Hybrid video-assisted thoracoscopic surgery lobectomy and en-bloc chest wall resection for non-small cell lung cancer

Video-assisted thoracoscopic segmentectomy with combined chest wall resection: A case report

Background

Resection of lung cancer with chest wall involvement is an invasive procedure.

Case presentation

We report a case of pulmonary adenocarcinoma with chest wall involvement that was resected through video-assisted thoracoscopic segmentectomy and combined en bloc resection of the chest wall (2nd to 4th ribs). Surgical stress was decreased by reducing the extent of lung parenchymal resection and applying a video-assisted technique with an additional posterior paravertebral incision.

Conclusion

A thoracoscopic surgical approach involving incisions in areas requiring resection of the proximal, lateral, and posterior sides of the involved ribs can be applied to tumors invading the chest wall.

Video-assisted thoracoscopic surgery lobectomy and en bloc resection of the chest wall with incision of the costovertebral joints for non-small cell lung cancer

We describe a case of lung lobectomy and resection of the rib neck and head in a lung cancer patient with an invasion of the chest wall. The tumor was located in the upper lobe, adjacent to the neck of the third rib. We performed a right upper lobectomy and en bloc resection of the third rib, including the rib neck and head, by video-assisted thoracoscopic surgery with an additional 6 cm posterior incision along the right paravertebral line. The costovertebral joint incision procedure is a useful technique to ensure tumor-free margins in cases where the tumor is located close to the rib’s neck and head.

Thoracoscopic (hybrid) complex chest wall resection in pediatric Ewing sarcoma

Askin tumor (a Ewing sarcoma variant) is the most common tumor of the chest wall in the pediatric age group. Multimodal treatment is required, with complete resection being the cornerstone of effective management. We describe the case of a 13-year boy with a left paraspinal Ewing sarcoma with intraspinal extension and spinal cord compression with neurological weakness. He underwent complex surgical resection using thoracoscopic resection of multiple ribs along with vertebral resection and reconstruction, after neoadjuvant therapy.

Hybrid treatment of T3 chest wall lung cancer lobectomy

Nowadays the treatment of patients with non-small cell lung cancer (NSCLC) that invades the chest wall is still questioned. The classic approach is a lobectomy that requires chest wall resection through thoracotomy, but thanks to the progress in the field of thoracoscopic surgery, this procedure can be performed by video-assisted thoracoscopic surgery (VATS). Major advances have been made in recent years both in the surgical technique associated with thoracoscopy and in the instrumentation available today. This has allowed the use of thoracoscopic technique even in advanced disease. To choose to perform complex surgery in assisted video surgery, considerable experience is needed to avoid making mistakes and giving up a better approach for the patient only for any technical difficulties. Thoracoscopy is not currently the preferred intervention for patients with chest wall invasion because there are insufficient studies on the feasibility of lobectomy with thoracoscopic wall resection, although the thoracoscopic approach has reduced mortality and morbidity in lung cancer cases not in advanced stage. We discuss our experience in three patients using hybrid approach with assisted video thoracoscopic lobectomy and a chest wall en-block resection with an alternative method of estimating thoracic wall resection that uses assisted video surgery and hypodermic needles (minimally invasive posterior approach).

Video-assisted thoracoscopic surgery en bloc chest wall resection

In the latest two decades, the video-assisted thoracoscopic surgery (VATS) technique has gained recognition as an effective alternative to conventional open surgery, and the field of its application has gradually extended to more complex diseases, such as locally invasive non-small cell lung cancer (NSCLC) requiring combined lung and chest wall resection. The en bloc chest wall resection can be accomplished by using a typical VATS port placement, each time adjusted to allow a better thoracoscopic guidance and a correct resection of the tumour to achieve negative margins. Different approaches have been described by experienced surgeons, with a remarkable variability in the number and disposition of the ports, in the surgical tools used and in the strategy of sparing the covering tissues. The common denominator of these experiences is the aim of extending the criteria of functional and oncological operability to high-risk patients who are not suitable for a conventional thoracotomy. Indeed, the VATS approach has shown effectiveness in reaching unchanged oncological outcomes in comparison with the thoracotomic technique but involving significantly less postoperative pain, faster recovery, shorter hospitalisation and lower overall complications.