) software packets are available [42–44]. However, there are also limitations regarding the utility of software to reconstruct 3D images of CT scans. For example, the identification and separation of the pulmonary artery and vein may be a challenging and time-consuming process. Moreover, in some cases, a contrast-enhanced CT scan is required to create 3D-simulations, which increases the risks of radiation exposure. In addition, the reconstruction commonly requires technical support and the assistance of radiology and information and communication technology (ICT) experts.

Oizumi et al. reported a study on the use of 3D reconstruction of multidetector CT (MDCT) images in order to plan and guide pulmonary segmentectomy preoperatively and during surgery [38]. It was noted that after the introduction of 3D-CT reconstruction, the number of (fairly) difficult classified segmentectomies that have been performed increased significantly, suggesting that preoperative 3D-CT simulation contributes fairly to the efficacy of surgical planning of complex segmentectomies. In addition, in a retrospective analysis of patients undergoing thoracoscopic segmentectomy reported by Xue et al., the authors found that when preoperative 3D-CT reconstruction was used to make operation plans, in 19% of the cases, the operation plan was changed due to the results of 3D simulation [42]. The original surgical plan of these cases was changed due to the expectation of an inadequate resection margin distance, based on pre-operative simulation results. This indicates that preoperative 3D simulation not only contributes to technical feasibility and efficacy of surgery, but also to the decision-making process from an oncological point of view.

Even though an increasing number of studies on the use of 3D-CT simulation are being published, the majority of them do not report on the differences in parameters of clinical outcome (such as perioperative blood loss, post-operative stay, and conversion rates to thoracotomy) but focus more on technical aspects and feasibility of 3D-simulation and surgery. However, the majority of reports do recognize the following advantages of preoperative 3D-simulation in the context of (sub-)lobar pulmonary resection: (1) classification and identification of anatomical (vascular and bronchial) abnormalities; (2) identification of unsuitable surgical cases for segmentectomy; (3) training of less experienced thoracic surgeons and surgical residents; (4) preoperative estimation of proper surgical resection margin; (5) a stepwise preoperative surgical planning; and (6) intraoperative navigation for identification of anatomical structures [38, 40–42].

3D-CT-mediated preoperative surgical planning and intraoperative guidance of (oncological) pulmonary surgery could contribute significantly to the development

*Update in Respiratory Diseases*

VATS procedures.

Melfi and her team [33] (**Figure 1D**).

*2.4.1 Sub-lobar resection: the rise of segmentectomy*

centers in the USA and Western Europe.

**surgery: a brief outlook into the future**

especially in the context of (oncologic) pulmonary resections.

**3.1 Three-dimensional computed tomography (3D-CT)**

Almost parallel with the introduction and evolution of VATS, the world saw the introduction of robotic-assisted thoracic surgery (RATS), first published by Franca

Up till now, no significant differences have been shown in complications and outcome between VATS, UVATS, and RATS [34]. The major reason that the introduction of RATS lagged behind in many institutions is a financial reason; it is not cost-efficient. In the meantime, VATS has evolutionized to three-dimensional VATS (3D VATS) and robotic-like instruments have become available for laparoscopic and

During the last decade, there is a growing interest in lung parenchyma-sparing resections. This need is more highlighted by the results of the two largest population based national screening studies (NLST, 2011 and NELSON, 2018) showing that discovery and resection of early stage lung cancer through screening programs lead to significantly better survival of patients [35, 36]. The NLST study showed a reduction of 20% in lung cancer mortality for annual screening over 3 years with low-dose CT with a greater benefit for screening in women. The NELSON study showed for screening with low-dose CT, a 26% reduction of lung cancer mortality in high-risk men and up to 61% reduction of lung cancer mortality in high-risk women over a 10-year period. Nowadays, there is a trend toward sub-lobar resection as segmentectomy, making the oncological lung surgery even more challenging. Moreover, this makes the role of peri-operative diagnostic tools as fluorescent indocyanine green (ICG) [37], 3D-CT modalities, and (navigational) bronchoscopy interventions (next section, **Figure 1E**) indispensable. Because of its anatomical complexity, many surgeons hesitate to perform segmentectomy. For this reason, in 2012, Hiroaki Nomori and Morihito Okada published the book "Illustrated Anatomical Segmentectomy for Lung Cancer" which is an essential book for surgeons starting a segmentectomy program at their centers. In 2019, segmentectomy is mostly performed in countries of Eastern Asia, such as Japan, followed by few

**3. Advances in thoracic imaging facilitating minimally invasive lung** 

Over the past few decades, imaging modalities such as CT, PET-CT, and standard chest X-ray imaging have played a key role in the non-invasive diagnostic work-up of thoracic disease. In addition, these imaging modalities are an essential part of the preoperative planning process of thoracic surgical procedures. Even though there is a broad range of clinical indications for various thoracic imaging modalities and the information provided by all different modalities is different, the purpose of this section is not to undertake a comprehensive evaluation of the characteristics of these imaging modalities. Specifically, this section will focus on innovative preoperative and intraoperative imaging modalities as a surgical planning and navigation tools and provide a brief overview of new developments in medical imaging,

In the setting of oncologic thoracic surgery, a standard chest CT scan can be used to evaluate the extensiveness of disease in terms of pleural, mediastinal, chest

**104**

of more accurate and safer (sublobar) anatomic resections. In the near future, this technology will become more common in thoracic surgery. However, in order to reach that stage, some (mostly technical) limitations need to be overcome.

## **3.2 Virtual reality, augmented reality, and mixed reality**

Virtual reality (VR) is a technology that enables users to interact with a computer-generated virtual 3D interface (**Figure 2**). More interestingly, in augmented reality (AR), the user is able to overlay aspects of the VR world within the real physical world. Finally, mixed reality (MR) allows users to create a hybrid physical and virtual world and offers the possibility to interact and analyze objects in the physical world by virtual projections [45, 46].

Recently, surgical intraoperative navigation as well as preoperative surgical simulation based on VR, MR, and AR have been developed and successfully used in various surgical fields including neurosurgery, liver surgery, kidney surgery, and orthopedic surgery [47–51]. In contrast to 2D interfaces (e.g. conventional CT scans), VR, MR, and AR enable not only visualization of anatomical structures but also allow interactive manipulation of the digital information (e.g. anatomic structures) provided by (wearable) computer-integrated devices (such as the Microsoft Hololens or the Google Glass). It has been suggested that these new interfaces might have the potential to benefit both the surgeon and the patient. For surgeons, this benefit comes by the way of improved preoperative surgical planning, better and more accurate intraoperative imaging guidance, and a better preoperative awareness of anatomical abnormalities. Patients will potentially benefit from shorter operative time, shorter length of hospital stay, and improved outcomes. Additionally, AR, VR, and MR offer the possibility to simulate surgical situations as well as facilitating training for surgeons and residents. In the field of thoracic surgery, some of these modalities have been used over the past few years in order to train surgical residents and surgeons to master the techniques necessary for minimally invasive lung surgery [52].

However, only very few reports are available on the use of AR, VR, or MR for surgical planning or intraoperative navigation for lung surgery [53–55]. Frajhof

#### **Figure 2.**

*An example of virtual reality application during minimally invasive lung cancer surgery in the operating theater.*

**107**

*The Realm of Oncological Lung Surgery: From Past to Present and Future Perspectives*

et al. recently published a study on the use of AR, VR, and MR technology in the preoperative planning of a technically demanding VATS left upper lobectomy [53]. In another study from Rouzé et al., augmented reality was used as a navigation tool in combination with cone beam CT (CBCT) to guide intraoperative localization of pulmonary nodules for wedge resection through VATS. The investigators firstly localized the lesions by CBCT intraoperatively. Subsequently, a 3D reconstruction of the nodule was created by using software. After this, an augmented fluoroscopic 3D image of the pulmonary nodule was projected on a screen in front of the operating table. By this, the surgeon was able to localize the lesion intraoperatively and

Interestingly, also some reports are available on the use of VR 3D reconstruction of the airways, known as virtual bronchoscopy, specifically used as a diagnostic aid tool in the assessment of airway masses and stenosis [56, 57]. Virtual bronchoscopy contributes fairly to the diagnostic process since it enables diagnostic maneuvers, such as assessing bronchial anatomy distally from stenoses, which are not possible with standard flexible bronchoscopy. Moreover, virtual bronchoscopy is a noninvasive method and does not bear any additional risks (e.g. radiation exposure or iatrogenic airway damage) for patients. Despite these advantages, virtual bronchoscopy is not expected to completely replace flexible bronchoscopy due to some limitations. For example, tumor boundaries can be misjudged by intrabronchial secretions that might lead to a false-positive result. Moreover, it has shown not to be sensitive and effective enough for detecting small mucosal abnormalities (e.g. erythema and erosion), dynamic stenoses (caused by, for example, the respiratory cycle or vocal cords), and in differentiating mucus plugs from a mass. Finally, virtual bronchos-

*DOI: http://dx.doi.org/10.5772/intechopen.90658*

perform a wedge resection safely [54].

copy has the limitation that it does not enable biopsies.

**cancer surgery**

ablation therapy.

**4.1 Thermal ablation therapy**

*4.1.1 Radiofrequency ablation (RFA)*

**4. Advances in the armamentarium of (the endo-bronchial) lung** 

In the past two decades, there has been an increase in the development of innovative technologies to facilitate more accurate, efficient, and safe (minimally invasive) thoracic interventions. Specifically, there have been some reports on the progress of innovative therapeutic modalities that approach lung cancer through other minimally invasive methods than direct surgery. Examples of these therapeutic options are thermal ablation, including radiofrequency ablation (RFA), microwave ablation (MWA), and cryoablation of malignant lung lesions. This section will touch on some of these developments and review some outcomes of thermal

Amongst various thermal ablation therapies, RFA is a well-studied method, especially in the treatment of liver cancer [58, 59]. Due to favorable outcomes in the treatment of liver cancer, specifically hepatocellular carcinoma, the application of this technology to malignant lesions in other organs, including the lungs, has been growing. RFA involves the insertion of a probe inside the affected target tissue. The electrode on the probe generates frictional heat that creates coagulation necrosis of the surrounding (tumor) lung parenchyma. In pulmonary surgery, the use of RFA has been reported in the treatment of various malignant lesions including

#### *The Realm of Oncological Lung Surgery: From Past to Present and Future Perspectives DOI: http://dx.doi.org/10.5772/intechopen.90658*

et al. recently published a study on the use of AR, VR, and MR technology in the preoperative planning of a technically demanding VATS left upper lobectomy [53]. In another study from Rouzé et al., augmented reality was used as a navigation tool in combination with cone beam CT (CBCT) to guide intraoperative localization of pulmonary nodules for wedge resection through VATS. The investigators firstly localized the lesions by CBCT intraoperatively. Subsequently, a 3D reconstruction of the nodule was created by using software. After this, an augmented fluoroscopic 3D image of the pulmonary nodule was projected on a screen in front of the operating table. By this, the surgeon was able to localize the lesion intraoperatively and perform a wedge resection safely [54].

Interestingly, also some reports are available on the use of VR 3D reconstruction of the airways, known as virtual bronchoscopy, specifically used as a diagnostic aid tool in the assessment of airway masses and stenosis [56, 57]. Virtual bronchoscopy contributes fairly to the diagnostic process since it enables diagnostic maneuvers, such as assessing bronchial anatomy distally from stenoses, which are not possible with standard flexible bronchoscopy. Moreover, virtual bronchoscopy is a noninvasive method and does not bear any additional risks (e.g. radiation exposure or iatrogenic airway damage) for patients. Despite these advantages, virtual bronchoscopy is not expected to completely replace flexible bronchoscopy due to some limitations. For example, tumor boundaries can be misjudged by intrabronchial secretions that might lead to a false-positive result. Moreover, it has shown not to be sensitive and effective enough for detecting small mucosal abnormalities (e.g. erythema and erosion), dynamic stenoses (caused by, for example, the respiratory cycle or vocal cords), and in differentiating mucus plugs from a mass. Finally, virtual bronchoscopy has the limitation that it does not enable biopsies.

## **4. Advances in the armamentarium of (the endo-bronchial) lung cancer surgery**

In the past two decades, there has been an increase in the development of innovative technologies to facilitate more accurate, efficient, and safe (minimally invasive) thoracic interventions. Specifically, there have been some reports on the progress of innovative therapeutic modalities that approach lung cancer through other minimally invasive methods than direct surgery. Examples of these therapeutic options are thermal ablation, including radiofrequency ablation (RFA), microwave ablation (MWA), and cryoablation of malignant lung lesions. This section will touch on some of these developments and review some outcomes of thermal ablation therapy.

### **4.1 Thermal ablation therapy**

#### *4.1.1 Radiofrequency ablation (RFA)*

Amongst various thermal ablation therapies, RFA is a well-studied method, especially in the treatment of liver cancer [58, 59]. Due to favorable outcomes in the treatment of liver cancer, specifically hepatocellular carcinoma, the application of this technology to malignant lesions in other organs, including the lungs, has been growing. RFA involves the insertion of a probe inside the affected target tissue. The electrode on the probe generates frictional heat that creates coagulation necrosis of the surrounding (tumor) lung parenchyma. In pulmonary surgery, the use of RFA has been reported in the treatment of various malignant lesions including

*Update in Respiratory Diseases*

of more accurate and safer (sublobar) anatomic resections. In the near future, this technology will become more common in thoracic surgery. However, in order to reach that stage, some (mostly technical) limitations need to be overcome.

Virtual reality (VR) is a technology that enables users to interact with a computer-generated virtual 3D interface (**Figure 2**). More interestingly, in augmented reality (AR), the user is able to overlay aspects of the VR world within the real physical world. Finally, mixed reality (MR) allows users to create a hybrid physical and virtual world and offers the possibility to interact and analyze objects in the

Recently, surgical intraoperative navigation as well as preoperative surgical simulation based on VR, MR, and AR have been developed and successfully used in various surgical fields including neurosurgery, liver surgery, kidney surgery, and orthopedic surgery [47–51]. In contrast to 2D interfaces (e.g. conventional CT scans), VR, MR, and AR enable not only visualization of anatomical structures but also allow interactive manipulation of the digital information (e.g. anatomic structures) provided by (wearable) computer-integrated devices (such as the Microsoft Hololens or the Google Glass). It has been suggested that these new interfaces might have the potential to benefit both the surgeon and the patient. For surgeons, this benefit comes by the way of improved preoperative surgical planning, better and more accurate intraoperative imaging guidance, and a better preoperative awareness of anatomical abnormalities. Patients will potentially benefit from shorter operative time, shorter length of hospital stay, and improved outcomes. Additionally, AR, VR, and MR offer the possibility to simulate surgical situations as well as facilitating training for surgeons and residents. In the field of thoracic surgery, some of these modalities have been used over the past few years in order to train surgical residents and surgeons to master the techniques necessary for

However, only very few reports are available on the use of AR, VR, or MR for surgical planning or intraoperative navigation for lung surgery [53–55]. Frajhof

*An example of virtual reality application during minimally invasive lung cancer surgery in the operating* 

**3.2 Virtual reality, augmented reality, and mixed reality**

physical world by virtual projections [45, 46].

minimally invasive lung surgery [52].

**106**

**Figure 2.**

*theater.*

inoperable lung cancer [60–62], primary or metastatic pulmonary tumors of less than 3.5 cm in size [63], and stage I-4 non-small cellular lung cancer (NSCLC) not eligible for surgery [64–67]. Results from retrospective studies on RFA of primary malignant lung lesions have suggested reasonable overall 1-year survival rates ranging from 78 to 94% in patients with early stage lung cancer [66, 68–70]. A 5-year survival rates have been reported to be significantly lower and in the range of 25–58% [66, 71, 72]. Important prognostic factors in RFA therapy of lung cancer, in terms of survival, are the additional use of targeted systemic therapies, lesions less than 3 cm (diameter), a Charlson comorbidity index (an index of associated comorbidities) >5, and lower stage disease [66, 73].

A major drawback of RFA therapy compared with surgical resection is the poor results of local progression control [74]. This limitation might be explained by the fact that in RFA therapy no systematic lymph node dissection is carried out and, additionally, no good method exists to check for local adequate treatment margins. With regard to complications, pneumothorax is one of the most common complications associated with RFA. However, it is most often (>80%) treated conservatively without the need for chest tube drainage [75]. In addition, pleural effusion might develop after RFA, however, similar to pneumothorax, does not often (<5%) require intervention [75]. In summary, RFA therapy seems an effective and relatively safe intervention for treating lung cancer, however, a careful patient selection is necessary. Moreover, more future long-term and large randomized controlled trials are necessary to compare the clinical outcomes between RFA, surgical resection, and other modalities of thermal ablation therapy.

## *4.1.2 Microwave ablation (MWA)*

MWA involves hyperthermia-mediated ablation of tissue by causing friction between water molecules in the target tissue. By creating a dipole excitation, hyperthermia is generated and coagulation necrosis results in the lesion and surrounding tissue [76, 77]. The placement of the probes is commonly guided by CT/CT-fluoroscopy. MWA has been successfully used to create larger ablation zones than RFA. Compared with RFA, MWA technology is thought to be more effective in creating larger zones of coagulation necrosis due to the elimination of heat loss through heat sink (the loss of heat through blood flow inside the target tissue) [76].

