East Jefferson General Hospital's Dr. Michael Brothers recently performed his 200th complete anatomic lobectomy with lymph node dissection for lung cancer using the Video Assisted Thoracic Surgery (VATS) procedure. As the only MD Anderson network credentialed cardiothoracic surgeon in Louisiana performing this complex but minimally invasive surgery, Dr. Brothers is able to remove cancerous areas of the lungs and lymph node chains through several small holes. Lung cancer is the most common fatal malignancy in men and women in America.
The traditional method of performing this lobectomy calls for a large incision through the chest, approximately 6 – 12 inches in length and for the patient to be cut through the chest muscles. The next step is to spread the ribs apart to expose the area that needs to be removed. The patient often remains in the hospital for one to two weeks and painful recovery may take months. In addition, because of the trauma associated with the surgery, many patients who were not healthy enough or who had other complications could not have this procedure because the risk was too great.
Unlike traditional methods, with the VATS procedure, an entire cancer operation now takes place through several small holes, each approximately the diameter of a large pencil. Using video monitoring through one of the small openings, the cancerous lobe of the lung and all lymph nodes are removed through one of the other holes. The patient can leave the hospital in one to three days. VATS lobectomy has become the new standard of care.
Dr. Brothers has performed thousands of lung operations but finds this procedure the most significant development in his career as a cardiothoracic chest surgeon. "This was once the most painful surgery a person could have," says Dr. Brothers. "Now, my patient's experience is almost pain-free. They awaken immediately after the procedure, are ambulatory, and most importantly, long-term survival appears to be as good, or better than the original open operation."
Since performing his first procedure in 1976, Dr. Brothers has steadily challenged the traditional method of surgery to continually make it less invasive and traumatic for his patients. In the late 1980s, Dr. Brothers modified the operation. Instead of cutting chest wall muscles, the ribs were spread apart using retractors normally required for small children. This meant the ribs were spread less open and trauma to the patient was minimized. In the 1990s, Dr. Brothers gained further experience performing hundreds of simple procedures using video cameras and specifically-designed longer instruments.
As Dr. Brothers steadily refined the procedure, the patient's coordinating physicians, such as their oncologist, pulmonologist, cardiologist and internal medicine physician, realized that VATS puts far less surgical stress on the patient's body. This allowed them to dramatically expand the number of candidates who they could refer for surgery. The result is the potential to save time and lives through the ability to treat and diagnose patients earlier.
Removing the Lungs Through Small Incisions
The lungs are organs that absorb life-giving oxygen and expel carbon dioxide. The lungs are located on the left and right sides of the chest and are each divided into lobes. The right lung is comprised of three lobes while the left side is comprised of two lobes. Numerous lymph nodes drain the lungs at the center of the chest.
When a surgeon needs to remove cancerous masses from the lungs, there are a few options to the amount of the lung being taken. If the mass is small, only the spot or lesion on the lung, also known as nodule, will be cut away. In more extensive cases, an entire lobe can be removed. In more rare cases, an entire lung may need to be completely removed. The amount being removed will decrease lung function and breathing capability, so surgeons are careful to remove only the amount necessary.
"Under the VATS procedure, Dr. Brothers deflates the lung, cuts out the lobe or nodule, and places it in a small bag that is then extracted from the small incision he has made," says Dr. Thomas Nuttli, East Jefferson General Hospital Pulmonologist and MD Anderson credentialed physician. "Since this is so much less invasive than the traditional method, it has truly expanded the range of lung cancer patients able to get the liferestoring surgery they need."
VATS Offers Less Pain and Fewer Complications
VATS also has made a big improvement in the amount of post-operative pain a patient may experience and in the potential postoperative complications. Pain levels in the past were intensely high because of the physical demands of the surgery. The chest muscles healing and recovery usually kept a patient in the hospital for a week or two, and severely limited the return to normal functions of everyday life for months.
"With VATS, the patients will spend the first night in Intensive Care so that they can be monitored," says Dr. Nuttli. "That next day, however, they get up and walk themselves from ICU to the room they are moving to. They are doing that well coming out of the surgery."
Dr. Stanley Bleich, East Jefferson General Hospital Cardiologist, has seen similar results in his cardiac patients who need to undergo VATS. He notes that the patients often have fewer serious complications, much less blood loss, less chance of developing heart arrhythmia, and because they are in the hospital for a shorter period, fewer blood clots and post-operative infections.
"The concern I had for patients when they went through the traditional surgery was the longer the post-op treatment, the greater the risk is to have these severe and potentially life-threatening complications," says Dr. Bleich. "In addition, because the heart is located between the lungs, cardiac irritation would commonly occur as the surgeon had to move the organs around to get to the area that needed to be removed. That is not the case with VATS."
Patients who have had previous cardiac surgeries or heart disease especially need to return to their daily fitness routines and are at greater risk for negative effects from being sedentary too long. But for all patients, quickly and safely returning to their normal quality of life and workplace is the ultimate goal.
"VATS is not just a little better than the traditional surgery. It's a night and day difference," says Dr. Bleich. "They are up and running out the door in a couple of days with VATS whereas in the past they limped out of the hospital a week or two later."
Physicians Hail the Breakthrough Procedure
Through the use of VATS technology, Dr. Jayne Gurtler, East Jefferson General Hospital Oncologist and an MD Anderson credentialed physician, has seen a tremendous difference in her ability to examine suspect areas found on an x-ray. In the past, having only the traditional open surgery available, many patients simply could only be monitored, and perhaps have a biopsy taken, to see if the mass was cancerous. She believes that simply monitoring the patients was a missed opportunity to catch something serious in earlier stages.
"We know that you can't just cut everyone's chest open to take a look," says Dr. Gurtler. "The traditional method couldn't be used on patients who were too sick or too elderly. With the VATS procedure however, there is almost no limitation. It has taken a potentially lethal procedure and made it minor."
Dr. Gurtler went on to say that VATS offers a tremendous benefit to be able to go into the chest and physically cut the mass out if needed and at the same time see if there is a fungus or infection also present that can be treated. The mass already extracted can be tested and is no longer a danger of growing larger to cause problems down the line.
"I think it is important to note that having a procedure like VATS available is one thing, but having a meticulous surgeon that will do a good job with the procedure is crucial," says Dr. Gurtler.
To learn more about the VATS procedure, call the Heart, Lung and Vascular Institute at East Jefferson General Hospital at (504) 454-2222.