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Overview

Thoracic surgeons specialize in treating diseases of the chest, primarily cancers of the lungs and the esophagus. They also noncancerous conditions such as benign chest wall tumors, gastroesophageal reflux disease, and paraesophageal hernia. 

At Yale Medicine, specialists like Daniel J. Boffa, MD, clinical program leader of the Yale Medicine Thoracic Oncology Program at Smilow Cancer Hospital, are on the leading edge of minimally invasive techniques that offer the best possible outcome for their patients. “The best minimally invasive surgeon is the one that is skilled at both approaches, and can tailor surgical treatment to the individual patient," Boffa says.

What’s the difference between minimally invasive and open thoracic surgery?

There are two aspects of the minimally invasive approach that can directly benefit patients. First, the incisions are smaller (typically ranging from 1/2 inch to 2 inches, compared with 5 to 7 inches required for open surgery). 

There's also much less trauma to the tissues of the chest and abdomen. While open procedures require stretching and pulling of tissues to allow surgeons to see all the areas they need to work, the minimally invasive procedure allows the surgeon can see all regions of the chest and abdomen by simply rotating a camera, resulting in less discomfort and a faster recovery. 

However, in some cases it can be difficult to remove a tumor using a minimally invasive approach. “Surgeons and patients should never accept smaller incisions as a trade off for a less complete surgery,” says Dr. Boffa.

How does minimally invasive thoracic surgery work?

The surgeon will enter a patient’s chest through plastic tubes or sheaths that keep incisions open and protect the surrounding tissues. Long, skinny instruments can be inserted through these ports or sheaths and manipulated from outside the patient to grab, spread or cut tissues inside the patient. 

This is all possible because of a long camera, called a thoracoscope, which allows the surgeon to see inside the patient. Not only can the thoracoscope be rotated, but it also magnifies the view, so that surgeons can actually see more of the body and with greater detail than is possible with an open approach. A surgeon can also further increase the view by creating more room between the body wall and the tissues he or she is operating on.

Who a good candidate for minimally invasive thoracic surgery?

“The majority of patients are candidates for a minimally invasive approach by one of our surgeons, but we do a thorough evaluation and match the patient with the approach that is best for them,” Dr. Boffa says. 

“With cancer surgery, the goals are to safely and completely remove the tumor and restore the anatomy to as normal as humanly possible. It should never be a shortcut or a compromised operation," he says.

As tumors become larger or grow closer to important structures, like blood vessels, airways or nerves, for example, minimally invasive operations become more challenging. If a patient’s surgeon does not think a procedure should be done minimally invasively, Dr. Boffa recommends a second opinion from a surgeon that is extremely experienced using both techniques. 

What are the most common thoracic surgeries performed with the minimally invasive approach?

The most common lung cancer surgery is a lobectomy, in which surgeons remove one of the patient’s five lobes. There are two on the left side and three on the right. In a patient with esophageal cancer, surgeons most often remove the part of the esophagus containing the tumor, a portion of the stomach, and many surrounding lymph nodes. Most often the stomach is fashioned into a tube and pulled up through the chest to meet the remaining segment of esophagus. 

The Yale Medicine team has surgeons who specialize in each of the above surgeries, as well as those that treat non-cancer conditions such as hiatal hernia and chest-wall tumors with the minimally invasive approach.

What is the recovery period like for a patient who undergoes minimally invasive thoracic surgery?

One advantage of the minimally invasive approach can be a shorter recovery. Recovery time is generally 30 to 40 percent shorter than is required for a traditional open surgery. 

Still, most thoracic surgeries are considered major operations, no matter how large or small the incisions are. Once home, patients who’ve undergone a minimally invasive surgery for lung cancer typically regain most of their strength, stamina, energy level, and breathing after two to three weeks. For open surgery, this level of recovery may take three to five weeks. There is typically less postoperative pain with a minimally invasive approach, and, in general, it’s associated with fewer complications, such as pneumonia or irregular heartbeat. A patient’s chances of surviving an operation are equally high with both approaches.

What makes Yale Medicine’s approach to minimally invasive thoracic surgery unique?

Minimally invasive surgery is a technique that many providers are not able to offer their patients, Dr. Boffa says. Many patients come to Yale Medicine for successful treatment after having been told elsewhere that they’re not candidates for the minimally invasive approach.

“We've have also had many patients come to us having been told by experienced surgeons that their tumor was inoperable, and we have safely and completely removed their tumors through an open approach,” says Dr. Boffa. “I’m proud of this.”