Studies and long-term data after MWA as a thermal ablation modality are limited when compared with RFA. In a recent review, Yuan and colleagues reported a meta-analysis of clinical outcomes after RFA and MWA for primary and metastatic pulmonary malignancies [75]. The authors identified 11 studies based on MWA compared with 42 studies based on RFA therapy, all with a retrospective study design. In this meta-analysis, it was demonstrated that RFA seems to be superior to MWA with regard to overall survival (up to 5 years) for both primary and metastatic pulmonary malignancies. However, the authors note that the results of lung metastasis should be interpreted carefully, since small groups of patients were included in the analysis based on only a few retrospective studies. With regard to local tumor progression free survival, RFA and MWA showed similar results. In addition, similar to RFA, MWA is a relatively safe intervention which is not associated with high complication rates. Yuan et al. reported comparable rates of pneumothorax and pleural effusion after ablation by MWA and RFA [75]. Concerning prognostic factors negatively affecting survival and local tumor progression control, more advanced disease stage, tumors >3 cm (diameter), and emphysematous lungs have been identified [78].

**109**

**5. Conclusions**

*The Realm of Oncological Lung Surgery: From Past to Present and Future Perspectives*

An opposite method of hyperthermia induced ablation, termed cryoablation, creates protein denaturation, ischemia, cell rupture, and necrosis through local hypothermia (temperatures < −40°C) [79]. In this technique, compressed argon gas is used to create freezing temperatures that induce local injury to the tissue. Subsequently, helium is used to thaw the tissue. Comparable to MWA, in cryoablation, multiple probes can be used to increase the ablation area in the tissue and placement under the guidance of CT/CT-fluoroscopy. Although cryosurgery is a relatively old ablative technique, use of cryoablation in the context of lung cancer and long-term studies are limited. Besides percutaneous cryoablation, other methods of cryoablative strategies are endo-bronchial (for obstructive intrabronchial tumors) (**Figure 1E**) and intrathoracic (during surgery). Specific indications for each modality have been reviewed by Niu and colleagues and are beyond the scope

Since thermal ablation therapies are commonly reserved for patients not eligible for curative surgery, tumor recurrence after radiotherapy or patients who refuse surgery, even though they have resectable lesions, cryoablation is often offered as a therapy to palliate symptoms or to increase survival in advanced disease stage. Consequently, a number of reports have been published on the use of cryoablation for the treatment of medically inoperable NSCLC, advanced stages of NSCLC, and for pulmonary metastasis [80–84]. Niu et al. reported on a series of 840 patients with NSCLC who received percutaneous cryoablative therapy for various stages of NSCLC ranging from IIa to IV. The reported overall survival was 68, 52, 34, 26, and 17% for 1-, 2-, 3-, 4-, and 5-year, respectively. Local and peripheral recurrence rates were 28.3 and 47.2%, respectively, after a median follow-up of 34 months (range 4–63 months). For patients with less advanced NSCLC, better outcome is reported in terms of overall survival. In 2012, Yamauchi et al. demonstrated a 2-year overall survival of 88% in medically inoperable patients with stage I NSCLC who were treated with percutaneous cryoablation [84]. In addition, Moore and colleagues published a study in which an overall survival rate of 67.8% was reported in patients

Regarding cryoablation therapy in metastatic lung lesions, studies have also proven the efficacy and safety of percutaneous cryoablation. For example, Yamauchi et al. reported a 3-year progression free survival rate of 59% for patients with metastatic colorectal carcinoma treated with cryoablation [85]. Factors associated with local tumor progression or poor prognosis have been studied by multivariate analyses. Interestingly, most of these factors (e.g. tumor size <3 cm and stage of disease) are comparable to the factors in other modalities of thermal ablation [78, 80]. Regarding the safety profile of cryoablation compared with other modalities of thermal ablation, comparable rates of pneumothorax and pleural effusion are reported in the literature [77, 80]. However, incidental reports of transient recurrent laryngeal nerve neuropraxia have also been documented [86].

Until the late nineteenth century, the inside of the chest cavity was a no-go area for complex surgical interventions. The world still was not ready yet for primary lung resections. To make the lung surgery possible, several giant steps were undertaken: the introduction of aseptic concept by Joseph Lister in 1867, the discovery of X-ray by William Konrad Rontgen in 1895, and the introduction of positive pressure ventilation

*DOI: http://dx.doi.org/10.5772/intechopen.90658*

*4.1.3 Cryoablation*

of this chapter [80].

with stage I NSCLC after 5 years [82].

#### *4.1.3 Cryoablation*

*Update in Respiratory Diseases*

comorbidities) >5, and lower stage disease [66, 73].

other modalities of thermal ablation therapy.

*4.1.2 Microwave ablation (MWA)*

tous lungs have been identified [78].

target tissue) [76].

inoperable lung cancer [60–62], primary or metastatic pulmonary tumors of less than 3.5 cm in size [63], and stage I-4 non-small cellular lung cancer (NSCLC) not eligible for surgery [64–67]. Results from retrospective studies on RFA of primary malignant lung lesions have suggested reasonable overall 1-year survival rates ranging from 78 to 94% in patients with early stage lung cancer [66, 68–70]. A 5-year survival rates have been reported to be significantly lower and in the range of 25–58% [66, 71, 72]. Important prognostic factors in RFA therapy of lung cancer, in terms of survival, are the additional use of targeted systemic therapies, lesions less than 3 cm (diameter), a Charlson comorbidity index (an index of associated

A major drawback of RFA therapy compared with surgical resection is the poor results of local progression control [74]. This limitation might be explained by the fact that in RFA therapy no systematic lymph node dissection is carried out and, additionally, no good method exists to check for local adequate treatment margins. With regard to complications, pneumothorax is one of the most common complications associated with RFA. However, it is most often (>80%) treated conservatively without the need for chest tube drainage [75]. In addition, pleural effusion might develop after RFA, however, similar to pneumothorax, does not often (<5%) require intervention [75]. In summary, RFA therapy seems an effective and relatively safe intervention for treating lung cancer, however, a careful patient selection is necessary. Moreover, more future long-term and large randomized controlled trials are necessary to compare the clinical outcomes between RFA, surgical resection, and

MWA involves hyperthermia-mediated ablation of tissue by causing friction between water molecules in the target tissue. By creating a dipole excitation, hyperthermia is generated and coagulation necrosis results in the lesion and surrounding tissue [76, 77]. The placement of the probes is commonly guided by CT/CT-fluoroscopy. MWA has been successfully used to create larger ablation zones than RFA. Compared with RFA, MWA technology is thought to be more effective in creating larger zones of coagulation necrosis due to the elimination of heat loss through heat sink (the loss of heat through blood flow inside the

Studies and long-term data after MWA as a thermal ablation modality are limited when compared with RFA. In a recent review, Yuan and colleagues reported a meta-analysis of clinical outcomes after RFA and MWA for primary and metastatic pulmonary malignancies [75]. The authors identified 11 studies based on MWA compared with 42 studies based on RFA therapy, all with a retrospective study design. In this meta-analysis, it was demonstrated that RFA seems to be superior to MWA with regard to overall survival (up to 5 years) for both primary and metastatic pulmonary malignancies. However, the authors note that the results of lung metastasis should be interpreted carefully, since small groups of patients were included in the analysis based on only a few retrospective studies. With regard to local tumor progression free survival, RFA and MWA showed similar results. In addition, similar to RFA, MWA is a relatively safe intervention which is not associated with high complication rates. Yuan et al. reported comparable rates of pneumothorax and pleural effusion after ablation by MWA and RFA [75]. Concerning prognostic factors negatively affecting survival and local tumor progression control, more advanced disease stage, tumors >3 cm (diameter), and emphysema-

**108**

An opposite method of hyperthermia induced ablation, termed cryoablation, creates protein denaturation, ischemia, cell rupture, and necrosis through local hypothermia (temperatures < −40°C) [79]. In this technique, compressed argon gas is used to create freezing temperatures that induce local injury to the tissue. Subsequently, helium is used to thaw the tissue. Comparable to MWA, in cryoablation, multiple probes can be used to increase the ablation area in the tissue and placement under the guidance of CT/CT-fluoroscopy. Although cryosurgery is a relatively old ablative technique, use of cryoablation in the context of lung cancer and long-term studies are limited. Besides percutaneous cryoablation, other methods of cryoablative strategies are endo-bronchial (for obstructive intrabronchial tumors) (**Figure 1E**) and intrathoracic (during surgery). Specific indications for each modality have been reviewed by Niu and colleagues and are beyond the scope of this chapter [80].

Since thermal ablation therapies are commonly reserved for patients not eligible for curative surgery, tumor recurrence after radiotherapy or patients who refuse surgery, even though they have resectable lesions, cryoablation is often offered as a therapy to palliate symptoms or to increase survival in advanced disease stage. Consequently, a number of reports have been published on the use of cryoablation for the treatment of medically inoperable NSCLC, advanced stages of NSCLC, and for pulmonary metastasis [80–84]. Niu et al. reported on a series of 840 patients with NSCLC who received percutaneous cryoablative therapy for various stages of NSCLC ranging from IIa to IV. The reported overall survival was 68, 52, 34, 26, and 17% for 1-, 2-, 3-, 4-, and 5-year, respectively. Local and peripheral recurrence rates were 28.3 and 47.2%, respectively, after a median follow-up of 34 months (range 4–63 months). For patients with less advanced NSCLC, better outcome is reported in terms of overall survival. In 2012, Yamauchi et al. demonstrated a 2-year overall survival of 88% in medically inoperable patients with stage I NSCLC who were treated with percutaneous cryoablation [84]. In addition, Moore and colleagues published a study in which an overall survival rate of 67.8% was reported in patients with stage I NSCLC after 5 years [82].

Regarding cryoablation therapy in metastatic lung lesions, studies have also proven the efficacy and safety of percutaneous cryoablation. For example, Yamauchi et al. reported a 3-year progression free survival rate of 59% for patients with metastatic colorectal carcinoma treated with cryoablation [85]. Factors associated with local tumor progression or poor prognosis have been studied by multivariate analyses. Interestingly, most of these factors (e.g. tumor size <3 cm and stage of disease) are comparable to the factors in other modalities of thermal ablation [78, 80]. Regarding the safety profile of cryoablation compared with other modalities of thermal ablation, comparable rates of pneumothorax and pleural effusion are reported in the literature [77, 80]. However, incidental reports of transient recurrent laryngeal nerve neuropraxia have also been documented [86].

### **5. Conclusions**

Until the late nineteenth century, the inside of the chest cavity was a no-go area for complex surgical interventions. The world still was not ready yet for primary lung resections. To make the lung surgery possible, several giant steps were undertaken: the introduction of aseptic concept by Joseph Lister in 1867, the discovery of X-ray by William Konrad Rontgen in 1895, and the introduction of positive pressure ventilation by Meltzer and Auer in 1909. With the lung cancer epidemic after World War I, the number of patients with potentially resectable lung cancer increased significantly. Surgeons around the world were debating on the preferable resection (lobectomy vs. pneumonectomy) and the best surgical technique: mass hilar ligation versus anatomical dissection. While the first report on lobectomy for lung cancer in 1932, it took almost 30 years to report that lobectomy was the preferred resection for lung cancer surgery. In the same period, the anatomical dissection technique gained wider application. This all together with the discovery of double lumen endo-tracheal tube by Carlens in 1949 paved the way for modern lung resection techniques. The introduction of diagnostic tools as CT, MRI, PET-CT, and later EUS and EBUS facilitated even better tumor localization and mediastinal evaluation decreasing the surgical mortality.

The next major challenge was decreasing the morbidity of thoracotomy: high percentages of long standing post-operative pain, discomfort, and functional loss. The solution led to the development of modern minimally invasive lung surgery. In 2006, Robert McKenna published a standardized approach for VATS lobectomy in a series of 1100 cases leading to global adaptation of VATS for lung surgery. While VATS showing to be superior with respect to major adverse events, less pain on post-operative day 2 and shorter median hospital stay with an equal oncological outcome, studies on chronic pain, however, did not show a major difference in pain between thoracotomy and VATS. This moved surgeons to search for even less invasive methods, eventually leading to the concept of uniportal VATS, first proposed by Rocco in 2004, subxiphoid and cervical approaches, and hybrid approach combining 5 mm intercostal ports with a subxiphoid approach. At the same time, the world witnessed the introduction of RATS by Franca Melfi and her team, however, because of the financial reasons, the introduction of RATS in many centers lagged behind. In the meantime, VATS has evolutionized to 3D-VATS and robotic like instruments have become available for laparoscopic and VATS procedures. Whether all these approaches will lead to reduction of chronic pain is yet to be determined.

The results of major screening programs have shifted the trend of lung resection toward sub-lobar resection as segmentectomy, making the lung surgery even more challenging. Moreover, this makes the role of peri-operative imaging tools as fluorescent indocyanine green (ICG), 3D-CT modalities, and (navigational) bronchoscopy interventions indispensable.

The upcoming VR, AR, and MR enable a more naturalistic 3D presentation of human anatomy in a digital interface. As a diagnostic tool, it can provide physicians with a more realistic view of the patient's anatomy and might enable diagnostic assessment, preoperative surgical planning, and intraoperative guidance. In addition, it can provide training and learning platform for students, residents, and surgeons. It has already proven its added value for a broad range of surgical procedures; however, AR/VR/MR has not been used widely in thoracic surgery yet. Considering the speed of development of this technology in other areas, it is expected that it will make its way into the world of thoracic surgery in the near future. In this perspective, hybrid operating theaters including 3D-CT and (robotic-assisted) navigational bronchoscopy tools are already on their way. To address this, however, it is essential that thoracic surgeons have an active and open attitude toward the introduction of innovative (digital) applications.

With respect to endo-bronchial interventions, thermal ablation therapy seems to provide an efficacious and safe alternative for surgical therapy of lung cancer and lung cancer metastasis. However, patient's selection should be carried out with caution and should be personalized for each patient based on type of cancer (e.g. NSCLC), comorbidities, tumor size, and disease stage. Specifically, thermal ablation therapy could offer a palliative or even a life-prolonging treatment option for non-surgical candidates. Hopefully future long-term and larger prospective

**111**

*The Realm of Oncological Lung Surgery: From Past to Present and Future Perspectives*

necessary and need to be generated by future multicenter trials.

(randomized controlled) trials will answer the remaining questions. For example, it will be necessary to study the impact of combining thermal ablation therapy with other conventional (e.g. systemic or radiotherapy) therapies for the treatment of lung cancer. In addition, more data are warranted on the determination of the best therapy for incomplete ablations and/or local recurrence of disease. More interestingly, biomarkers or novel imaging techniques to follow-up on ablative therapies are also required, especially since the radiological follow-up of recently ablated lung tissue is very challenging. More data and confirmation of these data are therefore

To conclude, this chapter provides a historical overview and a summary of state-of-the-art surgical techniques in the treatment of lung cancer today. The journey of lung surgery was and is a very challenging one, with major hurdles to overcome. It departed from a "no-go" era, leaving behind the golden standard of pneumonectomy and thoracotomy, to arrive in the current era of minimally invasive and robotic-assisted surgery. The journey continues toward the horizon of non-intubated operations, sub-lobar resections, virtual reality imaging modalities, navigational bronchoscopy interventions, and hybrid procedures. We are heading toward the era of incisionless, natural orifice surgery: an almost science fiction

The contribution of Egied Simons (Simons Productions, Mathenesserdijk 236A, 3026 GL, Rotterdam, The Netherlands) and Chris Hordijk (Medical VR, van Eeghenstraat 98, 1071JL, Amsterdam, The Netherlands) in generating the figures is highly appreciated. We would like to thank Dr. F. Incekara (Departments

of Neurosurgery and Radiology, Erasmus Medical Center, Rotterdam, The

*DOI: http://dx.doi.org/10.5772/intechopen.90658*

vision, yet nothing is more real.

Netherlands) for his helpful advice.

3D three-dimensional

ICG indocyanine green

VR virtual reality AR augmented reality MR mixed reality

VATS video-assisted thoracic surgery

RATS robotic-assisted thoracic surgery

CT computed tomography scanner

UVATS uniportal video-assisted thoracic surgery

AATS American Association for Thoracic Surgery MRI magnetic resonance imaging scanner PET positron emission tomography EUS endo-esophageal ultrasound

EBUS endo-bronchial ultrasound bronchoscopy

CBCT cone beam computed tomography

NSCLC non-small cellular lung cancer

RFA radiofrequency ablation MWA microwave ablation

ICT information and communication technology MDCT multidetector computed tomography

**Acknowledgements**

**Abbreviations**

#### *The Realm of Oncological Lung Surgery: From Past to Present and Future Perspectives DOI: http://dx.doi.org/10.5772/intechopen.90658*

(randomized controlled) trials will answer the remaining questions. For example, it will be necessary to study the impact of combining thermal ablation therapy with other conventional (e.g. systemic or radiotherapy) therapies for the treatment of lung cancer. In addition, more data are warranted on the determination of the best therapy for incomplete ablations and/or local recurrence of disease. More interestingly, biomarkers or novel imaging techniques to follow-up on ablative therapies are also required, especially since the radiological follow-up of recently ablated lung tissue is very challenging. More data and confirmation of these data are therefore necessary and need to be generated by future multicenter trials.

