Surgery is an operation to remove the tumor. It is most commonly used in early stage non-small cell lung cancer (NSCLC) and rarely in small cell lung cancer (SCLC). For patients with early stage lung cancer, surgical removal of the tumor and the lung tissue surrounding the tumor is the standard of care. If the tumor is too large for surgery at diagnosis, many lung cancer patients will receive radiation and/or chemotherapy to shrink the tumor before the surgery is performed. In many circumstances chemotherapy and/or radiation is recommended after surgery.
It is important to understand your treatment options and to discuss them with your treatment team.
The type of surgery depends on the tumor’s location, size and stage of the lung cancer. Two surgical approaches used to remove lung tumors:
- Thoracotomy: The traditional open surgery in which a large incision is made in the chest to remove lung tissue.
- Minimally Invasive Surgery: Newer surgical procedures, including VATS (video assisted thorascopic surgery) and robotic-assisted thoracic surgery, that generally require shorter hospital stays and less recovery time than thoracotomy.
These types of lung cancer surgeries can be done using either surgical technique:
- Wedge resection: Removal of the tumor as well as a small amount of normal lung tissue (the margin).
- Segmental resection (segmentectomy) : Removal of the segment of the lung where the tumor is located. There are 10 segments in the right lung and 8 in the left.
- Lobectomy: Removal of an entire lobe of the lung. The right lung is divided into 3 lobes; the left lung has 2 lobes.
- Sleeve resection: Removal of a lobe of the lung and a part of the airway (bronchus). Also called a sleeve lobectomy.
- Bilobectomy: Removal of two lobes of the right lung.
- Pneumonectomy: Removal of an entire lung.
A thoracotomy is done by a 5-10 inch incision on the chest, typically under the shoulder blade, but the location varies somewhat by surgeon and location of the tumor. The underlying muscles are either split or divided and the ribs are spread apart with a retractor or removed to give the surgeon access to the chest cavity and tumor.
Patients having a thoracotomy are completely asleep under general anesthesia and are placed on their side. Using a special tube inserted into the windpipe (trachea) the lung being operated on is deflated or collapsed, while the other one is inflated with the assistance of a mechanical device called a ventilator.
Once the surgery is completed, the lung is re-inflated and the chest is repaired by closing the ribs, muscles and skin with sutures. One or two drainage tubes are left in place to evacuate air and fluid. These tubes are usually removed after 3-5 days.
The first day after surgery may be spent in the intensive care unit of the hospital. A variety of tubes, catheters, and monitors may be required after surgery to monitor heart rate, blood pressure and oxygen saturation. The usual hospital stay after a thoracotomy is 4-6 days.
Minimally Invasive Surgery
Minimally invasive techniques usually require a hospital stay of 1-4 days and recovery time after surgery is typically much shorter than with thoracotomy. Although minimally invasive surgery can be used in many situations, not all lung cancer can be removed by minimally invasive surgery, all patients may not be candidates and the techniques may not be available everywhere.
Video-assisted thorascopic surgery (VATS) enables doctors to view and work inside of the chest cavity after making between 2 and 4 small incisions (cuts). Typically, one incision is about 2 ½ inches long and the others are half inch long. A tube with a small video camera on its end is inserted through one of the incisions.
Video captured from inside the chest is transmitted onto a computer monitor in the operating room allowing the surgeon to see a magnified view of the chest structures. The surgeon uses special long instruments to perform the lung resection through the other incisions. No rib spreading is needed.
VATS is done under general anesthesia with the patient on their side. Once the surgery is completed, the incisions are closed with sutures and one or two chest tubes are used to drain the chest. Chest tubes are removed one to two days after surgery. Most VATS patients are in the hospital for one day for a wedge resection and three days for a lobectomy.
The procedure may not be appropriate in cases involving large tumors (larger than 7 centimeters), tumors that are growing into the chest wall, or tumors that involve the central airway (main bronchial tubes).
Robotic-Assisted Thoracic Surgery
Robotic-assisted thoracic surgery is done through the da Vinci® System, which allows surgeons to operate through 3-4 small, half-inch incisions made between the ribs. No rib spreading is needed. A tiny 3D-HD video camera is inserted into one of the incisions to give the surgeon a magnified, detailed view of the lung or inside of the chest. Miniature instruments are used, which the surgeon moves by hand and foot controls.
The technology of the camera, the instruments and the skill of the surgeon allows for the removal of large or hard-to-reach tumors. Robotic-assisted thoracic surgery is done under general anesthesia.