Your lungs consist of five sections, or lobes – three on the right and two on the left. Lobectomy, an operation to remove a single diseased lobe, is the most common surgery for lung cancer. If you need a lobectomy, a major choice is whether to have a rib-spreading operation called a thoracotomy or a less-invasive procedure known as video-assisted thoracic surgery, or VATS.
Obviously, the August 2013 CT scan showing lung cancer was bad news for Jeff Ehlers, now 48 and vice president of operations for a commercial glazing contractor in Sherwood, Arkansas. However, Ehlers says, his oncologist was “almost excited” because the tumor was apparently confined to a single lobe.
Ehlers’ oncologist and surgeon agreed that removing the entire upper right lobe gave the best chances for getting rid of all the cancer. That made sense to him, he says: “It was just, there it is – let’s get rid of it.” Three-and-a-half days later, he had a VATS lobectomy.
The surgery went “very well,” Ehlers says. He woke with chest tubes attached and spent a single night in the intensive care unit. An allergic reaction to painkillers lengthened his hospital stay to about a week. Follow-up treatment included four rounds of chemotherapy.
After discharge, Ehlers eased back into driving and work. “I bounced back pretty quickly, thankfully,” he says.
When a patient is diagnosed with lung cancer, doctors use staging to describe the cancer’s location, size and whether it has spread within the lungs and to other parts of the body, as detailed on the Cancer.Net website.
Tumors that can respond to surgery, known as “resectable” tumors, include stage 1 to some stage 3A tumors, says Dr. Joe Shrager, a professor and chief of the division of surgery at Stanford University School of Medicine. When lung cancer reaches 3A and above, he says, chemotherapy and radiation become the primary treatments.
The smallest, least-aggressive tumors can be treated with procedures that only remove the affected part of the lobe. A wedge resection is the simplest procedure, while a segmentectomy involves removing a little more of the lung. “A lobectomy allows you to take the entire lobe and all the lymph nodes that drain that lobe,” Shrager says. For cancers extending beyond a single lobe, more complex surgery to remove an entire lung is called a pneumonectomy.
A lobectomy done by “open thoracotomy” is a major surgery in which surgeons open your chest wall with a large incision and spread your ribs to gain access to your lungs. With VATS, by contrast, surgeons make three small incisions in the chest, armpit and shoulder-blade area. “Then we have a video camera through one of those incisions, and we’re projecting the inside of the chest up on a TV screen,” Schrager says. “In the other two incisions, we have long instruments that we’re doing the operation with while watching on the screen, basically.”
Surgical incision sites for VATS lobectomy.(Courtesy of Stanford School of Medicine, Dept. of Cardiothoracic Surgery)
The key advantage to VATS is that surgeons work beneath the ribs without spreading them, Shrager says. Less muscle is divided during surgery, and patients have much less pain afterward. Hospital stays are shorter, and patients come off pain medicine, recover and return to full activity sooner.
However, not every patient is a good candidate for VATS lobectomy. “It’s very well-established for stage 1 that survival rates are the same,” Shrager says. “Most of us think for stage 2 it’s the same. It’s still very controversial for stage 3, [and] most of us would do a thoracotomy.”
A 2013 study examined costs and outcomes. “Lobectomy performed by the VATS approach as compared with an open technique results in shorter length of stay, fewer adverse events and less overall cost,” concluded researchers at Brigham and Women’s Hospital and Harvard Medical School. VATS patients have less need for opioid drugs, which is another advantage.
When choosing a surgeon for lung cancer surgery, your best bet is a surgeon whose practice is devoted specifically to lung operations, says Dr. Louis Jacques, a lung cancer surgeon with Minnesota Oncology, a practice in The US Oncology Network. A general thoracic surgeon is board-certified in cardiothoracic surgery, which includes the heart and lung. “But their only practice is basically lung – they don’t do heart surgery,” he says.
Having done a higher volume of lung procedures is a signficant advantage, Jacques says. Also, he says, lung-focused surgeons tend to work within a well-established group involving medical oncologists, nursing coordinators, radiation therapists and pathologists, all collaborating on decisions and treatments as a multidisciplinary team.
Ask about qualifications. “Any surgeon who you want to operate on you would be very comfortable taking about that,” Shrager says. “If a surgeon hasn’t done 100, at least, of the operation you’re going to be having, then you don’t want that surgeon. I would ask the surgeon, ‘Are you completely comfortable doing this? Is it totally in your wheelhouse? How many have you done?'”
Finding the best hospital in your area is important. One way is to look at the latest U.S. News Best Hospitals rankings, which for the first time include lung cancer surgery as one of nine common procedures and conditions evaluated to rate hospital performance. For another resource, the National Cancer Institute lists 69 NCI-Designated Cancer Centers for cutting-edge cancer treatment.
Good nursing care is essential for a good recovery, Shrager notes. Magnet hospitals, which meet multiple criteria for high-level nursing care, are worth looking into.
Ehlers’ follow-up care included periodic lung scans to make sure cancer hadn’t returned. Unfortunately, a second tumor showed up in February 2015. The setback “really knocked the wind out of my sails,” he says. By then, he was much more educated about lung cancer. “I understood the implications a lot more of what it means to have a recurrence,” he says.
The tumor in the lower left lobe was small, and in April 2015 Ehlers had a wedge resection with VATS, followed by 16 rounds of chemo, for which he still has a port in his neck.
This time, Ehlers says, he understood how to help his body heal as quickly as possible. “Just be aware that you’re going to be sore, but you have to push yourself to do the exercises they tell you,” he says. Now he’s doing well and says he has barely slowed down, other than getting short of breath more easily because of reduced lung capacity.
Ehlers has found support through online communities like LUNGevity, a lung cancer advocacy group. He’s grateful to friends who stopped by the hospital after surgery. As a patient, he says, even though you don’t look your best “with tubes coming out of your nose and chest, you want to get that contact.”