To conclude, this chapter provides a historical overview and a summary of state-of-the-art surgical techniques in the treatment of lung cancer today. The journey of lung surgery was and is a very challenging one, with major hurdles to overcome. It departed from a "no-go" era, leaving behind the golden standard of pneumonectomy and thoracotomy, to arrive in the current era of minimally invasive and robotic-assisted surgery. The journey continues toward the horizon of non-intubated operations, sub-lobar resections, virtual reality imaging modalities, navigational bronchoscopy interventions, and hybrid procedures. We are heading toward the era of incisionless, natural orifice surgery: an almost science fiction vision, yet nothing is more real.

## **Acknowledgements**

*Update in Respiratory Diseases*

bronchoscopy interventions indispensable.

innovative (digital) applications.

by Meltzer and Auer in 1909. With the lung cancer epidemic after World War I, the number of patients with potentially resectable lung cancer increased significantly. Surgeons around the world were debating on the preferable resection (lobectomy vs. pneumonectomy) and the best surgical technique: mass hilar ligation versus anatomical dissection. While the first report on lobectomy for lung cancer in 1932, it took almost 30 years to report that lobectomy was the preferred resection for lung cancer surgery. In the same period, the anatomical dissection technique gained wider application. This all together with the discovery of double lumen endo-tracheal tube by Carlens in 1949 paved the way for modern lung resection techniques. The introduction of diagnostic tools as CT, MRI, PET-CT, and later EUS and EBUS facilitated even better tumor localization and mediastinal evaluation decreasing the surgical mortality. The next major challenge was decreasing the morbidity of thoracotomy: high percentages of long standing post-operative pain, discomfort, and functional loss. The solution led to the development of modern minimally invasive lung surgery. In 2006, Robert McKenna published a standardized approach for VATS lobectomy in a series of 1100 cases leading to global adaptation of VATS for lung surgery. While VATS showing to be superior with respect to major adverse events, less pain on post-operative day 2 and shorter median hospital stay with an equal oncological outcome, studies on chronic pain, however, did not show a major difference in pain between thoracotomy and VATS. This moved surgeons to search for even less invasive methods, eventually leading to the concept of uniportal VATS, first proposed by Rocco in 2004, subxiphoid and cervical approaches, and hybrid approach combining 5 mm intercostal ports with a subxiphoid approach. At the same time, the world witnessed the introduction of RATS by Franca Melfi and her team, however, because of the financial reasons, the introduction of RATS in many centers lagged behind. In the meantime, VATS has evolutionized to 3D-VATS and robotic like instruments have become available for laparoscopic and VATS procedures. Whether all these approaches will lead to reduction of chronic pain is yet to be determined. The results of major screening programs have shifted the trend of lung resection toward sub-lobar resection as segmentectomy, making the lung surgery even more challenging. Moreover, this makes the role of peri-operative imaging tools as fluorescent indocyanine green (ICG), 3D-CT modalities, and (navigational)

The upcoming VR, AR, and MR enable a more naturalistic 3D presentation of human anatomy in a digital interface. As a diagnostic tool, it can provide physicians with a more realistic view of the patient's anatomy and might enable diagnostic assessment, preoperative surgical planning, and intraoperative guidance. In addition, it can provide training and learning platform for students, residents, and surgeons. It has already proven its added value for a broad range of surgical procedures; however, AR/VR/MR has not been used widely in thoracic surgery yet. Considering the speed of development of this technology in other areas, it is expected that it will make its way into the world of thoracic surgery in the near future. In this perspective, hybrid operating theaters including 3D-CT and (robotic-assisted) navigational bronchoscopy tools are already on their way. To address this, however, it is essential that thoracic surgeons have an active and open attitude toward the introduction of

With respect to endo-bronchial interventions, thermal ablation therapy seems to provide an efficacious and safe alternative for surgical therapy of lung cancer and lung cancer metastasis. However, patient's selection should be carried out with caution and should be personalized for each patient based on type of cancer (e.g. NSCLC), comorbidities, tumor size, and disease stage. Specifically, thermal ablation therapy could offer a palliative or even a life-prolonging treatment option for non-surgical candidates. Hopefully future long-term and larger prospective

**110**

The contribution of Egied Simons (Simons Productions, Mathenesserdijk 236A, 3026 GL, Rotterdam, The Netherlands) and Chris Hordijk (Medical VR, van Eeghenstraat 98, 1071JL, Amsterdam, The Netherlands) in generating the figures is highly appreciated. We would like to thank Dr. F. Incekara (Departments of Neurosurgery and Radiology, Erasmus Medical Center, Rotterdam, The Netherlands) for his helpful advice.

## **Abbreviations**


*Update in Respiratory Diseases*

## **Author details**

Alexander Maat, Amir Hossein Sadeghi, Ad Bogers and Edris Mahtab\* Department of Cardio-thoracic Surgery, Erasmus Medical Centre, Erasmus University, Rotterdam, The Netherlands

\*Address all correspondence to: e.mahtab@erasmusmc.nl

© 2019 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.

**113**

*The Realm of Oncological Lung Surgery: From Past to Present and Future Perspectives*

[12] Ochsner A, Blalock J, Sucre A. Carcinoma of the stomach. The American Surgeon. 1955;**21**:1-16

[13] Churchill ED. The surgical treatment of carcinoma of the lung. The Journal of Thoracic Surgery.

removal of an entire lung for carcinoma of the bronchus. JAMA.

1984;**251**(2):257-260

1999;**1**(3):109-125

[14] Graham EA, Singer JJ. Successful

[15] Ochsner A, DeBakey M. Primary pulmonary malignancy: Treatment by total pneumonectomy; analysis of 79 collected cases and presentation of 7 personal cases. The Ochsner Journal.

[16] Shimkin MB, Connelly RR,

Surgery. 1962;**44**:503-519

1956;**1**(3):169-186

1959;**14**(48):48-54

Marcus SC, Cutler SJ. Pneumonectomy and lobectomy in bronchogenic

carcinoma. A comparison of end results of the Overholt and Ochsner clinics. The Journal of Thoracic and Cardiovascular

[17] Kent EM, Blades B. The anatomic approach to pulmonary resection. Annals of Surgery. 1942;**116**(5):782-794

[18] Thomas CP. Conservative resection of the bronchial tree. Journal of the Royal College of Surgeons of Edinburgh.

[19] Johnston JB, Jones PH. The treatment of bronchial carcinoma by lobectomy and sleeve resection of the main bronchus. Thorax.

[20] Carlens E. Mediastinoscopy: A method for inspection and tissue biopsy in the superior mediastinum. Diseases

of the Chest. 1959;**36**:343-352

[21] Kirklin JW, McDonald JR, Clagett OT, Moersch HJ, Gage RP.

1933;**2**:254-261

*DOI: http://dx.doi.org/10.5772/intechopen.90658*

[1] Celsus A. De Medicina, with an English Translation by W. G. Spencer. 3 Vols. Cambridge: Harvard University

[3] Walcott-Sapp S. The History of Pulmonary Lobectomy: Two Phases of Innovation. CTSNet. 2016. Available from: https://www.ctsnet.org/article/ history-pulmonary-lobectomy-two-

[4] Estlander JA. Résection des côtes dans l'empyèma chronique. Revista medicochirurgicala a Societatii de Medici si Naturalisti din Iasi (Paris). 1879;**3**:157-170

[5] Lister J. On the antiseptic principle in the practice of surgery. The Lancet.

[6] Barton M. The History of Surgical Gloves. 2018. Available from: https:// www.pastmedicalhistory.co.uk/ the-history-of-surgical-gloves/

[7] Hage JJ, Brinkman RJ. Andreas Vesalius' understanding of pulmonary ventilation. Respiratory Physiology &

Neurobiology. 2016;**231**:37-44

[8] Sauerbruch F. Intrathoracic operations. Lancet. 1904;**7**:1308

[9] Meltzer A. Dr. Samuel James Meltzer and intratracheal anesthesia.

[10] Meltzer SJ. Continuous respiration without respiratory movements. The Journal of Experimental Medicine.

[11] Blum A. Alton ochsner, MD, 1896- 1981 anti-smoking pioneer. The Ochsner

1990;**2**(1):54-58

1909;**11**(4):622-625

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[2] Christopoulou-Aletra H, Papavramidou N. "Empyemas" of the thoracic cavity in the Hippocratic corpus. The Annals of Thoracic Surgery.

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*Update in Respiratory Diseases*

**112**

**Author details**

University, Rotterdam, The Netherlands

provided the original work is properly cited.

Alexander Maat, Amir Hossein Sadeghi, Ad Bogers and Edris Mahtab\* Department of Cardio-thoracic Surgery, Erasmus Medical Centre, Erasmus

© 2019 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,

\*Address all correspondence to: e.mahtab@erasmusmc.nl

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[14] Graham EA, Singer JJ. Successful removal of an entire lung for carcinoma of the bronchus. JAMA. 1984;**251**(2):257-260

[15] Ochsner A, DeBakey M. Primary pulmonary malignancy: Treatment by total pneumonectomy; analysis of 79 collected cases and presentation of 7 personal cases. The Ochsner Journal. 1999;**1**(3):109-125

[16] Shimkin MB, Connelly RR, Marcus SC, Cutler SJ. Pneumonectomy and lobectomy in bronchogenic carcinoma. A comparison of end results of the Overholt and Ochsner clinics. The Journal of Thoracic and Cardiovascular Surgery. 1962;**44**:503-519

[17] Kent EM, Blades B. The anatomic approach to pulmonary resection. Annals of Surgery. 1942;**116**(5):782-794

[18] Thomas CP. Conservative resection of the bronchial tree. Journal of the Royal College of Surgeons of Edinburgh. 1956;**1**(3):169-186

[19] Johnston JB, Jones PH. The treatment of bronchial carcinoma by lobectomy and sleeve resection of the main bronchus. Thorax. 1959;**14**(48):48-54

[20] Carlens E. Mediastinoscopy: A method for inspection and tissue biopsy in the superior mediastinum. Diseases of the Chest. 1959;**36**:343-352

[21] Kirklin JW, McDonald JR, Clagett OT, Moersch HJ, Gage RP. Bronchogenic carcinoma: Cell type and other factors relating to prognosis. Surgery, Gynecology & Obstetrics. 1955;**100**(4):429-438

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[23] Pearson FG, DeLarue NC, Ilves R, Todd TR, Cooper JD. Significance of positive superior mediastinal nodes identified at mediastinoscopy in patients with resectable cancer of the lung. The Journal of Thoracic and Cardiovascular Surgery. 1982;**83**(1):1-11

[24] Hoksch B, Birken-Bertsch H, Müller JM. Thoracoscopy before Jacobaeus. The Annals of Thoracic Surgery. 2002;**74**(4):1288-1290

[25] Lewis RJ, Caccavale RJ, Sisler GE. Imaged thorascopic surgery: A new thoracic technique for resection of mediastinal cysts. The Annals of Thoracic Surgery. 1992;**53**:38-20

[26] McKenna RJ Jr. Lobectomy by video-assisted thoracic surgery with mediastinal node sampling for lung cancer. The Journal of Thoracic and Cardiovascular Surgery. 1994;**107**(3):879-882

[27] Lim E. In hospital clinical efficacy, safety and oncologic outcomes from VIOLET: A UK multi-centre RCT of VATS versus open loebctomy for lung cancer. In: World Conference on Lung Cancer. London: Royal Brompton Hospital; 2019

[28] Bayman EO, Parekh KR, Keech J, Selte A, Brennan TJ. A prospective study of chronic pain after thoracic surgery. Anesthesiology. 2017;**126**(5):938-951

[29] Rocco G, Martin-Ucar A, Passera E. Uniportal VATS wedge pulmonary resections. The Annals of Thoracic Surgery. 2004;**77**(2):726-728 [30] Liu CC, Shih CS, Liu YH, Cheng CT, Melis E, Liu ZY. Subxiphoid single-port video-assisted thoracoscopic surgery. Journal of Visceral Surgery. 2016;**2**:112

[31] Zieliński M, Rami-Porta R. The Transcervical Approach in Thoracic Surgery. Berlin Heidelberg: Springer-Verlag; 2014. 221 p

[32] ElSaegh MMM, Ismail NA, Mydin MI, Nardini M, Dunning J. Subxiphoid uniportal lobectomy. Journal of Visceral Surgery. 2017;**3**:24

[33] Melfi F. Early experience with robotic technology for thoracoscopic surgery. European Journal of Cardio-Thoracic Surgery. 2002;**21**(5):864-868

[34] Subramanian MP, Colditz GA. Time trends of perioperative outcomes in early-stage non-small cell lung cancer resection patients (statistical commentary). Annals of Thoracic Surgery. 2019. Available online 19 October 2019. https://doi.org/10.1016/j. athoracsur.2019.09.031. In Press

[35] Aberle J, Reining F, Dannheim V, Flitsch J, Klinge A, Mann O. Metformin after bariatric surgery—An acid problem. Experimental and Clinical Endocrinology & Diabetes. 2012;**120**(3):152-153

[36] De Koning H, Van Der Aalst C, Ten Haaf K, Oudkerk M. PL02.05 effects of volume CT lung cancer screening: Mortality results of the NELSON randomised-controlled population based trial. Journal of Thoracic Oncology. 2018;**13**(10):S185

[37] Seguin-Givelet A, Grigoroiu M, Brian E, Gossot D. Planning and marking for thoracoscopic anatomical segmentectomies. Journal of Thoracic Disease. 2019;**10**:1187-1194

[38] Oizumi H, Kanauchi N, Kato H, Endoh M, Suzuki J, Fukaya K, et al. Anatomic thoracoscopic pulmonary

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[46] Shuhaiber JH. Augmented reality in surgery. Archives of Surgery.

Nguyen N, Gupta S, McFaul C, Yang VXD. Augmented reality in neurosurgery: A review of current concepts and emerging applications. The Canadian Journal of Neurological Sciences.

Dirven C, Vincent A. Clinical feasibility of a wearable mixed-reality device in neurosurgery. World Neurosurgery.

[50] Shirk JD, Thiel DD, Wallen EM, Linehan JM, White WM, Badani KK, et al. Effect of 3-dimensional virtual reality models for surgical planning of robotic-assisted partial nephrectomy on surgical outcomes: A randomized clinical trial. JAMA Network Open.

[51] Tang R, Ma LF, Rong ZX, Li MD, Zeng JP, Wang XD, et al. Augmented reality technology for preoperative planning and intraoperative navigation during hepatobiliary surgery: A review of current methods. Hepatobiliary & Pancreatic Diseases International.

[52] Jensen K, Bjerrum F, Hansen HJ, Petersen RH, Pedersen JH, Konge L. A new possibility in thoracoscopic virtual reality simulation training:

2013;**81**(3):410-415

2004;**139**(2):170-174

2019;**6**:38

[47] Chytas D, Malahias MA, Nikolaou VS. Augmented reality in orthopedics: Current state and future directions. Frontiers in Surgery.

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2017;**44**(3):235-245

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2018;**17**(2):101-112

[49] Incekara F, Smits M,

*DOI: http://dx.doi.org/10.5772/intechopen.90658*

segmentectomy under 3-dimensional multidetector computed tomography simulation: A report of 52 consecutive

[39] Saji H, Inoue T, Kato Y, Shimada Y, Hagiwara M, Kudo Y, et al. Virtual segmentectomy based on high-quality three-dimensional lung modelling from computed tomography images. Interactive Cardiovascular and Thoracic

cases. The Journal of Thoracic and Cardiovascular Surgery.

Surgery. 2013;**17**(2):227-232

[40] Shimizu K, Nakazawa S, Nagashima T, Kuwano H,

evaluation of thoracoscopic

Journal of Thoracic Disease. 2016;**8**(Suppl 9):S710-S7S5

[42] Xue L, Fan H, Shi W, Ge D, Zhang Y, Wang Q, et al. Preoperative 3-dimensional computed tomography

lung simulation before videoassisted thoracoscopic anatomic

on three-dimensional image reconstruction for preoperative simulation in thoracic surgery. Journal of Thoracic Disease. 2016;**8**(Suppl 3):

2018;**10**(12):6598-6605

[44] Iwano S, Yokoi K, Taniguchi T, Kawaguchi K, Fukui T, Naganawa S. Planning of segmentectomy using three-

angiography with a virtual safety margin: Technique and

Surgery. 2017;**3**:88

Mogi A. 3D-CT anatomy for VATS segmentectomy. Journal of Visceral

[41] Wu WB, Xu XF, Wen W, Xu J, Zhu Q, Pan XL, et al. Three-dimensional computed tomography bronchography and angiography in the preoperative

segmentectomy and subsegmentectomy.

segmentectomy for ground glass opacity in lung. Journal of Thoracic Disease.

[43] Chen-Yoshikawa TF, Date H. Update

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2011;**141**(3):678-682

*The Realm of Oncological Lung Surgery: From Past to Present and Future Perspectives DOI: http://dx.doi.org/10.5772/intechopen.90658*

segmentectomy under 3-dimensional multidetector computed tomography simulation: A report of 52 consecutive cases. The Journal of Thoracic and Cardiovascular Surgery. 2011;**141**(3):678-682

*Update in Respiratory Diseases*

1955;**100**(4):429-438

[22] Reynders H. Radicale' of 'conservatieve' pneumonectomie? Nederlands Tijdschrift voor Geneeskunde. 1962;**2257**

Bronchogenic carcinoma: Cell type and other factors relating to prognosis. Surgery, Gynecology & Obstetrics.

