The Advent of VATS

During my thoracic surgical residency though the late 1950’s to the middle 1960’s, it became apparent to me that the traditional thoracotomy incision was the most burdensome and painful portion of the thoracic operation. Insertion of the rib-spreader, no matter how carefully opened, frequently caused ribs to fracture and costochondral joints to become dislocated. Large muscles were stretched, ligaments torn and nerves injured. Because of these unavoidable but detrimental occurrences, normal, spontaneous respirations postoperatively produced exquisite, intolerable pain. Either this pain or the large doses of narcotics required to lessen it could depress pulmonary respirations enough to result in pneumonia, hypercarbia, hypoxia, etc. Patients with limited pulmonary reserves quickly became compromised. Eventually, after stabilizing and hospital discharge, these patients could continue to experience moderate to severe incisional pain for months or even years. Interestingly, the complicated intra-thoracic operation which was performed usually presented few problems for the patient. The predominant postoperative hardship always seemed to emanate from the chest wall trauma. If the traumatic access to the thoracic organs could be reduced, possibly, the patient might experience less pain and have a quicker and easier recovery.

During my residency, I tried various, accceptable techniques of that period to decrease operative pain from a thoracotomy. These included excision of small segments of ribs to prevent fractures from occurring when the ribs were spread to open the chest, spreading minimally and working through narrow spaces, dividing or injecting intercostal nerves, postoperative anesthetic drips to the intercostal nerves, and muscle sparing. Despite using these endorsed pain relieving maneuvers almost all patients continued to experience significant pain following thoracotomy. Sacrificing the attributes of good visualization and readily available access to all organs, which a wide open chest provides, for a narrow, limited, compromised incision did not bring any noticeable reduction in pain for the patient. It became very frustrating to perform a technically challenging procedure successfully and then watch the patient suffer and, on occasion, even deteriorate from debilitating chest pain. This thoracic wall pain interfered with chest wall mechanics increasing respiratory complications and leading to morbidities. Various types of incisions, muscle sparing approaches, and modifications and adjustments of a host of analgesics did not seem to meaningfully influence postoperative chest wall pain.

In 1966, I entered practice with a technically superb surgeon , Dr. Philip Kunderman. Under his tutelage I learned many of the nuances of endoscopy and became expert in mediastinoscopy and traditional thoracoscopy. Because of the proximity of a Johns Manville asbestos factory, I began to see numerous patients with findings related to asbestos. Mesothelioma was a common diagnosis. As a young, energetic surgeon, I initially performed thoracotomies, with radical pleuropneumonectomies and radical lymphadenectomies, for patients with confirmed mesothelioma. It soon became apparent that these operations were neither curative nor even beneficial for this group of patients. During this period of time, it was essential that confirmatory tissue for mesothelioma be obtained so these patients could qualify for much needed health and disability benefits. Since tissue was mandated, minithoracotomy was substituted for access to drain loculated effusions, decorticate restricted lung and retrieve generous biopsies. Even this lesser operation proved to be burdensome. These were all terminal patients whose life span was averaging only one or two years, at the most, even when aggressive therapy was used  such as radical surgery, maximum radiation, and prolonged chemotherapy. Hoping to further decrease the difficult postoperative course resulting from even minithoracotomy , and since I had now become adept at various types of endoscopy, I elected to try different combinations of scopes. I began to employ flexible and rigid bronchoscopes, traditional thoracoscopes and Carlen’s mediastinoscopes to explore, treat, and biopsy the intrathoracic contents.

This allowed the intrathoracic objectives to be achieved without severely traumatizing the chest wall. Eventually two or three Carlen’s mediastinoscopes provided adequate visualization and allowed satisfactory maneuverability for instruments. This rudimentary set up, although far from perfect, did permit loculations to be drained, limited decortications to be accomplished and adequate biopsies to be obtained. Strikingly and gratifyingly the postoperative course was very benign and recovery  rapid using this technique. Hospitalizations were two to three days.

