Feasibility of video-assisted thoracoscopic surgery as a redo chest approach for lung resection in patients with a history of surgical procedures on the same side

Introduction

As minimally invasive surgery gained popularity, surgeons improved their skills and began using video-assisted thoracoscopic surgery (VATS) for increasingly high-risk cases including lung cancer resection after induction therapy or extended resection for locally advanced disease. In addition, surgeons started employing VATS for more technically demanding procedures including pneumonectomy (1) and sleeve resection (2,3).

Nowadays, there is a growing trend in treating patients with previous history of thoracic surgery. This includes patients developing a second primary lung cancer or recurring lung metastases but also patients who previously underwent intrathoracic procedure for non-oncological reason. Repeat surgery could carry a higher risk of complication due to pleuro-pulmonary adhesions and scar tissue around the hilum. Of particular concern is the dissection of pulmonary vessels, which could be high skills demanding and, in case of vascular injury, could lead to life-threatening situation. Management of such complications requires specific training for both medical and healthcare professionals. Consequently, many clinicians are reluctant to use VATS approach in patients who have already undergone ipsilateral thoracic surgery.

Our aim is to report the early outcomes of redo-VATS and assess whether benefit warrants the risk. We present this article in accordance with the STROBE reporting checklist (available at https://jtd.amegroups.com/article/view/10.21037/jtd-24-216/rc).

Methods

This study analyzed the results of the VATS approach for lung resection in patients who had a history of intrathoracic procedure on the same side, irrespective of the type of surgery. Our study was classified as a retrospective monocentric observational study. Medical files were identified from the thoracic surgery department database. Pre, intra and early postoperative data were collected. The study period ranged from January 2018 to May 2023. Approval for the study was obtained from the French Society of Cardiothoracic Surgeons Ethical Committee (CERC-SFCTCV-2023-11-21_31847_Olaf Mercier), which waived the need for informed patient consent, in compliance with French law on retrospective studies of anonymized data. The study was conducted in accordance with the declaration of Helsinki (as revised in 2013).

Preoperative work-up included thoracic CT-scan, brain imaging, and positron emission tomography in all patients. Operability was assessed through pulmonary functional tests, blood gas analysis, echocardiography, and clinical evaluation. All surgical decisions were made by a multidisciplinary board including senior surgeons, pneumologists, oncologists, anesthesiologists, radiologists, and radiotherapists. For the management of a patient already operated on the thorax, the decision to use a VATS approach rather than an open one relied solely on the expertise and choice of the senior surgeon in charge.

Procedures were conducted following the Copenhagen anterior approach (4). Briefly, patients were positioned laterally with the arm raised on the operated side and intubated with a double-lumen tube under general anesthesia. To ensure postoperative pain control, a thoracic epidural catheter was inserted. A utility incision, approximately 5 cm long, was made in the fourth intercostal space along the axillary line. A soft tissue retractor (Alexis XS^®, Applied Medical, USA) was then placed without rib spreading. Two thoracoscopic ports (12 mm) were inserted—one anteriorly in the 6^th intercostal space and another posteriorly around the 8^th intercostal space. Tissue dissection was carried out using an energy device such as Harmonic^® (Ethicon, USA) or Sonicision^® (Covidien, USA). In the event of conversion, the utility incision through the fourth space was enlarged to accommodate a rib retractor. Mediastinal lymph node dissection was performed if not done previously or if easily accessible nodes were identified during surgery Various aerostatic products (TachoSil^®, Takeda, Japan; Progel^®, Becton Dickinson, USA; Neoveil^®, Gunze, USA) were utilized based on the surgeon’s preference. Intraoperative blood loss less than 200 mL was not routinely quantified in our practice. Chest tubes were removed when there was no air leakage, and daily pleural effusion was less than 300 mL.

The safety and feasibility of the redo-VATS technique were evaluated with surgical and oncological criteria routinely employed for usual VATS lung malignancies resection. These criteria included perioperative bleeding, conversion rate to thoracotomy, mortality, complication rate (especially prolonged air leaks), complete oncological resection (R0 with no microscopic or macroscopic tumoral residue), and analysis of mediastinal lymph nodes.