[30] Liu CC, Shih CS, Liu YH, Cheng CT, Melis E, Liu ZY. Subxiphoid single-port video-assisted thoracoscopic surgery. Journal of Visceral Surgery. 2016;**2**:112

[31] Zieliński M, Rami-Porta R. The Transcervical Approach in Thoracic Surgery. Berlin Heidelberg: Springer-

[32] ElSaegh MMM, Ismail NA, Mydin MI, Nardini M, Dunning J. Subxiphoid uniportal lobectomy. Journal of Visceral Surgery. 2017;**3**:24

[33] Melfi F. Early experience with robotic technology for thoracoscopic surgery. European Journal of Cardio-Thoracic Surgery. 2002;**21**(5):864-868

[34] Subramanian MP, Colditz GA. Time trends of perioperative outcomes in early-stage non-small cell lung cancer resection patients (statistical commentary). Annals of Thoracic Surgery. 2019. Available online 19 October 2019. https://doi.org/10.1016/j. athoracsur.2019.09.031. In Press

[35] Aberle J, Reining F, Dannheim V, Flitsch J, Klinge A, Mann O. Metformin after bariatric surgery—An acid problem. Experimental and

Clinical Endocrinology & Diabetes.

[37] Seguin-Givelet A, Grigoroiu M, Brian E, Gossot D. Planning and marking

segmentectomies. Journal of Thoracic

[38] Oizumi H, Kanauchi N, Kato H, Endoh M, Suzuki J, Fukaya K, et al. Anatomic thoracoscopic pulmonary

for thoracoscopic anatomical

Disease. 2019;**10**:1187-1194

[36] De Koning H, Van Der Aalst C, Ten Haaf K, Oudkerk M. PL02.05 effects of volume CT lung cancer screening: Mortality results of the NELSON randomised-controlled population based trial. Journal of Thoracic Oncology. 2018;**13**(10):S185

2012;**120**(3):152-153

Verlag; 2014. 221 p

[23] Pearson FG, DeLarue NC, Ilves R, Todd TR, Cooper JD. Significance of positive superior mediastinal nodes identified at mediastinoscopy in patients with resectable cancer of the lung. The Journal of Thoracic and Cardiovascular Surgery. 1982;**83**(1):1-11

[24] Hoksch B, Birken-Bertsch H, Müller JM. Thoracoscopy before Jacobaeus. The Annals of Thoracic Surgery. 2002;**74**(4):1288-1290

Sisler GE. Imaged thorascopic surgery: A new thoracic technique for resection of mediastinal cysts. The Annals of Thoracic Surgery. 1992;**53**:38-20

[26] McKenna RJ Jr. Lobectomy by video-assisted thoracic surgery with mediastinal node sampling for lung cancer. The Journal of Thoracic and Cardiovascular Surgery.

[27] Lim E. In hospital clinical efficacy, safety and oncologic outcomes from VIOLET: A UK multi-centre RCT of VATS versus open loebctomy for lung cancer. In: World Conference on Lung Cancer. London: Royal Brompton

[28] Bayman EO, Parekh KR, Keech J, Selte A, Brennan TJ. A prospective study of chronic pain after thoracic surgery. Anesthesiology. 2017;**126**(5):938-951

[29] Rocco G, Martin-Ucar A, Passera E. Uniportal VATS wedge pulmonary resections. The Annals of Thoracic Surgery. 2004;**77**(2):726-728

1994;**107**(3):879-882

Hospital; 2019

[25] Lewis RJ, Caccavale RJ,

**114**

[39] Saji H, Inoue T, Kato Y, Shimada Y, Hagiwara M, Kudo Y, et al. Virtual segmentectomy based on high-quality three-dimensional lung modelling from computed tomography images. Interactive Cardiovascular and Thoracic Surgery. 2013;**17**(2):227-232

[40] Shimizu K, Nakazawa S, Nagashima T, Kuwano H, Mogi A. 3D-CT anatomy for VATS segmentectomy. Journal of Visceral Surgery. 2017;**3**:88

[41] Wu WB, Xu XF, Wen W, Xu J, Zhu Q, Pan XL, et al. Three-dimensional computed tomography bronchography and angiography in the preoperative evaluation of thoracoscopic segmentectomy and subsegmentectomy. Journal of Thoracic Disease. 2016;**8**(Suppl 9):S710-S7S5

[42] Xue L, Fan H, Shi W, Ge D, Zhang Y, Wang Q, et al. Preoperative 3-dimensional computed tomography lung simulation before videoassisted thoracoscopic anatomic segmentectomy for ground glass opacity in lung. Journal of Thoracic Disease. 2018;**10**(12):6598-6605

[43] Chen-Yoshikawa TF, Date H. Update on three-dimensional image reconstruction for preoperative simulation in thoracic surgery. Journal of Thoracic Disease. 2016;**8**(Suppl 3): S295-S301

[44] Iwano S, Yokoi K, Taniguchi T, Kawaguchi K, Fukui T, Naganawa S. Planning of segmentectomy using threedimensional computed tomography angiography with a virtual safety margin: Technique and

initial experience. Lung Cancer. 2013;**81**(3):410-415

[45] Chinnock C. Virtual reality in surgery and medicine. Hospital Technology Series. 1994;**13**(18):1-48

[46] Shuhaiber JH. Augmented reality in surgery. Archives of Surgery. 2004;**139**(2):170-174

[47] Chytas D, Malahias MA, Nikolaou VS. Augmented reality in orthopedics: Current state and future directions. Frontiers in Surgery. 2019;**6**:38

[48] Guha D, Alotaibi NM, Nguyen N, Gupta S, McFaul C, Yang VXD. Augmented reality in neurosurgery: A review of current concepts and emerging applications. The Canadian Journal of Neurological Sciences. 2017;**44**(3):235-245

[49] Incekara F, Smits M, Dirven C, Vincent A. Clinical feasibility of a wearable mixed-reality device in neurosurgery. World Neurosurgery. 2018;**118**:e422-e427

[50] Shirk JD, Thiel DD, Wallen EM, Linehan JM, White WM, Badani KK, et al. Effect of 3-dimensional virtual reality models for surgical planning of robotic-assisted partial nephrectomy on surgical outcomes: A randomized clinical trial. JAMA Network Open. 2019;**2**(9):e1911598

[51] Tang R, Ma LF, Rong ZX, Li MD, Zeng JP, Wang XD, et al. Augmented reality technology for preoperative planning and intraoperative navigation during hepatobiliary surgery: A review of current methods. Hepatobiliary & Pancreatic Diseases International. 2018;**17**(2):101-112

[52] Jensen K, Bjerrum F, Hansen HJ, Petersen RH, Pedersen JH, Konge L. A new possibility in thoracoscopic virtual reality simulation training:

Development and testing of a novel virtual reality simulator for video-assisted thoracoscopic surgery lobectomy. Interactive Cardiovascular and Thoracic Surgery. 2015;**21**(4):420-426

[53] Frajhof L, Borges J, Hoffmann E, Lopes J, Haddad R. Virtual reality, mixed reality and augmented reality in surgical planning for video or robotically assisted thoracoscopic anatomic resections for treatment of lung cancer. Journal of Visualized Surgery. 2018;**4**:143

[54] Rouze S, de Latour B, Flecher E, Guihaire J, Castro M, Corre R, et al. Small pulmonary nodule localization with cone beam computed tomography during video-assisted thoracic surgery: A feasibility study. Interactive Cardiovascular and Thoracic Surgery. 2016;**22**(6):705-711

[55] Tan W, Ge W, Hang Y, Wu S, Liu S, Liu M. Computer assisted system for precise lung surgery based on medical image computing and mixed reality. Health Information Science and Systems. 2018;**6**(1):10

[56] Finkelstein SES, M R, Nguyen DM, Stewart JH, Tretler JA, Schrump DS. Virtual bronchoscopy for evaluation of malignant tumors of the thorax. The Journal of Thoracic and Cardiovascular Surgery. 2001;**123**(5):967-972

[57] Rapp-Bernhardt U, Welte T, Doehring W, Kropf S, Bernhardt TM. Diagnostic potential of virtual bronchoscopy: Advantages in comparison with axial CT slices, MPR and mIP? European Radiology. 2000;**10**(6):981-988

[58] Rossi S, Di Stasi M, Buscarini E, Cavanna L, Quaretti P, Squassante E, et al. Percutaneous radiofrequency interstitial thermal ablation in the treatment of small hepatocellular

carcinoma. The Cancer Journal from Scientific American. 1995;**1**(1):73-81

[59] Shiina S, Teratani T, Obi S, Hamamura K, Koike Y, Omata M. Nonsurgical treatment of hepatocellular carcinoma: From percutaneous ethanol injection therapy and percutaneous microwave coagulation therapy to radiofrequency ablation. Oncology. 2002;**62**(Suppl 1):64-68

[60] Dupuy DE, DiPetrillo T, Gandhi S, Ready N, Ng T, Donat W, et al. Radiofrequency ablation followed by conventional radiotherapy for medically inoperable stage I non-small cell lung cancer. Chest. 2006;**129**(3):738-745

[61] Okuma T, Matsuoka T, Yamamoto A, Oyama Y, Hamamoto S, Toyoshima M, et al. Determinants of local progression after computed tomography-guided percutaneous radiofrequency ablation for unresectable lung tumors: 9-year experience in a single institution. Cardiovascular and Interventional Radiology. 2010;**33**(4):787-793

[62] Powell JW, Dexter E, Scalzetti EM, Bogart JA. Treatment advances for medically inoperable non-small-cell lung cancer: Emphasis on prospective trials. The Lancet Oncology. 2009;**10**(9):885-894

[63] Gillams A. Ablation of lung tumours. Cancer Imaging. 2012;**12**:361-362

[64] Hiraki T, Gobara H, Iishi T, Sano Y, Iguchi T, Fujiwara H, et al. Percutaneous radiofrequency ablation for clinical stage I non-small cell lung cancer: Results in 20 nonsurgical candidates. The Journal of Thoracic and Cardiovascular Surgery. 2007;**134**(5):1306-1312

[65] Pennathur A, Luketich JD, Abbas G, Chen M, Fernando HC, Gooding WE, et al. Radiofrequency ablation for the

**117**

*The Realm of Oncological Lung Surgery: From Past to Present and Future Perspectives*

Lung tumors treated with percutaneous radiofrequency ablation: Computed tomography imaging follow-up. Cardiovascular and Interventional Radiology. 2011;**34**(5):989-997

[73] Simon TG, Beland MD, Machan JT, Dipetrillo T, Dupuy DE. Charlson comorbidity index predicts patient outcome, in cases of inoperable non-small cell lung cancer treated with radiofrequency ablation. European Journal of Radiology.

[74] Li G, Xue M, Chen W, Yi S. Efficacy and safety of radiofrequency ablation for lung cancers: A systematic review and meta-analysis. European Journal of

Zheng J, Li WA. Meta-analysis of clinical outcomes after radiofrequency ablation and microwave ablation for lung cancer and pulmonary metastases. Journal of the American College of Radiology.

Kavanagh PV, Safran H. Percutaneous radiofrequency ablation of malignancies in the lung. AJR. American Journal of Roentgenology. 2000;**174**(1):57-59

[77] Robert Sheu Y, Hong K. Percutaneous lung tumor ablation. Techniques in Vascular and Interventional Radiology.

Sofocleous CT, Lewandowski RJ. The role of percutaneous image-guided thermal ablation for the treatment of pulmonary malignancies. AJR. American Journal of

Roentgenology. 2017;**209**(4):740-751

[79] Gage AA, Baust J. Mechanisms of tissue injury in cryosurgery. Cryobiology. 1998;**37**(3):171-186

2012;**81**(12):4167-4172

Radiology. 2018;**100**:92-98

2019;**16**(3)

[75] Yuan Z, Wang Y, Zhang J,

[76] Dupuy DE, Zagoria RJ, Akerley W, Mayo-Smith WW,

2013;**16**(4):239-252

[78] Mouli SK, Kurilova I,

*DOI: http://dx.doi.org/10.5772/intechopen.90658*

treatment of stage I non-small cell lung cancer in high-risk patients. The Journal of Thoracic and Cardiovascular Surgery.

[66] Simon CJ, Dupuy DE, DiPetrillo TA, Safran HP, Grieco CA, Ng T, et al. Pulmonary radiofrequency ablation: Long-term safety and efficacy in 153 patients. Radiology. 2007;**243**(1):268-275

[67] Thanos L, Mylona S, Pomoni M, Athanassiadi K, Theakos N, Zoganas L, et al. Percutaneous radiofrequency thermal ablation of primary and metastatic lung tumors. European Journal of Cardio-Thoracic Surgery.

2007;**134**(4):857-864

2006;**30**(5):797-800

[68] Dupuy DE, Fernando HC, Hillman S, Ng T, Tan AD, Sharma A, et al. Radiofrequency ablation of stage IA non-small cell lung cancer in medically inoperable patients: Results from the American College of Surgeons Oncology Group Z4033 (Alliance) trial.

Cancer. 2015;**121**(19):3491-3498

and Cardiovascular Surgery.

[70] Liu B, Liu L, Hu M, Qian K, Li Y. Percutaneous radiofrequency ablation for medically inoperable patients with clinical stage I non-small cell lung cancer. Thoracic Cancer.

[71] Ambrogi MC, Fanucchi O, Cioni R, Dini P, De Liperi A, Cappelli C, et al. Long-term results of radiofrequency ablation treatment of stage I non-small cell lung cancer: A prospective intentionto-treat study. Journal of Thoracic Oncology. 2011;**6**(12):2044-2051

[72] Palussiere J, Marcet B, Descat E, Deschamps F, Rao P, Ravaud A, et al.

2011;**142**(1):24-30

2015;**6**(3):327-333

[69] Hiraki T, Gobara H, Mimura H, Matsui Y, Toyooka S, Kanazawa S. Percutaneous radiofrequency ablation of clinical stage I non-small cell lung cancer. The Journal of Thoracic

*The Realm of Oncological Lung Surgery: From Past to Present and Future Perspectives DOI: http://dx.doi.org/10.5772/intechopen.90658*

treatment of stage I non-small cell lung cancer in high-risk patients. The Journal of Thoracic and Cardiovascular Surgery. 2007;**134**(4):857-864

*Update in Respiratory Diseases*

2015;**21**(4):420-426

Surgery. 2018;**4**:143

2016;**22**(6):705-711

Systems. 2018;**6**(1):10

2001;**123**(5):967-972

2000;**10**(6):981-988

[56] Finkelstein SES, M R,

Nguyen DM, Stewart JH, Tretler JA, Schrump DS. Virtual bronchoscopy for evaluation of malignant tumors of the thorax. The Journal of

Thoracic and Cardiovascular Surgery.

[57] Rapp-Bernhardt U, Welte T, Doehring W, Kropf S, Bernhardt TM. Diagnostic potential of virtual bronchoscopy: Advantages in comparison with axial CT slices, MPR and mIP? European Radiology.

[58] Rossi S, Di Stasi M, Buscarini E, Cavanna L, Quaretti P, Squassante E, et al. Percutaneous radiofrequency interstitial thermal ablation in the treatment of small hepatocellular

Development and testing of a novel virtual reality simulator for video-assisted thoracoscopic surgery lobectomy. Interactive Cardiovascular and Thoracic Surgery. carcinoma. The Cancer Journal from Scientific American. 1995;**1**(1):73-81

[59] Shiina S, Teratani T, Obi S, Hamamura K, Koike Y, Omata M. Nonsurgical treatment of hepatocellular carcinoma: From percutaneous ethanol injection therapy and percutaneous microwave coagulation therapy to radiofrequency ablation. Oncology.

2002;**62**(Suppl 1):64-68

2006;**129**(3):738-745

[60] Dupuy DE, DiPetrillo T, Gandhi S, Ready N, Ng T, Donat W, et al. Radiofrequency ablation followed

by conventional radiotherapy for medically inoperable stage I non-small cell lung cancer. Chest.

[61] Okuma T, Matsuoka T, Yamamoto A, Oyama Y, Hamamoto S, Toyoshima M, et al. Determinants of local progression after computed tomography-guided percutaneous radiofrequency ablation for unresectable lung tumors: 9-year experience in a single institution. Cardiovascular and Interventional Radiology. 2010;**33**(4):787-793

[62] Powell JW, Dexter E, Scalzetti EM, Bogart JA. Treatment advances for medically inoperable non-small-cell lung cancer: Emphasis on prospective

trials. The Lancet Oncology.

[63] Gillams A. Ablation of lung tumours. Cancer Imaging.

