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OBJECTIVE: Vats lobectomy or segmentectomy after previous lobectomies is uncommon. It's safety and feasibility is reviewed.
METHODS: Between 2006 and 2009, 6 out of 21 (2.2%) of vats major resections were for repeat vats lobectomy or segmentectomy.No cases were converted to thoracotomy. All underwent preoperative staging PET scans and pulmonary function test. Extent of repeat surgey was determined by type of previous surgery, residual lung capacity and underlying pathology.Technical considerations include careful lysis of chestwall and hilar adhesions during mobilisation of hilar structures when reoperating on the same side. Special anaesthetic techniques to tolerate single lung ventilation were needed when operating on the contralateral side. In 2 cases with previous left lobectomies,selective isolation of the intermediate bronchus by bronchial blocker allowed for successful right vats lower lobectomy with associated lymphadenectomy.In 2 cases with previous lobectomy applying CPAP(5 to 10mm Hg pressure) to the operative lung allowed for right vats anterior segmentectomy and right upper lobectomy to be performed safely with adequate oxygenation. All surgeries were performed totally endoscopically by watching the TV monitor using a 2-3 cm non-rib spreading utility incision with individual division of the hilar structures.
RESULTS: 5 were males. Mean age was 59.8 years(range,50-71).Mean interval between surgeries was 12.5yrs(range,4-30yrs).Indcations for repeat surgery was metachronous lung cancer in 5 and bronchiectasis in 1. Previous surgery was done by thoracotomy in 5 and by Vats in 1. Prior surgery was lobectomy for lung cancer in 4 and bronchiectasis in 2.Mean hospital stay was 5.4 days(range,3-11days).Duration of surgery was 172mins(range,120-300mins).Repeat vats resections were 4 lobectomies and 2 segmentectomies.In 2 cases the surgery were done on the same side as previous surgery. There were no mortality and 1 had atrial fibrillation.
CONCLUSIONS: Repeat Vats major resections can be done safely after previous lobectomies.Attention to dissecting scarred hilar structures is needed when operating on the same side as previous surgery. Modified anaesthetic strategies may be needed when operating on the opposite side for single lung ventilation.

Table 1

PATIENT DATA	TYPE OF PREVIOUS SURGERY/ APPROACH/ INDICATION	TYPE OF REPEAT VATS SURGERY/ APPROACH/ INDICATION	TIME INTERVAL BETWEEN SURGERY
Male/71years	Left upper double sleeve lobectomy/thoracotomy/Stage IIIA lung cancer	Right Vats lower lobectomy/StageIA lung cancer	6 years
Male/50years	Left upper lobectomy/thoracotomy/bronchiectasis	Right vats lower lobectomy/bronchiectasis	30 years
Male/53years	Right upper lobectomy/thoracotomy/Stage IA lung cancer	Right vats superior segmentectomy lower lobe/Stage IA lung cancer	5 years
Male/68yeras	Left lower lobectomy/thoracotomy/Stage IB lung cancer	Right vats anterior segmentectomy upper lobe/Stage IA lung cancer	4 years
Male/65years	Right Vats lower lobectomy/StageIB lung cancer	Right Vats middle lobectomy	4 years
Male/52years	Left lower lobectomy/thoracotomy/bronchiectasis	Right Vats upper lobetomy/Stage IB lung cancer	25 years