A subgroup analysis was proposed based on the most relevant factors to consider when planning a redo thoracic procedure: category of procedure (lung resection vs. other), surgical approach (open vs. VATS) and type of lung resection (anatomical vs. non-anatomical) during the initial surgery; type of lung resection (anatomical vs. non-anatomical) during the redo procedure.

Statistical analysis

Data were expressed as median with range (minimum and maximum value) for continuous data and numbers with percentage for categorical data. The subgroups analysis was solely descriptive, as the sample small size would have made it difficult to interpret any comparative statistics. Statistical and graphical analyses were performed using Prism^® V.8 (GraphPad, San Diego, CA, USA).

Results

During the study period, we identified 38 patients who underwent redo VATS: 22 males and 16 females. The patients’ characteristics are summarized in Table 1. Mean age was 66±12.2 years, with the majority being smokers (73.7%). First surgeries predominantly involved lung resections for malignancies using VATS (N=23, 60.5%) or open thoracotomy (N=15, 39.5%) approach. Sixteen procedures required pulmonary hilum dissection.

On average, there were 340 patients per year undergoing lung resection in our department and redo-VATS cases represented less than 3% of the overall activity (Figure 1). The median duration between first procedure and redo VATS was 30 (range, 2–99) months. Median operative time was 153 (range, 30–287) min. Blood loss exceeding 200 mL occurred in four patients (10.5%). Two of them required intraoperative red blood cell transfusions. All redo resections had negative margins (R0) at final pathology results (Table 2).

Figure 1 Da Vinci Robot Surgical System. The robotic arms are prepared with a sterile cover prior to entering the operating field. VATS, video-assisted thoracoscopic surgery.

Conversion to open thoracotomy occurred in five patients (13.2%), 2 after pulmonary artery injury, and 3 because of the inability to correctly identify and control structures due to tight adhesions or hemorrhagic swelling. Table 3 provides detailed information regarding the 5 patients requiring conversion to thoracotomy.

Postoperative complications are summarized in Table 4. Median hospital length of stay was 5 (range, 3–24) days, and chest drainage length was 3 (range, 1–37) days. Complications were observed in sixteen patients (42%), with the most frequent being prolonged air leak (>5 days) in 9 cases (23.7%). The 30-day mortality rate was 0%.

Table 5 compares subgroups statistics for the safety parameters of redo-VATS. Regarding the outcomes based on data from the initial procedures, the subgroup of previous non-pulmonary resection (N=6; lung transplant, esophagectomy, pleural procedures) had longer operative time [median 217 (range, 125–287) min], high conversion rate (33.3%), frequent prolonged air leaks (50%) and longer hospital stays [median 11 (range, 6–24) days]. Patients operated on for non-anatomical lung resection (N=14) during the redo procedure appeared to experience better outcomes than those operated on for anatomical lung resection (N=24): operative time 98 (range, 30–200) vs. 192 (range, 83–287) min, conversion rate 7.1% vs. 16.7%, prolonged air leaks 7.1% vs. 33.3%, hospital stays 5 (range, 3–8) vs. 7 (range, 3–24) days.

Discussion

Our study demonstrated that using VATS as the first-intent approach for lung resection in patients with prior chest surgeries is feasible but challenging. It resulted in an acceptable conversion rate of 13.2%, with no reported mortality. The more common postoperative complication was prolonged air leak. From an oncological perspective, tumor resection was always complete and lymph nodes sampling was performed when indicated.

Redo cases are rare, and their management remains a matter of debate. For a long time, the dogma has been to use an open approach from the outset due to concerns about surgical difficulties. Therefore, we proposed four parameters to consider when planning these procedures, which might have spontaneously contraindicated a minimally invasive approach (surgeries other than pulmonary resection, open approach and anatomical lung resection during the first surgery, and lung anatomical resection during the redo procedure). However, VATS has been proven feasible in each of these situations. This technique demands good experience in traditional minimally invasive surgery, and therefore time, before offering it to patients. Consequently, the size of our population was too small to define which patient may derive the greatest benefit. Our results contribute to better defining the indication of open and VATS approaches but require further development through larger studies.

