A kinder, gentler lung surgery

Seattle Cancer Care Alliance's Michael Mulligan joins healing hands with digital eyes in video-assisted thoracic surgery
Warren Bailey playing raquetball
Video-assisted thoracic surgery has enabled internationally ranked racquetball player Warren Bailey to avoid open-chest surgery and stay in the game. Photo by Jim Barker

We're an active bunch here in the Northwest. With Seattle and its surroundings consistently ranked among the fittest areas in the country, it's clear that Northwesterners can tough out our infamous weather and short winter daylight hours. Still, if rain and gloom can't dampen our athletic spirits, shouldn't we at least slow down for lung surgery?

Dr. Michael Mulligan, who directs the lung transplant program and cardiothoracic research lab at the University of Washington Medical Center within the Seattle Cancer Care Alliance (SCCA), doesn't think so. Or at least not as much as traditional procedures once required.

Using video-assisted thoracic surgery (VATS). a technique that is less invasive than traditional methods, Mulligan and his colleagues have demonstrated success at getting lung-cancer and other thoracic-surgery patients back on their feet quickly, and in better shape than they might have been otherwise. Mulligan is the first board-certified thoracic surgeon in the region to develop expertise and a significant practice with the technique.

VATS procedure

VATS involves inserting a tiny camera through a millimeters-long incision to see inside a patient's chest. This allows the surgeon to operate without the same impact to surrounding tissue that a traditional, open-chest procedure requires. VATS cannot replace open-chest procedures in many cases, and is not meant for late-stage cancer patients who have undergone significant chemotherapy or radiation, but it is well suited to removing early stage lung cancers. It may also be used for benign-disease operations. Mulligan believes that VATS will become more and more commonplace because of its benefits to patients — athletic or not.

"For young, active people in particular — and there are so many of them in the Northwest who like to engage in outdoor activities — it makes a lot of sense," Mulligan said. "It's also superb for the older, sicker patients because it's less surgical trauma, and they tend to weather that storm much, much better."

The VATS camera gives doctors a magnified, panoramic image to work with, and because it can fit through a small incision, it lets them avoid cutting muscles and cutting or shifting ribs to get an unobstructed view. "We do all of the operation on the monitor," Mulligan explained.

Like the camera incision, incisions for the surgeon's tools are also kept small to minimize tissue damage. Otherwise, VATS procedures are similar to traditional procedures — the same tools are used to do the same job. And results can be just as conclusive as open-chest surgery. "There are no differences in terms of long-term oncological outcomes," Mulligan said. "In other words, the cancer-specific factors are essentially the same: disease-free survival and overall survival are essentially the same."

Dr. Renato Martins, a medical oncologist in the SCCA who works closely with Mulligan, praises the results. "If one can achieve the same oncological outcome using smaller incisions in a less-invasive procedure, that's in the best interest of the patient," he said.

The benefits to patients are significant. Mulligan said that post-operative discomfort is lessened, shoulder function is usually better, patients need less medication afterward, and patient recovery times are reduced.

He told the story of internationally ranked racquetball player Warren Bailey, who underwent a VATS procedure to remove metastases in his lungs. Bailey, in his late 50s at the time of the operation, went home after only three days in the hospital. According to Mulligan, he might have been hospitalized for a week after an open-chest operation. Instead, he was playing racquetball again in little more than a week. "All you have to do is see one of these folks after a VATS and compare them to a recent thoractomy [open-chest] patient to realize that there are major advantages to doing it this way," Mulligan said.

An athlete himself, Mulligan has long been a proponent of what he calls muscle-sparing procedures. He said that his long experience with lung transplants and the resulting awareness of anatomy in three dimensions is what allowed him to move toward low-impact surgery — a direction he was headed even before training in VATS.

He had already been working on making smaller incisions, shifting muscles aside wherever possible instead of cutting them, and using a single incision when it was more common to make multiple incisions for surgical instruments and chest drains.

By the time Mulligan went to train in the VATS technique with Dr. Robert McKenna of Cedars-Sinai Hospital in Beverly Hills, his working knowledge helped him master the new technique much more quickly than usual. Again, he credits his transplant experience for his adeptness with VATS.

"It requires much greater familiarity with anatomy, and much more operative flexibility. You absolutely can't be rigid about the way you're going to do this — you have to let the operation talk to you."

Lung-care excellence

Mulligan's VATS work fits into a broader goal in the SCCA to bring an interdisciplinary approach to lung-patient treatment, said Dr. Douglas Wood, a University of Washington thoracic surgeon who works closely with Mulligan at the SCCA. "What Dr. Mulligan is doing is adding in minimally invasive procedures," Wood said. "It's another option for patients to get the best level of care."

Due to the efforts of Mulligan and SCCA colleagues, the Northwest is building an impressive record with VATS and other lung-care procedures. While a few other Northwest hospitals use VATS, the SCCA program — backed by Mulligan's credentials — arguably leads the field. The University of Washington Medical Center has been recognized as a regional center of excellence for VATS, and now handles a large volume of referrals. Meanwhile, Mulligan has become the go-to surgeon for training new doctors in the technique.

As for what the future holds, Mulligan is confident that the benefits of VATS will help him and others propel it toward even more widespread use. "We know that it works," he said. "My task now will be to publish our experience with it, and raise local and regional awareness so that patients get a better crack at having operations done the right way."

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