Complications and Rehabilitation Challenges of Lung Cancer Surgeries

Open Thoracotomy

The most conventional approach is the open thoracotomy that involves separation of the ribs using a retractor ( Fig. 16.1 ). It consists of an approximately 8 cm incision, performed most commonly through the posterolateral thorax, at the fourth or fifth intercostal space. This approach divides the latissimus dorsi, intercostal muscles, and sometimes the trapezius and rhomboid muscles. An alternate anterior approach could be used, where an axillary incision is performed. The anterior approach involves splitting the serratus anterior and intercostal muscles in order to access the pleural cavity. This procedure allows the surgeon to use the two-handed surgical technique to properly expose and dissect the tumor.

The muscle-sparing thoracotomy is performed using an anterolateral approach, with a vertical skin incision at the midaxillary line, from below the hairline to the ninth intercostal space. The latissimus dorsi muscle is elevated and retracted, and the serratus anterior muscle is detached from its rib insertion. The intercostal muscle is divided anteriorly and posteriorly. Muscles retractors are used to maintain the serratus and pectoralis muscles anteriorly and the latissimus dorsi posteriorly.

Video-Assisted Thoracoscopic Surgery

As a less morbid alternative to the open thoracotomy, the video-assisted thoracoscopic surgery (VATS) is preferred for the early stages of lung cancer. This technique spares rib separation and consists of a skin incision of 4–5 cm through the sixth intercostal space at the anterior axillary line, where the thoracoscope is inserted. Additional 3–5 small incisions of approximately 1–2 cm are used for positioning additional surgical equipment. Intraoperatively, the camera allows only a two-dimensional view of the thoracic cavity, and the surgeon has to perform a sweeping method for visualization. Thus, this limits the VATS to patients with peripherally located tumors of up to 7 cm, without nodal involvement or distant organ metastasis, which do not require access to difficult areas for fine nodal or vascular dissection.

Robotic-Assisted Thoracoscopic Surgery

The robotic-assisted thoracoscopic surgery (RATS) requires 8 mm incisions in the posterolateral thorax for ports placement. The surgeon controls the instruments from a console and does not have direct contact with the organs. The RATS has multiple advantages, including an optimal tridimensional view of the surgical field, allowing better access to difficult areas that require fine and controlled dissection, including hilar structures, central tumors, and mediastinal lymph nodes in locally advanced disease. Despite its multiple advantages, the RATS technique is limited by the elevated cost of the equipment and its maintenance and the highly specialized surgical training.