title: Fissureless fissure-last video-assisted thoracoscopic lobectomy for all lung lobes: a better alternative to decrease the incidence of prolonged air leak?
abstract: OBJECTIVE
  Prolonged air leak (PAL) after major lung resections is a common postoperative complication that leads to extended length of hospital stay (LOS) and increased hospital costs. Dissection of the lung tissue through the fissure may increase the incidence of PAL especially in the patients with incomplete fissures. The objective of this study was to evaluate the impact of the fissureless fissure-last technique in VATS lobectomy on immediate outcome, especially relating to air leak and LOS.
  
  
  METHODS
  This is an observational analysis on prospectively collected data of a single thoracic surgery unit. A total of 54 consecutive patients underwent VATS lobectomy and mediastinal lymphadenectomy-in 24 patients conventional VATS lobectomy (Group 1), in 30 patients fissureless VATS lobectomy (Group 2) was performed. The two groups were compared according to preoperative, operative and postoperative parameters.
  
  
  RESULTS
  No differences were found when comparing patient characteristics, operation time (M1 = 185 min; M2 = 176 min; P = 0.52) and number of staplers used (M1 = 6.2; M2 = 7.7; P = 0.088). The presence of air leak (P = 0.004; RR = 3.5), PAL (P = 0.003; RR = 10), in days with chest tube (M1 = 7.2; M2 = 4.2; P = 0.028) and LOS (M1 = 12.7; M2 = 8.9; P = 0.020) was significantly more frequent in patients that underwent conventional VATS lobectomy. Focusing on the air leak, significance was present in male gender (P = 0.034; RR = 2.41), higher ASA (M1 = 3.04; M2 = 2.67; P = 0.012), postoperative complications other than air leak (P = 0.001; RR = 5.78) and age between groups with and without air leak (M1 = 63.9; M2 = 74.1; P < 0.001).
  
  
  CONCLUSIONS
  Fissureless fissure-last VATS lobectomy is a feasible and equivalent to conventional VATS lobectomy in terms of operation time, stapler use and complications. Fissureless fissure-last VATS lobectomy, however, appears to be a superior technique to conventional VATS lobectomy in terms of preventing PAL and reducing the LOS.
authors.affiliation: Department of Thoracic Surgery, St Vincentius Kliniken, Karlsruhe, Germany davor.stamenovic@vincentius-ka.de.
authors.forename: Davor
authors.initials: D
authors.lastname: Stamenovic
authors.affiliation: Department of Thoracic Surgery, Faculty of Medicine, Marmara University, Istanbul, Turkey.
authors.forename: Korkut
authors.initials: K
authors.lastname: Bostanci
authors.affiliation: Department of Thoracic Surgery, St Vincentius Kliniken, Karlsruhe, Germany.
authors.forename: Antje
authors.initials: A
authors.lastname: Messerschmidt
authors.affiliation: Department of Thoracic Surgery, St Vincentius Kliniken, Karlsruhe, Germany.
authors.forename: Tillmann
authors.initials: T
authors.lastname: Jahn
authors.affiliation: Department of Thoracic Surgery, St Vincentius Kliniken, Karlsruhe, Germany.
authors.forename: Thomas
authors.initials: T
authors.lastname: Schneider
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000388:Air; D005240:Feasibility Studies; D005260:Female; D005541:Forced Expiratory Volume / Q000502:physiology; D006801:Humans; D008175:Lung Neoplasms / Q000503:physiopathology / Q000601:surgery*; D008197:Lymph Node Excision; D008207:Lymphatic Metastasis; D008297:Male; D008875:Middle Aged; D061646:Operative Time; D011183:Postoperative Complications / Q000209:etiology; D011446:Prospective Studies; D017792:Surgical Stapling / Q000379:methods; D013529:Surgical Wound Dehiscence / Q000517:prevention & control; D020775:Thoracic Surgery, Video-Assisted / Q000379:methods*; D000267:Tissue Adhesions / Q000209:etiology
keywords: Lobectomy; Lung cancer surgery; Parenchymal fistula; Pleural air leak; Thoracoscopy/video-assisted thoracoscopy