[64] Hiraki T, Gobara H, Iishi T, Sano Y, Iguchi T, Fujiwara H, et al. Percutaneous radiofrequency ablation for clinical stage I non-small cell lung cancer: Results in 20 nonsurgical candidates. The Journal of Thoracic and Cardiovascular Surgery. 2007;**134**(5):1306-1312

[65] Pennathur A, Luketich JD, Abbas G, Chen M, Fernando HC, Gooding WE, et al. Radiofrequency ablation for the

2009;**10**(9):885-894

2012;**12**:361-362

[53] Frajhof L, Borges J, Hoffmann E, Lopes J, Haddad R. Virtual reality, mixed reality and augmented reality in surgical planning for video or robotically assisted thoracoscopic anatomic resections for treatment of lung cancer. Journal of Visualized

[54] Rouze S, de Latour B, Flecher E, Guihaire J, Castro M, Corre R, et al. Small pulmonary nodule localization with cone beam computed tomography

surgery: A feasibility study. Interactive Cardiovascular and Thoracic Surgery.

[55] Tan W, Ge W, Hang Y, Wu S, Liu S, Liu M. Computer assisted system for precise lung surgery based on medical image computing and mixed reality. Health Information Science and

during video-assisted thoracic

**116**

[66] Simon CJ, Dupuy DE, DiPetrillo TA, Safran HP, Grieco CA, Ng T, et al. Pulmonary radiofrequency ablation: Long-term safety and efficacy in 153 patients. Radiology. 2007;**243**(1):268-275

[67] Thanos L, Mylona S, Pomoni M, Athanassiadi K, Theakos N, Zoganas L, et al. Percutaneous radiofrequency thermal ablation of primary and metastatic lung tumors. European Journal of Cardio-Thoracic Surgery. 2006;**30**(5):797-800

[68] Dupuy DE, Fernando HC, Hillman S, Ng T, Tan AD, Sharma A, et al. Radiofrequency ablation of stage IA non-small cell lung cancer in medically inoperable patients: Results from the American College of Surgeons Oncology Group Z4033 (Alliance) trial. Cancer. 2015;**121**(19):3491-3498

[69] Hiraki T, Gobara H, Mimura H, Matsui Y, Toyooka S, Kanazawa S. Percutaneous radiofrequency ablation of clinical stage I non-small cell lung cancer. The Journal of Thoracic and Cardiovascular Surgery. 2011;**142**(1):24-30

[70] Liu B, Liu L, Hu M, Qian K, Li Y. Percutaneous radiofrequency ablation for medically inoperable patients with clinical stage I non-small cell lung cancer. Thoracic Cancer. 2015;**6**(3):327-333

[71] Ambrogi MC, Fanucchi O, Cioni R, Dini P, De Liperi A, Cappelli C, et al. Long-term results of radiofrequency ablation treatment of stage I non-small cell lung cancer: A prospective intentionto-treat study. Journal of Thoracic Oncology. 2011;**6**(12):2044-2051

[72] Palussiere J, Marcet B, Descat E, Deschamps F, Rao P, Ravaud A, et al. Lung tumors treated with percutaneous radiofrequency ablation: Computed tomography imaging follow-up. Cardiovascular and Interventional Radiology. 2011;**34**(5):989-997

[73] Simon TG, Beland MD, Machan JT, Dipetrillo T, Dupuy DE. Charlson comorbidity index predicts patient outcome, in cases of inoperable non-small cell lung cancer treated with radiofrequency ablation. European Journal of Radiology. 2012;**81**(12):4167-4172

[74] Li G, Xue M, Chen W, Yi S. Efficacy and safety of radiofrequency ablation for lung cancers: A systematic review and meta-analysis. European Journal of Radiology. 2018;**100**:92-98

[75] Yuan Z, Wang Y, Zhang J, Zheng J, Li WA. Meta-analysis of clinical outcomes after radiofrequency ablation and microwave ablation for lung cancer and pulmonary metastases. Journal of the American College of Radiology. 2019;**16**(3)

[76] Dupuy DE, Zagoria RJ, Akerley W, Mayo-Smith WW, Kavanagh PV, Safran H. Percutaneous radiofrequency ablation of malignancies in the lung. AJR. American Journal of Roentgenology. 2000;**174**(1):57-59

[77] Robert Sheu Y, Hong K. Percutaneous lung tumor ablation. Techniques in Vascular and Interventional Radiology. 2013;**16**(4):239-252

[78] Mouli SK, Kurilova I, Sofocleous CT, Lewandowski RJ. The role of percutaneous image-guided thermal ablation for the treatment of pulmonary malignancies. AJR. American Journal of Roentgenology. 2017;**209**(4):740-751

[79] Gage AA, Baust J. Mechanisms of tissue injury in cryosurgery. Cryobiology. 1998;**37**(3):171-186

[80] Niu L, Xu K, Mu F. Cryosurgery for lung cancer. Journal of Thoracic Disease. 2012;**4**(4):408-419

[81] McDevitt JL, Mouli SK, Nemcek AA, Lewandowski RJ, Salem R, Sato KT. Percutaneous cryoablation for the treatment of primary and metastatic lung tumors: Identification of risk factors for recurrence and major complications. Journal of Vascular and Interventional Radiology. 2016;**27**(9):1371-1379

[82] Moore W, Talati R, Bhattacharji P, Bilfinger T. Five-year survival after cryoablation of stage I non-small cell lung cancer in medically inoperable patients. Journal of Vascular and Interventional Radiology. 2015;**26**(3):312-319

[83] Uhlig J, Case MD, Blasberg JD, Boffa DJ, Chiang A, Gettinger SN, et al. Comparison of survival rates after a combination of local treatment and systemic therapy vs systemic therapy alone for treatment of stage IV nonsmall cell lung cancer. JAMA Network Open. 2019;**2**(8):e199702

[84] Yamauchi Y, Izumi Y, Hashimoto K, Yashiro H, Inoue M, Nakatsuka S, et al. Percutaneous cryoablation for the treatment of medically inoperable stage I non-small cell lung cancer. PLoS One. 2012;**7**(3):e33223

[85] Yamauchi Y, Izumi Y, Kawamura M, Nakatsuka S, Yashiro H, Tsukada N, et al. Percutaneous cryoablation of pulmonary metastases from colorectal cancer. PLoS One. 2011;**6**(11):e27086

[86] Maiwand MO, Asimakopoulos G. Cryosurgery for lung cancer: Clinical results and technical aspects. Technology in Cancer Research & Treatment. 2004;**3**(2):143-150

**119**

**Chapter 9**

**Abstract**

lung surgery with VATS.

**1. History of thoracoscopy**

Advances in Minimally Invasive

Over the last 25 years, improvement in instrumentation and surgical techniques has led to widespread adaptation of thoracoscopic (VATS) surgery in the field of thoracic oncology. What once was a niche operation like VATS wedge resection to now hybrid VATS chest wall resections, and advanced surgeries like bronchoplasty and sleeve resections are done with VATS. This has led to improved surgical outcomes for our patients and increased use of surgery in the treatment of chest disease. We review the history of VATS and its current state with most recent changes and upgrades in the technique in this chapter. We review the advancement in uniportal VATS, robotic assisted resection, complex VATS resection, and awake

While the modern era of thoracoscopy begins in the early 1990s and includes Giancarlo Roviaro's report of the first thoracoscopic lobectomy as a major milestone [1], the term thoracoscopy dates back to a procedure performed by Francis Richard Cruise and Samuel Gordon in 1865 [2]. Using a device similar to the "Leichtleiter" used by Bozzini with a light source improved by Antonin Jean Desormeaux, Cruise examined the pleural space of an 11 years old suffering from an empyema and a pleurocutaneous fistula. Several years later, in 1882, coincidentally the year Robert Koch discovered *Mycobacterium tuberculosis* [3], Carlo Forlanini observed that spontaneous pneumothorax could collapse cavitary lesions and lead to their resolution [4]. From this observation, he introduced a procedure of inducing artificial closed pneumothoraces by inserting a needle in the anterior axillary line and forcing air

Surgery for Lung Cancer

*Rachit Shah and Nils-Tomas Delagar McBride*

**Keywords:** VATS, uniportal, robotics, awake VATS, hybrid resections

into the pleural space, the first minimally invasive thoracic procedure.

for most of the twentieth century until the modern era.

Though he is considered by many to be the father of thoracoscopy, Hans Christian Jacobeus published his eponymous Jacobeus Operation in 1910; this operation involved inducing pneumothorax, inserting a thoracoscope through one incision, and introducing an galvanocautery instrument in through a separate incision for the purpose of releasing adhesions to allow the lung collapse to treat pulmonary tuberculosis [5]. Subsequently, antibiotics, improved anesthetics, and intraoperative oxygen delivery, thoracoscopy was neglected as a therapeutic option

Attributed in large part to fiber optics for light transmission, enhanced image processing and rendering, and the advent of the surgical staplers, interest in VATS was piqued. The classic three-port technique focused the camera from hip-to-head

## **Chapter 9**

*Update in Respiratory Diseases*

[81] McDevitt JL, Mouli SK,

2012;**4**(4):408-419

2016;**27**(9):1371-1379

2015;**26**(3):312-319

Open. 2019;**2**(8):e199702

2012;**7**(3):e33223

[80] Niu L, Xu K, Mu F. Cryosurgery for lung cancer. Journal of Thoracic Disease.

Nemcek AA, Lewandowski RJ, Salem R, Sato KT. Percutaneous cryoablation for the treatment of primary and metastatic lung tumors: Identification of risk factors for recurrence and major complications. Journal of Vascular and Interventional Radiology.

[82] Moore W, Talati R, Bhattacharji P, Bilfinger T. Five-year survival after cryoablation of stage I non-small cell lung cancer in medically inoperable patients. Journal of Vascular and Interventional Radiology.

[83] Uhlig J, Case MD, Blasberg JD, Boffa DJ, Chiang A, Gettinger SN, et al. Comparison of survival rates after a combination of local treatment and systemic therapy vs systemic therapy alone for treatment of stage IV nonsmall cell lung cancer. JAMA Network

[84] Yamauchi Y, Izumi Y, Hashimoto K, Yashiro H, Inoue M, Nakatsuka S, et al. Percutaneous cryoablation for the treatment of medically inoperable stage I non-small cell lung cancer. PLoS One.

[85] Yamauchi Y, Izumi Y, Kawamura M, Nakatsuka S, Yashiro H, Tsukada N, et al. Percutaneous cryoablation of pulmonary metastases from colorectal cancer. PLoS One. 2011;**6**(11):e27086

[86] Maiwand MO, Asimakopoulos G. Cryosurgery for lung cancer: Clinical

results and technical aspects. Technology in Cancer Research & Treatment. 2004;**3**(2):143-150

**118**

## Advances in Minimally Invasive Surgery for Lung Cancer

*Rachit Shah and Nils-Tomas Delagar McBride*

## **Abstract**

Over the last 25 years, improvement in instrumentation and surgical techniques has led to widespread adaptation of thoracoscopic (VATS) surgery in the field of thoracic oncology. What once was a niche operation like VATS wedge resection to now hybrid VATS chest wall resections, and advanced surgeries like bronchoplasty and sleeve resections are done with VATS. This has led to improved surgical outcomes for our patients and increased use of surgery in the treatment of chest disease. We review the history of VATS and its current state with most recent changes and upgrades in the technique in this chapter. We review the advancement in uniportal VATS, robotic assisted resection, complex VATS resection, and awake lung surgery with VATS.

**Keywords:** VATS, uniportal, robotics, awake VATS, hybrid resections

### **1. History of thoracoscopy**

While the modern era of thoracoscopy begins in the early 1990s and includes Giancarlo Roviaro's report of the first thoracoscopic lobectomy as a major milestone [1], the term thoracoscopy dates back to a procedure performed by Francis Richard Cruise and Samuel Gordon in 1865 [2]. Using a device similar to the "Leichtleiter" used by Bozzini with a light source improved by Antonin Jean Desormeaux, Cruise examined the pleural space of an 11 years old suffering from an empyema and a pleurocutaneous fistula. Several years later, in 1882, coincidentally the year Robert Koch discovered *Mycobacterium tuberculosis* [3], Carlo Forlanini observed that spontaneous pneumothorax could collapse cavitary lesions and lead to their resolution [4]. From this observation, he introduced a procedure of inducing artificial closed pneumothoraces by inserting a needle in the anterior axillary line and forcing air into the pleural space, the first minimally invasive thoracic procedure.

Though he is considered by many to be the father of thoracoscopy, Hans Christian Jacobeus published his eponymous Jacobeus Operation in 1910; this operation involved inducing pneumothorax, inserting a thoracoscope through one incision, and introducing an galvanocautery instrument in through a separate incision for the purpose of releasing adhesions to allow the lung collapse to treat pulmonary tuberculosis [5]. Subsequently, antibiotics, improved anesthetics, and intraoperative oxygen delivery, thoracoscopy was neglected as a therapeutic option for most of the twentieth century until the modern era.

Attributed in large part to fiber optics for light transmission, enhanced image processing and rendering, and the advent of the surgical staplers, interest in VATS was piqued. The classic three-port technique focused the camera from hip-to-head while increased experience determined that a modified approach should focus from umbilicus-to-shoulder. Aside from traditional three-port VATS technique, some procedures, including thoracic sympathectomy, have been performed via needlescopic VATS as well as two-port and uniportal VATS. Additionally, robotic assisted thoracic surgery (RATS) can serve a role in thoracic surgery, particularly for mediastinal procedures. Each of these different techniques has the potential to serve an important role as part of the thoracic surgeon's armamentarium [6].

## **2. VATS lobectomy**

As mentioned in the previous section, Roviaro reported the first VATS lobectomy in 1991. However, in 1993, only 2% of the cases reported by the Video Assisted Study Group were VATS lobectomies while 49% were wedge resections. As reports continued to show the feasibility of VATS lobectomies as well as possible advantages, familiarity with the procedure improved technique. Even so, skepticism remained for the use of VATS for the treatment of non-small cell lung cancer (NSCLC). The results of a randomized control trial by Kirby et al. [7] failed to demonstrate the superiority of VATS though it also failed to demonstrate inferiority. In this study, 30 patients were randomized to the traditional muscle-sparing thoracotomy while 24 were put into the VATS group. No difference was found between the duration of chest tube drainage, hospital length of stay, pain score, or time prior to returning to work. The study specifically expressed concerns about the adequacy of lymph node dissection for an operation intended for malignancy.

McKenna et al. reviewed 298 cases of patients that underwent VATS lobectomy and lymph node dissection for NSCLC with the intent of determining adequacy of resection [8]. Their multi-institutional review included patients with stage I to IIIA and featured a 6% conversion rate with a single report of an incisional recurrence. In this study, the survival rate at 4 years for patients with stage I disease was 70%. Comparatively, Li and Wang [9] retrospectively evaluated outcomes for 76 patients that underwent lobectomies with lymph node dissection via VATS or thoracotomy for clinical N0 disease that was discovered to be pathologic N2 NSCLC. In their study, the number of lymph nodes recovered and the number of stations sampled were similar. The survival and disease-free survival rates are presented in **Table 1**. In addition to these reported survival and disease-free survival rates, VATS patients had shorter operative times and less blood loss.

A subsequent larger study was performed by Onaitis et al. [10] on VATS lobectomies for benign and malignant disease including 500 patients. Of these lobectomies, 83.2% were performed for NSCLC with an overall conversion rate of 1.6% (8 of 500). The pathologic stage of the patients included in this study were stage I (55.3%), stage II (9.6%) and stage III or greater (10.6%). The overall 2-year survival rate in the patients with stage I NSCLC and stage II was comparable to those undergoing thoracotomy (85% vs. 77%). Additionally, perioperative mortality for benign pathologies was 0% while it was 1% for malignant pathologies.


**121**

**Table 2.**

*Five-year overall survival.*

*Advances in Minimally Invasive Surgery for Lung Cancer*

**3. Long-term outcomes of VATS lobectomy for NSCLC**

Whitson et al. [11] analyzed 147 patients who underwent lobectomies for stage I NSCLC (59 by VATS and 88 by thoracotomy). In this particular study, patients who underwent thoracotomy had a larger yield of nodes and shorter time in the ICU, potentially because of the additional comorbidities reported in the VATS patients. However, no significant differences were found in operative times, length of hospi-

To justify the continued use of VATS for lobectomies as treatment for NSCLC, data continues to be collected and reported by many groups. Multi-institutional experience of 145 patients with clinical stage IA NSCLC less than or equal to 2 cm was reported by Shigemura et al. [12]. For this study, three approaches were utilized: complete thoracoscopic technique without any rib spreading, assisted VATS, which included VATS with a mini-thoracotomy and open thoractomy. The overall 5-year survival rates did not differ significantly between techniques (VATS—96.7%, assisted VATS—95.2%, and open—97.2%). Higuchi et al. [13] also reported their experience of 160 patients with stage IA NSCLC with patients who underwent VATS lobectomy and open thoracotomy. The reported 5-year disease-free survival was equivalent with 88% in the VATS group and 77.1% in the thoracotomy group. The 5-year overall survival for pathologic stage IA NSCLC was 94.8% in the VATS group and 96.2% in the thoracotomy group, showing no statistical difference in survival. Lee et al. [14] performed a retrospective review of patients who underwent lobectomy for NSCLC, from their institution using propensity-matched scores in 416 patients. The review included clinical stage I to III with the majority being stage IA. The 3- and 5-year overall survival for the patients with clinical stage IA who underwent VATS lobectomy were 87.4 and 76.5%, respectively, and 81.6 and 77.5% for thoracotomy. Their analysis also showed no inferiority of VATS lobectomy for early stage NSCLC. Murakawa et al. [15] also evaluated survival outcomes in patients with early stage NSCLC and found VATS and open thoracotomy to be equivalent. Yang et al. [16] queried the national cancer database to evaluate the national survival outcomes following VATS versus open lobectomy for stage I NSCLC. After propensity score matching 2928 patients were included in the final analysis. In the matched patients there was no difference in 5-year survival between VATS and open thoracotomy, 66.3 and 65.8%, respectively. Data published by Flores et al. [17], which included intent to treat analysis in 741 patients (398 VATS and 343 open thoracotomy) demonstrating similar 5 year survival. The majority of their patients treated with lobectomy were clinical stage IA and demonstrated 79% 5-year survival in the VATS group and 75%

**Reference Year # of patients VATS Open** Shigemura et al. [12] 2006 145 96.7% 97.2% Flores et al. [17] 2009 741 79% 75% Higuchi et al. [13] 2014 160 94.8% 96.2% Lee et al. [14] 2013 416 76.5% 77.5% Yang et al. [18] 2017 2928 66.3% 65.8%

*DOI: http://dx.doi.org/10.5772/intechopen.93102*

in the open thoracotomy group (**Table 2**).

tal stay, or median survival.

