Due to the public’s emphasis on health, many people with small nodular lesions in the lungs are found on chest CT during annual physical examinations, and after screening, some of them have lung cancer and need surgical treatment. Minimally invasive lung cancer surgery is now commonly carried out in major hospitals nationwide, creating various surgical styles and schools of thought. How to improve the surgical efficacy is a question that each of our thoracic surgeons must think about, and it is also the main concern of patients. There are near-term and long-term efficacy, near-term efficacy is how to reduce surgical complications, so that patients recover early; long-term efficacy is how to improve the survival and quality of life of patients.
I. Reduction of surgical complications.
Complications of minimally invasive lung cancer surgery mainly include bleeding, lung infection, bronchopleural fistula, etc.
1. Bleeding: There are intraoperative bleeding and postoperative bleeding. Since the pulmonary vessels are directly connected to the heart, even a pinhole-sized bleeding point can cause more bleeding. In order to prevent intraoperative bleeding, minimally invasive pulmonary surgery requires skilled operating techniques, careful and cautious working style, and the ability to handle the situation in the face of danger.
To prevent intraoperative hemorrhage: when separating blood vessels, hold the suction device in one hand and the electric hook in the other hand. The electric hook is inserted into the sheath of the blood vessel to pick up the sheath, the suction device bluntly separates and protects the blood vessel, and then the sheath is cut with electrocoagulation, which is generally controlled at about 30 to 40. If the vessel is separated by ultrasonic knife, the side with ultrasonic energy must be far away from the vessel wall, and the side with plastic sheet is inserted between the vessel sheath and the vessel, so that the choice of cutting the vessel sheath will not burn the vessel and cause bleeding. Secondly, the vessel freeing should be thorough, too short crossing will be difficult, too long will damage the vessel branches causing bleeding, if there are lymph nodes, remove them as much as possible to make crossing the vessel easier. When cutting the vessel, the cutting suture should be passed through the vessel gently, paying attention to the direction and angle, and not forcing it through when there is resistance, or after freeing the vessel again. After crossing, the direction of the instrument and the position of the head end should be seen before closing the cut. The stump of the vessel is usually around 5mm, too long will form a thrombus, too short when the stump if bleeding is not easy to stop.
If there is bleeding from vascular injury, first of all, do not panic, press the bleeding place with the suction head as fast as possible to stop the bleeding by compression, then try to block the proximal and distal ends of the vessel, after the bleeding is controlled, 4-0 Prolene suture can be used to stop the bleeding point two sides.
Postoperative bleeding: Generally, there are bronchial artery bleeding, intercostal artery bleeding, lung cutting edge bleeding and chest wall incision bleeding, etc. The bronchial artery and intercostal artery come from the aortic branches with high pressure.
Prevention of postoperative bleeding: intraoperatively, the thicker bronchial arteries are closed with titanium clamps and then cut off, and the mediastinal and inferior bulbar lymph nodes are cleared with ultrasonic knife coagulation before cutting off the vessels and stopping bleeding with spray coagulation. When cutting the vessels and lung tissue with cutting sutures, the vessels should be closed for 15 seconds, and the tissue should be compressed and the staples should be shaped before cutting and withdrawing, which can prevent bleeding from the stump and the cut edge, and bleeding from the vessel stump can be compressed with gauze for several minutes or closed with titanium clamps to stop bleeding, and in severe cases, the bleeding can be stopped by sutures. During or after surgery, all traumatic surfaces and blood vessels, bronchial stumps, chest wall incisions, lymph node dissection and chest apex should be inspected for adhesion cord fracture and bleeding.
2. Prevention and treatment of pulmonary infection.
Preoperatively: smokers should be prohibited from smoking for about two weeks, and those with a lot of sputum should be given sputum chemotherapy drugs and nebulized inhalation to facilitate sputum excretion, and sputum culture and drug sensitivity test should be done for postoperative reference of antibiotics selection, and those with infectious lesions should be controlled before surgery.
Intraoperatively: prophylactic application of antimicrobial agents to prevent infection, intraoperative aspiration by anesthesiologists, and aspiration of sputum before opening the lungs after surgery to facilitate expansion of the remaining lungs. The operator should pay attention to aseptic operation.
Postoperatively: use sensitive antimicrobial agents, usually for 2 to 3 days, strengthen postoperative care, assist in coughing up sputum, nebulized inhalation, sputum-removing drugs and other sputum-removing measures, inject saline 3 to 5 ml/time into the trachea when coughing up sputum is difficult, force coughing up sputum, and make fibrinoscopic aspiration if there is lung atelectasis.
3. Bronchopleural fistula: There are bronchial stump leakage and bronchoalveolar leakage at the lung cut edge or dissection surface.
The bronchial stump fistula may be formed due to the dislodgement of the staple or due to the obstruction of blood supply caused by cutting off too many bronchial arteries during lymph node dissection. Therefore, attention should be paid to preserving the blood supply to the bronchi during lymph node dissection. If the bronchial stump is not satisfactorily stapled, strengthen the suture with absorbable thread. If there is air leakage at the lung cut edge or dissection surface, continuous sutures with 3-0 Prolene thread can be used to reduce alveolar air leakage.
II. Improving the long-term efficacy of minimally invasive lung cancer surgery
In order to improve the survival and quality of life of lung cancer patients, we should strictly implement the relevant lung cancer treatment norms.