After a period of time, I became comfortable and developed confidence in these minimally invasive surgical techniques. It seemed reasonable to employ them instead of an open thoracotomy, whenever possible, for other types of benign and malignant intrathoracic problems. Loculated pleural effusions could be fully drained, metastases on the pericardium, visceral or parietal pleura biopsied and even pericardial windows made in cases of malignant pericardial effusions thus eliminating the exploratory thoracotomy. Soon after, it was found lung biopsies for diffuse parenchymal disease could be successfully performed. Of interest, once again, almost all of these patients had a benign and rapid postoperative recovery. It now became obvious that if the thoracotomy could be avoided, most patients would no longer experience the pain and debilitation which  so frequently followed that incision. In other words, patients could benefit markedly from lesser access incisions. This provided a strong incentive to pursue minimally invasive thoracic surgery.

During the 1970’s and 1980’s, I became involved with researchers at Ethicon in Somerville, NJ.  I discussed my interest in minimally invasive thoracic techniques and even made proposals for special equipment and instruments  that could be helpful. One instrument was a single, action lung biopsy forceps that could be inserted into the chest blindly. It would then grasp lung, staple and excise it in one maneuver.  Prototypes were being evaluated when I observed innovative orthopedic surgeons, in my hospital, visualizing and operating on various joints through very small incisions by using scopes that projected images on a television monitor. This was very impressive and caused me to believe that a similar type of technique could bring extraordinary benefits to thoracic surgical patients. The predominant problem for me concerned the orthopedic scopes  and  instrumentation. They seemed to be incompatible with the needs of the thoracic surgeon. Even the scopes and instruments used in gynecology were not satisfactory. Over the following years, despite continuing to build and run a large thoracic practice and tend to numerous administrative and residency duties at the medical school, I still remained preoccupied with minimally invasive thoracic surgery and continued to find time to study, develop and refine a technique.

During the late 1980’s, the French were experimenting with videoscopic surgery, and by 1989, the first clinical “lap choles” were being performed in the United States. This procedure provoked immediate and widespread controversy in the hallways of the Annual ACS Meeting that year. Much of it was very negative. However, to me, it became a strong impetus to proceed further in thoracic surgery by using similar techniques. In selected cases, I would project the intrathoracic anatomy on a video screen before proceeding with the planned open thoracotomy and resection. Visualization was suboptimal because, initially, a double lumen tube was not utilized. Also, fogging of the lens was a frequent disturbance. Instrumentation, which was borrowed from other specialties  was not really suitable for thoracic surgery. After I found an anesthesiologist who had patience, skill and interest in using double lumen tubes, visualization improved markedly.

At first, I continued to be overwhelmed with the intrathoracic anatomy that could now be seen on the video monitor that was never really appreciated when merely peering into the open thorax. The apex and costophrenic angles could be inspected easily and completely. Each internal rib counted effortlessly. Magnification by the scope revealed pulsating diminutive vessels in the parietal pleura, and each structure seemed to have more color. It was a most beautiful sight to behold, one which I had never seen despite the many years I had been doing resections. This introductory maneuver, of gaining experience manipulating the scope and examining the anatomy, before proceeding with a traditional thoracotomy, served as an excellent preparation for videoscopic surgery.  It allowed a rapid accumulation of knowledge and skills which proved to be very helpful when it came time to actually perform this type of surgery. Early in my experience, it became apparent that pleural metastases could be easily identified after the scope was inserted and before proceeding with  the planned thoracotomy. These were metastases that had avoided detection despite an extensive preoperative evaluation. Biopsy and frozen section prevented a major thoracotomy in these patients with incurable, metastatic carcinoma of the lung. This convinced me of the many potential benefits that could be derived from this technique.

Gradually, as knowledge, skill, and confidence were slowly acquired, on occasion, select, simple problems such as loculated effusions, lung biopsy, bullous disease, mediastinal node biopsy, pneumothorax, etc were treated. Thoracotomies were always planned for these patients with the set up available. If the intended videoscopic procedure could not be completely and successfully accomplished, there was never any hesitation to proceed expeditiously to traditional open surgery. The absolute safety of the patient and performance of a quality operation, comparable to that attained with open techniques, were two goals always mandated and paramount in my mind. It soon became evident that the postoperative course was relatively benign and hospitalization shortened when surgery could be achieved by videoscopic surgery. Recovery was amazingly fast, and early clinical results were superior to anything anticipated.

