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Video-Assisted Lung Cancer Surgery: Small Incisions Mean Reduced Pain, Faster Recovery

01.13.2011

Bonnie Borton had already bested one kind of cancer twice – lymphoma, the kind that emerges in the body's lymphatic system. She'd gone through chemo twice, lost her hair and moved back into the regular rhythm of her life. Her oncologist kept a close eye on her.

Two years after her second occurrence of lymphoma, however, a scan showed some very tiny lesions in her lungs. She opted not to have a needle biopsy, a calculated risk that left her not at all surprised when another scan several months later revealed one particularly suspicious tumor. "I knew at the time I was rolling the dice," she said.

And now she was 78, not an age where the body can easily handle the traditional surgical approach to remove tumors from the lung: Long incision, ribs spread, and sometimes broken, muscles split apart, all in a procedure that can mean significant pain and several months of recovery. Borton, however, was offered by her Stanford physicians a minimally invasive option not available until relatively recently, supported by advances in technology and human expertise: a video-assisted lobectomy, or VATS lobectomy. Surgeons would make just three, one to two inch incisions into her torso and, guided by a high grade video camera, remove her tumor. Not only would it be gone, but she'd probably be out of the hospital within a few days and back to her usual activities in a few weeks.

One of the great joys in Borton's life is her garden. Because her Stanford surgeon, an expert in minimally invasive thoracic surgery, was able to remove her cancerous lung lesion with just three small incisions, she was back in her garden very quickly.

The chest, said Stanford's Chief of Thoracic SurgeryJoseph Shrager, has been one of the last frontiers for minimally invasive surgery. The chest is filled with critical structures like each of the pulmonary arteries that carry half the body's blood flow. "If you nick a muscle around the gall bladder during a minimally invasive approach, that's probably going to be okay," he said. "The downside of having trouble in the chest is much, much greater."

Focused skills

The field also includes surgery for esophageal cancer and other cancers of the chest. Nor had the medical profession developed, until the last two decades, the kind of training that produced surgeons who specialized in the chest's special geography. Before that training emerged cardiothoracic surgeons "were basically heart surgeons who did a little thoracic on the side and didn't really have a dedicated interest in the lungs or in cancer," Shrager said. Now there are about 20 hospitals in the U.S.—Stanford among them—where separate groups of surgeons specialize in thoracic cancers and also carry on thoracic surgery-focused teaching and research. Shrager's special interests include minimally invasive techniques to replace those traditional operations whose long incisions make them dangerous for older and sicker patients and whose after-effects can linger long after surgery. The incisions used for the decades-old procedures are "the most painful in any surgery," Shrager said. "You divide major muscles, you have to spread the ribs and no matter how careful you are, the nerves that run between the ribs are sensitive to manipulation."

I liked Dr. Shrager the minute I met him, and with my experience, I'm a pretty good judge.

-Bonnie Borton, patient, Stanford Hospital & Clinics

The post-surgical pain is more than a question of discomfort; it can create dangerous complications. "Pain makes it difficult to cough and if you can't cough after a lung operation, you have the tendency to develop pneumonia," Shrager said.

Many people who have lung surgery will also need chemotherapy, and that needs to be started as soon after surgery as possible. "Minimally invasive procedures mean a quicker recovery time," Shrager said, "and in some cases, the faster you can get chemo started, the more likely you are to have a good outcome."

"I liked Dr. Shrager the minute I met him," Borton said, "and with my experience, I'm a pretty good judge. Also, I'd already gotten on the Internet and checked him out. I also knew that my oncologist would bend over backwards to make sure I had the very best doctors. I feel very fortunate."

Expertise required

Shrager and his partners at Stanford are a select team. They are among an estimated 50 physicians in the U.S. trained in a particular technique called sleeve lobectomy. It allows a surgeon to remove one of a lung's lobes and then reconnect the remaining lobe or lobes. It's another way to reduce the risks of lung surgery—by avoiding the removal of the entire lung. Shrager has performed more than 2,000 lung lobectomies in his career. His three thoracic surgeon colleagues at Stanford bring their collective experience to at least double that number.

Surgical nurse Wilberto Gutierrez, RN, holds the long wand that holds a fiberoptic scope for the video camera that enables video-assisted thoracic surgery (top). The scope allows Stanford physician Joseph Shrager to work inside the lungs and chest with sharp and detailed visibility. The smaller photo shows two sizes of video lenses.

