Single-port Complete Thoracoscopic Lobectomy Feasibility

Single- port Complete Thoracoscopic Lobectomy FeasibilityClinical comparisons of single-port versus three-port accomplish thoracoscopic lobectomy for lung pubic louse patients surchargeObjective To compare the feasibility and safety of single-port versus three-port complete thoracoscopic lobectomy for lung stinkercer patients.Methods A retrospective ponder was conducted on 60 lung crab louse patients from June 2014 to supercilious 2014 in Department of thoracic Surgery, Union Hospital, Fujian Medical University. there were 30 patients in single-port complete thoracoscopic lobectomy root (single-port multitude) and other 30 in three-port complete thoracoscopic lobectomy substructure (three-port pigeonholing). Total lymph lymph lymph gland result, mediastinal lymph pommel harvest, dissection of mediastinal lymph node groups, cognitive run theatre fourth dimension, intraoperative store loss, extubation time, postoperative hospital persevere, visual analogue weighing machine ( vessel) one day subsequently operation, and the complication prize were thoroughly compared surrounded by the twain groups.Results in that location were no square differences in total lymph node harvest, mediastinal lymph node harvest, dissection of mediastinal lymph node groups, intraoperative blood loss, extubation time, postoperative hospital stay, and complication treasure between the two groups (p 0.05). However, the operation time of single-port group (209.045.5 min) was significantly longer than that of three-port group (154.530.9 min) (pConclusion For lung cancer patients, the feasibility and safety of single-port complete thoracoscopic lobectomy is similar to three-port complete thoracoscopic lobectomy. Compared with three-port complete thoracoscopic lobectomy, the operation time of single-port complete thoracoscopic lobectomy is longer, but its postoperative pain is gentler. As the get under ones skin accumulating, single-port complete thoracoscopic lobe ctomy should be popularized with its merits of minimal invasiveness.Keywords single-port, three-port, lobectomy, lung cancer.IntroductionCurrently, lobectomy is the prior intervention to traverse early- gunpoint non-small cell lung cancer (NSCLC) 1. As a minimally invasive proficiency, thoracoscopic lobectomy has been astray utilise in current thoracic department 2. Although single-port complete thoracoscopic lobectomy has been introduced to treat NSCLC, no literature was procurable to compare its feasibility and safety with three-port complete thoracoscopic lobectomy. Therefore, we conducted a retrospective comparison study in lung cancer patients enrolled from June 2014 to August 2014 to investigate the feasibility and safety of single-port complete thoracoscopic lobectomy.1. Methods and materials1.1 General teachingA total of 60 lung cancer patients from June 2014 to August 2014 in Department of Thoracic Surgery, Fujian Medical University Union Hospital were included in thi s retrospective study. There were 30 patients in single-port complete thoracoscopic lobectomy group (single-port group) and other 30 in three-port complete thoracoscopic lobectomy group (three-port group). All patients underwent associated examination such(prenominal) as thoracic computed tomography (CT), cerebral magnetic resonance imaging (MRI), skeletal firing computed tomography (ECT), and abdominal and cervical color Doppler ultrasound (CDU). Positron emission tomography-CT (PET-CT) might also need to be conducted to exclude metastasis if necessary. Electrocardiogram, cardiac CDU, and pneumonic function test were conducted to assess cardiopulmonary function. The inclusion criteria include 1) patients with stage I-II (cTNM classification) peripheral lung cancer 2) no thoracic surgical process history 3) lobectomy can be tolerated by cardiopulmonary function 4) preoperative complications have been stably controlled.1.2 Anesthesia and surgical procedureDouble-lumen endobronchi al tubes (DLT) were used for intubation for the two groups, and the ruddy lung received ventilation. All patients underwent thoracoscopic lobectomy under general anesthesia. For single-port group, a 3.5-4.5cm incision was do from the 4th intercostal situation to the 5th intercostal space on the prior(a) aliform line. The patients underwent thoracoscopic lobectomy with video assistance. For three-port group, a 1.5cm observation port was do on the cross point of midaxillary line and the 7th intercostal space, and a 2-4cm operation port was do on the cross point of anterior axillary line and the 4th/5th intercostal space. A 1.5-2.5cm operation-aided port was made on the cross point of the 7th intercostal space and infrascapular line. For peripheral lung cancer, pulmonary wedge resection was