Transdiaphragmatic Minimally Invasive Lobectomy is feasible in a Pig, is NOTES next?
Fox Chase Cancer Center, Philadelphia, PA, USA.
OBJECTIVE: Lobectomy is the treatment of choice for lung cancer. VATS lobectomy has gained acceptance as a safe, advantageous and oncologic sound alternative the open procedure. Some authors associate VATS lobectomy with a lower morbidity and mortality due to multi-factorial reasons. Intercostal incisions alter chest wall mechanics and lead to post operative pain. We postulated that performing the procedure without disruption of the intercostal spaces (ICS) may lead to better outcomes due to decreased effect on: chest wall mechanics and post operative pain. This initial experiment attempts to test the feasibility, safety and changes in technique during trans diaphragmatic lobectomy and lymphadenectomy based on currently available instrumentation.
METHODS and RESULTS: An anesthetized adult pig was positioned in a left lateral decubitus. Three access ports were placed beneath the costal margin, and the thoracic cavity was accessed through the diaphragm. Modifying the standard thoracoscopic VATS approach while adhering to the principles of surgical oncologic resection, a transdiaphragmatic minimal invasive right lower lobectomy with lymph adenectomy was performed uneventfully using current commercially available standard instrumentation and long Endo-GIA staplers. The specimen was removed using an Endo-catch bag through an access port. A complete (9,8,7,4R) lymph node dissection and sampling was carried out. An apical chest tube was introduced through a port site, other diaphragm incisions were closed under vision. CONCLUSIONS: We report and present on video the first transdiaphragmatic minimal invasive right lower lobectomy and lymphadenectomy in a pig. The procedure is safe and feasible using current commercially available standard instrumentation in a pig. Further study is warranted to further refine the surgical technique. Future instrumentation and experiments may eventually lead to a one-port or NOTES lobectomy provided that the principles of surgical oncology and safety can be achieved.
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