Minimally Invasive Surgery For Lung Cancer

Minimally invasive surgery for lung cancer( VATS/thoracoscopic/Key hole)

What is lung cancer:
Cancer is an excessive and abnormal growth of cells which manifest as a tumour in solid organs like lung, liver, kidney etc. Lung cancer is an abnormal growth of cells in lung tissues. There are mainly two types of lung cancer your doctor will be referring to

  • Primary lung cancer – cancer comes from lung tissues itself
  • Secondary lung cancer – cancer from somewhere else is deposited in lung tissue. Also known as metastasis.

Any cancer has three ways to spread:

  • Direct spread – cancers grows into whichever tissue part it comes into contact with
  • Blood spread – cancer cells leak into blood vessels and cancer cells lodge into other organs via blood stream. This is one of the mechanisms of secondary cancers
  • Lymphatic spread – Apart from blood, cancers are also serviced by lymphatic channels. With this method cancer can spread to lymph glands

Stages :
Staging of cancer is quite complex even for doctors to remember. I am going to simplify for you for easier understanding. If you have more questions you can discuss further with Dr Joshi

  • Early stage lung cancer – Cancer is confined to tissues of lung and not detected in lymph glands or other organs based on available tests
  • Slightly advanced or mid way lung cancer – cancer has gone out of the lung and is now found in the lymphatic gland of that lung tissue.
  • Advanced lung cancer – Cancer is found in lymph glands that don’t belong to that lung tissue or found in other organs like the brain, liver, bones etc.

Surgical treatment of lung cancer:

In general surgery is beneficial in prolonging survival of patients who have early stage or slightly advanced stage of lung cancer. There are two type of options for surgery

  • Thoracotomy – larger incision and spreading of the ribs. Operation is done with direct vision or telescope assisted.
  • Minimally invasive or thoracoscopic – small incision of 3 cm. No rib spreading or cracking and entire surgery is done with telescope assistance. No direct vision is possible due to small size of incision

One of the main problems with lung cancer surgery is a thoracotomy incision. Thoracotomy (incision and opening of thorax/chest) requires cutting through major chest wall muscle which are vital to our work of breathing. After surgery they need to be stitched together but everytime you breathe or move it causes a lot of pain and sometimes dysmorphia of the chest wall. The second problem is rib spreading. Ribs are held together by three layers of muscle in between the chest wall muscles. When they are spread at the time of thoracotomy they often break. Also, there is a high risk of damaging nerves which results in chronic pain in the long term. Minimally invasive thoracoscopic surgery does not require rib spreading and quite a small portion of the muscle is divided hence, resulting in better breathing capacity after lung resection surgeries, early recovery and return to life, early administration of chemotherapy if needed. It also eliminates large scars and dysmorphia of the chest wall. Some cancers can be recurrent and may require future surgeries. It can be quite difficult to reoperate after previous thoracotomy compared with previous minimally invasive thoracoscopic surgery.

Minimally invasive lung surgery is also referred to as “keyhole surgery”. Minimally invasive approach requires two small incisions about 1 cm in size in the lower aspect of the chest wall. There is a third incision which is about 3 cm in the upper aspect of the chest which allows the surgeon to introduce instruments in the chest and also remove the resected lung through the small incision. This incision in technical terms is still called thoracotomy but differs compared to traditional open thoracotomy in not spreading ribs and not cutting large chunks of chest wall muscles. Surgery is done under general anaesthesia. The majority of time you will not have a urinary catheter. The entire operation is performed under the guidance of video assistance which is obtained by introducing a camera/telescope through one of the bottom holes. This camera provides a significantly magnified view of structure detailing anatomy. There is no rib spreading or cutting with this approach which makes it quite patient friendly in terms of postoperative pain and recovery. Most surgeries will take about 1-1.5 hrs. Patients are awake straight after surgery and transferred to the recovery room prior to sending them back to the ward. You will have a tube coming out of your chest connected to the drain bottle. This drain is left in deliberately to assist removal of any residual blood/fluid that accumulates,or for evacuation of air that may leak from suture lines from your lung. Majority of drains are removed after 48 hrs and patients are discharged home with pain killers.

During your hospitalization, your pain is very well managed by the anaesthetist and nurses looking after you . Sometimes we involve a pain team but generally this is not necessary. Your pain is controlled with either button controlled system or a nerve block introduced in your back. You will also get oral pain killers but they can sometimes have significant side effects like nausea, vomiting and constipation.

You will get pre discharge education from the nurse in the ward. You will go home with dressings on your skin incision. Please remove it after 2 weeks under a running shower. You will also have drain stitches on the site of drains. These will need to be removed by your GP. Typically drain stitches are removed 5-7 days after your drain has been removed. It is not uncommon for fluid to leak from your drain site. Don’t panic if you see it. You can call Dr Joshi’s practice nurse during day time and if not accessible then visit your GP or ED. Make sure when you go home you have a signed form for follow up x ray and discharge summary

Once your cancer is removed it is sent to the pathology lab for further tests. It can take up to 10 days before we get the results. Dr Joshi or your referring specialist will convey results to you when you meet them next. Dr Joshi prefers to discuss the results in a multi-disciplinary team meeting which includes cancer specialists, radiation specialists, pathologists, surgeons and radiation specialists. The advantage of these meeting discussions is that the patient gets the advantage of all specialist opinions and the best treatment recommendation without having to visit them.

Will I need chemotherapy or radiotherapy ?
This will depend on the discussion at the MDT meeting,where the best treatment option for you will be decided once your pathology results are reviewed

You will have an appt to see Dr Joshi 4-6 weeks after your surgery and you will need to have a chest x-ray done before this appt,You will be given a form for this before you leave hopsital.You will also need to make an appt to see your referring doctor following your surgery