conducted to remove the localize. Once the resection samples were confirmed as cancerous tumor by fast frozen pathology, the following standardized lobectomy and mediastinal lymphadenecto my would be employed. For central lung cancer, standard lobectomy was conducted. Once the resection samples were confirmed as malignant tumor by fast frozen pathology, the following mediastinal lymphadenectomy would be employed. Electrocautery and supersonic scalpel were used to distract the vessels and bronchus. Suture clamps were used to fix great vessels such as pulmonary veins, pulmonary artery and so on. Hemolock, titanium clip, electrocautery, unhearable scalpel and silk ligation were used to handle small vessels. No definite order was made to conduct the lobectomy, which mostly depended on the development of interlobar fissure. Specimen bag was used to extract the removals preventing from contaminating the cuts, and analgesia pumps were used for the two groups. Indications for removing the drain included 24h waste pipe flow was less than 100mL postoperative lung recruitment was favorable without pleural effusion.1.3 notice parametersThe observation parameters included 1) p arameters during perioperative period operation time, intraoperative blood loss, postoperative waste pipe flow, postoperative thoracic cavity drainage time, visual analogue scale (VAS) one day after operation, postoperative hospital stay, death rate during perioperative period, complications during perioperative period. 2) parameters related to tumor resection total lymph node harvest, node-positive number, node-positive rate, N1 lymph nodes, N2 lymph nodes, N2 lymph node rate, and N2 lymph node groups.1.4 statistical methodsStatistical software SPSS 16.0 was conducted to analyze the data. Quantitative data was showed as xs, and independent t-test was used to test the group comparisons. Enumeration data was presented as rate, and test was used to test group comparisons. Statistical significance was toughened as P2. Results2.1 Clinical characteristicsThere were no significant differences in sex, age, tumor location, postoperative ghoulish type, tumor invasion, visceral pleura inv asion, and tumor classification, separately (P 0.05) (Table 1). In addition, there were no significant differences in total lymph node harvest, positive lymph node number, total mediastinal lymph node harvest, and dissection of mediastinal lymph node groups (P 0.05) (Table 2).Table 1. Comparisons of pathological information between single-port group and three-port group.Single-port group (n=30)Three-port group (n=30)P assessGender0.183Male911Female2119Age (year)*25-77(61)45-70(58)0.583Tumor location0.096Left upper lobe84Left low lobe53Right upper lobe89Right middle lobe34Right inferior lobe610Tumor type0.341Adenocarcinoma2522Squamous carcinoma26Others32Tumor invasion0.583Carcinoma in situ20Micro invasion56encroachment2324Visceral pleura invasion0.799No2221Yes89TNM classification0.989 detail 011Stage Ia1410Stage Ib610Stage IIa23Stage IIb32Stage IIIa44*ageextreme value (median).Table 2. Comparisons of lymph node harvest between single-port and three-port group.Single-port group (n= 30)Three-port group (n=30)P valueTotal lymph node harvest23.611.225.47.30.737Positive lymph nodes1.53.11.94.90.971Total mediastinal lymph node harvest16.29.217.26.50.731Dissection of mediastinal lymph node groups4.41.04.40.80.6372.2 Perioperative informationAll operations were under the video-assistance of total thoracoscopic lobectomy without other assisted endoscope incision. There were no deaths during preoperative period. However, there were a total of five cases with complications, two cases (1 case of arrhythmia 1 case of systemic infections) in single-port group (6.7%), and another three cases (1 case of arrhythmia 1 case of wrinkle leakage 1 case of chylothorax) in three-port group (10.0%). There was no significant difference in complications between the two groups (P0.05). Additionally, no significant differences in intraoperative blood loss, postoperative extubation time and postoperative hospital stay were observed (P0.05). However, operation time in single-port group (2 09.045.5 min) was longer than that in three-port group (154.530.9min) (PTable 3. Comparisons of perioperative outcomes between single-port and three-port groupSingle-port group (n=30)Three-port group (n=30)P valueOperation time (min)209.045.5154.530.90.000Intraoperative blood loss (ml)90.649.379.545.20.840Postoperative extubation time (d)4.01.55.43.70.256Postoperative VAS3.60.75.51.00.000Postoperative hospital stay (d)6.94.08.511.80.441Postoperative complications230.799Arrhythmia11Systemic complications10Air leakage01Chylothorax013. DiscussionsSingle-port thoracoscopic proficiency was first reported to diagnose and treat non-complicated