**Table 1.** *Comparative survival rates.* *Update in Respiratory Diseases*

**2. VATS lobectomy**

while increased experience determined that a modified approach should focus from umbilicus-to-shoulder. Aside from traditional three-port VATS technique, some procedures, including thoracic sympathectomy, have been performed via needlescopic VATS as well as two-port and uniportal VATS. Additionally, robotic assisted thoracic surgery (RATS) can serve a role in thoracic surgery, particularly for mediastinal procedures. Each of these different techniques has the potential to serve an important role as part of the thoracic surgeon's armamentarium [6].

As mentioned in the previous section, Roviaro reported the first VATS lobec-

McKenna et al. reviewed 298 cases of patients that underwent VATS lobectomy and lymph node dissection for NSCLC with the intent of determining adequacy of resection [8]. Their multi-institutional review included patients with stage I to IIIA and featured a 6% conversion rate with a single report of an incisional recurrence. In this study, the survival rate at 4 years for patients with stage I disease was 70%. Comparatively, Li and Wang [9] retrospectively evaluated outcomes for 76 patients that underwent lobectomies with lymph node dissection via VATS or thoracotomy for clinical N0 disease that was discovered to be pathologic N2 NSCLC. In their study, the number of lymph nodes recovered and the number of stations sampled were similar. The survival and disease-free survival rates are presented in **Table 1**. In addition to these reported survival and disease-free survival rates, VATS patients

A subsequent larger study was performed by Onaitis et al. [10] on VATS lobectomies for benign and malignant disease including 500 patients. Of these lobectomies, 83.2% were performed for NSCLC with an overall conversion rate of 1.6% (8 of 500). The pathologic stage of the patients included in this study were stage I (55.3%), stage II (9.6%) and stage III or greater (10.6%). The overall 2-year survival rate in the patients with stage I NSCLC and stage II was comparable to those undergoing thoracotomy (85% vs. 77%). Additionally, perioperative mortality for benign

> **3-year disease-free survival**

VATS 82.6% 49.3% 84.9% 64.0% Thoracotomy 72.0% 51.3% 71.2% 42.7%

**1-year survival**

**3-year survival**

tomy in 1991. However, in 1993, only 2% of the cases reported by the Video Assisted Study Group were VATS lobectomies while 49% were wedge resections. As reports continued to show the feasibility of VATS lobectomies as well as possible advantages, familiarity with the procedure improved technique. Even so, skepticism remained for the use of VATS for the treatment of non-small cell lung cancer (NSCLC). The results of a randomized control trial by Kirby et al. [7] failed to demonstrate the superiority of VATS though it also failed to demonstrate inferiority. In this study, 30 patients were randomized to the traditional muscle-sparing thoracotomy while 24 were put into the VATS group. No difference was found between the duration of chest tube drainage, hospital length of stay, pain score, or time prior to returning to work. The study specifically expressed concerns about the adequacy

of lymph node dissection for an operation intended for malignancy.

had shorter operative times and less blood loss.

pathologies was 0% while it was 1% for malignant pathologies.

**1-year disease-free survival**

**120**

**Table 1.**

*Comparative survival rates.*

Whitson et al. [11] analyzed 147 patients who underwent lobectomies for stage I NSCLC (59 by VATS and 88 by thoracotomy). In this particular study, patients who underwent thoracotomy had a larger yield of nodes and shorter time in the ICU, potentially because of the additional comorbidities reported in the VATS patients. However, no significant differences were found in operative times, length of hospital stay, or median survival.

## **3. Long-term outcomes of VATS lobectomy for NSCLC**

To justify the continued use of VATS for lobectomies as treatment for NSCLC, data continues to be collected and reported by many groups. Multi-institutional experience of 145 patients with clinical stage IA NSCLC less than or equal to 2 cm was reported by Shigemura et al. [12]. For this study, three approaches were utilized: complete thoracoscopic technique without any rib spreading, assisted VATS, which included VATS with a mini-thoracotomy and open thoractomy. The overall 5-year survival rates did not differ significantly between techniques (VATS—96.7%, assisted VATS—95.2%, and open—97.2%). Higuchi et al. [13] also reported their experience of 160 patients with stage IA NSCLC with patients who underwent VATS lobectomy and open thoracotomy. The reported 5-year disease-free survival was equivalent with 88% in the VATS group and 77.1% in the thoracotomy group. The 5-year overall survival for pathologic stage IA NSCLC was 94.8% in the VATS group and 96.2% in the thoracotomy group, showing no statistical difference in survival. Lee et al. [14] performed a retrospective review of patients who underwent lobectomy for NSCLC, from their institution using propensity-matched scores in 416 patients. The review included clinical stage I to III with the majority being stage IA. The 3- and 5-year overall survival for the patients with clinical stage IA who underwent VATS lobectomy were 87.4 and 76.5%, respectively, and 81.6 and 77.5% for thoracotomy. Their analysis also showed no inferiority of VATS lobectomy for early stage NSCLC. Murakawa et al. [15] also evaluated survival outcomes in patients with early stage NSCLC and found VATS and open thoracotomy to be equivalent. Yang et al. [16] queried the national cancer database to evaluate the national survival outcomes following VATS versus open lobectomy for stage I NSCLC. After propensity score matching 2928 patients were included in the final analysis. In the matched patients there was no difference in 5-year survival between VATS and open thoracotomy, 66.3 and 65.8%, respectively. Data published by Flores et al. [17], which included intent to treat analysis in 741 patients (398 VATS and 343 open thoracotomy) demonstrating similar 5 year survival. The majority of their patients treated with lobectomy were clinical stage IA and demonstrated 79% 5-year survival in the VATS group and 75% in the open thoracotomy group (**Table 2**).


**Table 2.** *Five-year overall survival.*

## **4. Mediastinal lymph node dissection (MLND) via VATS**

An essential component of each complete pulmonary resection for NSCLC is an adequate mediastinal lymph node dissection (MLND). With the advent of VATS lobectomy particularly for NSCLC, the efficacy of a VATS MLND has been evaluated in comparison to MLND via thoracotomy. The National Comprehensive Cancer Network's (NCCN) NSCLC Database was evaluated by D'Amico et al. [19] to compare VATS MLND to MLND via thoracotomy. The number of lymph node stations evaluated by both techniques was at least 3 and the number of N2 nodes evaluated by both techniques was not significantly different. A single institution randomized control trial reported by Palade et al. [20] included 66 patients with stage 1 NSCLC. In this study, there was no statistically significant difference in the overall number of lymph nodes sampled or the number of lymph nodes in each station. Because VATS MLND has comparable efficacy to open dissection, adequate lymph node dissection can be performed thoracoscopically.

## **5. Clinical advantages of VATS lobectomy vs. thoracotomy**

Multiple studies have documented several advantages of VATS lobectomies including improved quality of life, decreased postoperative pain, and shorter hospital stays. A retrospective study by Villazmizar et al. [21] evaluated 1097 patients that underwent lobectomies with 697 lobectomies via VATS and 382 lobectomies via thoracotomy. In reviewing these cases, the incidence of postoperative complications, including atrial fibrillation, atelectasis, prolonged air leak, transfusion requirements, pneumonia, renal failure death, and shorter hospital stay, were all found to be less common in the VATS lobectomy group. Paul et al. [22] found similar results in evaluating the STS database and reviewing 6323 lobectomies, 5024 via thoracotomy and 1281 via VATS. Propensity matched analysis of these cases found that 73% of VATS patients experienced no complications while 65.3% of thoracotomy patients had no complications. Furthermore, patients undergoing VATS lobectomy in this review had a lower incidence of arrhythmias, reintubations, and blood transfusion as well as shorter duration of chest tube drainage and length of stay.

Predictably, patients requiring pulmonary resections for management of NSCLC often suffer from decreased pulmonary function, which makes them high risk. Because VATS has reduced the risks associated with lobectomy, patients previously considered prohibitive risks are potentially resectable. Donahoe et al. [23] evaluated a cohort of 608 patients (including 72 high risk and 536 standard risk) that underwent lobectomy for NSCLC. For those patients who underwent a VATS lobectomy, there was no difference in complication rate or overall survival between high risk and standard risk patients. Another study by Bertani et al. [24] found that VATS lobectomy patients with reduced preoperative FEV1 had similar outcomes as those with normal preoperative FEV1, despite a longer hospital stay. Patient with a predicted postoperative FEV1% of less than 60% had an average length of stay of 8.7 days while those with a predicted postoperative FEV1% of greater than 60% was 6.8 days (8.7 vs. 6.8 days, p = 0.05) (**Table 3**).

In light of these advantages, it is important to establish not only efficacy but cost effectiveness as a measure of quality. Swanson et al. [25] evaluated the costs of open versus VATS lobectomy for 3961. In this study, patients who underwent a VATS lobectomy had a shorter length of stay, less adverse events, and cost the hospital less than an open lobectomy.

**123**

via VATS.

**Ppo FEV1%**

*†*

*‡*

**Table 3.**

*cut-offs [24].*

*Fisher's exact test.*

*Advances in Minimally Invasive Surgery for Lung Cancer*

**n Grade I Grade II Grade** 

**6. Clinical advantages of VATS lobectomy vs. thoracotomy**

nique for either benign or malignant disease.

**7. Development of single port VATS**

two propensity matched groups.

As a direct result of the advantages and similar survival rates for patients after VATS lobectomy for NSCLC, many institutions have adopted this surgical approach. In addition to VATS lobectomies, other anatomic resections have been performed

*Complications of patients undergoing video-assisted thoracic surgery lobectomy based on different ppo-FEV1* 

**IIIa**

≥40% 98 22 (45.83) 24 (50.00) 1 (2.08) 1 (2.08) 7.18 (±3.83)

≥50% 96 21 (44.68) 24 (51.06) 1 (2.13) 1 (2.13) 7.10 (±3.72)

≥60% 82 18 (46.15) 21 (53.85) 0 (—) 0 (—) 6.80 (±3.52) *LOS, overall hospital length of stay; n.s., not significant; ppo-FEV1, predicted postoperative forced expiratory* 

<40% 2 0 (—) 1 (100.00) 0 (—) 0 (—) n.s 5.90 (±2.23) n.s

<50% 4 1 (50.00) 1 (50.00) 0 (—) 0 (—) n.s 9.18 (±6.31) n.s

<60% 18 4 (40.00) 4 (40.00) 1 (10.00) 1 (10.00) 0.067 8.74 (±4.79) 0.05

**Grade IIIb**

**p-value† LOS, Mean** 

**(±SD)**

**p-value‡**

Recent data have indicated that an anatomic segmentectomy can be considered an acceptable operation to obtain an R0 resection for small stage I NSCLC lesions. In a study reviewing 225 anatomic segmentectomies by Schuchert et al. [26], VATS segmentectomies were compared to those performed via thoracotomy demonstrating similar overall mortality, complications, recurrence rates, and overall survival.

Liu et al. [27] difference was seen in transfusion rates, number of lymph nodes dissected, estimated blood loss, duration of chest tube drainage, overall complication rates, or length of hospital stay. Operative time was longer in the VATS group while postoperative mean pain scores were higher in the higher in the thoracotomy group. From their data, they conclude that VATS pneumonectomy is a safe tech-

The first description of single port VATS by Rocco et al. [28] was published in 2004.

Single port VATS has been evaluated for safety and efficacy in the treatment of NSCLC. Comparing VATS and single port VATS lobectomy patients, Dai et al. [31] reported that single port VATS patients reported a higher satisfaction score, less

Initially used for diagnosis or treatment of primary spontaneous pneumothorax, the uses of single port VATS expanded to include management of pleural effusions, nonanatomic wedge resections, and diagnostic thoracoscopy for lung cancer during this study's 10 year experience. The conversion rate to a 2 or 3 port VATS or mini thoracotomy was 3.7%. Xie et al. [29] reported their single-institution experience of single port VATS in 1063 cases with a conversion rate of 4.6%. Institutional data reported by Shih et al. [30] comparing single port VATS to multiport VATS for anatomic segmentectomies in treating primary lung cancer indicated similar operative outcomes in the

*DOI: http://dx.doi.org/10.5772/intechopen.93102*

*volume in 1 s; SD, standard deviation.*

*t-test with equal or unequal variance.*


*LOS, overall hospital length of stay; n.s., not significant; ppo-FEV1, predicted postoperative forced expiratory volume in 1 s; SD, standard deviation.*

*† Fisher's exact test.*

*‡ t-test with equal or unequal variance.*

#### **Table 3.**

*Update in Respiratory Diseases*

**4. Mediastinal lymph node dissection (MLND) via VATS**

**5. Clinical advantages of VATS lobectomy vs. thoracotomy**

Multiple studies have documented several advantages of VATS lobectomies including improved quality of life, decreased postoperative pain, and shorter hospital stays. A retrospective study by Villazmizar et al. [21] evaluated 1097 patients that underwent lobectomies with 697 lobectomies via VATS and 382 lobectomies via thoracotomy. In reviewing these cases, the incidence of postoperative complications, including atrial fibrillation, atelectasis, prolonged air leak, transfusion requirements, pneumonia, renal failure death, and shorter hospital stay, were all found to be less common in the VATS lobectomy group. Paul et al. [22] found similar results in evaluating the STS database and reviewing 6323 lobectomies, 5024 via thoracotomy and 1281 via VATS. Propensity matched analysis of these cases found that 73% of VATS patients experienced no complications while 65.3% of thoracotomy patients had no complications. Furthermore, patients undergoing VATS lobectomy in this review had a lower incidence of arrhythmias, reintubations, and blood transfusion as well as shorter duration of chest tube drainage and length

Predictably, patients requiring pulmonary resections for management of NSCLC

often suffer from decreased pulmonary function, which makes them high risk. Because VATS has reduced the risks associated with lobectomy, patients previously considered prohibitive risks are potentially resectable. Donahoe et al. [23] evaluated a cohort of 608 patients (including 72 high risk and 536 standard risk) that underwent lobectomy for NSCLC. For those patients who underwent a VATS lobectomy, there was no difference in complication rate or overall survival between high risk and standard risk patients. Another study by Bertani et al. [24] found that VATS lobectomy patients with reduced preoperative FEV1 had similar outcomes as those with normal preoperative FEV1, despite a longer hospital stay. Patient with a predicted postoperative FEV1% of less than 60% had an average length of stay of 8.7 days while those with a predicted postoperative FEV1% of greater than 60% was

In light of these advantages, it is important to establish not only efficacy but cost effectiveness as a measure of quality. Swanson et al. [25] evaluated the costs of open versus VATS lobectomy for 3961. In this study, patients who underwent a VATS lobectomy had a shorter length of stay, less adverse events, and cost the hospital less

dissection can be performed thoracoscopically.

6.8 days (8.7 vs. 6.8 days, p = 0.05) (**Table 3**).

An essential component of each complete pulmonary resection for NSCLC is an adequate mediastinal lymph node dissection (MLND). With the advent of VATS lobectomy particularly for NSCLC, the efficacy of a VATS MLND has been evaluated in comparison to MLND via thoracotomy. The National Comprehensive Cancer Network's (NCCN) NSCLC Database was evaluated by D'Amico et al. [19] to compare VATS MLND to MLND via thoracotomy. The number of lymph node stations evaluated by both techniques was at least 3 and the number of N2 nodes evaluated by both techniques was not significantly different. A single institution randomized control trial reported by Palade et al. [20] included 66 patients with stage 1 NSCLC. In this study, there was no statistically significant difference in the overall number of lymph nodes sampled or the number of lymph nodes in each station. Because VATS MLND has comparable efficacy to open dissection, adequate lymph node

**122**

than an open lobectomy.

of stay.

*Complications of patients undergoing video-assisted thoracic surgery lobectomy based on different ppo-FEV1 cut-offs [24].*

## **6. Clinical advantages of VATS lobectomy vs. thoracotomy**

As a direct result of the advantages and similar survival rates for patients after VATS lobectomy for NSCLC, many institutions have adopted this surgical approach. In addition to VATS lobectomies, other anatomic resections have been performed via VATS.

