Analysis of Unexpected Conversion to Thoracotomy During Thoracoscopic Lobectomy in Lung Cancer

Since anatomical lung resection by video-assisted thoracoscopic surgery (VATS) was first introduced, VATS has played a major role in lung cancer. However, conversion to thoracotomy is a major concern because an unexpected thoracotomy increases the risk of potentially adverse outcomes. Therefore, we compared patients who were and were not converted to thoracotomy and identified the risk factors for thoracotomy conversion.

Between January 2005 and December 2013, 69 of 1,110 VATS lobectomies for lung cancer required an unexpected conversion to thoracotomy. Each converted patient was individually matched to 3 randomly selected nonconverted patients based on date of operation, type of operation, and pathologic stage.

The most common cause of conversion was fibrocalcified lymph nodes, found in 28 patients (40.6%), followed by vascular injury in 20, tumor invasion or extension in 11, pleural adhesion in 5, incomplete interlobar fissure in 3, and failure of single-lung ventilation in 2. The differences in overall postoperative complications and in-hospital deaths were not significant; however, respiratory complications were significantly more common in the conversion group (p = 0.012). The independent risk factors for conversion were age 65 years and older, forced expiratory volume in 1 second of less than 1.8 L, and the presence of fibrocalcified lymph nodes on preoperative chest computed tomography.

Unexpected conversion to thoracotomy during VATS lobectomy in lung cancer does not appear to increase overall surgical morbidity and mortality. However, with high-risk patients, the surgeon requires careful selection for VATS candidate. Also, if necessary, the decision to convert must be made promptly to reduce possible critical respiratory complications.