It's like putting your eye right into the chest, right next to the things you're dissecting.

-Joseph Shrager, Chief, Thoracic Surgery and video-assisted lobectomy expert, Stanford Hospital & Clinics

The VATS procedure Shrager used to treat Borton's lung cancer isn't appropriate for every patient, he said. The cancer must be in its earliest stages, which means only one in three patients may benefit. "What you need is a tumor that is embedded in the lung tissue, but not stuck to anything or growing or spreading into other structures," he said.

"He told me he'd like to use this approach," Borton said. "He said he couldn't guarantee that he'd be able to do it and that if he couldn't, that he'd have to spread my ribs." As it had before, Borton's luck held. In an operation lasting just two hours, Shrager was able to remove the upper lobe of her lung, where the 1.3 cm tumor was, and all the draining lymph nodes, with the VATS technique.

WHAT YOU SHOULD KNOW ABOUT LUNG CANCER
  • Lung cancer is the second most common cancer in men and women. It is the leading cause of cancer-related deaths in the U.S. Cigarette smoking is the cause of most lung cancers, but approximately 10% of lung cancers occur in non-smokers.
  • Symptoms can include persistent coughing, coughing up blood, hoarseness, chest pain, wheezing, lung infection, or  weight loss. A chest X-ray or CT scan may determine the first indications of illness.
  • PET scan, endobronchial ultrasound or mediastinoscopy, or brain MRI may be needed to track the possible spread of the disease to the  lymph nodes in the chest or to distant sites in the body.
  • A lobectomy is the most common operation and involves the removal of an entire lobe of the lung. In most hospitals, it is still performed with a large incision, rib-spreading procedure called a thoracotomy. At Stanford and a few other medical centers, surgeons have the option of VATS, video-assisted thoracic surgery, which is completed with three small incisions and without spreading the ribs.
  • A pneumonectomy removes an entire lung and is considered the most drastic approach. Some patients do well with this, but it can mean long-term disability because of shortness of breath.
  • A sleeve lobectomy is used when cancer is found at the origin of the airway to a lobe. It is the most complex type of surgery but may avoid the more injurious pneumonectomy.
  • A segmentectomy means just a portion of a lobe is removed and can be appropriate for some smaller tumors.

The optics that guided him mean the view is magnified so "it's like putting your eye right into the chest, right next to the things you're dissecting," Shrager said. The tools he manipulated to cut, cauterize and suture are now articulated, like the human wrist, to allow for important flexibility.

Research underway at Stanford is exploring methods for an even more detailed view of cancer's presence in the lymph nodes nearest the lungs. The Division of Thoracic Surgery is also investigating molecular aspects of lung cancer that may lead to future blood tests that could speed the diagnosis of lung cancer and build treatments that are less severe than chemotherapy and surgery.

Speedy recovery

Borton's quick surgery was followed by a quick recovery: Shrager operated on a Wednesday; Borton was released home three days later on a Saturday. On Sunday morning, Borton woke up and went into her kitchen full with several family members and friends who'd arrived to help care for her during her recovery. "I recall walking around the kitchen, giving each one of them a hug and they were looking at me like, 'God, this woman just had major surgery!' In another three days, just a week after her surgery, Borton decided she wanted to buy a replacement lounge chair. A few hours of shopping later, with the chair found and ordered, her companion asked whether Borton thought it might be a good idea to go home. "I guess so," Borton replied.

That quick recovery was important for Borton in another way, too. "I'm a pretty independent woman and I don't like to be a burden to my children," she said. Now, three small scars are the only marks of her VATS surgery.

I was walking around the kitchen and I was giving each one of them a hug and they were looking at me like, 'God, this woman just had major surgery!'

-Bonnie Borton, patient, Stanford Hospital & Clinics

Not exercising the way she once did, but perfectly capable of doing most of those things that are the great pleasures of her life—taking care of the home she's lived in for almost 50 years and tending to its garden, whose fruit trees and flowers she attentively nurtures. And, every day, she walks for at least 30 minutes, usually encountering a neighbor with a dog. She loves to read, as does her cat, apparently. As soon as she sits down with book in hand, Tippy leaps up onto her lap.

She doesn't think much about her illnesses. "I don't worry about it. I can only live today," she said. Nor is she thinking about any big moves. "I'm where I need to be. My husband was treated at Stanford. And I've had enough to do with Stanford to feel very comfortable right here. I'm happy to be where I am."

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