Simultaneous Minimally Invasive Surgery in a Patient with Lung Cancer and Coronary Artery Disease

Special Article – Minimally Invasive Surgery

Austin J Surg. 2018; 5(7): 1150.

Simultaneous Minimally Invasive Surgery in a Patient with Lung Cancer and Coronary Artery Disease

Kim WJ, Kang CH*, Hwang HY and Kim K-B

Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Korea

*Corresponding author: Kang CH, Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul 03080, Korea

Received: September 20, 2018; Accepted: October 16, 2018; Published: October 23, 2018


A 77-year-old woman with aggravating chest pain for a month visited our outpatient clinic. Nearly occluded left anterior descending coronary artery and right lower lobe nodule suggesting lung cancer were identified in coronary angiogram and computed tomogram, respectively. To minimize postoperative complication, simultaneous robot-assisted minimally invasive coronary artery bypass grafting (CABG) and video-assisted thoracoscopic surgery (VATS) of right lower lobectomy were performed. Postoperative course was uneventful except transient atrial fibrillation. The patient was discharged on the 8th postoperative day. Simultaneous minimally invasive CABG and VATS lobectomy instead of median sternotomy and thoracotomy approach could be a safer treatment option for concurrent coronary artery disease and lung cancer in high-risk patients.

Keywords: Minimally invasive cardiac surgery; Video-assisted thoracoscopic surgery; Coronary artery bypass graft surgery; Robot assisted surgery; Lung cancer

Case Report

A 77 years old woman visited our outpatient clinic with aggravated chest pain 1 month prior to visit. The patient underwent imaging and laboratory evaluation for possible coronary artery disease. Chest x-ray scan showed a suspicious nodular opacity in the right lower lung field. Computed tomography (CT) coronary angiography showed 90% stenosis of proximal left anterior descending coronary artery (LAD) and 1.3cm-sized part solid nodule in the right lower lobe (Figure 1). A suspicious lung cancer with a clinical stage of cT1bN0M0 was diagnosed based on the chest CT scan, positron emission tomography and bronchoscopic evaluation. Coronary angiography was performed and near total occlusion of the proximal LAD was confirmed (Figure 1). To minimize the risk of combined right lower lobectomy and coronary artery bypass grafting (CABG) in this elderly woman, simultaneous robot-assisted minimally invasive direct CABG (MIDCAB) and video-assisted thoracoscopic surgery (VATS) for right lower lobectomy was planned. The patient was positioned supine, and a camera port and 2 robot arm ports were made on the 4th and 2nd and 6th left intercostal spaces, respectively. The left internal thoracic artery (LITA) was harvested as skeletonized fashion using da Vinci Surgical System (Intuitive Surgical, Inc. Sunnyvale, CA, USA). Pericardiotomy and identification of the target vessel was followed. Then, left arm port incision was extended medially about 5cm along the sub-mammary crease to perform hand-sewn anastomosis of LITA to LAD. One more port incision was made on the 6th intercostal space to insert a shaft for a stabilizer designed for MIDCAB. After finishing robot assisted MIDCAB, the patient’s position was changed to left lateral decubitus. One utility incision was made on the 5th intercostal space along the anterior axillary line, and the other 3 additional ports were made in mid- and posterior axillary line. After confirming adenocarcinoma by intraoperative pathologic examination of frozen sectioned wedge-resected specimen, VATS right lower lobectomy and mediastinal lymph node dissection was performed. Total operation time was 330 minutes including 210 minutes for robot-assisted- MIDCAB and 120 minutes for VATS. The amount of blood loss was 80cc and no transfusion was performed. Pathologic staging was pT1aN0 with 17 regional lymph nodes harvested and surgical margin was free from adenocarcinoma. Therefore, no adjuvant chemotherapy was needed. The patient was extubated at 13th postoperative hours. One-day postoperative coronary angiography showed patent LITA to LAD graft. Total amounts of postoperative drain were 580 and 870 mL in the right and left chest tubes, respectively. She recovered well without any complications except a transient atrial fibrillation on the 1st postoperative day, which was well controlled with amiodarone infusion. She recovered well on the 4th postoperative day. However, her discharge was delayed due to poorly controlled blood glucose level and she was discharged on the 8th postoperative day. Pain score measured with a visual analogue scale (VAS) were 4 and 2 on the first postoperative week and first postoperative month, respectively.