The team was becoming more expert and skillful as more cases were done. .Anesthesiologists no longer had difficulty with placement and management of double lumen tubes. Scrub nurses commandeered various instruments from other specialties, and circulating nurses became adept at maintaining and keeping the available primitive scopes and monitors functioning to some degree during surgery. Patient positioning, draping, monitor placement, arrangement of the O.R. team, duty sequences, etc. were all being developed and refined. With time, videoscopic surgery became easier and more effortless. There was little realization or appreciation of how mature this new technique had become in my practice.  We now accepted it as a routine procedure for certain types of cases. The early frustrations were slowly dissipating.

By mid 1991, using video techniques, I had already done most of the general thoracic procedures that previously would have required a formal, open thoracotomy. This included even anatomic lobectomy.  Each of these operations was performed in a manner identical to that used in the open thoracotomy. Only the access incision was different. In my operating room, videoscopic surgery was beginning to replace the thoracotomy, and regional surgeons were requesting permission to observe the technique. In early 1991, Ethicon invited several general surgeons , who were becoming leaders in videoscopic general surgery, to a meeting in New Brunswick N.J.  I was also asked to attend and was the only thoracic surgeon present. The discussion centered on “Lap Chole” and other possible applications for general surgeons. I was disturbed to hear that some of these general surgeons had performed lung biopsies videoscopically.  In May of 1991, Ethicon combed the country searching for surgeons in the various specialties who had an interest in videoscopic surgery. Few could be found outside of orthopedics, gynecology, and general surgery. A small group was invited to a meeting in Phoenix, Az. to exchange information on this topic. Besides myself, there was only one other thoracic surgeon present who had no experience and no apparent interest in video surgery. In fact, he left the meeting early. Again, I learned that general surgeons were making great strides and even entering other areas of the body such as the thorax. One general surgeon from Texas had done over 65 chest procedures. I asked what his thoracic surgeons in that hospital were doing?  He informed me they had no interest and didn’t even come into his operating room. I was astounded and believed we were on the verge of losing a potentially new, large segment of thoracic surgery. During this time, we were also in the process of losing pacemakers, bronchoscopy, esophagoscopy, chest tubes, and Cabg. It seemed unbelievable to me that thoracic surgeons could sit idly on the sidelines and not eagerly pursue and develop videoscopic chest procedures.

After leaving Phoenix, in a state of mild anxiety, I went directly to the 1991 AATS Meeting in Washington, D.C.  I had done about 80 to 90 thoracic videoscopic procedures and was somewhat distraught that a general surgeon had done almost as many. At the AATS I had a singular, important mission and that was to clarify the situation of thoracic surgeons in the evolving field of video surgery. Two people, whom I believed had the pulse of thoracic surgery, Tom Ferguson—Editor of The Annals of Thoracic Surgery and John Kirklin, Editor of The Journal of Thoracic and Cardiovascular Surgery should be able to enlighten me. Tom was at lunch when I asked him how many papers he had received on this new technique. He answered none and added he never heard of it. This amazed me. When I expounded on the general surgeons’ involvement, Tom decided immediate action was required to resolve this growing problem. After locating John Kirklin and having a similar discussion, he, also, knew nothing about it. All three of us agreed, at that meeting, that it was vitally urgent to have this emerging  field  introduced to all thoracic surgeons as soon as possible.