pleura-related disease in 20037. In 2004, it was used in pulmonary wedge resection by Rocco et al.8. Seven long time later, single-port thoracoscopic technique was reported to conduct lobectomy and lymphadenectomy by Gonzalez et al9. Since then, it was applied gradually in segment resection of lung 10, total pneumonectomy 11, bronchial sleeve resecti on 12 and angioplasty of pulmonary arteries 13. However, most available literature focused on the feasibility and safety of single-port thoracoscopic lobectomy, and no studies compared it with three-port thoracoscopic lobectomy. The presented study retrospectively investigated the differences of clinical outcomes between single-port thoracoscopic lobectomy and three-port thoracoscopic lobectomy for lung cancer. Jiang et al. 14 compared 160 cases of thoracoscopic lobectomy and 247 cases of conventional open mental process and found no significant differences in perioperative death (0.6% vs. 2.8%) and complication rate (9.4% vs. 11.7%) (P0.05). It is indicated that thoracoscopic lobectomy was technically safe to treat NSCLC. too in our study, the complication grade were 6.7% and 10.0% for single-port group and three-port group, respectively. However, there were no deaths during perioperative period in our study. Therefore, our study indicated that single-port lobectomy was at least technically safe compared with three-port group.The vital factor for radical resection of lung cancer by single-port thoracoscopic lobectomy was the dissection of lymph nodes. Jiang et al. 14 found no significant differences in dissection of lymph node groups (2.41.5 vs. 2.61.6) and lymph node harvest (9.86.2 vs. 9.95.9) between thoracoscopic lobectomy group and conventional open surgery group (P 0.05). Similarly, Zhang et al.15 found no significant differences in lymph node harvests (14.67.5 vs. 15.24.5) between video-assisted thoracoscopic surgery group and video-assisted micro thoracoscopy group. That was to say, the lymph node dissection by thoracoscopic lobectomy was at least combining weight to that by open surgery. In the presented study, there were no significant differences in total lymph node harvest (23.611.2 vs.25.47.3), mediastinal lymph node harvest (16.29.2 vs. 17.26.5), dissection of mediastinal lymph node groups (4.41.0 vs. 4.40.8) between the single-port group an d three-port group. These results suggested that the lymph node harvest was at least equivalent to the precedent studies. In other words, the dissection of lymph nodes by single-port thoracoscopic lobectomy was feasible in respect of radical removal of tumors. However, the long-term outcomes need further follow-up to confirm in the future.The incision of single-port thoracoscopic lobectomy was located at the cross point of anterior axillary line and the 4th/5th intercostal spaces, which, unlike conventional three-port thoracoscopy, did not have observation port or assisted-operation port. The 4th/5th intercostal spaces were wider with less muscle and less bleeding, which might have little preserve on the postoperative recover with less pain. After comparing 20 cases of three-port thoracoscopic lobectomy and 10 cases of single-port thoracoscopic lobectomy in treating interstitial lung disease, Chen et al.16 found that postoperative one-day VAS in single-port group (4.950.39) was si gnificantly trim than that in three-port group (4.50.7) (P=0.03). Similarly in our study, postoperative one-day VAS in single-port group (3.60.7) was significantly lower than that in three-port group (5.51.0) (PIn the presented study, the operation time (209.045.5 min) in single-port group was significantly lower than that in three-port group (154.530.9 min). The reasons included 1) all the operating instruments and thoracoscopy went through the single port, which might interfere each other, especially when the focus was near the dorsal cavity and diaphragm. 2) single-port thoracoscopic lobectomy had a strict skill destiny of qualified camera assistant. The camera assistant was supposed to know how to fall in with the operator, how to allocate the location within the incision, and how to keep the camera stable. Our operation team up launched the single-port-thoracoscopic lobectomy since May 2014, and we believed that the operation time would be shortened as we optimized our tech nique gradually.In summary, the feasibility and safety of single-port thoracoscopic lobectomy were similar to three-port thoracoscopic lobectomy for lung cancer patients. With the development of instruments, the optimisation of surgical procedure, and the accumulation of surgical experience, the operation time would likely be shortened gradually. Therefore, single-port complete thoracoscopic lobectomy was supposed to be popularized with its merits of minimal invasiveness.