If you’ve been diagnosed with lung cancer, you may be advised that surgery will be part of your treatment protocol. Typically reserved for patients with stage 1 or 2 non-small cell lung cancer, surgery for lung cancer has traditionally meant a lobectomy, in which a lobe or section of the lung is removed. A 2018 study in The Annals of Thoracic Surgery found that patients with early stage lung cancer live longer after receiving a lobectomy than they do after having a less extensive operation or radiation treatment.
But a lobectomy traditionally has required a thoracotomy — a large incision in the chest and spreading of the ribs to grant the surgeon access to the lungs. “A thoracotomy is considered ‘open’ surgery,” says Dr. Bernard J. Park, deputy chief of thoracic surgery at Memorial Sloan Kettering Cancer Center in New York. “That’s where we make a cut on the side and then we have to divide some muscles and cut the muscle between two ribs and spread the ribs to see inside the chest cavity so we can do our work.”
[See: 7 Things You Didn’t Know About Lung Cancer.]
Up until the early 1990s, open surgery was the standard approach, and “actually, in the U.S, probably about half the cases are [still] done that way,” Park says. “It gives access to the chest. You can see everything, you can work with your hands,” and in cases where there could be complications, sometimes it’s preferable for the surgeon to have that level of access.
However, this type of surgery can be very hard on the patient, because it cuts through major muscle groups. Sometimes ribs are fractured in the process, and the larger the incisions, generally the longer they need to fully heal. Therefore, “ever since the early 1990s there’s been a continuingly increasing movement to do minimally invasive surgery,” Park says.
With minimally invasive surgery for lung cancer, the surgeon doesn’t open up the patient’s chest entirely. “We use smaller incisions — anywhere from one to three or four small incisions,” through which video cameras and instruments are inserted. Then, using the visual feedback provided by the video camera (in what’s called video-assisted thoracic surgery or VATS) the surgeon can proceed to remove the cancerous section of lung. “The advantage of that is there’s less trauma,” Park says. “And with proper training and skill, you can do the same operation” without having to cut the patient open and spread the ribs.
Dr. Sudish Murthy, chief of the section of general thoracic surgery at the Cleveland Clinic and professor of surgery at Case Western Reserve University School of Medicine, says the difference in size of incisions between traditional and minimally invasive surgeries is significant. “Traditionally, incisions varied from 6 inches to 8 inches on the thorax cavity. Those have been truncated now to small incisions that are generally in the 1-centimeter [0.4-inch] range. We’re talking about a few half-inch incisions scattered around the chest. The biggest incision is generally the smallest incision it takes to get that segment of lung out of the chest,” which can be quite small given that like a balloon, the section of lung that’s being removed can be deflated and squeezed down to a much smaller size than it would take up when inflated inside the body.
Park says minimally invasive surgeries are generally aimed at early-stage lung cancer patients, those with stage 1 and 2 lung cancer, but increasingly, stage 3 patients may be offered minimally invasive approaches, too. He says use of robotic surgery, another form of minimally invasive surgery, is also increasing. The surgeon uses remote robotic equipment to perform the surgery inside the chest. “About 15 percent of the lung cancer lobectomies are done robotically now. Probably about 40 percent are done by video-assisted surgery. A still substantial amount are done open.”
Minimally invasive surgeries typically cut a patient’s hospital stay from about five days with traditional open surgery to about three days with the minimally invasive approach, Murthy says. Because of this reduction in trauma to the patient and because the surgery has similar outcomes to open surgery, minimally invasive techniques have gained in prevalence. “Across the country, we are seeing more use of minimally invasive lobectomy in the treatment of lung cancer. So this is a national trend that translates across the country,” Murthy says. Indeed, a 2016 article in the journal Oncology noted that “lobectomy is the standard of care for early-stage lung cancer, and minimally invasive approaches should be considered for all patients with operable tumors.”
Such is the case at the Cleveland Clinic, Murthy says. “We generally are very close to about 90 percent of patients who have stage 1 lung cancer who are otherwise deemed operative candidates will get a minimally invasive operation, whether it’s a VATS lobectomy or a robotic lobectomy. Our goal is to push that to 100 percent.”