When I returned from the AATS, Ethicon asked me to give a two day course to about 12 surgeons identified as thought-leaders in thoracic surgery. A course was hastily put together consisting of a didactic session and videos the first day, followed by an animal lab the second day. Some participants were very interested, others indifferent and a few critical of the technique.  In early June, my hospital called a press conference to explain this new technique. I did not realize I would be the center of attention. The press conference proceeded smoothly, but, at this early stage, there were more questions than answers. The hospital established a Minimally Invasive Institute and appointed me Director. This included my own operating room and personnel. The Director of Marketing arranged interviews for me with most of the New York television stations, and  numerous newspapers and magazines. Some of the media  reports  were truthful and some not so truthful. Formal courses were soon established with help from my hospital, Ethicon, and the proficient participation of my two partners, Glenn Sisler and Robert Caccavale. The courses remained sold-out for over two years and attracted many national and international leaders in thoracic surgery. Despite their success, 2 ½ years later I had to terminate them. The demands of a large, growing practice, numerous visitors to the operating room everyday, expanding travel, administrative duties as chief of thoracic surgery in three hospitals, Chief of the University Thoracic Surgical Service which included teaching responsibilities for thoracic and general surgical residents and medical students, medical  school and hospital administrative commitments, publications, presentations, and many obligations as President of The Cardio-Thoracic Surgical Group allowed no time for courses.

In July 1991, a paper on endoscopic thoracic surgery, which I had submitted earlier that year, was published in N.J. Medicine. During Oct., I presented at Grand Rounds at Barnes Hospital and later that month to the combined Councils of the STS/AATS. Martin McKneally and I were appointed Co-Chairs of an ad-hoc committee to develop guidelines and instruction for this new technique. In Nov., our Ad-Hoc Committee invited young thoracic surgeons, with an interest in video surgery, to a meeting in Chicago for discussions. It was decided to call the technique Video Assisted Thoracic Surgery or VATS. Subcommittees were appointed to develop data bases, guidelines, courses, etc. In Dec., I gave a presentation on VATS at the Annual Meeting of the NJ Medical Society.  At the 1992 STS, I presented VATS at the Post Graduate Course. It was very well received. At the Plenary Session, President Bob Jamplis gave me a very generous introduction which I didn’t deserve but which I will never forget.

VATS seemed to excite, stimulate and infuse new energy into the field of thoracic surgery. Following the STS Meeting, innumerable national and international invitations began to arrive from medical schools and medical centers. It appeared everyone wanted to learn more about VATS. The entire experience was enjoyable but also overwhelming and was beginning  to interfere with my usual , daily routines. These outside influences were growing as I was leaving for the AATS Meeting in Los Angeles. At this time, almost everybody gave the impression they were exuberant about VATS although there were unappreciated pockets of skepticism. I was gratified to have my paper selected as the first presentation at the 1992 Annual Meeting of The AATS. Unfortunately, I had decided to present the applications of VATS for thoracic malignancies. In retrospect, it was a bad decision and really far too early, in the embryonic life of VATS, to introduce this extremely controversial subject to the membership. Two days before the Meeting a moderate earthquake shook the city but not quite to the extent that the auditorium shook after I finished my presentation advocating the use of VATS for cancer. Immediately, many excellent, piercing and penetrating questions were put to me by members of the leadership. Rightfully and correctly, they were searching for credible evidence supporting this new proposed use of video surgery. Since, I, myself, was still climbing the VATS learning curve and had vast gaps in my own knowledge, my responses, at best, were very limited and guarded. I did not convince or, in anyway, change the opinion of the newly formed opposition. Following this presentation, I began to sense a slow erosion of support for VATS for cancer from some of the leadership. As guardians of patient care, these eminent surgeons, really had every right, and one might even say obligation, to critically comment on any and all new unproven treatments. I truly believe that my adversarial responses to them did more to impede the progress and acceptance of VATS than any other single occurrence.