1. Preoperative perfection of various examinations for clear diagnosis.
Clinical medicine, primary diagnosis. Before deciding to perform minimally invasive lung cancer surgery, the thoracic surgeon should look at medical history, laboratory tests, tumor marker tests, sputum to find exfoliated cells, imaging tests such as chest CT, PET-CT and their dynamic changes, endoscopic tests such as direct vision biopsy under fibrinoscopy, brush examination, lavage cytology, transbronchial needle aspiration biopsy (TBNA), ultrasound bronchoscopy-guided transbronchial needle aspiration biopsy ( EBUS-TBNA), CT-guided percutaneous lung aspiration biopsy, and thoracoscopic local excision of the lesion followed by frozen section examination. Lobectomy should be done only when the malignancy of the lung nodule cannot be ruled out, and should not be done hastily to avoid unnecessary damage and trouble.
2, standardized surgery.
Follow the maximization of lesion removal and maximization of healthy lung tissue preservation. TV-assisted thoracoscopic surgery is a very mature technique for minimally invasive lung surgery, which consists of two parts: resection of the diseased lung and lymph node dissection, from which complete resection, incomplete resection and indeterminate resection evolve, and we should strive for complete line resection in order to improve the long-term efficacy of surgery.
(1) Diseased lung resection.
Minimally invasive pulmonary surgery can be divided into anatomic lobectomy and sublobar resection according to the size, morphological structure, pathological type and physical condition of the patient.
Anatomic lobectomy: It is still the gold standard for radical lung cancer surgery. The surgical sequence should deal with the pulmonary veins first, followed by the pulmonary arteries and bronchi, and finally the interlobular fissure. However, the order can be different due to individual differences and different surgical styles to facilitate and safety needs. Intraoperatively, squeezing, pulling and clamping of tumor tissue should be prevented, and the diseased lung should be placed in a specimen bag when removed to avoid contamination of the incision and implantation.
Sublobar resection: It includes anatomical lung segmental resection and lung wedge resection. Current indications can be considered as: advanced age, poor lung function or physical condition that does not allow lobectomy, peripheral type lung nodules with lesions located in the outer 1/3 of the lung parenchyma, lesions ≤50px in diameter, and adenocarcinoma with solid component less than 50% in CT suggestive of ground glass lesions. The extent of sublobar resection requires that the cutting edge is ≥50px from the lesion margin or the distance between the cutting edge and the tumor margin ≥ the lesion diameter. The bronchial cut ends and lung cut edges should be examined intraoperatively by cryopathology, and those with positive results should be treated accordingly.
(2) Lymph node dissection.
For complete resection, in addition to complete resection of the lung lobe where the primary lesion is located, systematic intrapulmonary and mediastinal lymph node dissection should be routinely performed. The guidelines stipulate that a minimum of 3 mediastinal drainage areas (station N2) should be cleared or sampled for lymph nodes, and that the lymph nodes should be removed in their entirety as much as possible. The number of lymph nodes cleared, in addition to the scope, is generally required to be more than 10.
Removal of lymph nodes requires no grasping exposure and complete and thorough excision. Complete and thorough clearance of lymph nodes is essential to prevent metastasis of lung cancer.
3. Comprehensive treatment improves long-term efficacy
The guidelines call for the combination of multidisciplinary comprehensive treatment and individualized treatment for lung cancer, and the rational application of surgery, chemotherapy, radiotherapy and molecular targeted therapy according to the patient’s tumor pathological classification, stage and molecular typing and the patient’s organism condition, in order to prolong the patient’s survival, control tumor progression and improve the quality of life.
Indications for surgery.
(1) Stage I, stage II and some stage IIIa mediastinal lymph nodes <75px or unfused, non-small cell lung cancer and stage I small cell lung cancer.
(2) Some stage IV non-small cell lung cancers with solitary contralateral lung metastasis, solitary brain or solitary adrenal metastasis.
(3) Intrapulmonary nodules with high clinical suspicion of lung cancer, which cannot be characterized by various examinations, can be surgically explored.
After surgery, stage Ia and Ib lung cancer generally do not require chemotherapy, but those with high-risk factors in stage Ib should be given postoperative chemotherapy. These include: cancer involving the pleura, cancer thrombus in the vasculature, poor differentiation, neuroendocrine carcinoma, wedge resection of the lung, inadequate lymph node dissection, and cancer diameter >100px.
Postoperative adjuvant chemotherapy, radiotherapy and targeted therapy are not recommended for completely resected stage Ia and stage Ib (except for high-risk factors). For the remaining stages of lung cancer, comprehensive treatment is used according to the guidelines to improve the efficacy, prolong survival and improve the quality of life. During the treatment period, regular follow-ups should be conducted. Follow-up of tumor markers: once every 3 months from 1 to 3 years, once every 6 months from 3 to 5 years, and once a year after 5 years. If there is elevation (>25%), it should be retested once a month. Postoperative follow-up: once every 3 to 6 months within 2 years, once every 6 months within 2 to 5 years, and once a year after 5 years. The follow-up includes chest CT, cranial MR, bone scan, ultrasound of liver, adrenal gland, supraclavicular lymph nodes, etc. If there is any abnormality, please ask the relevant specialist for appropriate treatment.