Advances in thoracic surgery

Cardiothoracic surgeon Dr Lim Chong Hee from C H Lim Thoracic Cardiovascular Surgery talks about the latest in surgical procedures for lung cancer.

Surgery to treat lung cancer used to always be a major surgery. To get access to the lungs, the thoracic surgeon would have to do a posterolateral thoracotomy, which involves an incision between 13 cm and 25 cm long slanting from the back to the side. Sometimes a rib may have to be removed temporarily, or a special equipment has to be used to spread the ribs to gain access to the space.

However, thanks to recent developments in minimally invasive surgery, most procedures such as lobectomies (the removal of a lobe in the lung) can be done with much less pain and blood loss.

In terms of minimally invasive surgical procedures, two options are currently available – video-assisted thoracic surgery (VATS) or robotic surgery.

VATS or robots

VATS involves creating a small incision to insert a thoracoscope (a long, thin tube which has a camera) that allows surgeons to examine the chest cavity. Some scopes are just 2 mm in diameter. Additional instruments are inserted through other ports to remove tissue.

Robotic surgery using the da Vinci Surgical System also uses tiny incisions. The robot’s movements are controlled by the surgeon. Robotic surgery offers better visualisation (using 3D technology) and better access to some tissues.

Both robotic surgery and VATS only require small incisions to insert the camera and the tools, which is much less invasive compared to the traditional thoracotomy.

Apart from better procedures, developments such as endo staplers have also helped to make thoracic surgery safer. Endo staplers cut and seal at the same time, which speeds up surgery. Being able to seal quickly is important because when you cut the lung, it leaks fluid into the cavity, which puts the patient at risk from chest infections and reduced lung function.

Minimally invasive surgery

With early stage lung cancer, at Stages 1 and 2, surgery offers the potential of a cure and a VATS lobectomy is a good option. Just three ports, two 10 mm ports and a single 40 mm port are needed. As a result, this is less invasive and more acceptable to patients. The results are also equivalent or better than open surgery.

The other advantages of minimally invasive surgery are that there is less pain, no retraction of ribs is needed, and patients have shorter hospital stays, and the ability to return to work sooner.

In Singapore, about 90 per cent of lobectomies are done via VATS, but the procedure is poorly adopted in Southeast Asia. In most countries in the region, less than 15 per cent of lobectomies use VATS. This is because of the steep learning curve involved. Other factors that hinder its adoption are the fact that an operation via VATS takes longer and a high initial investment is required.

Less invasive staging

Staging for lung cancer has also become less invasive, thanks to better procedures. The most common method for doing a biopsy is mediastinoscopy. This involves a small incision above the neck and placing a scope in the opening. The scope allows doctors to view the area. The scope can also collect tissue samples, which is needed for the biopsy. This procedure, however, has to be done with the patient under general anaesthesia.

However, a relatively new option called endobronchial ultrasound (EBUS) now exists. Introduced about two years ago, EBUS allows doctors to perform a technique known as transbronchial needle aspiration (TBNA) to obtain tissue or fluid samples.

A special endoscope fitted with an ultrasound processor and a fine-gauge aspiration needle is inserted into the patient’s mouth and is guided through the trachea. With EBUS, no incisions are necessary and patients only need to be sedated, rather than being under general anaesthesia.

Over the last few years, patients who need lobectomies have the option of using minimally invasive surgery over the traditional thoracotomy. Minimally invasive surgery for lung cancer is proven, versatile and in demand from patients because it involves smaller incisions, less painful, lower blood loss and faster recovery times. 

In future, the demand for minimally invasive surgery will increase. In terms of surgical procedures, it is likely that more surgeons will move towards single port surgery to further minimise incisions. In addition, robotic surgery is also likely to become more popular.

Written by Jimmy Yap



Tags: cancer laparoscopic (minimally invasive) surgery, cancer ultrasound, lung infection, new ways to treat cancer, robotic surgery, thoracotomy