It seems that less is more, in many situations. “All things being equal, the minimally invasive approach is thought to offer equivalent outcomes for cancer and improved outcomes in terms of shorter length of stay in the hospital, less pain immediately after surgery, fewer complications, particularly in high risk patients — so older patients, those with heart disease, patients with poor lung function like emphysema,” Park says. “It appears to have an advantage over the open technique.”
[See: What Not to Say to Someone With Lung Cancer.]
Still, there are some patients for whom minimally invasive surgery won’t work — those who have specific complications or comorbidities that elevate risk or otherwise make what’s already a complex surgery too challenging to do safely or effectively. For patients with very large or difficult-to-access tumors, open surgery might be a better option, and Park says sometimes a patient will be slated for a minimally invasive approach but that converts to open surgery in the OR. “Certainly, open surgery is the fallback position and to be perfectly honest, converting from minimally invasive to open surgery is not a failure. In fact, in most instances it’s a good decision,” based on the additional information the surgeon acquires after having used the videoscope to “get the lay of the land.”
The appeal of reduced recovery time is a big reason why VATS and robotic minimally invasive procedures are gaining in popularity. “If you take all comers, some of the advantages even out in terms of long-term pain and recovery, but there are a lot of short-term benefits, both in terms of complications, death rate immediately after surgery usually from complications and better ability to tolerate additional treatment like chemotherapy or some other treatment after surgery if it’s indicated,” he says. Older patients with less lung function may see bigger short-term benefits from a minimally invasive approach than younger, overall healthier patients. But it can work in a variety of situations and for a range of patients. “Pretty much anybody who can have open surgery can have minimally invasive surgery,” Park says.
But it’s important to remember that even when done minimally invasively, a lobectomy is still a major surgery. “Regardless of the size of the incision or the minimal access nature of the surgery, you still have to do the proper cancer operation first and foremost. You’re still doing the same operation. You’re still taking a portion of the lung,” which needs to be done safely and effectively, Park says. “The reason a lot of the [lung cancer] operations are still done open is because of the perceived risk profile. If you get bleeding or other problems, when the chest is open, you have a little greater access to control that or to deal with that rather than having a closed chest.” Such risks are minimized, however, when minimally invasive surgery is completed by a skilled an experienced surgeon, he says.
For any kind of lung surgery, “the fitter you are coming in to the surgery, the fitter you’ll be going out,” Murthy says, and this can dictate how long it takes you to resume your normal activities after any kind of surgery. He says on average, full recovery takes about eight days outside of the hospital for every day spent in the hospital. So for patients who’ve had minimally invasive lung surgery, a three-day hospital stay correlates to nearly a month of recovery time before they’ll be resuming normal activities, because even though the incisions might be smaller, a lobectomy of any kind is still a major surgery. “You can’t lose sight of the fact that you have lost a segment of lung. The geometry in your chest is different and the physiology of your breathing is different.” It takes time for the body to adjust to all that, but it may be able to do so faster without all the muscle trauma of a thoracotomy.
[See: 7 Innovations in Cancer Therapy.]
The bottom line, Park says, “is that the most important priority is to make sure that from a cancer and complication standpoint, the patient has a good procedure. If that’s minimally invasive, that’s great. If it’s open, so be it. I think lots of people mistakenly think everything has to be done minimally invasively,” but that’s not the case so long as the patient has a good outcome, he says.
If you’re interested in pursuing minimally invasive surgery for lung cancer, both Murthy and Park urge finding a well-trained surgeon who has a lot of experience with this very particular type of surgery. “They’re very sophisticated, complex operations. In the improperly trained surgeon’s hands, they can be more risky,” Murthy says.
Park adds, “if I had one message for patients: You do have to pick your surgeon properly.” He recommends asking your prospective surgeon how many years he or she has been using minimally invasive surgical techniques and how many such procedures the surgeon completes each week. The higher those two numbers are, the more experienced and skilled the surgeon is likely to be. He also recommends seeking a surgeon who specializes in non-heart chest surgery, as that usually indicates a higher level of practice and skill with these kinds of procedures.
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What Is Minimally Invasive Surgery for Lung Cancer? originally appeared on usnews.com