Recent data have indicated that an anatomic segmentectomy can be considered an acceptable operation to obtain an R0 resection for small stage I NSCLC lesions. In a study reviewing 225 anatomic segmentectomies by Schuchert et al. [26], VATS segmentectomies were compared to those performed via thoracotomy demonstrating similar overall mortality, complications, recurrence rates, and overall survival.

Liu et al. [27] difference was seen in transfusion rates, number of lymph nodes dissected, estimated blood loss, duration of chest tube drainage, overall complication rates, or length of hospital stay. Operative time was longer in the VATS group while postoperative mean pain scores were higher in the higher in the thoracotomy group. From their data, they conclude that VATS pneumonectomy is a safe technique for either benign or malignant disease.

## **7. Development of single port VATS**

The first description of single port VATS by Rocco et al. [28] was published in 2004. Initially used for diagnosis or treatment of primary spontaneous pneumothorax, the uses of single port VATS expanded to include management of pleural effusions, nonanatomic wedge resections, and diagnostic thoracoscopy for lung cancer during this study's 10 year experience. The conversion rate to a 2 or 3 port VATS or mini thoracotomy was 3.7%. Xie et al. [29] reported their single-institution experience of single port VATS in 1063 cases with a conversion rate of 4.6%. Institutional data reported by Shih et al. [30] comparing single port VATS to multiport VATS for anatomic segmentectomies in treating primary lung cancer indicated similar operative outcomes in the two propensity matched groups.

Single port VATS has been evaluated for safety and efficacy in the treatment of NSCLC. Comparing VATS and single port VATS lobectomy patients, Dai et al. [31] reported that single port VATS patients reported a higher satisfaction score, less

postoperative pain, and less blood loss. Fan et al. [32] reported a similar operative time and number of lymph nodes dissected in both single port VATS and open lobectomies for locally advanced NSCLC. In this study, single port patients had a shorter period of chest tube drainage and length of hospital stay but a higher complication rate than thoracotomy. The complications studied included prolonged air leak, atrial fibrillation, bleeding, pneumonia, bronchopleural fistula, chylothorax, death, and 30-day mortality. However, neither study reported data on recurrence rates of overall survival.

### **8. Development of robotic-assisted VATS**

With data indicating that VATS is safe and efficacious for the resection of NSCLC as well as having a variety of advantages over open surgery, it has been established as the preferred technique. However, with the availability of the robotic assistance, techniques for robotic procedures have been developed and examined. Utilizing three robotic ports as well as an assistance port, Melfi et al. [33] reported their early experience using the Da Vinci platform, describing lobectomies, enucleations, excisions, and bulla stitching. Single institution experiences have reported safety and shown similar outcomes in robotic resection when compared to VATS with improvement in postoperative pain. Other experiences with larger cohorts found higher incidence of operative injury, and bleeding compared to VATS. Robotic-assisted operations are also significantly more costly [34]. Park et al. [35] reported the long-term oncologic outcomes from three institutions and found them to be similar to VATS lobectomies.

Rajaram et al. [36] evaluated the use of robotic surgery for stage I to IIa NSCLC in the National Cancer Database from 2010 to 2012. They found 62,206 patients who underwent lobectomies including the open (n = 45,427), VATS (n = 12,990), and robotic (n = 3689) techniques. They found that the over the two-year period the use of the robotic lobectomy technique increased by 6%. Patients who underwent a robotic lobectomy had a lower length of stay compared to open lobectomy but had a higher rate of prolonged length of stay compared to VATS. The number of lymph nodes examined was significantly higher in the VATS group compared to robotic, with no difference in number of lymph nodes in the robotic and open groups. The resection status, margin positivity, was comparable between all groups. The evaluation of this data and the known increase in cost for the robotic technique did not show any potential advantages to the use of robotic surgery for a lobectomy compared to VATS. With the use of robotic techniques in treatment for NSCLC, early outcomes have been evaluated. Mungo et al. [37] found no negative effect on outcomes in patients who underwent robotic resection.

Park et al. [38] reported long-term outcomes to be similar in robotic assisted lobectomies compared to VATS and open thoracotomy. Yang et al. [18] compared the use of robotic, VATS, and open thoracotomy in patients treated with lobectomy for stage I NSCLC. An advantage of the robotic approach they report is a higher number of mediastinal lymph node stations dissected compared to the other techniques. The patients treated with the minimally invasive approach, robotic and VATS, had shorter hospital stays. The long term outcomes were similar in all the groups with 5 year overall survival reported for robotic, VATS and open thoracotomy as 77.6%, 73.5%, and 77.9%, respectively.

Cerfolio et al. [39] demonstrated the efficacy of robotic segmentectomies. For 100 planned robotic segmentectomies, 7 converted to lobectomies though every case was completed robotically. In this cohort, there were no mortalities at 30 or 90 days. Only 2 patients suffered major morbidity, each of which were

**125**

justified.

*Advances in Minimally Invasive Surgery for Lung Cancer*

field block, or ipsilateral stellate ganglion block [40].

and decreased need for chest tube drainage.

postoperative pneumonias. Of the 79 patients that underwent robotic segmentectomy, there were only 3 recurrences (3.4%) with median follow up of 30 months

Optimal visualization for a VATS is typically achieved with general anesthesia for double lumen tube intubation. However, awake VATS under regional anesthesia may be appropriate for selected patients. Potential anesthetic approaches include intercostal nerve block, paravertebral block, thoracic epidural block, peripheral

A randomized study of 43 patients by Pompeo et al. [41] assessed the feasibility and efficacy of awake VATS in patients with spontaneous pneumothoraces that require intervention. Patients were randomized to undergo VATS bullectomy and pleural abrasion with either thoracic epidural anesthesia or general anesthesia. The patients undergoing awake VATS had shorter operating room times, improved pain scores, and shorter hospital stays compared to the general anesthesia group. Awake VATS patients did suffer minor complications including vomiting and transient urinary retention though there was no difference in morbidity and mortality between groups. Recurrences at 12 months were similar in each group. Tacconi et al. [42] reported satisfactory lung reexpansion in 95% in 19 patients that underwent awake VATS for pleural decortication. A single institution study by Chen et al. [43] reported 285 cases of awake VATS for pathologies such as primary lung cancer, metastatic lung cancer, benign lung tumors, and pneumothorax. Operative interventions included lobectomies, wedge resections and segmentectomies with a 4.9%

Additionally, Chen et al. [44] examined outcomes for patient undergoing awake VATS in stage I and II NSCLC. For 30 patients undergoing awake VATS lobectomy under epidural anesthesia and intrathoracic vagal block with sedation and 30 patients undergoing VATS lobectomy under general anesthesia with single lung ventilation, there was evidence that each group had comparable pathologic stages and number of lymph nodes resected. Additionally, no statistical difference was seen in postoperative complication though the awake VATS group had shorter hospital stays

At this point in the development of minimally invasive thoracic surgery, there is evidence that there are advantages as well as proof of non-inferiority. Additionally, robotic-assisted minimally invasive surgery has been proven safe in the hands of those adept in it on selected patients but carries the burden of additional cost. Follow up data from some studies show that long term outcomes are equivalent. Additional study is still required to fully establish if the costs of robotic surgery are

*DOI: http://dx.doi.org/10.5772/intechopen.93102*

while overall survival was 95%.

intubation rate.

**10. Conclusion**

**9. Development of awake VATS**

postoperative pneumonias. Of the 79 patients that underwent robotic segmentectomy, there were only 3 recurrences (3.4%) with median follow up of 30 months while overall survival was 95%.

## **9. Development of awake VATS**

*Update in Respiratory Diseases*

rates of overall survival.

to be similar to VATS lobectomies.

outcomes in patients who underwent robotic resection.

cotomy as 77.6%, 73.5%, and 77.9%, respectively.

**8. Development of robotic-assisted VATS**

postoperative pain, and less blood loss. Fan et al. [32] reported a similar operative time and number of lymph nodes dissected in both single port VATS and open lobectomies for locally advanced NSCLC. In this study, single port patients had a shorter period of chest tube drainage and length of hospital stay but a higher complication rate than thoracotomy. The complications studied included prolonged air leak, atrial fibrillation, bleeding, pneumonia, bronchopleural fistula, chylothorax, death, and 30-day mortality. However, neither study reported data on recurrence

With data indicating that VATS is safe and efficacious for the resection of NSCLC as well as having a variety of advantages over open surgery, it has been established as the preferred technique. However, with the availability of the robotic assistance, techniques for robotic procedures have been developed and examined. Utilizing three robotic ports as well as an assistance port, Melfi et al. [33] reported their early experience using the Da Vinci platform, describing lobectomies, enucleations, excisions, and bulla stitching. Single institution experiences have reported safety and shown similar outcomes in robotic resection when compared to VATS with improvement in postoperative pain. Other experiences with larger cohorts found higher incidence of operative injury, and bleeding compared to VATS. Robotic-assisted operations are also significantly more costly [34]. Park et al. [35] reported the long-term oncologic outcomes from three institutions and found them

Rajaram et al. [36] evaluated the use of robotic surgery for stage I to IIa NSCLC in the National Cancer Database from 2010 to 2012. They found 62,206 patients who underwent lobectomies including the open (n = 45,427), VATS (n = 12,990), and robotic (n = 3689) techniques. They found that the over the two-year period the use of the robotic lobectomy technique increased by 6%. Patients who underwent a robotic lobectomy had a lower length of stay compared to open lobectomy but had a higher rate of prolonged length of stay compared to VATS. The number of lymph nodes examined was significantly higher in the VATS group compared to robotic, with no difference in number of lymph nodes in the robotic and open groups. The resection status, margin positivity, was comparable between all groups. The evaluation of this data and the known increase in cost for the robotic technique did not show any potential advantages to the use of robotic surgery for a lobectomy compared to VATS. With the use of robotic techniques in treatment for NSCLC, early outcomes have been evaluated. Mungo et al. [37] found no negative effect on

Park et al. [38] reported long-term outcomes to be similar in robotic assisted lobectomies compared to VATS and open thoracotomy. Yang et al. [18] compared the use of robotic, VATS, and open thoracotomy in patients treated with lobectomy for stage I NSCLC. An advantage of the robotic approach they report is a higher number of mediastinal lymph node stations dissected compared to the other techniques. The patients treated with the minimally invasive approach, robotic and VATS, had shorter hospital stays. The long term outcomes were similar in all the groups with 5 year overall survival reported for robotic, VATS and open thora-

Cerfolio et al. [39] demonstrated the efficacy of robotic segmentectomies. For 100 planned robotic segmentectomies, 7 converted to lobectomies though every case was completed robotically. In this cohort, there were no mortalities at 30 or 90 days. Only 2 patients suffered major morbidity, each of which were

**124**

Optimal visualization for a VATS is typically achieved with general anesthesia for double lumen tube intubation. However, awake VATS under regional anesthesia may be appropriate for selected patients. Potential anesthetic approaches include intercostal nerve block, paravertebral block, thoracic epidural block, peripheral field block, or ipsilateral stellate ganglion block [40].

A randomized study of 43 patients by Pompeo et al. [41] assessed the feasibility and efficacy of awake VATS in patients with spontaneous pneumothoraces that require intervention. Patients were randomized to undergo VATS bullectomy and pleural abrasion with either thoracic epidural anesthesia or general anesthesia. The patients undergoing awake VATS had shorter operating room times, improved pain scores, and shorter hospital stays compared to the general anesthesia group. Awake VATS patients did suffer minor complications including vomiting and transient urinary retention though there was no difference in morbidity and mortality between groups. Recurrences at 12 months were similar in each group. Tacconi et al. [42] reported satisfactory lung reexpansion in 95% in 19 patients that underwent awake VATS for pleural decortication. A single institution study by Chen et al. [43] reported 285 cases of awake VATS for pathologies such as primary lung cancer, metastatic lung cancer, benign lung tumors, and pneumothorax. Operative interventions included lobectomies, wedge resections and segmentectomies with a 4.9% intubation rate.

Additionally, Chen et al. [44] examined outcomes for patient undergoing awake VATS in stage I and II NSCLC. For 30 patients undergoing awake VATS lobectomy under epidural anesthesia and intrathoracic vagal block with sedation and 30 patients undergoing VATS lobectomy under general anesthesia with single lung ventilation, there was evidence that each group had comparable pathologic stages and number of lymph nodes resected. Additionally, no statistical difference was seen in postoperative complication though the awake VATS group had shorter hospital stays and decreased need for chest tube drainage.

## **10. Conclusion**

At this point in the development of minimally invasive thoracic surgery, there is evidence that there are advantages as well as proof of non-inferiority. Additionally, robotic-assisted minimally invasive surgery has been proven safe in the hands of those adept in it on selected patients but carries the burden of additional cost. Follow up data from some studies show that long term outcomes are equivalent. Additional study is still required to fully establish if the costs of robotic surgery are justified.

*Update in Respiratory Diseases*

## **Author details**

Rachit Shah\* and Nils-Tomas Delagar McBride Virginia Commonwealth University Medical Center, USA

\*Address all correspondence to: rachit.shah@vcuhealth.org

© 2020 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.

**127**

discussion -2

*Advances in Minimally Invasive Surgery for Lung Cancer*

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consecutive patients. Annals of Surgery.

[12] Shigemura N, Akashi A, Funaki S, Nakagiri T, Inoue M, Sawabata N, et al. Long-term outcomes after a variety of video-assisted thoracoscopic lobectomy approaches for clinical stage IA lung cancer: A multi-institutional study. The Journal of thoracic and cardiovascular

[13] Higuchi M, Yaginuma H, Yonechi A, Kanno R, Ohishi A, Suzuki H, et al. Long-term outcomes after videoassisted thoracic surgery (VATS) lobectomy versus lobectomy via open thoracotomy for clinical stage IA non-small cell lung cancer. Journal of Cardiothoracic Surgery. 2014;**9**:88

[14] Lee PC, Nasar A, Port JL, Paul S, Stiles B, Chiu YL, et al. Long-term survival after lobectomy for non-small cell lung cancer by video-assisted thoracic surgery versus thoracotomy.

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*DOI: http://dx.doi.org/10.5772/intechopen.93102*

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*Advances in Minimally Invasive Surgery for Lung Cancer DOI: http://dx.doi.org/10.5772/intechopen.93102*

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*Update in Respiratory Diseases*

**126**

**Author details**

Rachit Shah\* and Nils-Tomas Delagar McBride

provided the original work is properly cited.

Virginia Commonwealth University Medical Center, USA

\*Address all correspondence to: rachit.shah@vcuhealth.org

© 2020 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,

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[15] Murakawa T, Ichinose J, Hino H, Kitano K, Konoeda C, Nakajima J. Long-term outcomes of open and video-assisted thoracoscopic lung lobectomy for the treatment of early stage non-small cell lung cancer are similar: A propensity-matched study. World Journal of Surgery. 2015;**39**(5):1084-1091

[16] Yang CF, Meyerhoff RR, Mayne NR, Singhapricha T, Toomey CB, Speicher PJ, et al. Long-term survival following open versus thoracoscopic lobectomy after preoperative chemotherapy for non-small cell lung cancer. European Journal of Cardiothoracic Surgery: Official Journal of the European Association for Cardio-Thoracic Surgery. 2016;**49**(6):1615-1623

[17] Flores RM, Park BJ, Dycoco J, Aronova A, Hirth Y, Rizk NP, et al. Lobectomy by video-assisted thoracic surgery (VATS) versus thoracotomy for lung cancer. The Journal of Thoracic and Cardiovascular Surgery. 2009;**138**(1):11-18

[18] Yang HX, Woo KM, Sima CS, Bains MS, Adusumilli PS, Huang J, et al. Long-term survival based on the surgical approach to lobectomy for clinical stage I nonsmall cell lung Cancer: Comparison of robotic, video-assisted thoracic surgery, and thoracotomy lobectomy. Annals of Surgery. 2017;**265**(2):431-437

[19] D'Amico TA, Niland J, Mamet R, Zornosa C, Dexter EU, Onaitis MW. Efficacy of mediastinal lymph node dissection during lobectomy for lung cancer by thoracoscopy and thoracotomy. The Annals of Thoracic Surgery. 2011;**92**(1):226-231; Discussion 31-2

[20] Palade E, Passlick B, Osei-Agyemang T, Gunter J, Wiesemann S. Video-assisted vs open mediastinal lymphadenectomy for stage I non-small-cell lung cancer: Results of a prospective randomized trial. European Journal of Cardio-Thoracic Surgery: Official Journal of the European Association for Cardio-Thoracic Surgery. 2013;**44**(2):244-249; Discussion 9

[21] Villamizar NR, Darrabie MD, Burfeind WR, Petersen RP, Onaitis MW, Toloza E, et al. Thoracoscopic lobectomy is associated with lower morbidity compared with thoracotomy. The Journal of Thoracic and Cardiovascular Surgery. 2009;**138**(2):419-425

[22] Paul S, Altorki NK, Sheng S, Lee PC, Harpole DH, Onaitis MW, et al. Thoracoscopic lobectomy is associated with lower morbidity than open lobectomy: A propensity-matched analysis from the STS database. The Journal of Thoracic and Cardiovascular Surgery. 2010;**139**(2):366-378

[23] Donahoe LL, de Valence M, Atenafu EG, Hanna WC, Waddell TK, Pierre AF, et al. High risk for thoracotomy but not thoracoscopic lobectomy. The Annals of Thoracic Surgery. 2017

[24] Bertani A, Ferrari PA, De Monte L, Russo E, Di Paola G. Video-assisted thoracic surgery lobectomy in patients with reduced pulmonary function: A single-center series. Future Oncology (London, England). 2016;**12**(23s):39-45

[25] Swanson SJ, Meyers BF, Gunnarsson CL, Moore M, Howington JA, Maddaus MA, et al. Video-assisted thoracoscopic lobectomy is less costly and morbid than open lobectomy: A retrospective multiinstitutional database analysis. The Annals of Thoracic Surgery. 2012;**93**(4):1027-1032

[26] Schuchert MJ, Pettiford BL, Pennathur A, Abbas G, Awais O,

**129**

*Advances in Minimally Invasive Surgery for Lung Cancer*

[33] Melfi FM, Menconi GF, Mariani AM, Angeletti CA. Early experience with robotic technology for thoracoscopic surgery. European Journal of Cardio-Thoracic Surgery: Official Journal of the European

[34] Park BJ, Flores RM. Cost comparison of robotic, videoassisted thoracic surgery and

2008;**18**(3):297-300; vii

2017;**103**(4):1092-1100

2016;**26**(4):243-248

[38] Park BJ, Melfi F, Mussi A, Maisonneuve P, Spaggiari L, Da Silva RK, et al. Robotic lobectomy for non-small cell lung cancer (NSCLC): Long-term oncologic results. The Journal of Thoracic and Cardiovascular

Surgery. 2012;**143**(2):383-389

[39] Cerfolio RJ, Watson C, Minnich DJ, Calloway S, Wei B. One hundred planned robotic segmentectomies: Early results, technical details, and preferred Port placement. The Annals of Thoracic Surgery. 2016 Mar;**101**(3):1089-1095; Discussion 1095-1096. DOI: 10.1016/j.