One of the primary concerns is the presence of pleural adhesions, where the required adhesiolysis can be time-consuming and may lead to poor visualization, bleeding, and potential breaches to the lung parenchyma. Despite it not being a contraindication to VATS (5), many surgeons choose to avoid this approach for redo operations. In our experience, we have found that, in patients with dense pleural adhesions undergoing open surgery, employing a camera can be useful to obtain a clearer view during adhesiolysis. This hybrid technique is particularly valuable when dealing with extensive pleural adhesions located at the apex or at the costodiaphragmatic recess posteriorly, which can be especially challenging with a thoracotomy. Considering these factors, we find it reasonable to propose VATS as the first-intent approach in case of reoperations rather than opting for open surgery.

Sun et al. (6) reported the outcomes of 14 patients who underwent VATS major lung resections after a prior VATS lung nodule resection. The authors retrospectively categorized the procedures based on the degree of pulmonary hilum fibrosis. They observed that in certain cases, the fibrosis was not so dense, allowing for relatively straightforward interventions, almost akin to non-redo cases. Conversely, as in our cohort, it is evident that patients with significant fibrosis of the hilum pose the greatest challenge and are at the highest risk of conversion. Currently, there is no reliable preoperative imaging technique capable of evaluating the degree of healing inside the chest after the first surgery. While pleural thickening can be visualized on a CT scan, it remains impossible to predict the complexity of adhesion dissection during thoracoscopy. Initiating the procedure with VATS allows for real-time assessment of its feasibility, providing the option to convert if necessary.

The largest series of redo-VATS to date has been reported by Verzeletti et al. (7). However, the population of 51 patients over a seven-year period differs from ours. In their study, patients were exclusively treated with a VATS approach for the initial procedure, with those who underwent thoracotomy excluded. Their focus was solely on lung nodule resection, without including other surgeries such as lung transplants or vascular bypass as seen in our series. Nevertheless, their results mirror ours, with a few cases per year, a conversion rate of 11.8% and post operative courses primarily impacted by prolonged air leaks. The authors also concluded on the feasibility of redo-VATS, emphasizing the need for experienced surgeons. We agree that these cases should be managed by expert centers.

Several pitfalls and strategies are noteworthy when performing these procedures. It is crucial to anticipate difficulties, and patients should be thoroughly informed about the potential for conversion and specific complications. Offering a peridural catheter for postoperative analgesia is recommended, ensuring that if conversion to thoracotomy is required, it can be better managed. Additionally, instruments for open surgery should be readily available on the operating table from the outset. One port at the level of the 8^th intercostal space mid axillary line is made first, as it offers the widest access to the pleural cavity. In cases of tight pleural adhesions at this level, we initiate the procedure by delicately peeling away the pleura using an electric scalpel and, if necessary, digitally under direct vision. The primary objective is to create sufficient intrathoracic workspace to accurately place ports under visual control. Subsequently, the camera is inserted to visualize the pleural cavity. Hemostasis of pleural adhesions should be meticulously conducted with energy devices due to their often-vascularized nature, especially underneath previous incisions.

The conversion rate to thoracotomy in our study was 13.2%, exceeding the 5% to 10% range reported for large series of minimally invasive lung resections (8-11). However, it is essential to acknowledge that our study involved a relatively small number of patients, and a higher conversion rate was anticipated due to the complexities of redo surgeries. Conversion has long been a concern for thoracoscopic surgeons, with literature offering varied perspectives on its consequences. While some authors have suggested that it increases postoperative complications (12-14), others argue that morbidity and mortality do not significantly differ from non-converted patients (5,15). In our series, two of the converted patients experienced uneventful recoveries, while the remaining three encountered complications of varying severity.

