Dr. Xu stimulating manuscript (1) shows the progress made in VAT surgery over recent years. The series of patients undergoing bronchial sleeve resections via VATS represent another new challenge for thoracic surgeons in the search for improved outcomes.
Now it is finally accepted the role of bronchial sleeve resections as a beneficial alternative to pneumonectomy whenever technically possible and the argument VATS vs. open lobectomy approaches conclusion due to the recent widespread adoption of the different VATS approaches by surgeons worldwide, the authors present the next step of evolution in the indications for VATS surgery.
As with any less common indication for a surgical technique the manuscript touches on important factors to ensure safe and successful implementation of surgical techniques. Experience by the surgeon in both VATS lung resection and in open airway reconstructions is vital to perform these procedures safely and efficiently by VATS.
The authors mention two important technical points specific to these operations: complete circumferential excision of the bronchus (avoiding “wedge” bronchoplasty) and the change from an interrupted into a continuous suture for the anastomosis. While it is tempting for the inexperienced surgeon to maintain some continuity between the two bronchial ends thinking it will facilitate the anastomosis, only when confidence grows and complete sleeves are performed one realizes that the anastomosis is constructed easier if the ends are fully free and separated and it will also improve the anastomotic result with avoidance of possible early stenosis and angulation of the bronchoplasty. Many surgeons, normally following experiences in transplant techniques, made a transition from interrupted to continuous anastomoses in their open airways reconstructions that makes the procedure simpler, faster and less likely to create winding of the sutures. This is clearly magnified in a VATS approach as the surgical field is restricted.
The authors so far had avoided vascular reconstructions with their VATS approach, although other selected groups have reported their experiences. I am sure their step-by-step introduction of VATS techniques with their large experience will soon be performing them. Indeed these are the keys for efficient introduction of VATS bronchial sleeves by more surgeons: progressive experience in open sleeves and VATS lobectomy, careful consideration to the steps to be taken during the operation and once these skills are achieved the individual experience will be the determinant of progress. In my opinion it is of paramount importance, however, to learn (even small details) from surgeons performing the operations, be in the form of formal training, visits or by non-edited videos of procedures. The experiences of pioneer surgeons should not be discarded because of individual limits. “Is there anyone so wise as to learn by the experience of others?” Voltaire dixit.
Disclosure: The author declares no conflict of interest.
- Xu X, Chen H, Yin W, et al. Thoracoscopic half carina resection and bronchial sleeve resection for central lung cancer. Surg Innov 2014;21:481-6. [PubMed]