Needlescopic video-assisted wedge resection combined with the subcostal trans-diaphragmatic approach for undetermined peripheral pulmonary nodules
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Reduced mortality from lung cancer by computed tomography (CT) screening facilitates the use of video-assisted thoracic surgery (VATS) lung wedge resection to obtain a definite diagnosis and to treat tiny nodules. The authors evaluated their initial experience using novel needlescopic VATS wedge resection combined with the subcostal trans-diaphragmatic (SCTD) approach for managing undetermined peripheral pulmonary nodules.
Between 2009 and 2012, 35 patients who had 36 operations underwent needlescopic VATS wedge pulmonary resection with the SCTD approach. Preoperative percutaneous CT-guided marking of the nodule was performed. Two 3-mm miniports were placed in the thorax for the thoracoscopic camera and minigrasper. Just anterior to the 10th rib, a 2-cm subcostal incision was made, and a 12- or 15-mm port was placed trans-diaphragmatically into the chest cavity. Wedge resection of the lung was performed with endostaplers introduced through a subcostal port.
The median tumor size was 1.1 cm. Localization of the tumor was widely distributed. The mean operation time was 51 min, and the mean blood loss was 4.2 mL. No patients required conversion to thoracotomy, and one patient required conversion to conventional VATS. Additional thoracic ports were placed in five patients, and the needlescopic incision was extended to 15 mm in one patient. The median duration of chest drainage was 1 day. Additional analgesia was not required for 22 patients and was used for less than 1 day for three patients, less than 2 days for seven patients, and less than 3 days for seven patients. The pathologic diagnosis of the nodules was malignant for 28 patients and benign for 8 patients. On postoperative day 7 or at admission, 34 patients were free of postoperative neuralgia.
Needlescopic VATS wedge pulmonary resection combined with the SCTD approach is both safe and feasible and offers the specific advantages of minimal invasiveness and good cosmetic outcomes.
KeywordsLung cancer Minimally invasive surgery Needlescopic surgery Subcostal trans-diaphragmatic approach Video-assisted thoracic surgery Wedge pulmonary resection
Makoto Oda, Isao Matsumoto, Masaya Takizawa, Ryuichi Waseda, Mitsutaka Suzuki, Yasuhiro Ishiyama, Takatoshi Abe, Norihiko Ishikawa, and Go Watanabe have no conflicts of interest or financial ties to disclose.
Video 1. Patient position and placement of the first 3-mm thoracoport for a 3-mm high-definition videothoracoscope. (MPG 9,734 kb)
Video 2. Trans-diaphragmatic 12-mm port placement viewed under a videothoracoscope inserted through a 3-mm intercostal port. (WMV 6,222 kb)
Video 3. Wedge pulmonary resection using long staplers introduced through a 12-mm subcostal port. (WMV 5,791 kb)
Video 4. Extraction of the resected lung, which was placed in a removal bag; placement of a 19-Fr Blake drain; and the subcostal skin incision closure (WMV 6,396 kb)
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