Notably, Fourdrain et al. (16) identified thirteen preoperative risk factors for conversion during VATS anatomical lung resection, including previous thoracic surgery, and proposed an intraoperative conversion risk score. However, the score’s discriminatory power was found to be low, and its clinical relevance in our population is debatable. It is important to emphasize that a high-risk score should not deter the initiation of the procedure minimally invasively; instead, feasibility should be assessed intraoperatively. In redo-VATS, the consideration of a high conversion risk should prompt the systematic adaptation of anesthetic and surgical strategies.

The management of iterative lymph node removal remains a subject of controversy due to the difficulty of dissecting mediastinal structures in the presence of adhesions. Notably, 5 patients treated for non-small cell lung cancer (NSCLC) were staged pNx as the operating surgeon deemed redo lymphadenectomy not relevant. Additionally, two other patients treated for NSCLC were found to have mediastinal lymph node metastasis (N2) on definitive pathology, and one patient treated for a colorectal lung metastasis had an invaded node in the pulmonary hilum. The significance of lymph node removal lies in enabling better cancer staging, thereby facilitating the adaptation of adjuvant treatment to improve prognosis (17). Our approach is always to attempt lymph node removal via thoracoscopy. However, as noted by other authors, this approach is both a risk factor for conversion and a valid reason for conversion (5,14). Surprisingly, there is a dearth of literature specifically addressing the oncological outcomes of iterative lymph node removal. Consequently, there is no consensus on the handling of lymph nodes in redo surgery, leading to varying practices between centers. This gap in knowledge could serve as a valuable subject for future research.

The overall complication rate in our study was 42.2%. The most common complication being prolonged air leak leaks occurring in 23.7% of the patients, notably higher than what is reported for standard lung resections. Rivera et al. (18), in a study involving more than 24,000 patients, calculated an air leak prevalence of 6.9% after lung resection. Air leaks, attributed to parenchymal breaches during the division of pleural adhesions, pose a significant challenge. It is not evident that choosing an open approach for iterative resection would have mitigated this issue. Prolonged air leaks are a source of additional hospital costs, logically extending the length of hospital stay (19). The use of aerostatic agents during surgery could potentially address this problem. While the effectiveness of these devices is still debated, they appear to reduce the duration of postoperative drainage (20). Although not used systematically in our procedures, their application seems particularly relevant in this situation.

This study has several strengths and limitations. Firstly, it is a small-sized observational and retrospective cohort. Secondly, patients were carefully selected for surgery, and we did not compare them to patients who underwent thoracotomy for redo lung resection during the same period. Nevertheless, the study demonstrates the feasibility of redo-VATS, whether the first surgeries were conducted with open or minimally invasive approaches, and with good surgical quality criteria, as several lymph node dissections revealed occult metastases. Additionally, the study highlights the possibility of VATS after non-malignant chest surgeries. Given the increasing lifespan, improved survival after NSCLC, and the implementation of pulmonary nodule screening programs, it is conceivable that redo cases will become a more frequent issue in thoracic surgery departments. Our experience could provide valuable insights for clinicians facing decision-making in these delicate situations

Conclusions

In conclusion, lung resection in a previously operated chest can be successfully performed using VATS, even with a history of open approaches, non-pulmonary chest surgery, or anatomical lung resection. The decision to proceed with VATS relies on the expertise of the surgeon. Nonetheless, we recommend initiating redo procedures with VATS and then assessing its feasibility. Systematic planning of these cases with a thoracotomy approach should be avoided. Further data are needed to better define which patients will derive the most benefit from this strategy, especially when it can be expected that this situation will occur more frequently.

Acknowledgments

Funding: None.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://jtd.amegroups.com/article/view/10.21037/jtd-24-216/rc

Data Sharing Statement: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-24-216/dss

Peer Review File: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-24-216/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-24-216/coif). O.M. reported MSD scientific board participation and Edwards Lifesciences supported research participation. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. Approval for the study was obtained from the French Society of Cardiothoracic Surgeons Ethical Committee (CERC-SFCTCV-2023-11-21_31847_Olaf Mercier), which waived the need for informed patient consent, in compliance with French law on retrospective studies of anonymized data. The study was conducted in accordance with the declaration of Helsinki (as revised in 2013).

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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