Although I continued to do anatomic, traditional lobectomies with lymphadenectomy, which were identical to the open thoracotomy,  using VATS for access,  this new technique for performing a lobectomy remained very controversial and provoked fierce debates. As if VATS Anatomic Lobectomy wasn’t contentious enough, I made one small technical change at the hilum that created a universal uproar of condemnation which continues to persist. This was called Simultaneous Stapling of the hilum. Even some of my supporters rejected this change. In the past, I had a very large experience with hilar dissection in the open chest. Years ago, I began to staple and divide the bronchus separately and then would staple all of the vessels simultaneously. Over the years, there was never a problem. On numerous occasions, for various reasons such as scarring, shortened hilum, frozen hilum of TBC, etc, all hilar structures, including the bronchus, would be stapled simultaneously. Once again, there was never a single complication resulting from this technique. No bleeding, BPF, AV fistula, etc. Every patient did very well. So, as my experience and confidence with VATS anatomic lobectomy grew, I decided to make a small technical change in selected patients and began to use Simultaneous Stapling. Every hilum was carefully and completely dissected so each anatomical structure could be definitively identified and nodes excised before stapling. Unfortunately, the majority of surgeons never really tried to understand the difference between “mass ligation” and this new technique. Without ever seeing it performed, many became staunch opponents. Of interest, those surgeons who did take the time to observe it became advocates. Simultaneously stapled lobectomy was used by me for over 500  patients over a 10 year period with great success. It seemed to be an excellent fit and enhancement for VATS Lobectomy. The more I tried to convince surgeons of its benefits during presentations and through publications, the less favorable were their responses.  Although a large number of national and international surgeons have informed me that they are using simultaneous stapling for lobectomy, they remain reluctant to go public. I am still convinced that in the future it will become the technique of choice for lobectomy. During this period of time, I had the largest series of VATS Lobectomies, and the results, in every aspect, were equal or superior to anything previously or recently published. When follow up for VATS cancer resections had reached 5 years in my practice, survivals remained comparable or better than open,   traditional resections.

Until I decided to retire in 2000, it was my very great privilege to be able to make contributions to the advancement of VATS. I will always be grateful for the amicable and gracious treatment extended to me by so many surgeons in so many countries. I feel compelled to express my thanks to each one. It is very obvious that nothing is ever accomplished alone. Myriads of surgeons have made huge contributions to VATS since its inception.  Throughout its course of development, it was my very good fortune and privilege to get to meet and to get to know many of them. Because so many have made such huge contributions to VATS, trying to name them all would be impossible. However, a few were there very early and played a large role in advancing, refining and contributing to this new type of surgery. My partners, Glenn Sisler, Robert Caccavale, and J.P. Bocage relieved me of some of my duties allowing me to spend more time on VATS. Each became a superior VATS surgeon and made numerous contributions to the field and our program. Their participation was incalculable. James Mackenzie, Chairman of Surgery, firmly supported, assisted, and encouraged my VATS endeavors, from the very first day, even at low moments. Martin McKneally was more essential to the success of VATS than can be imagined. As Co-Chair, his organizational skills excelled in planning and conducting meetings, establishing and presenting post graduate courses and assimilating our international colleagues into this new evolving field. I truly believe his common sense approach and solid guidance helped to make VATS the success it is today. A small group of young, innovative thoracic surgeons eagerly promoted VATS and made huge contributions. In this group were Michael Mack, Rodney Landreneau, Stephen Hazzelrigg, Tony Yim, Mark Krasna, Akio Wakabayashi. International surgeons began to advance VATS such as Hui-Ping Lui (Taiwan),  Tsuguo Naruke (Japan),  Shizuka Kaseda (Japan), Giancarlo Roviaro (Italy),  Hani Shennib (Canada), William Walker (Scotland),  Rolf Inderbitizi (Switzerland), Ulf Hermannson (Sweden),  Luis Losso (Brazil).

Some of the leadership were  more involved with VATS than others. Robert Ginsberg, Penfield Faber, Joel Cooper, Peter Pairolero all played a very important part by their constant observation and evaluation of all applications of VATS. Their scrutiny and pertinent comments made for even more responsible and cautious use of this new technique. Their input was very significant. Tom Ferguson and John Kirklin must be complimented for their expertise in carefully selecting VATS papers for publication. Their efforts provided an excellent, unbiased, orderly, progressive education for all thoracic surgeons.  From my own experience, their advice, wisdom, relevant questions, and editorial skills improved all of my papers.

This is my perspective of how VATS evolved.  It stimulated general thoracic surgery and caused excitement at meetings. In retrospect, there are some things I would have done differently if I had more insight, understanding and had known better at the time. However, it was a fantastic journey, and I feel privileged that I was allowed to make it.

Publication Date: 19-Jun-2007
Last Modified: 19-Jun-2007