Commentary: A seal of approval? In search of a better way to divide the fissure during lobectomy

Matthew C. Black, MD, and Victor H. van Berkel, MD, PhD

Central Message.

In patients with low-grade incomplete fissures, using the robotic platform vessel sealing system (VSS) provides an alternative technique for fissure division during lobectomy.

See Article page 211.

Regardless of the approach to pulmonary lobectomy, avoiding the complication of prolonged air leaks is one of the goals of every general thoracic surgeon. Air leaks can lead to a longer chest tube duration, longer hospital stay, and greater cost.¹ It is not surprising that novel techniques to tackle the fissure are constantly evolving, regardless of the approach used. Certainly, the identification of a well-formed fissure can change the timbre of an operation. Stapling devices have had a huge impact on postoperative air leaks, but these devices traditionally required an access window to deploy, gained by blunt dissection or electrocautery within the fissure. Fissureless techniques have been described to avoid making any defects in the overlying lung parenchyma, and this has led to further debate, centered upon whether the fissure should be divided first or last.2, 3, 4 Vessel-sealing technology by the thoracoscopic approach has been shown to be feasible and safe.⁵ Robotic platforms have incorporated instrumentation that mimics this technology, available in a wristed instrument designed for sealing vessels up to 7 mm, but the safety and feasibility in sealing and diving the lung parenchyma of the fissure have not been demonstrated.

In this issue of the Journal, Miyajima and colleagues⁶ retrospectively investigated outcomes of patients with low-grade incomplete fissures undergoing robotic lobectomy for lung cancer. They compared a standard stapler approach versus dividing the fissure using the DaVinci vessel sealing system (VSS). The fissure was graded by the operating surgeon prospectively and the technique chosen during the operation was at the discretion of the operating surgeon. A total of 111 patients were enrolled, excluding 7 for thick, incomplete fissures and 28 who had complete fissures that did not require division, leaving 46 in the VSS group and 30 in the stapler group. The mean operative and console time were shorter in favor of the VSS group. The intraoperative blood loss was reduced as well as surgical complication rates. The incidence of prolonged air leak was also less in the VSS group, and fewer stapler cartridges were used, equating to an overall cost reduction.⁶

The authors clearly demonstrate a viable technique in performing the interlobar fissure division in a special subset of patients. They make sure to emphasize and illustrate the technical nuance of performing the dividing line 1 to 2 mm from the actual interlobar line, staying on the resected lobe.⁶ Although obvious selection bias exists from the operating surgeon, the patients who underwent this technique did very well, with only one having a postoperative air leak (2.2%) that ultimately required intervention. Similarly, a cost-savings benefit with using this method over traditional stapling devices was evident. Whether this technique is ultimately superior to any of the other aforementioned fissure division techniques, and under what specific circumstances it is appropriate, remains to be determined, and would require a prospective randomized study to demonstrate. Nevertheless, this paper does offer a potential skill for general thoracic surgeons to file in their armamentarium.