2002;**21**(5):864-868

Association for Cardio-thoracic Surgery.

thoracotomy approaches to pulmonary lobectomy. Thoracic Surgery Clinics.

[35] Park BJ. Robotic lobectomy for non-small cell lung cancer: Long-term oncologic results. Thoracic Surgery Clinics. 2014;**24**(2):157-162; vi

[36] Rajaram R, Mohanty S, Bentrem DJ, Pavey ES, Odell DD, Bharat A, et al. Nationwide assessment of robotic lobectomy for non-small cell lung cancer. The Annals of Thoracic Surgery.

[37] Mungo B, Hooker CM, Ho JS, Yang SC, Battafarano RJ, Brock MV, et al. Robotic versus thoracoscopic resection for lung cancer: Early results of a new robotic program. Journal of Laparoendoscopic & Advanced Surgical Techniques Part A.

*DOI: http://dx.doi.org/10.5772/intechopen.93102*

Close J, et al. Anatomic segmentectomy for stage I non-small-cell lung cancer: Comparison of video-assisted thoracic surgery versus open approach. The Journal of Thoracic and Cardiovascular

Surgery. 2009;**138**(6):1318-25.e1

[27] Liu Y, Gao Y, Zhang H, Cheng Y, Chang R, Zhang W, et al. Video-assisted versus conventional thoracotomy pneumonectomy: A comparison of perioperative outcomes and short-term measures of convalescence. Journal of Thoracic Disease. 2016;**8**(12):3537-3542

[28] Rocco G, Martin-Ucar A, Passera E. Uniportal VATS wedge pulmonary resections. The Annals of Thoracic Surgery. 2004;**77**(2):726-728

[29] Xie D, Wang H, Fei K, Chen C, Zhao D, Zhou X, et al. Single-port videoassisted thoracic surgery in 1063 cases: A single-institution experiencedagger. European Journal of Cardio-Thoracic Surgery: Official Journal of the European Association for Cardio-thoracic Surgery.

2016;**49**(Suppl 1):i31-i36

S287-S294

[30] Shih CS, Liu CC, Liu ZY, Pennarun N, Cheng CT. Comparing the postoperative outcomes of videoassisted thoracoscopic surgery (VATS) segmentectomy using a multi-port technique versus a single-port technique for primary lung cancer. Journal of Thoracic Disease. 2016;**8**(Suppl 3):

[31] Dai F, Meng S, Mei L, Guan C, Ma Z. Single-port video-assisted thoracic surgery in the treatment of non-small cell lung cancer: A propensity-matched comparative analysis. Journal of Thoracic Disease.

[32] Fan J, Yao J, Wang Q, Chang Z. Safety and feasibility of uniportal video-assisted thoracoscopic surgery for locally advanced non-small cell lung cancer. Journal of Thoracic Disease.

2016;**8**(10):2872-2878

2016;**8**(12):3543-3550

*Advances in Minimally Invasive Surgery for Lung Cancer DOI: http://dx.doi.org/10.5772/intechopen.93102*

Close J, et al. Anatomic segmentectomy for stage I non-small-cell lung cancer: Comparison of video-assisted thoracic surgery versus open approach. The Journal of Thoracic and Cardiovascular Surgery. 2009;**138**(6):1318-25.e1

*Update in Respiratory Diseases*

2015;**39**(5):1084-1091

Singhapricha T, Toomey CB,

The Annals of Thoracic Surgery. 2013;**96**(3):951-960; discussion 60-1

[15] Murakawa T, Ichinose J, Hino H, Kitano K, Konoeda C, Nakajima J. Long-term outcomes of open and video-assisted thoracoscopic lung lobectomy for the treatment of early stage non-small cell lung cancer are similar: A propensity-matched study. World Journal of Surgery.

vs open mediastinal lymphadenectomy for stage I non-small-cell lung cancer: Results of a prospective randomized trial. European Journal of Cardio-Thoracic Surgery: Official Journal of the European Association for Cardio-Thoracic Surgery. 2013;**44**(2):244-249;

[21] Villamizar NR, Darrabie MD, Burfeind WR, Petersen RP, Onaitis MW, Toloza E, et al.

[22] Paul S, Altorki NK, Sheng S, Lee PC, Harpole DH, Onaitis MW, et al. Thoracoscopic lobectomy is associated with lower morbidity than open lobectomy: A propensity-matched analysis from the STS database. The Journal of Thoracic and Cardiovascular

Surgery. 2010;**139**(2):366-378

Pierre AF, et al. High risk for thoracotomy but not thoracoscopic lobectomy. The Annals of Thoracic

[25] Swanson SJ, Meyers BF, Gunnarsson CL, Moore M, Howington JA, Maddaus MA, et al. Video-assisted thoracoscopic lobectomy is less costly and morbid than open lobectomy: A retrospective multiinstitutional database analysis. The Annals of Thoracic Surgery.

2012;**93**(4):1027-1032

[26] Schuchert MJ, Pettiford BL, Pennathur A, Abbas G, Awais O,

Surgery. 2017

[23] Donahoe LL, de Valence M, Atenafu EG, Hanna WC, Waddell TK,

[24] Bertani A, Ferrari PA, De Monte L, Russo E, Di Paola G. Video-assisted thoracic surgery lobectomy in patients with reduced pulmonary function: A single-center series. Future Oncology (London, England). 2016;**12**(23s):39-45

Thoracoscopic lobectomy is associated with lower morbidity compared with thoracotomy. The Journal of Thoracic and Cardiovascular Surgery.

Discussion 9

2009;**138**(2):419-425

[16] Yang CF, Meyerhoff RR, Mayne NR,

Speicher PJ, et al. Long-term survival following open versus thoracoscopic lobectomy after preoperative

chemotherapy for non-small cell lung cancer. European Journal of Cardiothoracic Surgery: Official Journal of the European Association for Cardio-Thoracic Surgery. 2016;**49**(6):1615-1623

[17] Flores RM, Park BJ, Dycoco J, Aronova A, Hirth Y, Rizk NP, et al. Lobectomy by video-assisted thoracic surgery (VATS) versus thoracotomy for lung cancer. The Journal of Thoracic and Cardiovascular Surgery.

[18] Yang HX, Woo KM, Sima CS, Bains MS, Adusumilli PS, Huang J, et al. Long-term survival based on the surgical approach to lobectomy for clinical stage I nonsmall cell lung Cancer: Comparison of robotic, video-assisted thoracic surgery, and thoracotomy lobectomy. Annals of Surgery. 2017;**265**(2):431-437

[19] D'Amico TA, Niland J, Mamet R, Zornosa C, Dexter EU, Onaitis MW. Efficacy of mediastinal lymph node dissection during lobectomy for lung cancer by thoracoscopy and thoracotomy. The Annals of Thoracic Surgery. 2011;**92**(1):226-231; Discussion

[20] Palade E, Passlick B, Osei-Agyemang T, Gunter J, Wiesemann S. Video-assisted

2009;**138**(1):11-18

**128**

31-2

[27] Liu Y, Gao Y, Zhang H, Cheng Y, Chang R, Zhang W, et al. Video-assisted versus conventional thoracotomy pneumonectomy: A comparison of perioperative outcomes and short-term measures of convalescence. Journal of Thoracic Disease. 2016;**8**(12):3537-3542

[28] Rocco G, Martin-Ucar A, Passera E. Uniportal VATS wedge pulmonary resections. The Annals of Thoracic Surgery. 2004;**77**(2):726-728

[29] Xie D, Wang H, Fei K, Chen C, Zhao D, Zhou X, et al. Single-port videoassisted thoracic surgery in 1063 cases: A single-institution experiencedagger. European Journal of Cardio-Thoracic Surgery: Official Journal of the European Association for Cardio-thoracic Surgery. 2016;**49**(Suppl 1):i31-i36

[30] Shih CS, Liu CC, Liu ZY, Pennarun N, Cheng CT. Comparing the postoperative outcomes of videoassisted thoracoscopic surgery (VATS) segmentectomy using a multi-port technique versus a single-port technique for primary lung cancer. Journal of Thoracic Disease. 2016;**8**(Suppl 3): S287-S294

[31] Dai F, Meng S, Mei L, Guan C, Ma Z. Single-port video-assisted thoracic surgery in the treatment of non-small cell lung cancer: A propensity-matched comparative analysis. Journal of Thoracic Disease. 2016;**8**(10):2872-2878

[32] Fan J, Yao J, Wang Q, Chang Z. Safety and feasibility of uniportal video-assisted thoracoscopic surgery for locally advanced non-small cell lung cancer. Journal of Thoracic Disease. 2016;**8**(12):3543-3550

[33] Melfi FM, Menconi GF, Mariani AM, Angeletti CA. Early experience with robotic technology for thoracoscopic surgery. European Journal of Cardio-Thoracic Surgery: Official Journal of the European Association for Cardio-thoracic Surgery. 2002;**21**(5):864-868

[34] Park BJ, Flores RM. Cost comparison of robotic, videoassisted thoracic surgery and thoracotomy approaches to pulmonary lobectomy. Thoracic Surgery Clinics. 2008;**18**(3):297-300; vii

[35] Park BJ. Robotic lobectomy for non-small cell lung cancer: Long-term oncologic results. Thoracic Surgery Clinics. 2014;**24**(2):157-162; vi

[36] Rajaram R, Mohanty S, Bentrem DJ, Pavey ES, Odell DD, Bharat A, et al. Nationwide assessment of robotic lobectomy for non-small cell lung cancer. The Annals of Thoracic Surgery. 2017;**103**(4):1092-1100

[37] Mungo B, Hooker CM, Ho JS, Yang SC, Battafarano RJ, Brock MV, et al. Robotic versus thoracoscopic resection for lung cancer: Early results of a new robotic program. Journal of Laparoendoscopic & Advanced Surgical Techniques Part A. 2016;**26**(4):243-248

[38] Park BJ, Melfi F, Mussi A, Maisonneuve P, Spaggiari L, Da Silva RK, et al. Robotic lobectomy for non-small cell lung cancer (NSCLC): Long-term oncologic results. The Journal of Thoracic and Cardiovascular Surgery. 2012;**143**(2):383-389

[39] Cerfolio RJ, Watson C, Minnich DJ, Calloway S, Wei B. One hundred planned robotic segmentectomies: Early results, technical details, and preferred Port placement. The Annals of Thoracic Surgery. 2016 Mar;**101**(3):1089-1095; Discussion 1095-1096. DOI: 10.1016/j.

athoracsur.2015.08.092. [Epub: 02 February 2016]

[40] Kao MC, Lan CH, Huang CJ. Anesthesia for awake video-assisted thoracic surgery. Acta Anaesthesiologica Taiwanica: Official Journal of the Taiwan Society of Anesthesiologists. 2012;**50**(3):126-130

[41] Pompeo E, Tacconi F, Mineo D, Mineo TC. The role of awake videoassisted thoracoscopic surgery in spontaneous pneumothorax. The Journal of Thoracic and Cardiovascular Surgery. 2007;**133**(3):786-790

[42] Tacconi F, Pompeo E, Fabbi E, Mineo TC. Awake video-assisted pleural decortication for empyema thoracis. European Journal of Cardio-Thoracic Surgery: Official Journal of the European Association for Cardio-Thoracic Surgery. 2010;**37**(3):594-601

[43] Chen KC, Cheng YJ, Hung MH, Tseng YD, Chen JS. Nonintubated thoracoscopic lung resection: A 3-year experience with 285 cases in a single institution. Journal of Thoracic Disease. 2012;**4**(4):347-351

[44] Chen JS, Cheng YJ, Hung MH, Tseng YD, Chen KC, Lee YC. Nonintubated thoracoscopic lobectomy for lung cancer. Annals of Surgery. 2011;**254**(6):1038-1043

**131**

**Chapter 10**

**Abstract**

**1. Introduction**

the imaging techniques [1, 2].

Bronchiectasis

*Yasser Ali Kamal*

Surgical Management of

postoperative outcomes, and other important surgical issues.

Bronchiectasis is a chronic clinicopathological disease of the lung characterized by chronic cough, sputum production, recurrent pulmonary infection, and persistent bronchial dilatation on computed tomography. For many years, bronchiectasis associated with high mortality and morbidity particularly before the advent of antibiotics. The medical treatment of bronchiectasis includes antibiotic therapy, airway clearance, bronchodilators, and anti-inflammatory agents. Surgery is mainly performed for localized disease after failure of the medical treatment, including: segmentectomy, lobectomy, and pneumonectomy. This chapter highlights the current surgical considerations for treatment of bronchiectasis, regarding indications of surgery, preoperative evaluation and preparation, available operative procedures,

**Keywords:** lung, bronchiectasis, productive cough, thoracic surgery, lung resection

Bronchiectasis was originally described by René Laënnec in 1819. This term comes from two Greek words; "Bronkhia" and "Ektasis" meaning "Airway widening". As a medical term, bronchiectasis refers to chronic lung disease associated with irreversible dilatation of the bronchial tree. For many years, it was considered as an orphan disease; however, the detection of bronchiectasis has been increased in the recent years as a result of increased health awareness and modern advances in

The prevalence of bronchiectasis varies in relation to geographic location. The estimated prevalence of bronchiectasis in developed countries (USA, UK, Germany, Spain) is up to 566 cases per 100,000, with 40% increase in the past decade [3, 4]. The recent findings from the British lung foundation's project showed that around 212,000 people are currently living with bronchiectasis in the UK, with predominence of female gender and over-70 age [5]. In USA, 252,362 patients were indentified with an average annual prevalence of 701 per 100,000 persons between 2006 and 2014, with mean age of 76 years, predominace of female gender (65%), and dual diagnosis of chronic obstructive pulmonary disease (COPD) in most of the patients (51%) [6]. In China, the overall prevalence of physician-diagnosed bronchiectasis in people aged 40 years or older is estimated at 1.2% and is trending upward with aging of the population [7]. In comparison to European estimates, the recently reported patients with bronchiectasis in India were younger (median age

## **Chapter 10**

*Update in Respiratory Diseases*

February 2016]

2012;**50**(3):126-130

athoracsur.2015.08.092. [Epub: 02

[40] Kao MC, Lan CH, Huang CJ. Anesthesia for awake video-assisted thoracic surgery. Acta Anaesthesiologica Taiwanica: Official Journal of the Taiwan Society of Anesthesiologists.

[41] Pompeo E, Tacconi F, Mineo D, Mineo TC. The role of awake videoassisted thoracoscopic surgery in spontaneous pneumothorax. The Journal of Thoracic and Cardiovascular

Surgery. 2007;**133**(3):786-790

[42] Tacconi F, Pompeo E, Fabbi E, Mineo TC. Awake video-assisted pleural decortication for empyema thoracis. European Journal of Cardio-Thoracic Surgery: Official Journal of the European Association for Cardio-Thoracic Surgery. 2010;**37**(3):594-601

[43] Chen KC, Cheng YJ, Hung MH, Tseng YD, Chen JS. Nonintubated thoracoscopic lung resection: A 3-year experience with 285 cases in a single institution. Journal of Thoracic Disease.

[44] Chen JS, Cheng YJ, Hung MH, Tseng YD, Chen KC, Lee YC.

Nonintubated thoracoscopic lobectomy for lung cancer. Annals of Surgery.

2012;**4**(4):347-351

2011;**254**(6):1038-1043

**130**
